Prostate cancer can seem scary,
but it doesn't need to be.
It is important to understand how prostate cancer develops.
Before prostate cancer is diagnosed, we need to screen for it first.
What is the prostate?
The prostate is a small, walnut-sized gland located below your bladder and surrounds the urethra, the tube that drains the urine out of your bladder. Its purpose is to make some of the fluid that is present in semen.
Unfortunately as men get older the prostate can cause two problems: make urination difficult, and cause prostate cancer. This problems are not related - prostate cancer often does not present with urinary symptoms!
What is prostate cancer?
This cancer is the most commonly diagnosed cancer in men. It is a slow-growing disease that can take 10 to 20 years from the time it is diagnosed until it spreads and causes death. It does not usually cause symptoms until it is widespread throughout the body. This is why screening patients before they have symptoms is important.
What is PSA?
This is a chemical produced only by the prostate and can be measured by the PSA blood test. The level depends on prostate size, age, and the presence of prostate cancer. A “normal” PSA level changes as you get older. If your PSA is elevated, this can indicate prostate cancer, or it can be due to an abnormally large prostate or recent ejaculation or infection. Riding a bike or motorcycle or having a rectal exam does not usually make the PSA rise.
I have not had a PSA check, should I have mine checked?
The PSA can be checked in patients who have a life expectancy of 10 years or more, as there is a chance of catching and treating the prostate cancer before it causes death. Patients with a history of prostate cancer in siblings or father should be checked 10 years before the age of their family member’s diagnosis. Otherwise screening is recommended starting at age 55. Screening for prostate cancer is up to you, some men choose not to get screened with the understanding that prostate cancer might go undiagnosed.
What about a rectal exam?
Prior to PSA, this was the only way to diagnose prostate cancer. Dr. Chertack does not usually perform a rectal exam unless you have an abnormally elevated PSA. However, some doctors do feel there is some usefulness in the rectal exam, so you may have some doctors who performs it with every visit.
An elevated PSA is often the first indication to look for prostate cancer.
My PSA is elevated, what now?
First, your PSA may need to be re-checked depending on the level. Depending on the results and other factors, Dr. Chertack will often recommend an MRI or a prostate biopsy (or both).
What is the purpose of the MRI?
MRI of the prostate provides multiple pieces of useful information.
First, it gives information about prostate size - patients with very large prostates may have an abnormally high PSA level.
Second, the MRI shows whether there are areas of concern, known as “PIRADS lesions” by the radiologist. These are graded on a scale of 1 to 5, with 5 being most concerning for prostate cancer. However, this is not a perfect test - it is not a yes/no for cancer, only a “hey this looks concerning.”
Third, the MRI gives information that can be useful if you end up needing prostate cancer surgery.
Some patients cannot undergo an MRI. The most common reason is metal implants that prevent an MRI, or claustrophobia. Dr. Chertack would prefer an MRI but it is not required.
Do I need a biopsy?
Dr. Chertack will recommend a biopsy for a couple reasons
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Your MRI shows an area of concern
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Your MRI shows no areas of concern, but the size does not explain the PSA
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You have an abnormal rectal exam (with or without a normal MRI)
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You are unable to undergo MRI but have a high PSA
How does the biopsy work?
The easiest way to evaluate the prostate is with an ultrasound probe that goes into the rectum. Then the biopsies of the prostate will be taken either through the rectum or through the perineum (the patch of skin between the scrotum and the anus). Numbing medication will be injected prior to the biopsy, this makes the entire procedure much more tolerable for patients. Usually the biopsy takes 10-30 minutes total.
What do I need to do to prepare for my biopsy?
Every doctor has a different preparation. Dr. Chertack prefers you to perform an enema the night before and morning of your prostate biopsy. You will receive an antibiotic injection in clinic 30 minutes before your scheduled biopsy time, so show up early! If it is in clinic you do not need to fast before or the day of the biopsy. If you take blood thinning medications, these may need to be held but confirm before the biopsy.
What should I expect after my biopsy?
You will go home the same day. It is normal to be sore, place an ice pack behind your scrotum and take over-the-counter pain medications for a couple days. It is normal to see a small amount of blood in the stool for 2-3 days, urine for 2-3 weeks, and semen for up to 2-3 months. You should not be concerned unless you are seeing large amounts of bright red blood or unable to urinate after the biopsy. You will receive an antibiotic prior to the biopsy, this will help keep the risk of infection low. The risk of developing an infection after the biopsy is less than 1%.
Where will my biopsy be?
