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Prostate Cancer

The prostate is a male reproductive organ involved in the nourishment and transportation of sperm. Prostate cancer is one of the most common forms of cancer in men. It is usually slow-growing. There is a high chance of a successful prostate cancer treatment if the cancer is detected early.

 

Risk factors

While the actual cause of prostate cancer is unclear, there are some factors, which may put you at high risk of getting prostate cancer. They include, age: the older you are, the more at risk you are, and race: African men have a higher risk of prostate cancer and are most likely to have the most aggressive form.

 

Other risk factors include family history: if you have a history of men in your family who have had prostate cancer or family members with breast cancer, then you would have a higher risk of getting prostate cancer.

 

Symptoms

Early prostate cancer does not show any specific symptoms. Some prostate-related symptoms may also be caused by benign prostatic enlargement, such as trouble urinating and decreased force in the stream of urine.

 

Screening for and investigating prostate cancer

In testing for prostate cancer, urologists at Cape Urology conduct the following examinations:

 

  • History and physical examination, including a digital rectal examination.

  • Assessment of PSA (prostate-specific antigen) blood test.

  • Transrectal and abdominal ultrasound of the prostate and urinary tract.

  • Systematic transrectal or transperineal prostate biopsies.

  • Multiparametric MRI of the prostate.

  • Targeted MRI fusion biopsy of the prostate.

 
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Prostate Cancer Screening

Prostate cancer can be deadly but can also be completely curable if caught in its early stages. The older you are, the more likely you are to get prostate cancer. It is important to remember that many men die with prostate cancer, and not from prostate cancer. Your urologist is the best person to discuss prostate cancer screening with, to enable you to make a joint decision.

 

Risk factors

Age, obesity, family history and genetics are the main risk factors in the development of prostate cancer. 

 

Symptoms

Because early prostate cancer is almost always asymptomatic, screening is advised to find out if you are at risk. Rarely, prostate cancer can present with symptoms that include:

 

  • Urinary or voiding symptoms.

  • Haematuria.

  • Haematospermia.

  • Painful ejaculation.

  • Erectile dysfunction.

 

Advanced prostate cancer can present with a variety of symptoms, sometimes unrelated to the urinary tract.

 

Screening for and investigating prostate cancer

General annual physical or medical “check-ups” are a necessity for older men. Men with a family history of prostate cancer should begin screening from the age of forty. Men without a family history should also undergo early screening between the ages of 40 and 45 years, to enable your urologist to risk stratify your follow up over the next 10 years.

 

Prostate cancer screening includes at least a directed urological and medical history, a physical examination (which includes a digital rectal examination) and an evaluation of your PSA (Prostate Specific Antigen) blood test.

 

You may require further specialized tests such as, an ultrasound of the prostate and urinary tract, a multi-parametric MRI of the prostate and various blood or urine tests.

 

If there is a concern, your urologist may recommend a prostate biopsy to enable your doctors to analyze pieces of the prostate gland under a microscope (by a dedicated Histopathologist) to diagnose prostate cancer.

 
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Prostate Cancer Treatment Options

Cape Urology comprises of a team of specialist urologists who are all experts in diagnosing and treating prostate cancer. We believe in a multidisciplinary team approach, in line with international best practices for the treatment of prostate cancer. We will inform and guide you to choose the best individual treatment options.

 

We provide the following treatment options for prostate cancer:

 

  • Active surveillance protocol (deferring curative treatment while it is safe to do so): Our doctors closely monitor your prostate cancer. We do not administer any form of treatment during this stage. We do, however, initiate periodic tests to detect signs of the progression of prostate cancer.

  • Theda Vinci robotic-assisted laparoscopic prostatectomy (surgical removal of the prostate gland): In this operation to remove a diseased prostate, the urologist uses instruments attached to robotic arms and places them into your abdomen through small incisions. The urologist is seated at a control station (console) and uses hand controls to guide the robotic arms, which move the instruments inside your abdomen. This type of surgery helps the urologist to make more precise movements with the surgical tools as he/she removes the prostate gland.  A three-dimensional camera provides a detailed view of nearby muscles, blood vessels and nerves around the prostate. Visit Cape Robotic Surgery for more information,

  • Retropubic radical prostatectomy (traditional open nerve-sparing surgery to remove the prostate gland): At Cape Urology, our specialists perform retropubic radical prostatectomy on men who have early-stage prostate cancer, as an alternative to robotic prostatectomy.

