Prostate

What is Prostate

The prostate, is a part of the male reproductive system, is about the same size and shape as a walnut. It is located below the bladder and in front of the rectum and surrounds the urethra, the tube-like structure that carries urine from the bladder out through the penis. The main function of the prostate is to produce ejaculatory fluid.

Prostatic enlargement is a aging process and in Indian male prostate enlargement occurs after the age of 45 years. By the age of 70 years one in 3 males have significant symptoms requiring treatment.

Not all the persons having enlarged prostate require treatment if prostate is enlarged (even more than 50 gms) but not compressing urethra person does not have difficuty in urine and other symptoms so in that case no active treatment is required. (Provided S. PSA is normal). In contrast if prostate is mildly enlarged but compressing urethra patient’s develop early urinary symptoms so in that case medical or surgical treatment is essential.

Common disease conditions of Prostate

Some common problems related to Prostate are:

  1. Prostatitis
    • Prostatitis is inflammation of a prostate gland. Prostatitis commonly occur in young male patients.
    • In Prostatitis patients having pain in lower abdomen and perianal region.
    • Pain may or may not be associated with burning Micturition.
    • Few patients passes blood in urine.
    • In DRE prostate is tender and may or may not enlarged.
    • Urine report may or may not show pus cell( Infection).
    • Patient’s continuous focus is on the pain and difficult to live his quality life.
    • In few patient endoscopy is require to diagnose the condition.
    • Treatment:- Patient has to take medicine from one month to six month. Few patient may require treatment upto 2 years.
    • Trimethoprin – Sulpamethoxazole is the drug of choice for prostatitits.
  2. Enlargement of Prostate or Benign Prostatic Hyperplasia(BPH)Symptoms
    • Difficulty in passing urine
    • Thin stream of urine
    • Frequency of voiding particularly at night
    • Sense of incomplete voiding
    • Urgency
    • Burning while passing urine
    • Retention of urine

Diagnosis

At Devasya Institute our aim is to understand your bothering symptoms with the help of international scoring system (IPSS), make an accurate diagnosis by detailed examination and necessary tests including Ultrasound and Urine Flow test (Uroflowmetry). This along with your other medical problems and personal and social circumstances will help us in suggesting the best option of treatment. The prostatic enlargement is a aging process. In some patients we may find cancer in the prostate (Total S. PSA > 4 ng/ml)

In order to help assess the severity of such symptoms, the American Urological Association (AUA) BPH Symptom Score Index was developed. The AUA diagnostic system includes a series of questions that target the frequency of the urinary systems identified above, and as a result, helps identify the severity of the BPH – ranging from mild to severe.

There are a number of diagnostic test procedures that can be used to confirm BPH. The tests vary from patient to patient, but the following are the most common:

  1. IPSS (International Prostate Symptom Score) and Quality of Life Score (QOL): IPSS is a questionnaire designed to determine the intensity of man’s urinary symptoms and help diagnose prostate enlargement. The patient answers seven questions related to common symptoms of prostate enlargement and severity of each symptom is rated from 0 to 5. These numbers added together provide a score that is used to evaluate the condition. IPSS is a questionnaire designed to determine the intensity of man’s urinary symptoms and help diagnose prostate enlargement. The patient answers seven questions related to common symptoms of prostate enlargement and severity of each symptom is rated from 0 to 5. These numbers added together provide a score that is used to evaluate the condition.QOL is a questionnaire designed to determine the effect of the urinary symptoms on man’s daily routine. This is rated from 1 to 6.
  2. Digital Rectal Examination (DRE): The doctor inserts a lubricated, gloved finger into the patient’s rectum to feel the surface of the prostate gland through the rectal wall to assess its size, shape, and consistency. Healthy prostate tissue is soft and malignant tissue is firm to hard, and often asymmetrical.

