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Prostate Cancer in the Age of PSA Screening and Robotic Surgery: Early Diagnosis, Nerve-Sparing Treatment and Active Surveillance
Prostate cancer is the most common cancer in men, and it is fully treatable when caught early. Assoc. Prof. Dr. Tuncay Taş brings experience in robotic prostatectomy and nerve-sparing surgery to deliver both oncological success and quality of life.
What Is Prostate Cancer?
Prostate cancer arises from the uncontrolled multiplication of cells in the prostate gland, and it is the most commonly diagnosed cancer in men. Although it is usually a slow-moving disease, aggressive forms do exist. Treatment success in the early stages exceeds 95 percent.
The disease typically begins in the peripheral zone of the prostate. That is why it produces no symptoms early on and is often picked up incidentally during a PSA test or a prostate examination — which is precisely what makes screening so important.
"Prostate cancer is the most frequently diagnosed cancer in men worldwide. Among men over 50, one in six will be found to have prostate cancer during their lifetime." — Globocan 2020 report
Prostate Anatomy and Function
The prostate is a walnut-sized gland sitting just below the bladder and encircling the urinary passage (the urethra). It is an important part of the male reproductive system and produces roughly 30 percent of the ejaculate (semen) fluid.
The prostate is divided into three main zones:
- Peripheral zone (70%): where prostate cancer most often starts
- Transition zone (5–10%): where benign prostatic hyperplasia (BPH) develops
- Central zone (25%): cancer rarely arises here
Incidence and Statistics
- Most common cancer in men (14% of all cancers)
- Rare below age 50, most frequent between the ages of 65 and 75
- Estimated new cases per year: 1.4 million worldwide, 30,000 in Türkiye
- Five-year survival (localised): 99%
- Five-year survival (metastatic): 30%
- Incidence is twice as high in Black men
Risk Factors
Age
The strongest risk factor. Risk climbs sharply after 50, and 70 percent of cases are detected by the age of 80.
Family History
A first-degree relative with prostate cancer raises the risk two- to threefold. Relatives diagnosed young raise it further.
Genetics (BRCA)
BRCA1/BRCA2, HOXB13 and Lynch syndrome mutations increase the risk and predict more aggressive disease.
Ethnicity
Both incidence and aggressiveness are higher in Black men, and lowest in men of Asian descent.
Diet
Heavy animal fat and red meat intake, together with a diet low in fruit and vegetables, increases risk.
Obesity
A BMI above 30 raises the risk of aggressive disease and carries a higher rate of surgical complications.
Prostate Cancer Symptoms
Early-stage disease usually produces no symptoms at all, which is why screening is vital. In later stages the following may appear:
- Difficulty passing urine, or a weak urinary stream
- Frequent urination, particularly at night
- Blood in the urine or semen
- Pain on ejaculation, or reduced ejaculate volume
- Erectile dysfunction
- Pelvic, hip or lower back pain (a sign of bone metastasis)
- Fatigue, weight loss, anaemia (advanced disease)
Because these symptoms overlap heavily with those of BPH (benign prostatic enlargement), telling the two apart is difficult. Urological assessment is essential.
Screening: PSA Test and Digital Rectal Examination
The PSA (prostate-specific antigen) blood test and the digital rectal examination (DRE) form the backbone of prostate cancer screening.
Recommended Screening Ages
- General population: annual PSA and DRE between the ages of 50 and 70
- Men with a family history: from age 45
- Men with a BRCA mutation: from age 40 to 45
- Over 70: individualised according to general health and life expectancy
PSA Values and Age-Specific Upper Limits
| Age Range | Normal Upper PSA | Borderline Range | High Risk |
|---|---|---|---|
| 40–49 | ≤ 2.5 ng/ml | 2.5–4 | > 4 |
| 50–59 | ≤ 3.5 ng/ml | 3.5–4.5 | > 4.5 |
| 60–69 | ≤ 4.5 ng/ml | 4.5–6.5 | > 6.5 |
| 70–79 | ≤ 6.5 ng/ml | 6.5–7.5 | > 7.5 |
PSA is not read in isolation. PSA density, the free-to-total PSA ratio (below 15 percent indicates higher risk) and PSA velocity (a rise greater than 0.75 ng/ml per year) are assessed alongside it.