  • Low dose interstitial prostate brachytherapy (implantation of radioactive seeds to administer radiation to the prostate): Our surgeons use radiation therapy to treat prostate cancer. We implant radioactive seeds into the prostate gland to kill cancer cells. It has very little effect on nearby healthy tissue. 

  • Combined multimodal external beam radiation therapy (intensity-modulated and image-guided therapy and radiosurgery): For a more aggressive form of prostate cancer, our urologists initiate a multimodal approach to kill cancer cells. This may include brachytherapy combined with external beam radiation.

  • Treatment of recurrent prostate cancer after previous treatment: All patients with prostate cancer are followed up closely after their treatment. The management of recurrent prostate cancer involves monitoring PSA levels, diagnostic tests include CT, MRI, PET scan and nuclear medicine bone scans. A multidisciplinary team led by your urologist will manage treatments required for recurrent prostate cancer.

  • Treatment for advanced prostate cancer (New hormonal treatments, chemotherapy & Lutetium treatment): For advanced prostate cancer, our medical team at Cape Urology partner up with your oncologist and use hormone therapy, novel agents, chemotherapy, radiation and surgery, as well as new treatment modalities like Lutetium 177 to stop the spread of the disease and maintain your quality of life.

  • Focal therapy for selected cases: Focal therapy is localized to only one area of the prostate. This is experimental treatment and is not routinely offered.

 
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Prostate Brachytherapy

Prostate brachytherapy is a type of minimally invasive radiation treatment used to treat prostate cancer. It involves implantation of numerous radioactive iodine seeds into the prostate under ultrasound guidance. 

 

The procedure is done as a day-case, and allows on for a rapid return to normal activities. Sophisticated software, and the expertise of a Specialist Radiation Oncologist and a Medical Physicist, allow for delivery of a high dose of radiation to the prostate resulting in excellent cure rates, and minimal effect on the surrounding tissues. 

 

Prostate brachytherapy can be done as a single modality treatment in low risk, and low intermediate risk prostate cancer, or be part of a multimodality treatment regimen, in more aggressive/advanced prostate cancers. 

Brachytherapy has excellent, long-term (>20 years) data regarding clinical outcomes, and continues to play an important role in the management of prostate cancer

 
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Benign Prostatic Enlargement

Prostate gland enlargement commonly occurs in older men. Together with the aging bladder, this can cause problems with the flow of urine from the bladder. Benign prostatic hyperplasia (BPH) is a leading cause of urinary symptoms in aging men.

 

Risk Factors 

Age, genetics, family history of prostate disease, obesity, diabetes and heart disease are all contributory factors leading to urinary symptoms. 

Symptoms

Urinary symptoms are often complex and your urologist is the best person to evaluate your problem and make a correct diagnosis. In addition to checking for prostate cancer, your urologist is trained to evaluate your urinary system, and this forms part of the routine prostate check.

 

Symptoms relating to your urination are divided into those relating to the storage of urine in the bladder (storage symptoms) and those related to the ability of the bladder to empty the urine effectively when you want to (voiding symptoms).

 

Storage symptoms can include:

  • Inability to hold the urine (urgency).

  • Frequency of urination increased.

  • Excessive nighttime urination (nocturia).

  • Urinary tract infections.

  • Urinary incontinence.

 

Voiding symptoms include:

  • Difficulty in emptying bladder.

  • Poor urinary stream and dribbling.

  • Strained urination.

  • Taking a long time to empty the bladder.

Investigating your prostate

A basic urological check will include a careful focussed urological history, a clinical examination including a digital rectal examination (which remains a very important test), an ultrasound of the urinary tract and examination of the urine and urinary flow. You may need further laboratory tests, and sometimes an endoscopic evaluation of the urethra and bladder with a small telescope (flexible cystoscope).

 

Treatment options

Benign prostatic enlargement is part of normal aging, and does not necessarily need treatment. On the other hand, even men with small prostates can have very debilitating symptoms. Some men have very little symptoms but have significant pathology. Urologists can often improve urinary symptoms by treatment with medication or a variety of surgical procedures, some of which are listed below. Please feel free to discuss any procedure with us during your consultation.
 

  • Transurethral resection of the prostate (TURP): This is the gold standard treatment. 

  • Holmium or Thulium laser enucleation of the prostate: This is becoming the new gold standard. 

  • Open retropubic prostatectomy: For very large prostates..

