Tuesday, March 16, 2010

The prostatic enlargement:Everthing about the prostate,the disease and the tretament.How we do prostate surgery in Dr Ramayyas Centre

The following types of myths and misconceptions or inorance about the Benign Prostatic enlargement are prevalent.

1) we had a patient , 50 year old who came to us for prostate surgery.He was referred by a general practitioner for the surgery.He was thinking that LASER treatment will also prevent further development of carcinoma.The common prevalence of thought(rather myth) in general publics mind that LASER/TURP radically ablates the prostate and hence the prostate will not remain inside the body.The article also gives the anatomy and explains why the carcinoma can arise in tissue compressed as capsule(pseudo one) during LASER surgery.


2) Every patient of prostatectomy(LASER) think that they will invariably lose their manhood after the surgery.IT is true that some patients report sexual dysfunction(3-33%) and but not all.Infact those patients with severe Lower urnary tract symptoms(LUTS) prior may even improve their sex life because many a times severe LUTS mars the sexual life rather than prostate surgery.There are now medications which can do away impotence developing after prostate surgery.






3) Retogarde ejcaulation(dry ejaculation)should be explained to each patient.Sex is important part of life so concealing/hiding this aspect of life ;the man may become totally disappointed with the outcome although he may void in superflow.
In young patients with robust sexual life and small prostate we rather do LASER bladder neck Incision than prostate enucelation(impotence rate 20% and ejaculatory dysfunction 6-50%)






4)Many patients think that the prostate recures again(to some extent yes around 17-20% at the end of 8 years).There belief is because of mainly recurrence in form of stricture(OIU-STICTUROTOMY).This also for the patient is recurrence.Sometimes in large gland some residual tissue is left behind which grows within 2-3 years.These common complications of routine conventional Trans Urethral Resection of the Prostate are less common with LASER as it enuceates and removes the prostate till capsule.And the Thulium LASER which we use ; uses the sheath of 22.5 Fr rather 26 Fr used in TURP .Bigger is the sheath more are chances of stricture and vice-versa.
5)one more belief is that prostate removal 100% ensures relief from lower urinary tract symptoms.Infact 70% patients do improve but other patients may not because of presence of age related detrusor(Bladder fault) dysfunction and development of a new detrusor instability(De novo).So it is essential to explain to patient regarding these things.

6)Many patients report after they undergo general body check-up; they come across the finding of enlarged prostate in ultrasonography.Worried about its effect (mainly sexual life.In general people mind prostate is a sexual organ and secondly constant stressing about prostate cancer especially by western media/medicos/western colleagues) they come to us in a panicky mode.All prostatic enlargements donot need surgery(Infact there is no relationship between symptoms and size ).They may have to undergo DRE and serum PSA as part of the screening nothing apart from that.If the size gland is big(more than 70 gm or so) the randomised controlled studies and longitudinal studies have shown these people have more chance of urine retention and therefore surgery so progression is likely.These people can be kept under medical line of treatment if asymptomatic(dutasteride) or alpha-blocker and dutasteride combination if symptomatic.The prostate size per se donot make them a candidate for surgery.
7)PVR:Post Void Residual Urine:I have seen people literally keeping in mind their PVRs since last 8-10 years.They keep a diary also about the same.Sometimes becoming restless that PVR has increased by 30ml in last 3 months; sometimes rejoicing about decrease in PVR by few mls.
There are certain things that needs to be mentioned:
1) PVR doesnot correlate with signs ans symptoms of BPH
2) It maynot predict outcome of surgery
3) It may not denote future damage of kidney because of retention.
4) There is huge intra-individual variability limiting its use to predict the tretament.






ONLY ONE THING IS CERTAIN HIgH PVR PREDICTS IS HIGHER FAILURE RATE WITH WATCHFUL WAITING IF THEY CROSSOVER TO SURGERY AT A LATER PERIOD OF TIME.










The anatomy of the prostate gland:

The prostate is a walnut-shaped gland that forms part of the male reproductive system.The prostate is situated around the urethra - the tube that carries urine from the bladder out of the body.The normal prostate weighs around 18 gm ;3 cm in length,4 cm in width and 2 cm in depth.The prostate has posterior,anterior and lateral surfaces and a narrowed apex inferiorly and a broad base superiorly.
This gland is contiguous with the bladder base.