The biopsy is often performed at Albany Medical Center by one of Dr. Chertack’s colleagues, as we have the ability to use a computer program to combine MRI images with the ultrasound images during the biopsy. Occasionally Dr. Chertack will perform your biopsy in clinic if you are a patient at CMH. Most patients are fine with a clinic biopsy, but if you are not comfortable with a biopsy awake in clinic, Dr. Chertack can perform your biopsy in the operating room with sedation.
Some prostate cancers do not require treatment.
They require "active surveillance."
What is Active Surveillance?
Prostate biopsies are graded on a scale of 1-5. If your prostate biopsy shows only Grade Group 1, then you are usually considered to have Low Risk localized prostate cancer (with some exceptions). This means you are at low risk for cancer spread or death from prostate cancer, but we need to keep careful watch on the cancer to make sure it does not become worse.
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How does active surveillance work?
Dr. Chertack will keep a close eye on your prostate cancer a few different ways. First, he will re-check your PSA level 6 and 12 months after your initial biopsy. A repeat biopsy will be performed 12 months after the initial biopsy. If you did not previously have an MRI, then an MRI is recommended before the confirmatory biopsy. Once you are confirmed to have low risk prostate cancer (and not upgraded), then active surveillance can be officially started. This will require a combination of PSA checks, rectal exams, and occasionally an MRI.
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How long will I stay on active surveillance?
If a repeat biopsy shows worsening prostate cancer, then treatment may be recommended at that time.
If you reach a point where your predicted life expectancy is less than 5-10 years, then it is recommended to stop active surveillance - there is low chance that cancer will be found that would worsen your life expectancy.
Sometimes the prostate biopsy shows clinically significant cancer.
This often warrants definitive treatment.
What is my risk classification?
The American Urologic Association (AUA) has determined a risk classification that combines your biopsy results, your PSA level, and your rectal exam into a “risk level” - the risk that your cancer will spread in the future. If you are favorable intermediate, unfavorable intermediate, or high risk, treatment is recommended.
If you have unfavorable intermediate or high risk prostate cancer, Dr. Chertack will usually recommend an imaging test, known as a PSMA PET/CT, to look for spread of the cancer outside the prostate, which is helpful to know prior to recommending treatment.
What are my treatment options?
If your cancer needs treatment, the options are surgical removal of your prostate or radiation (with or without hormone blockade). Chemotherapy is not used to cure prostate cancer. Both surgery and radiation are considered equivalent for cure - one treatment has not been proven to be better than another in numerous studies.
Tell me more about surgery?
Surgery involves removal of the prostate and often the lymph nodes, small pieces of tissue in the pelvis where the cancer will spread (if it spreads). The surgery is done robotically, which means instead of one large incision it requires 5-6 small incisions on the belly and takes about 4 hours. After surgery you wake up with a catheter to drain the urine from the bladder and often stay in the hospital overnight (sometimes you can go home the same day). The catheter will stay for up to 1 week after surgery.
Benefits: The prostate is removed completely, therefore it can be examined under the microscope to see how much and how severe the cancer is. You only require one treatment (the surgery) then can go home.
Risks: The surgery has a risk of bleeding, infection, and injury to other organs in your belly. You will be sore after surgery and there will be a recovery process. Temporary urine leakage is common after surgery, this improves over time and most men (90-95%) have minimal leakage by 6-12 months after surgery. It is also common to have decreased erections after surgery, this can take 1-2 years to improve but may never reach the same level as before surgery. These issues can be managed with physical therapy, medications, and/or surgery.
Tell me more about radiation?
Radiation treatment involves exposing the prostate to radiation to kill the cancer. This can be performed by passing strong energy through the skin (similar to getting a X-ray or CT scan). Sometimes small radioactive seeds can be temporarily or permanently placed in the prostate, this is called brachytherapy.
Benefits: You will not require any surgery or removal of the prostate. There is no risk of urinary leakage. You will not need to stay overnight in the hospital.
Risks: You may have some temporary pain, burning, and blood with urination, you may also have some temporary irritation with bowel movements. These are usually temporary but can occasionally be long-term. Your prostate is not removed so you will not know exactly how much cancer was present. Erections can also worsen over time due to nerve damage from the radiation. If your cancer recurs, it can be more difficult to perform the prostate surgery with increased risk of surgical side effects.
Do I need hormone blockade?
Depending on your cancer severity, you may need blockade of your body’s testosterone production while receiving radiation treatments. It is not needed if you choose surgery. Blockade is performed by receiving a medication shot every 3-6 months. Mild symptoms are common such as hot flashes, weight gain, loss of muscle mass. It can affect your bone health, therefore it is recommended to take a Calcium and Vitamin D supplement. Rarely it can cause increased risk for heart or brain issues. After you complete treatment it can take months for your testosterone level to return to normal. Hormone blockade is not needed if you undergo surgery.
Which treatment is best for me?
