Robotic Surgery may prevent long term complications of hormone therapy for prostate cancer

Robotic surgery is now very well established as a leading treatment option for prostate cancer. In suitable patients, it is likely to provide the best long term quality and quantity of life. Even in men with relatively advanced disease (high risk/locally advanced) prostate cancer, robotic surgery offers a speedy recovery with excellent long term survival. However, a relatively under appreciated advantage of this technique is its ability to delay or avoid the need for hormone therapy in a large number of patients with prostate cancer.

Hormone therapy (androgen deprivation therapy in medical jargon) implies removing the male hormone, testosterone from the body by either removing its site of production (surgical removal of both testes, also called surgical castration) or suppressing it with regular injections (medical castration). Since, prostate cancer cells are dependent on testosterone for their growth and spread, this removal or suppression of testosterone in the body generally brings about a decrease in the amount of cancer and keeps the disease under control for a duration of time ranging from months to a few years.

However, hormone therapy takes a significant toll on the body by way of many short and long term complications. It causes fatigue, loss of muscle mass, loss of bone strength which may cause fractures, depression, loss of sexual function and a general slowdown of physical and mental functions. In the long term, it can lead to an increased susceptibility to develop diabetes, high cholesterol and weight gain. It has also been shown recently to increase the chances of having a heart attack or stroke in the future. In fact, the US Food and Drug Administration (FDA) and American Heart Association (AHA) have issued a warning advising a judicious use of hormone therapy in patients with prostate cancer and weighing the risks and benefits before starting this treatment in all patients.

Patients who undergo radiation therapy for prostate cancer also have to take hormone therapy ranging from 6 months to 3 years depending upon the stage and type (grade) of the disease. This is because radiation alone (without hormone therapy) has much inferior results as compared to surgery in most patients with prostate cancer. This addition of hormone therapy to radiation therapy, unfortunately, exposes patients to the combined onslaught of complications and problems associated with radiation as well as hormone therapy.

For suitable patients, choosing to undergo surgery may be the best way to avoid many of these complications, thereby leading to the best possible preservation of quality and quantity of life. While hormone therapy may need to be given even after surgery in certain situations, it has been shown that even in men with a relatively advanced disease (high risk/locally advanced prostate cancer), hormone therapy can be avoided or delayed in more than 50% of patients by choosing to undergo surgery for prostate cancer. Even if hormone therapy is required after surgery, it can be given in an on-off fashion (intermittent androgen deprivation therapy), thereby avoiding a continuous harmful exposure to the body for a long time.

So, while there will always be certain short term problems and risks associated with undergoing surgery, robotic surgery for prostate cancer may be the best treatment option for most patients with prostate cancer – especially in view of the recent realisation in the medical community that hormone therapy for prostate cancer may not be as innocuous as previously thought by many of us !

Dr Gagan Gautam is the head of urologic oncology and robotic surgery at Max Institute of Cancer Care, New Delhi, India. He is one of the leading specialists for prostate cancer treatment in India and is closely involved in the care, counselling and surgical treatment of patients with this disease.  


Urinary bladder cancer treatment in India – choosing the right options

Imagine this. Everything is coming along fine in your life until you visit the washroom one day and suddenly discover that there is blood in urine. You feel no pain, no weakness, no fever. More likely than not, you ignore this – try to pass it off as a mild ‘infection’ and get on with your life. Until, after a few weeks, it happens again; And again. You visit your neighborhood physician who orders a few tests and an ultrasound exam. When the results come in you are shocked to discover that you have a mass in the urinary bladder, which is highly likely to be cancer.

Unfortunately, this is a common sequence of events for almost half a million people worldwide who are diagnosed to have urinary bladder cancer every year. The biggest impediment to effective and complete cure for bladder cancer is delay in diagnosis. The initial symptoms are all too often ignored by patients and doctors alike, while a curable cancer inexorably grows and spreads unnoticed to become life threatening. Bleeding in urine is a dangerous symptom and must not be ignored!

Smoking is the most common cause of urinary bladder cancer with about 50% of these tumors attributable to this single cause. Other causes – mostly unknown – account for the other half, and include exposure to certain chemicals and chronic infections of the bladder. Smoking is also a very important cause of recurrence of this disease in those who have already received treatment for urinary bladder cancer. Kicking the habit is essential to decrease the chances of bladder cancer coming back after initial treatment.

Urinary bladder cancer treatment in India is now quite standardized. Once a growth in the urinary bladder seen on ultrasound, the next step is to do a ‘cystoscopy’ which involves putting a thin telescope through the urinary passage into the urinary bladder under anesthesia. The tumor is visualized with a camera and is cut out and removed with specialized instruments. This procedure is called transurethral resection of bladder tumor (TURBT). This procedure not only removes the tumor but also provides vital information about the type (grade) and degree of spread (stage) of the cancer.

Depending upon the microscopic features of the tumor, bladder cancer can be either low grade (less aggressive) or high grade (more aggressive). This has important implications on further treatment. In terms of staging, it is vital to assess whether the bladder cancer is ‘superficial’, involving only the superficial (innermost) layers of the bladder or ‘muscle invasive’, which implies an infiltration of the cancer into the deep muscle layer of the urinary bladder.

For ‘superficial’ bladder cancer, the standard treatment involves regular follow up with repeated ‘cystoscopy’ examinations and the use of medications instilled directly into the bladder through the urinary passage at regular intervals. For ‘muscle invasive’ bladder tumors, the most effective treatment is to perform major surgery to remove the urinary bladder completely (radical cystectomy) and create a new bladder or tube using segments of intestine (urinary diversion, orthotopic neobladder or ileal conduit). While this has traditionally been performed via open surgery, urinary bladder cancer treatment in India is now getting revolutionized with the advent of robotic surgery.

Robotic surgery for bladder cancer offers a faster recovery, lesser blood loss, lesser pain and a possibility of a lower complication rate. Cancer control and cure rates are similar to open surgery.

In summary, smoking is the most common cause of urinary bladder cancer and blood in urine, its most common symptom. After initial removal via TURBT, subsequent treatment depends on the grade and stage of the disease. If required in a particular situation, robotic surgery for bladder cancer can improve outcomes and may be the next big revolution in urinary bladder cancer treatment in India.

This blog has been written by Dr. Gagan Gautam, Head of Urologic Oncology & Robotic surgery at Max Institute of Cancer Care, New Delhi, India. Dr. Gautam is a specialist doctor for prostate, kidney and urinary bladder cancer treatment in India and is the country’s leading expert in robotic surgery for these diseases. Max Institute of Cancer Care, a part of Max hospitals, Saket, New Delhi is a tertiary referral center regarded by many as the best hospital for bladder cancer treatment in India. It is equipped with state of the art facilities for radiation, chemotherapy and surgery for bladder cancer – including the Da Vinci Xi HD robotic surgical system. It is situated 20 minutes away from New Delhi’s international airport.

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