Centre d'Urologie Générale-Beaulieu

Prostate cancer is the most common cancer in men over 50. It usually progresses slowly and only becomes metastatic after several years. The age at diagnosis is therefore of crucial importance.

Cancer is defined as the uncontrolled growth of cells that invade the surrounding tissue. These cells can also migrate to other organs, i.e. metastasis. Prostate cancer usually starts in the outer part of the gland. For this reason, abnormalities can be felt from the rectum. If left untreated, prostate cancer can lead to swelling of the legs due to obstruction of lymphatic drainage, bone pain, but also to kidney failure and eventually death.

Early detection is recommended for men over 50 years of age (45 years if there is a family history of prostate cancer) whose life expectancy is over 10 years. In patients over 75 years of age, screening for prostate cancer is no longer justified, as the survival benefit of treatment is usually only seen after 10 years, due to the slow progression of this cancer.

The prostate

The prostate is a gland that produces a secretion that is released through the urethra, along with seminal fluid and sperm, during ejaculation. This secretion accounts for about one fifth of the volume of the semen. The prostate consists of an outer glandular layer (70 % of the prostate volume) and an inner glandular core (30 % of the prostate volume). As the prostate lies in front of the rectum, a relatively large area of the gland can be palpated by the rectal exam.

Cause of prostate cancer

The cause is unknown, some risk factors have been identified: age, eating habits, heredity. If a first-degree relative (father or brother) has prostate cancer, the risk is multiplied by 2. This risk is increased in the West, probably due to the relatively high consumption of red meat and animal fats.

The tests

Neither the PSA (Prostate Specific Antigen, a protein secreted in the blood) nor the digital rectal exam can prove the existence of prostate cancer. The diagnosis can only be formally established by a tissue sample (biopsy). MRI (Magnetic Resonance Imaging) is an essential step in determining the location of the suspected area within the prostate. Based on the images obtained and by merging them with the ultrasound, the prostate biopsy will be performed with great precision on an outpatient basis, under local anaesthesia or with light sedation. The biopsy is used to establish a tumour grade, i.e. the degree of aggressiveness (Gleason score), on the basis of which treatment will be proposed.

Types of treatment

There are two very different situations with prostate cancer: localized, locally advanced cancer and metastatic cancer, which has already spread cells to other organs. Localized cancer can be cured, advanced cancer can be cured but will always tend to escape treatment in the long run. Nowadays, thanks to screening, most newly diagnosed cancers are in the localised, curable stage.

There are three options:

1. Active surveillance,
2. Surgery,
3. Radiotherapy.

The decision depends on a number of factors and is made after careful consideration by the patient and the caregivers. Factors to be assessed include the stage (T) and grade of the tumour (Gleason). The patient's general condition, the patient's history, the methods available and the experience of the doctors, and the patient's personal feelings about the different approaches will be the elements that will allow the treatment to be chosen as calmly as possible.

Active surveillance

Starting with a tumour that does not seem too aggressive (Gleason score <7), small (non-palpable tumour) and with a low PSA (<10), there is no rush. These 3 elements will be regularly re-evaluated (need to repeat biopsies if necessary) keeping in reserve surgery or radiotherapy the day one of the parameters worsens.

• Advantage: no immediate treatment.
• Disadvantage: the worry of living with an untreated cancer, the risk of being caught off guard by a small tumour that has grown close to the capsule and will surreptitiously transgress it. There is also the risk of having missed more aggressive cancerous sites during the first biopsy.

Radical prostatectomy

This operation aims to completely remove the prostate with its envelope (capsule) and the seminal vesicles and requires the bladder to be reconnected to the urinary canal (vesico-urethral anastomosis). The lymph nodes will also be removed. The Urology Centre offers the robot-assisted method (Da Vinci® robot) which is the evolution of laparoscopy by improving the vision and precision of the procedure.

Radiotherapy

Recommended for men over 70 years old, radiotherapy can also be indicated for younger men who have medical contraindications to surgery: cardiac or pulmonary problems in particular. Radiotherapy destroys the cancerous cells using rays directed at the prostate and prostate area. It can be internal (brachytherapy) or external (conformal radiotherapy).

Focal ultrasound treatment (HiFU)

Small, non-aggressive tumours can be treated with the Focal One, a device that focuses ultrasound on the diseased part of the prostate and allows its removal without surgery. The treatment is followed up by MRI scans and PSA measurements using the principle of active surveillance.