     
  3. Uroflowmetry (Urine flow test): With the help of a uroflowmeter, a test is performed which records urine flow to determine how quickly the bladder can be emptied. With a full bladder, the patient urinates into a device that measures the amount of urine, the time it takes for urination, and the rate of urine flow. A reduced flow rate may indicate prostate enlargement.
    • Laboratories Studies
    • Prostate Specific Antigen (PSA) Blood Test
    • PSA Test: This is a blood test to check the levels of prostate specific antigen (PSA) in a patient who may have BPH. Normal result generally means absence of prostate cancer. Higher level along with abnormal feeling prostate raises the suspicion of prostate cancer and requires further evaluation.
      • Urinalysis
      • Urine Culture
  1. Imaging techniques
    • Ultrasound test (including post void residue measurement): This test is performed with full bladder and immediately after urination. At full bladder, the volume of urine is measured and any changes in bladder wall due to prostate enlargement are noted. The shape and size of prostate are also noted. The patient is then asked to urinate and the residual urine is determined by ultrasound. Post void residue (PVR) less than 50 ml generally indicates adequate bladder emptying and measurements of 100 to 200 ml or higher often indicate blockage.Rectal Ultrasound
    • Intravenous Pyelogram (IVP)
    • Cystoscopy

Urodynamic Test is advised when patient is having Diabetes.

Treatment

  1. Watchful Waiting: Is recommended as an important option for men who have mild symptoms and do not find them particularly bothersome.
  2. Medical therapy: Today’s most common method for controlling moderate symptoms of BPH. Several medications are available to control moderate symptoms of BPH.Generally, early problem is controlled with medicines to relax prostate muscles or reduce the size. Medication is required on a long term basis, otherwise symptoms and problems would recur. Generally the improvement in symptoms and urine flow is significantly less with medicines than with surgery.When the symptoms progress, fail to respond to medicines or patient develops retention, stones or repeated infections, surgery is required to remove part of prostate to open urine passage.
  3. Minimally invasive treatment: Several minimally invasive therapies are available that allows the doctor to access the prostate through urethra and reduce the size of the prostate or decrease obstruction of the urethra.
  4. Surgical treatment: Surgical intervention is necessary in patients in whom benign prostates obstruction causes renal insufficiency, urinary retention, recurrent UTIs, bladder calculi, hydronephrosis, or large postvoid residual volume.
  1. For management of enlarged prostate:
    • conventional endoscopic resection of prostate :- TUR-P( Trans Urethral Resection of Prostate) is carried out by urologists under anaesthesia an endoscope is passed through urethra and all chips removed.
    • Laser Treatment for enlarged prostate

With the help of Laser technology prostate is either evaporated (burning of prostate tissue) or enucleated (lobe of prostate resected).

3 types of laser technologies available in market. Holmium Laser, Green Light Laser and Thulium Laser

100 watt Holmium Laser 120 watt Green Light Laser 120 watt Thulium Laser
First Laser technology After Holmium Laser this Technology came Latest Laser technology
Prostate tissue removed send for Histopathology examination (HPE) Tissue is vaporized so tissue not available for HPE so cancer is easily missed Tissue is removed and available for HPE
Laser fibre – Multiple useso treatment is cheaper Single use fibre so treatment is very costly Multiple use Laser fibre – so treatment is cheaper than other
Large scope is used so chances of stricture formation in urethra Thin scope is used so less chances of stricture urethra. Thin scope is used so less chances of stricture urethra.
Amount of enlarge Prostate removed– 80-91% Amount of enlarge Prostate removed– 85-95% Amount of enlarge Prostate removed– 95-98%

