Topic Prostate cancer shall be treated and can be treated with minimal morbidity

When I was a Medical Student, it was a common belief that most patients with prostate cancer would die with the disease, while only a minority would die of the disease itself.? This concept has undergone a phenomenal revolution.? The landmark paper by Gerald Chodak in 1994 told us that watchful waiting, or “intentional neglect”, was not applicable to those high grade tumours.? This is especially true in view of the steady increase in life expectancy, as the cancer has more time to kill.

Prostate cancer was fifth commonest cancer and the eighth commonest cause of cancer death in Hong Kong males in 2001.? In 2004, the corresponding ranks ascended to the fourth and the seventh, respectively.? Again, the increase in life expectancy is to be blamed.

According to the latest edition of European Association of Urology (EAU) guidelines updated in 2005, the indication of radical prostatectomy, with a curative intent, is localized disease in patients with life expectancy of more than ten years.? Given than prostate cancer is a slow growing tumour, and is usually aymptomatic in its early stage, one may question the validity of this major undertaking with its associated morbidities including blood loss, erectile dysfunction and urinary incontinence, especially with the emphasis on quality of life issues in current health care practice.

In 1982, Patrick Walsh described the anatomy of the dorsal venous complex and the neurovascular bundle (NVB) containing the cavernosal nerves.? This resulted in a significant reduction of blood loss and improved potency and continence rates after prostatectomy, as it had been shown that the NVB also contained nerve fibers contributing to urinary continence.

Patient acceptance of surgery increases with the development of minimally invasive techniques.? Urologists therefore have endeavoured to develop techniques of laparoscopic radical prostatectomy (LRP).? However, LRPis well known to have a steep learning curve.? Even the brave pioneers thought initially that laparoscopy was only good for the kidney, but bad for the prostate.? In 1997, William Schuessler in USA, after doing nine cases, concluded that LRP offered no advantage over open surgery, as the operative time averaged 9.4 hours.? Few years later, near the turn of the millennium, Bertrand Guilloneau and Claude Abbou in France reported that they were able to shorten the operation time to around four hours.

The digitally enhanced laparoscopic images, improved by magnification and illumination, greatly facilitate the anatomical dissection, which cannot be provided by open surgery.? In the figure, it can be appreciated that a good length of membranous urethra can be preserved, which also plays an important role in maintaining continence.? Although definitions of potency and continence vary from series to series, potency rate up 82% and continence rate up to 100% have been reported after LRP.? Parallel with this preservation of quality of life, there is no compromise of oncological control when compared with open surgery, as shown in several large series.

Currently in Hong Kong, several centres have reached these international standards, and Union Hospital is one of those that can provide this type of advanced laparoscopic urological service in the Minimally Invasive Centre.? Urology specialist services are also available in the Tsim Sha Tsui, Ma On Shan and Tseung Kwon O Polyclinics.