Structure:
The prostate contains 70% glandular elements and 30% fibromuscular stroma.The stroma is in continuity with the capsule.The urethra runs thropugh the length of the prostate and is close to the anterior surface of the prostate.The posterior urethra has a urethral crest which runs in the posterior midline and disappears at the striated sphincter.The urethral crest widens and forms verumontanum from which the utricle peeps.To either side of the utricle ejaculatory ducts open carrying semen in the urinary path during ejaculation.At the either side of the crest there are prostatic sinuses into which all the glandular elements of the prostate drain.At the midpoint the prostate bends at approxoimately 35 °.In the proximal part before the bend the circular smooth muscles form an involuntary smooth muscle sphincter.
Small periurethral gland enclosed in the longitudinal fibres of the prostate can grow sometimes in old age and constitute to the bulk of the prostatomegaly(they constitute otherwise only 1 % of the prostate bulk).





Clinically the prostate is talked of having two lateral lobes felt on digital rectal examination(DRE).And one median lobe which protrudes into the bladder causing urinary difficulty.But embryologicallY it contains central zone:surrounding the ejaculatory ducts(25% of the prostate bulk).The transition zone at the angle of preprostatic and prostatic urethra accounting for 5-15% of glandular tissue.
Peripheral zone accounts for 70% glandular tissue and covers the posterior and lateral aspects of the gland.Seventy % of prostate cancers arise in this gland.This zone is also the zone commonly affected by chronic prostatitis.
1/3 rd of the prostate is made by fibromuscular stroma ;it is in continuity with the prostatic capsule,anterior visceral fascia.The cancer rarely invades this region.










ZONAL ANATOMY OF THE PROSTATE
Functions of the prostate:
1)Secretes seminal fluid which carries sperm.This fluid nourishes the sperms.
2)During orgasm, prostate muscles contract and propel ejaculate out of the penis




Risk Factors for BPH
Age – increases with age
Hormones – androgen donot directly cause BPH; but there is imbalance(maintained levels) in intra-prostatic levels of dihydrotestosterone as well as androgen receptor as man ages inspite of peripheral androgen level decrease. The role of oestrogen although was postulated to be the cause of prostatic growth remains still unclear.
Familial – strong relationship found.The hazard -function ratio between first degree male relatives of the BPH and their relatives as controls was 4.2(95% confidence interval).About 50% of the men who undergo prostatectomy at less than 60 years of the age do show some evidence of heritable reason.
Higher socioeconomic status
Sexual activity:Ekman had suggested that the fibromuscular stroma increase as a result of sexual activity.Some people have found that there 40% reduction in the risk of prostatectomy in widowed versus single men.
Metabolic syndrome:Hypertension,obseity,smoking,altered lipid(cholesterol) levels,hyper-uricemia and prostatic enlargement are seen to go hands in hands.


Ref: BPH. Chapple CR. Blackwell Science Publication: 2003: 3-9

Pathophysiology of the Benign Prostatic nlargement:
Microscopically:Nodular prostatic hyperplasia consists of nodules of glands and intervening stroma. (Mostly glands).The glands variably sized, with larger glands have more prominent papillary infoldings.
Changes in Prostate
 Increase in stromal cells and smooth muscle cells
 Contraction of smooth muscle cells
 Contraction of prostatic capsule
Changes in the bladder
 Detrusor instability(can be obstruction related or De-Novo)
 Bladder neck smooth muscle contraction /Urethral compression
 Bladder hypertrophy-Thickness of the bladder wall increase-Good parameter in Ultrasonography to see whether prostatioc enlargement is causing locoregional imbalance.
 Trabeculation of the bladder /Diverticula formation- because of constant increase in bladder pressure for ensuring emptying of the bladder
 Hydroureter/Hydronephrosis: Back pressure changes when there is detrusor muscle failure and changes of chronic retention.







