Prostate Gland

The prostate is a gland in the male reproductive system found below the bladder and in front of the rectum. The Common Ailments Of Prostate Gland:

  • Prostatitis: is an inflammation of the prostate gland. It can be either acute or chronic. Acute Prostatitis is usually associated with bacterial infection and acute onset of symptoms of lower urinary tract e.g. burning micturition, poor stream and pain in perineal region and is usually accompanied with fever.
    Chronic Prostatitis can be bacterial or abacterial. It presents with vague lower tract symptoms with on and off exacerbation of symptoms.It is seen in younger patients.
  • Prostatic Abscess: is a focal accumulation of pus in the prostate gland. It presents with pain while passing urine, fever at times-retention of urine and heaviness in the perineal region.
  • Benign Enlargement Of Prostate (BEP): is a benign (non- cancerous) increase in the size of the prostate in older age group of males.
  • Prostate Cancer

Assessment

Assessment of prostate disease includes a detailed history which includes history of the act of micturition, past history and family history. A clinical examination is necessary including digital rectal examination to assess the prostate.
The investigations include laboratory investigation of urine and blood as indicated, assessment of flow of urine on Uroflowmeter and USG or Trans Rectal Ultrasound as and when indicated.

Treatment

  • Prostatitis: Acute prostatitis is treated with intravenous antibiotics. The patient may or may not require urinary drainage in the form of a per urethral catheter or a supra pubic catheter (catheter is put through the abdomen just above the bladder so as to avoid passage of urine through the urethral passage). Chronic prostatitis requires long term oral antibiotic treatment (if it is bacterial prostatitis) along with drugs to ease out urination and the congestion and inflammation of the prostate.
  • Prostatic Abscess: Under proper antibiotic coverage, Trans Rectal Ultrasound guided puncture of the abscess is done and pus is drained out. It’s treatment involves long term antibiotic and may require urinary drainage in the form of per urethral catheter or SPC.
  • BEP (Benign Enlargement Of Prostate): Most patients of prostate enlargement can be treated as out patients with medical treatment.

Surgery Of Prostate

Primarily involves removal or cutting of the adenomas so as to relieve the pressure on the prostatic urethra which results in a better urinary flow. Methods available are:

(Trans Urethral Resection Of Prostate) is GOLD STANDARDARD in prostatic management involves Endoscopic Trans Urethral Resection of the prostate with the mono polar current, with glycine as the irrigating fluid. Post-operatively patient is kept in hospital for 3-4 days.
(Plasma Kinetic Resection Of Prostate) is Conventionally like TURP, but here, the more superior method of cutting the tissue is used. PLASMA KINETIC CUTTING, which closes the blood vessels as cutting occurs, using normal saline as the irrigating fluid (NS is a physiological solution therefore its absorption is not dangerous )Bleeding is significantly low and hospital stay and catheter time is also less than TURP. Also called as BIPOLAR TURP, it is now replacing TURP majorly. It is successfully used for cardiac patients, high risk patients and patients on pace-makers.
TUBE (transurethral bipolar enucleation) of Prostate is the latest in treatment of BEP. Here the adenoma is enucleation using the bipolar. It has an advantages of blood loss, less operative synptoms e.g. Bony while hasty urine (specially post laser prostate surgery) lesser chances of urinary incontinence.
Here the energy source used to resect the adenoma of prostate is LASER (light amplification by stimulated emission of radiation). Various types of lasers have been coming and going ever since its advent 30 yrs ago. None of them have been able to replace the GOLD STANDARD TURP. HOL YAG is a versatile urology laser. Advantage of laser is that it is safer in patients with high cardiac risk .
Rarely done now a days. Only indication is a very large gland for example 250 gm or more. That too can be managed by a staged endoscopic procedure.

Prostate Cancer

Incidence of prostate cancer has increased significantly, or is it that we have better tools to diagnose them early? Well in the Indian scenario, we are now picking up prostate cancers much earlier as compared to what we were seeing ten years ago. With the advent of laparoscopy and robotics, Radical prostatectomy for prostate cancer has been revolutionized from a big incision and many blood transfusions to the fact that now we are discharging the patient in about 4 days,rarely requiring blood transfusion and a better social and sexual life post surgery.

  • Laparoscopic Radical Prostatectomy:
    Now being offered to even locally advanced prostate cancers and of course to localized prostate cancer too.

Assessment

  • PSA: blood serum test which when more than 4ng/ml, needs to be investigated further to rule out prostate cancer. It can be raised in cases of infection, trauma or a very big gland also. On the contrary highly differentiated Prostate Cancers may sometimes have normal PSA.

  • DRE: Digital Rectal examination is necessary for a complete assessment of prostate as it picks up hard a nodule or a nodular prostate which is suspicious of prostate cancer as compared to a smooth firm normal prostate . And on a DRE we are able to even assess the fixity of the prostate cancer to rectal mucosa of surrounding area.

  • TRUS: Trans Rectal Ultrasound is used to assess the prostate if PSA is high to localize the nodule or suspicious area in prostate (peripheral zone or transitional zone).

  • TRUS Guided Prostate Biopsy: Under adequate antibiotic coverage and Trans Rectal Ultrasound guidance, ( TRUS enables the urologist to take a precise biopsy from the suspicious area ), Prostate Biopsy is taken, as a day care procedure (12 core even up to 24 cores can be taken). Biopsy has a potential risk of retention of urine (post biopsy), hematuria ( blood in urine) or per rectal bleeding or sepsis with later abscess formation, All are easily treatable conservatively.

Treatment For Ca Prostate

  • Radical Prostatectomy: Involves removal of the prostate along with the seminal vesicle and Lymph nodes which can be achieved by:
    Open Surgery
    Laparoscopically
    Robotic Surgery
    Radical Prostatectomy is offered to patients with Localized Ca Prostate or in cases with locally advanced Ca prostate without any Lymph Nodes involvement.

  • Active Surveillence is a good option if the patient is old or has serious health problems or the cancer is slow growing. Active surveillance involves regular close monitoring of the progress of the cancer in form of periodical PSA levels and as and when required radiological investigation or even repeat prostate biopsy.

  • Hormonal Treatment involves Surgical Bilateral Orchiechtomy (testes removal) or monthly , 3 monthly or 6 monthly depot injections to suppress the formation of Testosterone which is formed in the testes. Normally these procedures are accompanied with oral tablets also. Hormonal treatment is a treatment option for locally advanced prostate cancers and advanced cancers with lymphnode or distant metastasis ( bone, liver, lungs or brain).

  • External Radiotherapy for localized prostate cancers or for the metastasis is another option for the patients not keen on surgery or for pain management in advanced metastasized cancers.

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