  • Prostatic stents: Sometimes used to alleviate obstruction.

  • Rezūm: Ablation of prostate tissue using steam delivered via specialised device.

 
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Vasectomy

Vasectomy is the best form of male contraception. It is a surgical procedure during which your urologist ties off the vas deferens, the small tubes that transport the sperm cells from the testicles into the body to behind the bladder where they are stored within the semen in the seminal vesicles. During ejaculation the semen (containing sperm) is deposited into the urethra to travel out through the tip of the penis.

 

During the vasectomy procedure, which can be performed under local or general anaesthesia, a small opening (the non- scalpel method) is made in the scrotal skin through which the vas deferens (about as thick as a match-stick) is brought out. A section of the vas is cut out and tied off with a suture and the open ends are fulgurated (sealed with heat) to obstruct the inside of the tube. The sperm cells therefore cannot travel into the body and join the semen. The spermatozoa remain in the epididymis and vas deferens until they are reabsorbed when they die.

 

Vasectomy remains the most effective form of contraception and is much less invasive than female sterilisation. It also has the benefit that we are easily able to check whether the man is sterile by performing a semen analysis.

 

The semen stored inside the body will still contain sperm for an average of 30 ejaculations and you should therefore remain on contraception for three months, after which you should provide a semen sample to the laboratory. This sample will check whether the semen is free of live and dead sperms. Only then can your surgeon declare you sterile and you can stop contraception.

 

No procedure comes with a 100% guarantee and rare cases have been described where the two ends of the tubes have grown back together. Other complications include bleeding and bruising, and rarely infection. If you develop swelling or pain after the procedure, please contact our rooms.

 

Rarely there might be some discomfort or pain in the testicles, which will take some time to resolve. Long term testicular discomfort or pain, not resolving after one year is very rare.

 

Vasectomy should be seen as a permanent procedure as the reversal operation is a much more complicated and costly procedure with a lower success rate, especially if it is performed long after the vasectomy has been done. If you are unsure, consider storing sperm at a fertility clinic before the operation.

Please download an illustrated brochure to give you more information about the procedure.

 

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Laser Prostatectomy
(HoLEP and ThuLEP)

One of the treatment options for obstructive voiding dysfunction is transurethral resection of the prostate. The aim is to remove prostatic tissue, which has over time caused some degree of obstruction to the outflow of urine from the bladder.

 

Laser prostatectomy refers to using a Holmium or Thulium laser to achieve this, by removal (enucleation) of the enlarged benign sections of the prostate.

 

During a laser prostatectomy, a large part of the prostate gland is removed with the help of a laser, using an endoscope (a telescope inserted via the penis). This differs from the traditional transurethral resection of the prostate (TURP) in that laser energy is used to divide tissue rather than electrical energy. The benefit, however, relies not just on the energy source but also on the technique used - which involves enucleation or removal of complete segments of overgrown benign prostatic tissue. 

 

With a conventional TURP one is removing little bits at a time (much like wood carving) using a metal loop heated with electricity. By using the laser enucleation technique, the whole overgrown lobe of the prostate is removed, mostly in one piece, leaving the capsule intact. The result of this technique is that there is better disobstruction with less chance of needing a redo procedure in the future. Further benefits include the ability to operate on larger prostates than one would usually do conventional TURP on, better haemostasis which makes it the technique of choice in patients on blood thinners, and quicker recovery post op (meaning shorter time with a catheter after the operation - which means less time in hospital).

 

Two types of lasers can be used, and are essentially similar in their effect on prostate tissue: The Holmium-YAG laser (HoLEP = Holmium Laser Enucleation of the Prostate) and the Thulium or Revolix laser (ThuLEP) procedure. In my experience, both lasers have similar patient outcomes.

 

Alternatives to this type of procedure include: doing nothing (if your urologist is satisfied that this is safe), continuing with medication, use of a catheter, conventional transurethral resection or open surgery to achieve the same result.

 
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Robotic Prostatectomy

Robotic prostatectomy with The da Vinci Surgical System is a minimally invasive procedure that is performed for the treatment of prostate cancer. Your surgeon is likely to recommend the procedure if there is cancer inside the prostate gland that hasn’t spread to the surrounding organs and tissue. In most cases a bilateral nerve sparing prostatectomy will be performed to ensure return of your sexual function after the surgery. In some cases, structures close to the prostate gland may also need to be removed to ensure that the cancer is completely removed.