Symptoms of prostatomegaly:

There can be obstructive symptoms like weak stream,interupted stream,hesitancy and sense of incmplete evacuation.There can be irritative symptoms like frequency,nocturia(getting up in the night for passing urine),urgency and urge incontinence.There can be an element of Urinary tract infection like burning of urination,fever and perineal /suprapubic pain.Some people end up in having complications like acute urinary retention(they cannot pass urine),bleeding(sometimes can be life-threatening),stone formation or renal (kidney) failure.There are sometimes sequels of BPH like developing hernia.



Evaluation:
 History and focused physical exam to include DRE and neurologic exam(Must:Famous Dictum:Put your finger in it otherwise you will have to put your foot in it).







This cartoon comes from a website maintained by survivors of prostate cancer. They tell in it how the DRE is so feared by men that many refuse to have it done, as the risk of their lives. They are meant to inject humor in lives of prostate cancer .

 Validated symptom questionnaire.(Photoraphs showing it)






 Urinalysis to exclude UTI and hematuria.
 PSA for those with 10 year life expectancy or for whom the diagnosis of prostate cancer may affect their management.
 Urine cytology in patients with:
 Predominance of irritative voiding symptoms.
 Smoking history
 Flow rate and post-void residual:Not necessary before medical therapy but should be considered in those undergoing invasive therapy or those with neurologic conditions.Generally patient with flow rate more than 12 ml/sec tend to be in unobtrsucted range.
Urodynamic studies:In patients who are young,more of irritative symptoms and urine flow more than 12 m/sec,presence of neurological disorders etc
 IVP: Especially in upper tract changes.But now-a-days it has been noticed that the IVP is really not necessary and changes the management in only 1-3 % cases.
 Rectal ultrasound:This is usually done if DRE finds some nodule or PSA is high so that abnormal zones can be noted and ultrasound guided biopsy can be done.It is also done in our centres before surgery as depicts true size of the gland so we can mentally be prepared before doing LASER surgery on the patient.
 Renal function tests:In case of renal function derangement the chance of complications are high almost to the tune of 20-25%
Management:

Watchful waiting( No medications):“is the preferred management technique in patients with mild symptoms and minimal bother”
Following advice is given to the patient with watchful waiting:

A. Decrease caffeine, alcohol and fluid intake.






B. Avoid bladder irritants to include dairy products, artificial sweeteners, carbonated beverages
C. Limit nighttime fluid consumption
Medical Management:
Medical therapies are not as efficacious as surgical therapies but may provide adequate symptoms relief with fewer and less serious associated adverse events.
 (A) a- blockers :
A. Mechanism Of The Action – Reduces muscle tone & relieves outlet obstruction. Drugs – Prazosin , Doxazosin , Alfuzosin,Terazosin , Tamsulosin
(B) Androgen Suppression :
 Mechansim of action – Blocks DHT & reduces growth
 Drugs – Finasteride and Dutasteride(5 a-reductase inhibitor)
C.Saw Palmetto (Serenoa repens, Sabal serrulata)
National Center for Complementary and Alternative Medicine (NCCAM) says “no role for the treatment of BPH with Saw Palmetto”
AUA concurs:Alpha blocker therapy is appropriate and effective treatment for patients with lower urinary tract symptoms due to BPH
Theory of efficacy is based on the thought that symptoms are caused by an alpha adrenergic contraction of prostatic smooth muscle resulting in bladder outlet obstruction.
a- blockers like doxazosin and terazosin have similar affinity for all three subtypes of alpha receptors.For specific action for relieving smooth muscle sphincteric tone,a1a and a1d blocking is required



Alpha receptor(1a and 1 d location in the trigone)


Blocking of a1b can lead to vasodilatation and Postural Hypotension (prazosin)
Tamsulosin is the most potent a1 agonist available but can causeasthenia,dizziness,rhinitis and abnormal ejaculation.(2%,5%,3% and 11%)respectively.
Alfuzosin has been called as uroselective agent and causes less of dizziness and ejaclatory dysfunction.
(5 a-reductase inhibitor):Dutasteride,Finasteride: Agents are effective and appropriate treatment for patients with lower urinary tract symptoms and demonstrable enlargement of the prostate.
Indications:
oAverage prostate size is 30 cc’s. Original studies showed benefit only in men with prostate sizes greater than 50 cc’s.
oLess effective for relief of BPH symptoms than alpha blockers
Adverse events include
 Decreased libido,Worsened sexual function
 Breast enlargement and tenderness
o Reduces risk of urinary retention by 3%/year.
o PSA must be doubled if screening for prostate cancer(as it reduces PSA by 50% )
o They also prevent hematuria secondary to BPH and reduce the need of surgery(70%)
 Surgical management:





Open simple prostatectomy
TURP
Laser prostatectomy(green light laser PVP,Holmiumand Thulium)
Patients may select surgical treatment as initial therapy if moderate or severe bother is present.
Patients who have developed complications of BPH (i.e urinary retention, renal insufficiency, recurrent UTI) are best treated surgically.
Transurethral resection of prostate (TURP)
1)Gold standard
2)Surgical procedure requiring spinal or general anesthesia
3)Resectoscope inserted through urethra
4)Gland removed in small chips by electrical cutting loop(electrocautery)
5)Inpatient hospitalization required(The pateint may need irrigation to flush out clot in the bladder through the catheter for 1-2 days and catheter removal is usually done after 3-5 days)
 Adverse events
hospital stay(3-5 days)
TUR syndrome (acute hyponatremia from free water absorption occurs in 2-3 % patients)
Risk of incontinence 1%
Decline in erectile function equivalent to watchful waiting
65% of retrograde ejaculation
Greater than 5% risk of:
1)Irritative voiding symptoms
2)Bladder neck contracture
3)UTI
4)Hematuria(the risk of hematuria can be upto 30% sometimes needing blood transfusion)
Dr Ramayya's Urology and Nephrology Institute´s Experience about LASER prostatectomy and review of literature for backing use of Thuium LASER as the LASER of choice in Benign Prostatic Hyperplasia
Traditionally, the gold standard for treatment of BPH (Benign prostatic Hyperplasia) has been the Monopolar Electrocautery based Trans-Urethral Resection of the Prostate (TURP).



TURP is fraught with complications like bleeding during procedure (30%). This results in the inability of the Surgeon to complete the procedure (Residual Prostate) especially in large glands, post operative clot retention, strictures in the urethra and bladder neck and occasionally the TUR syndrome( a cerebero vascular stroke like condition due to hyponatremia).



TURP usually considered to be the to be the Gold Standard because of the durable cavity it creates in a minimally invasive manner becomes a very unsatisfactory procedure in most hands for prostate gland volumes above 40 cc .
The new generation LASER (KTP, Holmium, Thulium Continuous Wave) technology has paved the way forward for a safe and bloodless prostatectomy which is independent of the prostate volume.
The advantages of Laser Therapy over traditional TURP include a virtually bloodless procedure for all gland sizes, shorter hospital stay, less incidence of strictures and early return to activity. As the Laser Energy is delivered in a precise manner without any penetration there is no deep charring of the surrounding tissues and delayed necrosis blood vessels resulting in less incidence of scarring at the bladder neck and delayed haematuria. The procedure can be carried out with smaller caliber instruments resulting in fewer urethral strictures. As the Laser, Plasma Seals the blood vessels there is virtually no bleeding during the procedure. As Normal Saline (0.9%) is used during the procedure TUR Syndrome is virtually unknown


There are several techniques for laser prostatectomy that continue to evolve. The main competing techniques are currently the Holmium Laser Enucleation of the Prostate (HOLEP) and the KTP (Green Light) and Revolix (Thulium Continuous Wave) Laser enucleation, vapo-resection or vaporization of the prostate.
Broadly all the three energy sources (KTP, Holmium, Thulium Continuous Wave) have similar benefits, subtle differences between each, makes the Revolix Continuous Wave Thulium Laser the most attractive option.
The KTP (Green Light) Laser can only be absorbed by hemoglobin. Hence for fibrous glands it is less effective. Secondly once the vaporization has taken place, the energy is not transmitted to the deeper areas of a large gland as the vaporized tissue, devoid of blood supply acts like a barrier, hence it is ineffective for large glands. It only has a side firing fiber making it impossible to enucleate. Finally the fiber cost is prohibitive as it has to be changed for every patient.