The consequences of treatment

The primary goal of treatment is to cure the cancer. At what cost? The prostate and seminal vesicles produce ejaculation, which will disappear completely with the surgical removal of the prostate. Enjoyment is surprisingly preserved, generally a little diminished. As the prostate is surrounded by erectile nerves that run along the posterolateral capsule, both surgical dissection and radiation may damage them. Two years after treatment, about 50 % of men who were sexually active at the time of diagnosis will have erectile difficulties. Nowadays there are many drugs or treatments available to restore an erection that allows penetration. As the prostate is located just above the urinary sphincter, its removal or irradiation may lead to urinary disorders in the form of incontinence or bladder irritation. These risks are reduced with the robot-assisted laparoscopic method. In the case of early prostate cancer, recovery is possible while maintaining continence and the possibility of penetrative sexual intercourse, with or without drug assistance.

Why choose robotic surgery?

Only surgery allows us to know the exact nature and extent of the tumour since the prostate gland once removed will be analysed in its entirety as well as the lymph nodes. The stage of the disease can therefore be accurately determined. The PSA 6 weeks after the prostatectomy should be 0.0 and remain so thereafter. In this situation, the PSA is indisputable and perfectly reliable. If the capsule is exceeded on analysis of the prostate, and the PSA persists or reappears (>0.2), additional radiotherapy at lower doses may provide a second chance of cure.

The quality of the prostate dissection is essential and the robotic technique allows a better vision (3 dimensions) and a better precision (no trembling, articulation of the end of the instruments on six axes with reduction of the movement, and disappearance of the effect of lever arm which one can have with a traditional instrument introduced in the abdominal cavity. This is in addition to the comfortable and ergonomic position of the surgeon sitting at the console, manipulating his instruments in a totally ambidextrous manner and in line with his 3D camera.

This is why prostatectomy performed with the Da Vinci robot has become the surgical technique of choice. Today, more than 85 % of radical prostatectomies in the US are performed with the Da Vinci robot.

Treatment with the robot: the main advantages

Robotic laparoscopy is a so-called "minimally invasive" technique which, thanks to the use of a remote manipulator with a three-dimensional view, makes it possible to recreate the conditions of a conventional operation, but while sitting at a console close to the patient. The improvements brought about by the robot technology are multiple. The main advantages concern both the patient and the surgeon.

For the patient :

• Increased safety
• Precision of dissection
• Small incisions
• Combined benefits of minimally invasive surgery:
• Reduced bleeding
• Reduced infection
• Reduced pain
• Shortened hospital stay and recovery

For the surgeon :

• Exceptional 3D vision
• Easy access to difficult surgical sites
• Ergonomic position
• Precision of the gestures by the reduction of the bleeding, the reduction of the movements and the rotation of the instruments on 6 axes

In 40 % of couples with fertility problems the cause is found on the male side.

The male check-up includes sperm analysis (spermogram), ultrasound examination and hormone measurements.

The Centre d'Urologie Générale-Beaulieu offers these couples various state-of-the-art medical or surgical treatments:

- Robotic-assisted microsurgical varicocele surgery.

- Repair of spermatic ducts: microsurgical robot-assisted vasoepididymostomy or vaso-vasostomy.

Finally, in collaboration with the Centre for Medically Assisted Reproduction (CPMA), it offers microsurgical testicular sperm sampling (micro-TESE) or epididymal sperm sampling (micro-MESA) with the aim of carrying out in vitro fertilisation with micro-injection (IVF-ICSI).

Family planning

The Centre d'Urologie Générale-Beaulieu also offers minimally invasive vasectomies, under local anaesthesia, using the so-called «no scalpel» method. The patient leaves the practice no later than 20-30 minutes after the end of the procedure, which itself takes about 20 minutes.

The vasectomy is reversible and the Centre d'Urologie Générale-Beaulieu offers operations to repermeabilise the vas deferens (vaso-vasostomy) if a patient wishes to regain fertility after a vasectomy.

Age-related enlargement of the prostate (adenoma) is a very common situation from the age of 50. It is manifested by frequent urination, a feeling of urgency, a weak stream and a feeling of incomplete emptying of the bladder after urination. Patients also often get up at night to urinate. If prostate cancer has been excluded, medication may be offered to relax the prostate and allow better and less frequent urination. If there is no improvement, surgical treatment is proposed, which is adapted to the size of the prostate and the patient's wishes

Endoscopic resection (TURP) is the standard treatment for prostate adenoma using a bipolar resector. If the volume of the adenoma exceeds 100 ml, a transvesical abdominal approach will be performed using the Da Vinci robot (adenomectomy)

In some cases a minimalist procedure is performed, through electroporation or endolift.