 

During the procedure, your surgeon will make tiny incisions in the abdomen. With the use of a surgical system, the prostate is removed in a small bag through one of these small cuts. The bladder is sutured back onto the urethra and a catheter is inserted into the urethra to help drain urine while your body heals, usually for a period of five days after the surgery. Most patients go home on the first or second post-operative day.

 
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Male Fertility

Many couples struggle to conceive as a result of male fertility issues. Low sperm counts, abnormal or poorly functioning sperm, as well as blockages of the vas deferens can all contribute towards male infertility.
 

Causes

There are many potential causes for male factor infertility, but it remains important that a multidisciplinary team of experts, who care for both the male and female, should manage the couple struggling to conceive. At Cape Urology we work closely with our local fertility clinics.

 

Urologists focus on male fertility and, apart from assisting with diagnosis, can help correct reversible causes and also assist with retrieving sperm for use in assisted reproductive techniques such as in vitro fertilization (IVF).

 

Investigation starts with a thorough history and physical examination, as well as, the analysis of your semen. Specialized ultrasound investigations are often needed as a part of the process.

 

Treatment 

Common procedures performed to improve male fertility are:

 

  • Varicocoele repair: This is commonly performed laparoscopically.

  • Testicular sperm extraction (TESE) and micro-TESE.

  • Testicular biopsy.

 
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Penile Surgery

Urologist deal with all penis related problems. Most do not require an operation. Here are a few common procedures:

  • Circumcision: Circumcision is a procedure to surgically remove the foreskin. Some reasons for having a circumcision include religious and cultural traditions, hygiene, tight, painful or diseased foreskin, and preference. During a circumcision, the surgeon removes the foreskin covering the penis' head (glans penis). Urologists use a scalpel rather than a clamp along with absorbable sutures suitable for plastic surgery. The procedure is done as a day case under local or general anaesthesia. Recovery typically takes 5-7 days.

 

  • Frenuloplasty: A frenulum breve describes a tight band of skin between the glans and shaft of the penis, which restricts normal foreskin movement. It is often associated with a phimosis, or tight foreskin, which is difficult to retract. A frenuloplasty involves lengthening the tiny fold of tissue known as the frenulum on the underside of the penis. 

 

  • Preputioplasty: Preputioplasty is a reconstructive plastic surgery to widen a narrow foreskin, which is unable to retract. This condition is called a phimosis. Small incisions are made at the tight ring of skin preventing retraction of the foreskin. It is a foreskin preserving procedure and an alternative to a circumcision.

 

  • Penile lengthening: Penile lengthening surgery usually involves release of the suspensory ligament of the penis, in order to make the penis appear longer. The procedure is therefore a cosmetic procedure. It is usually performed under anaesthesia as a day case.

 

  • Penile fracture surgery: A penile fracture usually occurs during sexual intercourse. The erect penis ruptures when bent too far, and blood accumulates under the skin. This is associated with a sudden snapping sound, accompanied by a sudden loss of erection, pain and penile swelling. It may be difficult to pass urine. Penile fracture is a medical emergency and requires urgent surgical repair.

 
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Peyronie’s Disease

Peyronie’s disease is a common condition that affects many men and is characterised by the formation of scar tissue in the erectile part of the penis. This causes a deformity in the penis, commonly curvature.
 

Signs of Peyronie’s disease include:

  • Bent or deformed penis

  • Palpable lump on the shaft of the penis

  • Pain during an erection or intercourse

  • Erectile dysfunction

 

Diagnosing Peyronie’s disease is mostly done by history and physical examination. Evaluating the penis in the erect state is important to determine the degree of curvature. Your urologist will conduct a physical exam to check for the presence of penile scar tissue, an may use ultrasound to examine the penis.

 

Peyronie’s Disease Treatment Options:

  • Reassurance: most men simply need reassurance that the condition is not dangerous. The condition is self-limiting and usually stabilises over time.

  • Penile traction therapy treats acute phases of Peyronie's disease-preventing curvature and penile shortening. 

  • Medications such as PDE5-inhibitors are important.

  • Sometimes injection therapy can help improve deformity.

  • Reconstructive surgery is reserved for severe curvature, which is affecting sexual functioning. There are various procedures available, depending on the type of deformity present.