The Holmium Laser is absorbed by the water molecule and hence can be used for all sizes and types of prostate glands. The main disadvantage of Holmium is that it is pulsed wave (hence an effective tool for stone disintegration). Pulsed wave dissects the tissue instead of cutting it cleanly and cannot vaporize. Hence it has limitation. It cannot vaporize the prostate tissue or cut it cleanly because of the pulsed nature of the technology. During the procedure a web like blanched appearance is evident hence making it on occasions, difficult to identify the correct plane during enucleation. Secondly while operating in the apical area the energy can be transmitted in different directions resulting in higher incidence of post operative sphincter weakness. Therefore Holmium Laser while being an effective stone laser, has limitations when it comes to the Prostate Gland as it can only enucleate the gland and not vaporize. Hence a morcellator is a must. Secondly as finding the correct plane during enucleation requires experience, the learning curve is very steep.
The Revolix (Thulium Continuous Wave Laser) is an advance over Holmium Laser in that; it is continuous wave (CW) as opposed to the pulsed wave of the Holmium. The CW technology results in clean cutting and effective vaporization.


It retains its ability to be absorbed in the water molecule making it effective for all types of glands including the fibrous gland. Revolix CW Laser can Enucleate (ROLEP, RevOlix Laser Enucleation of Prostate), Vaporize and also Vapo-Resect making it the most versatile Laser in the market for Laser prostatectomy. The clean cutting makes identification of the planes easier with accurate delivery of the energy due to a stable fiber (no vibrations like the Holmium) making the learning curve far less steep.
As it can vaporize as effectively as the KTP it can be used on patients who are unable to stop anticoagulants.
Both Holmium and Thulium CW Laser fibers are reusable and the fiber cost per patient is not more than Rs 1500 (One thousand Five Hundred)





Scientific Evidence
(TURP vs LASER)

A prospective study was conducted in Capital Medical University, Beijing, China by Xia et al in year 2009 comparing TURP and Thulium LASER prostatectomy. They randomized 100 consecutive patients to receive either a Transurethral Resection of Prostate (TURP) (n = 48) or Thulium Laser Prostatectomy (TmLRP) (n = 52). Pre-operative and peri-operative parameters at 1-, 6-, and 12-months follow-up were also evaluated.
TmLRP was significantly superior to TURP in terms of catheterization time (45.7 ± 25.8 h vs. 87.4 ± 33.8 h, P < 0.0001), hospital stay (115.1 ± 25.5 h vs. 161.1 ± 33.8 h, P < 0.0001), and drop in hemoglobin (0.92 ± 0.82 g/dl vs. 1.46 ± 0.65 g/dl, P < 0.001), whereas it required equivalent time to perform (46.3 ± 16.2 vs. 50.4 ± 20.7 min, P > 0.05).
TmLRP and TURP resulted in a significant improvement from baseline in terms of subjective symptoms scoring and urodynamic finding. TmLR was found to be is an almost bloodless procedure with high efficacy and little peri-operative morbidity.




(HOLMIUMvsTHULIUM)

One head to head trial between Holmium Laser and Thulium Laser in BPH patients was carried out in the same Capital Medical University, Beijing, China by Shao et al in 2009. Ninety-eight BPH patients were divided into 2 groups and underwent Transurethral Enucleation of the Prostate with Holmium Laser (Ho group) and Thulium Laser (Th group) respectively. No statistically significant differences were noted between the 2 groups in age and preoperative prostate volume, IPSS, PVR and Qmax (P > 0.05). The mean operation time was shorter in the Th group ([84.6 +/- 10.2] min) than in the Ho group ([70.5 +/- 7.5] min) (P = 0.032); blood loss was less in the former ([126.5 +/- 14.6] ml) than in the latter ([176.5 +/- 14.1] ml) (P = 0.071), with no blood transfusion necessitated; and the mean times of catheter indwelling were 2.4 d and 2.5 d respectively.
Preliminary results as shown in the above study clearly indicates that the CW Thulium Laser is superior to Holmium Laser .