These different methods do not remove the entire prostate gland and follow-up monitoring should be carried out as in non-operated men. These treatments do not reduce the risk of developing cancer later on.

After treatment the urine flow is restored and most of the troublesome symptoms disappear. Retrograde ejaculation is often a consequence of the surgery: during orgasm the semen flows back into the bladder and is released with the urine later.

Incontinence affects both men and women and can be due to a variety of causes (overactive bladder, postoperative sequelae, neurological damage). Their management takes place over several consultations with:

• An interrogation of the patient
• A thorough clinical examination
• A debimetry with calculation of the residual urinary volume (non-invasive ultrasound examination)
• Possibly a urodynamic assessment, which allows a better understanding of the underlying causes and a more accurate diagnosis.

Urodynamic assessment

The urodynamic assessment takes place over 30 minutes. Various probes with pressure sensors are used to obtain different values for the function of the bladder, both during the filling and emptying phases. If your urologist has indicated that you should undergo this test, he or she will explain the steps involved in more detail.

Therapeutic management

This may include physiotherapy, prescription of certain drugs or surgical treatment if necessary (intravesical injections of Botox, collagen injections, urinary slings and artificial sphincters, etc.).

Urinary stones are a frequent reason for consultation. They usually manifest themselves as back or flank pain, sometimes very severe. They are often due to insufficient hydration combined with dietary factors. Management includes a renal ultrasound and/or abdominal CT scan. If the stones do not pass naturally, surgical treatment is chosen.

The Centre d'Urologie Générale-Beaulieu, in association with the Clinique Générale-Beaulieu, offers all existing treatment options.

Extracorporeal shock wave lithotripsy breaks up the stone with incisional waves.

Ureterorenoscopy allows us to go up the natural tract with the help of a camera in order to visualise the stone directly and to pulverise it with a laser or to extract it with force.

When the stone is larger than 2 cm, percutaneous surgery can be performed by passing a camera through a tube in the patient's flank (NLPC). In 10 % of cases (uric acid stones), the stones can be dissolved by medication, sometimes avoiding surgery.

Erectile dysfunction

Erectile problems frequently occur from a certain age onwards and often for multiple reasons. A specialised consultation is offered at the Centre d'Urologie Générale-Beaulieu to determine the causes of the problem and to offer an adapted treatment.

Treatments are usually medicated but the centre also offers surgical implantation of malleable or hydraulic penile prostheses.

Penile curvature

Peyronie's disease manifests itself as a curvature of the penis which can be painful and sometimes compromises erectile function and sexual intercourse. There are few proven effective treatments. The centre's doctors offer Xiapex® injections and surgical interventions in cases of significant curvature or refractory to treatment.

Bladder Cancer

Bladder cancer is one of the 10 most frequently diagnosed cancers. Smoking is the main risk factor. It is often manifested by the presence of blood in the urine (haematuria).

The assessment includes a cystoscopy (inserting a camera into the bladder through the urethra) and a CT scan.

In most cases, the tumour is removed by transsurethral surgery and analysed under a microscope to make a final diagnosis.

In some cases, intravesical chemotherapy (or immunotherapy) via a temporary urinary catheter will be offered to you at the CUGB on an outpatient basis.

In the most severe cases, complete surgical removal of the bladder will be offered.

Kidney cancer

Tumours of the kidney are frequently discovered incidentally during an examination (often a CT scan) carried out for another reason. They may also be manifested by blood in the urine.

Some small tumours can be monitored without treatment, whereas significant tumours must be surgically removed using the Da Vinci robot, either by removing a whole kidney (nephrectomy) or only part of the kidney containing the tumour (partial nephrectomy).

Minimally invasive focal treatment under CT (radiofrequency) may be discussed on a case-by-case basis.

Testicular cancer

Testicular tumours usually affect young adults between the ages of 20 and 40. They often manifest as an increase in size of one of the testicles with a change in consistency, the tumour being harder than the rest of the testicle. It should be noted that an increase in size of the scrotum and/or testicle is not necessarily due to a testicular tumour. If in doubt, it is imperative to consult a doctor.

The assessment includes an ultrasound scan, blood tests and a CT scan. Sperm freezing may be offered.

The treatment consists of removing the testicle (orchiectomy). The placement of a prosthesis during the same operation is proposed in all cases. Other complementary treatments such as chemotherapy may be recommended on a case-by-case basis.

Generally speaking, testicular tumours have a very good prognosis.