Diagnostic Methods
- PSA + DRE: first-line screening
- Multiparametric prostate MRI (mpMRI): lesion localisation and PI-RADS scoring
- Transrectal ultrasound (TRUS): the older method, used together with mpMRI
- Fusion biopsy: targeted biopsy guided by MRI–ultrasound overlay
- PSMA PET-CT: for staging in high-risk cases
- Bone scintigraphy: screening for bone metastases
- CT/MRI (abdomen and pelvis): lymph nodes and other organs
Prostate Biopsy
Prostate biopsy is the definitive diagnostic method. Today the standard is MRI-fusion biopsy, which samples the targeted areas. Twelve to eighteen cores are usually taken, with additional sampling from targeted lesions.
Methods:
- Transrectal biopsy: the traditional approach; slightly higher infection risk
- Transperineal biopsy: the modern gold standard; infection risk is almost nil
- MRI-fusion biopsy: precise sampling of areas flagged as suspicious on MRI
The procedure takes 15 to 20 minutes under local anaesthesia, and the patient goes home the same day.
Gleason Score and ISUP Grading
The cancer tissue in the biopsy sample is given a Gleason score (from 3+3 to 5+5) based on its microscopic appearance. The score reflects how aggressive the cancer is. The modern classification has been updated to ISUP Grade Groups 1 to 5:
| ISUP Group | Gleason Score | Aggressiveness | Prognosis |
|---|---|---|---|
| 1 | ≤6 (3+3) | Very low | Excellent — suitable for active surveillance |
| 2 | 3+4=7 | Low to intermediate | Good |
| 3 | 4+3=7 | Intermediate | Intermediate |
| 4 | 8 (4+4 / 3+5 / 5+3) | High | Active treatment required |
| 5 | 9–10 | Very high | Multimodal treatment required |
TNM Staging System
Prostate cancer is staged according to the international TNM system:
- T1: clinically undetectable; found incidentally on PSA or biopsy
- T2: confined within the prostate (T2a, T2b, T2c)
- T3: extends beyond the prostate capsule (T3a: extracapsular; T3b: seminal vesicle involvement)
- T4: invasion of adjacent organs (bladder, rectum, levator muscles)
- N0/N1: lymph node metastasis absent / present
- M0/M1: distant metastasis absent / present (M1a: lymph nodes, M1b: bone, M1c: other sites)
Treatment Options
The treatment decision rests on the stage of the cancer, the Gleason score, PSA, age, coexisting illness and patient preference. The international D'Amico risk grouping guides that decision:
| Risk Group | PSA | Gleason | Clinical Stage | Preferred Treatment |
|---|---|---|---|---|
| Very low | < 10 ng/ml | ≤ 6 (ISUP 1) | T1c, ≤3 positive cores | Active surveillance |
| Low | < 10 ng/ml | ≤ 6 (ISUP 1) | T1–T2a | Active surveillance / surgery / RT |
| Intermediate | 10–20 ng/ml | 7 (ISUP 2–3) | T2b | Surgery / RT ± ADT |
| High | > 20 ng/ml | 8–10 (ISUP 4–5) | T2c or above | Surgery + LN / RT + ADT (2–3 years) |
| Very high | Any | Any | T3b–T4 or N+ | Multimodal treatment |
The main treatment options are:
- Active surveillance: for low-risk cancers
- Robotic or laparoscopic prostatectomy: the gold-standard surgery in localised disease
- External beam radiotherapy (IMRT / SBRT): the alternative to surgery
- Brachytherapy: radioactive seeds placed inside the prostate
- Hormone therapy (ADT): for advanced disease or in combination with radiotherapy
- Chemotherapy: for castration-resistant disease
- Immunotherapy and targeted agents: next-generation treatments for advanced disease
- Focal therapies (HIFU, cryotherapy): in selected patients
Active Surveillance
In low-risk patients, close monitoring may be preferred over treatment:
- ISUP Grade 1 (Gleason 3+3=6)
- PSA below 10 ng/ml
- Clinical stage T1c–T2a
- Low percentage of involvement
- Life expectancy greater than 10 years
Monitoring protocol:
- PSA every 3 to 6 months
- Digital rectal examination once a year
- mpMRI every 12 to 24 months
- Biopsy every 1 to 3 years
If signs of progression appear — a rapid PSA rise, a higher Gleason score, growth of the lesion — active treatment begins.