Prostate cancer

  1. Cause:
    • Exact cause of prostate cancer is not known. Individual with the family history of prostate cancer are at an increased risk of developing prostate cancer.
      • Risk is higher if an immediate family member has been diagnosed with prostate cancer. Risk of prostate cancer increase dramatically with age.
      • Diet rich in Dairy product and meat may be associated with higher risk of prostate cancer.
  2. Sign and Symptoms:
    • Early prostate cancer usually causes no symptoms. Sometimes, however, prostate cancer does cause symptoms, often similar to those of diseases such as benign prostatic hyperplasia. These include frequent urination, nocturia (increased urination at night), difficulty starting and maintaining a steady stream of urine, hematuria (blood in the urine), and dysuria (painful urination). A study based on the 1998 Patient Care Evaluation in the US found that about a third of patients diagnosed with prostate cancer had one or more such symptoms, while two thirds had no symptoms.
    • Prostate cancer is associated with urinary dysfunction as the prostate gland surrounds the prostatic urethra. Changes within the gland, therefore, directly affect urinary function. Because the vas deferens deposits seminal fluid into the prostatic urethra, and secretions from the prostate gland itself are included in semen content, prostate cancer may also cause problems with sexual function and performance, such as difficulty achieving erection or painful ejaculation
    • Advanced prostate cancer can spread to other parts of the body, possibly causing additional symptoms. The most common symptom is bone pain, often in the vertebrae (bones of the spine), pelvis, or ribs. Spread of cancer into other bones such as the femur is usually to the proximal part of the bone. Prostate cancer in the spine can also compress the spinal cord, causing leg weakness and urinary and fecal incontinence
  1. What Are the Symptoms of Prostate Cancer?:There are no warning signs of early prostate cancer. Once a tumor causes the prostate gland to swell, or once cancer spreads beyond the prostate, the following symptoms may happen:
    • A frequent need to urinate, especially at night
    • Difficulty starting or stopping a stream of urine
    • A weak or interrupted urinary stream
    • Leaking of urine when laughing or coughing
    • Inability to urinate standing up
    • A painful or burning sensation during urination or ejaculation
    • Blood in urine or semen
  1. Diagnosis
    • Sonography of prostate and KUB region:Mainly use for prostate cancer detection. We advise the patient trance rectal ultrasonography for the diagnosis of prostate cancer. Trance rectal prostatic biopsy is taken with the help of trance rectal ultra sound.
    • Total S. PSA or Free S. PSA test and prostate Biopsy:In patient having enlargement of prostate we routinely advise A. PSA test. If S. PSA is more than 4ng/ml than cancer in the prostate is suspected. We advise the patient to under go “Ultrasound guided biopsy”. A ultrasound probe inserted into the anal canal and from the channel of probe biopsy gun passes and small and long pieces of prostatic tissue removed(total six or eight biopsy taken) and send for histopathological examination.In S. PSA level less than 4ng/mi patient have benign prostatic enlargement of prostate.
    • Prostate MRI:Most accurate imagine method used for prostate cancer diagnosis. Prostate MRI has better soft tissue resolution than ultrasound. Prostate MRI particularly used for planning of Laparoscopic redical prostatectomy. It helps to decide weather to resect or spare the neurovascular bundle, determine to preserve urinary continence and help assess surgical difficulty. Prostate MRI particularly used for staging of prostate cancer.
    • Bone Scan:When prostatic biopsy shows cancer in the prostate along eith MRI prostate / CT prostate bone scan is needed to detect distal metastasis.
    • X- Ray chest: X-ray chest is require to detect metastasis in the lung.
  1. Prostate Cancer staging
    • Prostate cancer staging depends on MRI prostate/prostate biopsy/bone scan.
  1. Treatment of prostate cancer
    • Stage I prostate cancer or Carcinoma in situ:Laparoscopic Radical Prostatectomy (LRP)is advised when patient is having stage I prostate cancer or carcinoma in Situ (Patient came in very initial stage only detectd by S. PSA and prostatic biopsy)About more than 500 Laparoscopic Radical Prostatectomy have been done till date in our institute.Devasya Kidney Institute is only institute having highest number of Laparoscopic Radical Prostatectomy done.
    • Stage II and III prostate cancer:Treatment of stage II and Stage III prostate cancer differs from one Kidney institute to another institute. About half of the urologists of the world favours Laparoscopic Radical Prostatectomy and iliac lymph node dissection and other half of the urologists against Laparoscopic Radical Prostatectomy. Patient having obstructive urinary symptoms Trance Urethral resection of prostate (TUR-P) is advised. Bilateral Orchidectomy is routinely done for stage II and III cancer. Hormonal therapy in the form of Leuprolide acetate every 3 monthly given sub cutaneous.
    • Stage IV Prostate Cancer:Curative treatment is not possible in stage IV cancer. Only palliative therapy in the form of bilateral orchidectomy and hormonal therapy is recommended.Hormonal therapy in the form of sub cutaneous inj Luprolide acetate every 3 monthly.
      • Radiotherapy and Brachytherapy:In selected of early prostate cancer these are alternative modalities to surgery especially in medically unfit patients.Radiotherapy and Brachytherapy are also advised when patient refuse to Laparoscopic radical prostatectomy.
      • Screening:Just like USA and Scandinavian countries we provide screening progress for early detection of prostate cancer and comprehensive urological checkup for individuals and company executives.