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Prostate cancer is the most common and most curable cancer in the male population, if diagnosed in the early stages. However, even at a more advanced stage, survival is long.

Precisely because of the high incidence of this neoplasm, newer diagnostic and therapeutic practices have been proposed, adopted and implemented, in order to provide the male patient with the safest, most valid diagnosis with the appropriate treatments for each patient.

At the Athens Medical Center for Minimally Invasive Urology, we have implemented the most advanced diagnostic and necessary tests in cases of suspected prostate cancer. When the PSA and/or the Digital Rectal Examination (DRE) raise such suspicions, the patient needs a special MRI, the Multiparametric Magnetic Tomography of the Prostate. This is the only imaging test that can detect a clinically significant prostate cancer focus even with a diameter of a few millimeters.

Guided by the multiparametric MRI, the prostate biopsy will follow. This should be taken not only from each area of ​​the prostate, but also targeted from the suspicious area indicated by the MRI (fusion system).

Until recently, prostate biopsies were performed rectally.

Their disadvantage is the possibility of microbiemia and sepsis, due to the fact that intestinal microbes can enter the circulation.

Another disadvantage is rectal bleeding, i.e. a large discharge of blood from the rectum, if a large vessel is punctured by the needle. Also, in men with hemorrhoids and anal fissures, due to the ultrasound cylinder through the rectum, there is a great deal of irritation for days. All of this has been overcome, thanks to prostate biopsies through the perineum – transperineal biopsies with the fusion system.

All of the above complications are eliminated because the rectum is bypassed. Also, with transperineal biopsies, distant areas can be biopsied, such as on the anterior surface of the prostate, which may have escaped transrectal biopsies.

If the diagnosis is made, the appropriate treatment should be decided by the patient and his urologist.

First of all, there is very low and low risk prostate cancer. In this case, if this patient is directly offered radical prostatectomy, especially if he is over 70 years old, it is certainly a form of overtreatment.

Alternatively, this patient may be offered:

• Active surveillance. Surveillance involves the patient’s compliance with a PSA monitoring protocol, possibly repeating Multiparametric MRI and biopsies. The patient should be assured that the disease will not escape if he adheres to the protocol faithfully.
• Focal Therapy. It is a treatment between “do nothing and watch” and radical prostatectomy or radiotherapy, which are radical treatments. At the Center for Minimally Invasive Urology of Athens Medical Center, focal therapy has been applied in recent years with excellent oncological and functional results. It consists of thermal destruction of cancerous tissue in the prostate using radio waves from the rectum, carried out by the FocalOne

Only the focus that is visible from the Multiparametric Magnetic and has been biopsied can be thermally cauterized, as well as neighboring areas or even the entire prostate, if there are scattered small foci in the biopsy. The patient is discharged the same day or the next. Urinary continence is not affected. If the entire prostate is cauterized, only then can erectile function be affected, but again to a much lesser extent than with radical prostatectomy.

It should be noted that FocalOne focal therapy can be performed again in case of recurrence of the disease. It is also indicated in:

• Older patients (prostate cancer will not have time to threaten them, so focal therapy is a very good alternative)
• In men with serious cardiorespiratory and other problems who cannot receive long-term anesthesia for radical surgery
• In men with multiple abdominal surgeries who are not suitable candidates for surgery
• An excellent indication for focal therapy with FocalOne is the recurrence of prostate cancer in patients who had chosen to receive radiotherapy rather than a surgical solution (radical prostatectomy after radiation carries the risk of serious complications).

If radical surgical treatment is decided, the technique unanimously recommended by international literature is robotic radical prostatectomy with the system daVinci. Why is it superior to open:

• Oncologically and for all stages of prostate cancer, it has cleaner healthy resection margins of the prostate and seminal vesicles than the malignancy, an important factor for the non-recurrence of prostate cancer
• When the prostate cancer is moderately aggressive (Gleason score 4+3) or aggressive (Gleason score 8, 9, 10) or more advanced stage and removal of the pelvic lymph nodes is also required, the number of lymph nodes removed is far superior with robotics, so the “cleaning” of lymph nodes is much better. Therefore, if lymph nodes with metastatic infiltration are removed and the surgical field is cleaner, the recurrence of the disease is delayed and possible complementary treatments, such as radiotherapy, take place when the operated tissues have better healed.
• The total number of surgical complications is reduced compared to open radical prostatectomy, so the number of reoperations and readmissions to the hospital for complications is lower.
• The possibility of blood transfusion, which is surgically considered a complication, is very small in favor of robotic radical prostatectomy.
• The faster recovery of continence and erectile function outweighs in favor of robotics.The Center for Minimally Invasive Urology of the Athens Medical Center has performed a number of robotic radical prostatectomies among the largest in the country. Oncological results are better than the average of global cases of venipuncture, thanks to the experience and in-depth preoperative study of patients by a board of urologists, radiologists, oncologists and radiation therapists.

Innovations and steps for the best oncological results, as well as for the functional ones (continence and erectile function) include:

• The thorough study of multiparametric MRI of the prostate combined with the topography of positive biopsies (tumor boundaries from the capsule, disease in more foci and where in the prostate, distance of the cancer from the angioneurotic bundles of the prostate responsible for erection, etc.) – robot software.
• Knowledge of the anatomy and preservation of tissues responsible for urinary continence (very good mobilization of the bladder to eliminate tension, identification of all the muscle fibers of the sphincter, if possible preservation of the internal sphincter, etc.
• Knowledge of the anatomy and identification and preservation of the nerves responsible for erection, non-traction of these so as not to cause the so-called “neuroapraxia”, which leads to nerve disability, as well as postoperative sessions with shock waves, necessary for the rejuvenation of the blood supply to these nerves
• In cases of locally advanced prostate cancer or with metastases in lymph nodes known from before or even in oligometastatic disease (less than 3 bone metastases), cooperation and oncological protocols for special pharmacological treatment with oncological centers abroad, such as MD Anderson, Houston, etc. In these cases, it has been demonstrated that pharmacological treatments in combination with robotic radical prostatectomy promise much better survival with, above all, excellent quality of life for the patient.

In conclusion, a fully scientific prostate cancer center, as we believe the Center for Minimally Invasive Urology of the Athens Medical Center is, needs to provide all possible interventional and surgical treatments, individualizing each case of prostate cancer for each patient, with their own health problems, adapted to their temperament and psychology, of what they can tolerate and what they cannot. The patient must choose what they want for themselves, since they have the best information from their urologist and always with a heavier focus on their oncological safety, but also their mental one!