 
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Sexual Dysfunction

Sexual dysfunction is any physical and/or psychological problem that affects your sexual health and hinders you or your partner from having a healthy and satisfying sex life. The main types of sexual dysfunction in men include erectile dysfunction, premature ejaculation, delayed or inhibited ejaculation and low libido (sex drive).

 

Causes & risk factors

Sexual dysfunction can affect men of all ages, but due to the effects of aging, older men are more commonly affected. As there are physical and psychological causes of sexual dysfunction, younger men can also be affected.

 

The physical causes include hormone problems (commonly low testosterone levels), unwanted effects of some prescription drugs, smoking (tobacco and cannabis), alcohol abuse, drug abuse, cardiovascular disorders e.g. stroke and diabetes, and nerve damage from diabetes or previous surgery or radiation treatment. 

 

Symptoms may include:

  • Lack of sexual desire and fantasies, and lack of interest in sexual contact.

  • Inability to achieve or maintain an erection.

  • Difficulty in achieving an orgasm.

  • Premature ejaculation: trouble with controlling the timing of orgasm and ejaculation, such that it occurs very early in sexual contact, leaving the other partner dissatisfied. 

  • Persistent erection, which is not related to sexual desire, is called a Priapism. This is a medical emergency and you need to go to your nearest emergency room immediately.

  • Blood in the ejaculation.

 

Screening for and investigating sexual dysfunction 

To make a diagnosis, your urologist might take a careful medical, urological and sexual history and conduct a physical exam. Your urologist might ask you questions relating to your sexual or medical history, which might be personal. Please note that is important to be open and honest.

 

Some tests, which are regularly done to investigate sexual dysfunction include:

  • Blood tests to examine your testosterone levels, blood sugar and cholesterol.

  • Checking your blood pressure.

  • Rectal exam to examine your prostate.

  • Examination of your penis and testicles.

  • Weight and height and muscle measurement.

  • Questionnaires about your sexual function

 

Sexual dysfunction treatment options: 

Urologists of Cape Urology seek to provide you with the best medical care that you deserve. We advise and offer the following treatments for sexual dysfunction:

  • Medications: Drugs improve sexual function by increasing blood flow to the penis.

  • Hormone therapy: Testosterone replacements in the form of injections, creams or gels are administered to raise low testosterone. 

  • Psychological therapy: A counsellor or sex therapist addresses any issues of fear, anxiety or guilt, which may affect your sexual function. This is often useful for couples having trouble discussing the problem.

  • Mechanical aids: Vacuum devices and penile implants to assist men with erectile dysfunction. 

  • Surgery: The surgeon performs surgery to treat erectile dysfunction and restore your erection. This may involve the placement of a penile prosthesis.

 
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Testicular Cancer

The testicles are two small egg-shaped glands held in a sac known as the scrotum below the penis. The testicles are part of the male reproductive system, producing the male hormone (testosterone) and sperm. Almost all testicular cancers start in the germ cells within the testicles. Testicular cancer can affect one or both testicles.

Risk factors

Like all cancers, testicular cancer is caused by abnormal cellular changes and can affect any man. Those at higher risk of developing testicular cancer include those with an undescended testicle or carcinoma-in-situ of the testicle. It is most common between the ages of 20 and 40 years.

Symptoms

Testicular cancer is generally noticed as an area of hardness, a lump or swelling of the testicle. You will most likely develop an enlarged testicle and experience a heavy scrotum that is almost always painless. A medical doctor should evaluate any lump arising from the testicle.

Investigating testicular cancer 

After a physical exam of the testicles, your urologist may suggest an ultrasound of the scrotum and a blood tumour marker tests, as well as imaging such as a CT scan. If these tests suggest a tumour, an inguinal orchiectomy (removal of the affected testicle) is performed and the testicle is sent for analysis.

 

Testicular cancer treatment options 

Most of the time, the only treatment you will need will be the removal of the testicle. Before any further treatment starts, your urologist will discuss your fertility with you as many of these treatments can affect fertility. In most cases, you will be advised to cryopreserve sperm at a sperm bank. Alongside your urologist, an oncologist will be a part of your treatment team. 

 

Various treatment modalities exist and may be recommended, after you have had a radical inguinal orchiectomy:

 

  • Surveillance: Regular physical checks, combined with imaging and blood tests.

  • Chemotherapy: very effective and curing the cancer.

  • Radiation: used for certain types of testicular cancer

  • Retroperitoneal lymph node dissection (RPLND): This is an operation, which involves the removal of enlarged lymph nodes.