Our experience:

We use 70 W CW Thulium Revolix LASER with Richard Wolf 24 F Continuous Flow Resectoscope and a Richard Wolf Morcellator .
We have treated 300 patients with this technology (age ranging from 48 years to 105 years) and the gland volumes ranging from (10 cc to 210 cc). Many patients were referred because they were high risk from cardiological point of view and so risky for conventional TURP surgery. The catheter is usually removed on the next day. No patient has yet required blood transfusion.
The glands are either enucleated and morcellated or vaporized depending upon the ability to stop the anticoagulants or not.
Non irrigating Foleys 18 F catheter is placed postoperatively with mild traction on occasions. . 8 patients required re-catheterization for retention but it was successfully removed after a period of 3 days. Three patients had stress incontinence but it improved with time and medical management. There were eight patients in the series in which anticoagulation could not be stopped




The Uroflowmetry parameters, AUA score improved significantly in post-operative period and it maintained on long term follow-up also.
Summary:

The advent of modern laser technology continues to offer a serious threat to the current gold standards for treating BPH, viz. TURP/Open prostatectomy. In a randomized trial comparing TURP with HoLEP, Tan et al. demonstrated that HoLEP is superior to TURP in improving urodynamic bladder obstruction along with shorter catheterization time and decreased blood loss. In a recent randomized trial, HoLEP showed better outcomes as compared to open prostatectomy for adenomas larger than 100 g over a long-term follow-up of five years.
However, the learning curve for HoLEP is steep, which has prevented many urologists from accepting this technique.
The Thulium CW LASER is an advance over the Holmium technology. It has excellent cutting and vaporization properties making it very versatile for Vaporization, enucleation and vapo-resection. Hence it can be used for all gland sizes and on patients with anticoagulants which cannot be stopped.

As the fiber is without vibrations, it gives precise cut so in our opinion has edge over Holmium in terms of enucleation (Shao et al study shows the same).
Many Expeienced Holmium LASER Resectionists (enucleationists?) keep three way catheter and give traction. The incidence of immediate postoperative of incontinence is also very high ( through personal correspondence) unlike our series which shows that the CW Thulium Technology is the best, the present Laser Generation has to offer.
In our opinion Thulium CW LASER Protatectomy is the New Gold Standard for prostatectomy and this technology is the one to be adopted by Urologists..
Inspite of better technology it is saddening that there are still a very few centres in India( a population of 1 billion) using LASER rechnology as depicted in Figure





F.A. Q.s about Thulium LASER prostatectomy:

1)What is the recovery time?Is surgery painful?
The patient is undertaken for surgery under spinal anaesthesia so totally unaware about the procedure but he can at the same ime converse with the surgeon and anaesthetist and watch the video of the surgery.
Post-operative he may have burning in urine and bvladder spasms for which usually medications are given.The patient recovers the next day.

2)How long the catheter will be kept?
The common question .The catheter is usually kept for one day ;removed the next day(unlike TURP/open surgery where it is kept for longer)

3)How long will the improvement takje place?
The improvement is immediate but the total improvement may take 30 days(to recover from obstruction related detrusor dysfunction).There is also small risk of incontinence (1%) which improves with time or patient may have to resort to Kegels exercise for the same.
4)Any problem will be encountered at home after discharge?
Usually the post-operative recovery is smooth but few patients may continue to have burning micturition for 1 week or so;for which usually medications are prescribed.
5)How soon I can start sex life?
Sex can be started after 10 days(there are no fixed protocoals/studies).But we restrict them for 10 days; logically because sexual activity increase pelvic blood flow so the chance of bleeding(especially if urethra is also cut during surgery).But there are no studies in this regard.As LASER chars the tissue the bleeding anyway is remote.

6)The most common question I encounter especially from the better half of the patient is what diet I should put the patient on??(If patient doesnot opt for surgery)
The diets role in prevention of progression is unclear.
But urinary irritants-tea,coffee,alcohol can be avoided.(Espcially Beer)As BPH as we have already mentioned in pathophysiology is complex of metabolic syndrome-restrainst of refined carbohydrates(sugar,flour),fatty and oily stuff(unsaturated fatty acids are better),dairy products are to be avoided.
Grains,Fruits and vegetables should be bulk of the diet.
Tomotos(contains lycopene),Garlic and onion(contain quercetin,allicin),lettuces,spinach,carrots,asparagus may provide lots of anti-oxidants and help the cancer fighting abilities of the patient.

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