Dr. Chertack will review the risks and benefits of both options with you. He will discuss whether you would not be a candidate for one of the options or whether you would be a better fit for one of the options. Dr. Chertack will also have you speak with a radiation oncologist to discuss more of the details regarding the radiation treatment options.
Prostate removal surgery can be curative for many patients.
Depending on your type of prostate cancer, you may decide to undergo surgical removal of your prostate as a treatment for the cancer. This surgery is known as a “robot-assisted radical laparoscopic prostatectomy,” abbreviated as RALP.
What happens during my surgery?
The prostate will be disconnected from the bladder, the urethra, and the surrounding tissue. Dr. Chertack performs this surgery with the DaVinci robot. This allows him to perform the surgery through 5 small incisions instead of one large incision. The surgery takes around 3-4 hours to complete. A catheter will be left after surgery, the bladder will be closed with stitches and this will allow the bladder to heal.
What do I need to do before surgery?
You will need to complete the labs and imaging that Dr. Chertack orders.
Stop smoking - this is the best thing you can do to improve your recovery after surgery!
You will need to see your primary care doctor to confirm that you are as safe as possible to undergo surgery in order to decrease your risks.
If you take any blood thinner medications, Dr. Chertack will discuss stopping this prior to surgery.
You will need to take a laxative the night before surgery to empty your intestines, this helps make the surgery more straightforward.
What is normal after surgery?
You will stay in the hospital for one night after surgery, but almost all patients are able to go home the day after surgery. Make sure someone is able to drive you home and help you at home after surgery.
It is normal to be sore after surgery! You will be prescribed pain medications during your hospital stay, this will help get your pain to a manageable level.
After surgery, you will only be able to drink certain liquids. Usually the day after surgery these restrictions will be lifted and you can eat and drink whatever you want.
You will have a catheter to drain your urine after surgery. You will be sent home with this catheter, it will stay in for about 7 days.
Sometimes you may have a small drain in your belly to monitor for bleeding but this is almost always removed before you leave the hospital.
You are able to walk immediately after surgery. Walking and moving around is the best thing you can do for your recovery! The more you walk, the easier and faster your recovery will be.
Often patients have some difficulty will bowel movements after surgery. You do not need to poop or fart before leaving the hospital. You will take stool softeners to help with pooping after surgery.
You can shower starting two days after the surgery, it is okay to shower with your catheter.
What should I expect when I leave the hospital?
You will be sent home with medications for pain. Narcotics are almost never required for pain control.
You will be sent home with stool softener medications, take every day until you are having regular bowel movements without straining.
There are no diet restrictions, you can eat whatever you want.
You should stay active to help with your recovery. However no lifting more than 15-20 pounds for 6 weeks after surgery to make sure your incisions heal.
Please let Dr. Chertack know in advance if you need any paperwork for your employer.
What are the risks of the surgery?
The risk of bleeding is low but not zero, occasionally patients do need a blood transfusion after this surgery.
The risk of infection is uncommon, usually you do not need antibiotics before or after this surgery.
Any surgery inside your belly has a risk of injuring your other organs, Dr. Chertack will be extremely careful to avoid any potential injuries!
Urine leaks are rare after surgery but may require leaving a catheter for longer than one week or even drain placement. This can occasionally lead to scarring that requires further treatment.
If your lymph nodes are removed, this can rarely lead to a fluid collection in your pelvis. Usually this does not require any treatment but can occasionally require drainage if it leads to pain or infection.
What are the normal side effects of the surgery?
Prostate cancer surgery has the side effect of urine leakage. This is because some of the parts that prevent leakage are removed during surgery. It is normal to have some urinary leakage after surgery, but this will improve over time. Studies have shown that 90% of men are “dry” at 6 months and 95% by 12 months (“dry” meaning 0 or 1 pads per day). Dr. Chertack will discuss the benefits of physical therapy before and after surgery. If you are unfortunately still leaking 6-12 months after surgery, there may be surgical options to help.
This surgery usually affects the nerves to the penis that give erections. It is normal to have worse erections after surgery. These can take up to 1-2 years to improve, but never go back to pre-surgery level. There are treatment options including medication and surgery if you have persistent issues with erections after surgery. Dr. Chertack will do everything he can during surgery to minimize these effects, while still optimizing your cancer cure.
After surgery you will not produce any semen when you have an orgasm. It is also common to have a small amount of urine leakage during orgasm, this often improves over time.
Is there anything I need to watch for after surgery?
Notify the clinic if you are having pain not controlled by medications, fever, severe nausea/vomiting.
When will I follow up?
You will come to clinic for catheter removal 7 days after surgery. Dr. Chertack will review your pathology 2 weeks after surgery. He will then check your first PSA 1 month after surgery.