Robotic Radical Prostatectomy
Robotic radical prostatectomy is the gold-standard surgical method in localised prostate cancer, performed with high precision using the Da Vinci robotic system.
Advantages
- 3D high-definition vision
- Tenfold magnification — millimetric precision
- Robotic arms eliminate hand tremor
- Superior success in nerve preservation
- Less bleeding, less pain
- Two to three days in hospital
- Catheter for 7 to 10 days
- Return to work in 2 to 3 weeks
Surgical Steps
- General anaesthesia
- Six small ports (5–12 mm)
- The abdomen is insufflated with CO₂
- The robotic arms are docked
- The prostate and seminal vesicles are removed
- Bladder-to-urethra anastomosis
- Lymph node dissection (where required)
- Drain and urinary catheter
Laparoscopic Prostatectomy
The gold-standard alternative where a robotic system is not available. It follows the same principles, with the surgeon controlling the instruments directly. Oncological outcomes are comparable to robotic and open surgery, though the learning curve is longer.
Radiotherapy Options
External Beam Radiotherapy
- IMRT (intensity-modulated): the standard course, 7 to 8 weeks
- SBRT (stereotactic): five sessions at a higher dose
- Proton therapy: less damage to surrounding tissue
Brachytherapy
Radioactive seeds (LDR) or a temporary catheter (HDR) are placed inside the prostate. It may be preferred in low- and intermediate-risk cases.
Hormone Therapy (ADT)
Prostate cancer is androgen-dependent. Hormone therapy lowers testosterone levels and so holds back the growth of the cancer:
- LHRH agonists/antagonists: leuprolide, goserelin, degarelix
- Antiandrogens: bicalutamide, enzalutamide, apalutamide
- Surgical castration: bilateral orchiectomy
- CYP17 inhibitor: abiraterone
Advanced-Stage and Metastatic Treatment
- Chemotherapy: docetaxel, cabazitaxel
- Radiopharmaceuticals: radium-223 (bone metastases), lutetium-177 PSMA
- Immunotherapy: sipuleucel-T, pembrolizumab (in selected cases)
- PARP inhibitors: olaparib, rucaparib (in BRCA-mutated disease)
Treatment Side Effects
After Surgery
Urinary leakage (15% initially, below 5% at twelve months), erectile difficulty (a 20–50% effect where nerves are spared), slight shortening of penile length.
After Radiotherapy
Rectal irritation, bladder urgency, erectile difficulty (which may develop late), and rarely urinary leakage.
Hormone Therapy
Hot flushes, loss of libido, ED, gynaecomastia, loss of muscle mass, bone thinning, mood changes.
Chemotherapy
Fatigue, nausea, hair loss, neutropenia, peripheral neuropathy.
Rehabilitation After Surgery
Urinary Rehabilitation
Pelvic floor muscle exercises (Kegel) begin a week before the catheter is removed: three sets a day, 10 to 15 repetitions each. By twelve months, more than 90 percent of men have full control.
Sexual Rehabilitation
Early intervention is essential to preserve erectile function:
- Low-dose PDE5 inhibitor (tadalafil) once the catheter is out
- A vacuum device for the first three months
- Intracavernosal injections if that proves insufficient
- PRP or shockwave therapy may be added
- A penile implant where none of the above is sufficient
Follow-up and Recurrence After Treatment
Standard follow-up:
- Years 0–2: PSA every 3 months
- Years 2–5: PSA every 6 months
- Year 5 onwards: PSA once a year
- Annual digital rectal examination
Biochemical recurrence:
- After surgery: PSA above 0.2 ng/ml, confirmed on two measurements
- After radiotherapy: PSA nadir plus 2 ng/ml
Where recurrence occurs, PSMA PET-CT distinguishes local from distant disease, and salvage radiotherapy or systemic treatment is planned accordingly.