Medical Management

About Our Chief URO Surgeon DR.AVISHEK MUKHERJEE

Dr.Avishek Mukherjee has a vast experience in treating benign prostate diseases . He has treated 10000 such patients. These patients have received medical and surgical treatment . Surgery include TURP & the LASER HOLEP .

ANATOMY AND PATHO-PHYSIOLOGY OF THE PROSTATE

Prostate gland is located below the bladder only in males and it is the approximate counterpart of the uterus in females. Prostate is a reproductive organ which produces the seminal fluid needed for sperm survival and reproduction. Therefore the prostate has its biological utility only during the reproductive phase of an individual. However with advancing age the prostate enlarges in all males. Once the prostate increases in size it obstructs the outflow channel of the bladder. Therefore the patient develops symptoms.

COMMON SYMPTOMS OF PROSTATIC DISEASE?

Once the prostate starts enlarging the first symptom very often is frequency of urination, the patient also encounters a difficulty in holding urine once the urge to pass urine develops. Later the urine flow reduces and the patient feels the need to strain to pass urine and also after urination feels that the bladder is not yet completely empty.

PATIENT EVALUATION PROTOCOL

Once patient has these symptoms the patient must be evaluated by a uro-surgeon. The uro-surgeon examines the patient and then generally advises a few simple and easily performed tests to assess the extent of the disease. These tests include a urine routine examination, along with an ultrasonographic evaluation and an uroflowmetry. The patients random blood sugar, creatinine level and prostate specific antigen the PSA level are also routinely checked in all cases as a protocol.

MEDICAL MANAGEMENT OF PROSTATIC ENLARGEMENT?

In cases with mild obstruction the patient is advised for medical management of the disease. If the prostate is smaller than 40gm, uroflow is more than 15ml/sec and residual urine is less than 100ml, then the patient is well served by medical management. These medications are typically alpha blockers, which are related to medicines used to control the blood pressure. These medicines relax the bladder outlet and therefore allow the patients to pass urine more easily. These medications are typically designed for long term usage and therefore have to be continued indefinitely in cases found beneficial by the patient. However in those cases where the obstruction is more severe or the patient does not get benefit from medical management the patient is then transferred to microsurgical therapy.

INVESTIGATION OF PROSTATE GLAND

WHAT IS PSA?

Prostate specific antigen is a protein secreted by the prostate gland. This protein is a part of the male seminal secretion. When the prostate is inflamed or damaged by malignancy then the level of PSA in the serum of the patient increases. Therefore the PSA is an important marker for prostatic health today.

WHAT IS THE NORMAL RANGE FOR PSA?

PSA is normally less than 4ng/ml,however in most patients with healthy prostate the PSA levels are much lower. Whenever the PSA level rises it must be correlated with the size of the prostate, the presence of infection, the amount of retained urine , and the physical examination of the prostate.

WHAT ARE THE USUAL REASONS FOR INCREASE OF PSA VALUE IN THE SERUM?

PSA increases proportionately to the size of a benign prostate, therefore in general, larger prostatic volume also means larger value for the PSA. The PSA also increases with the volume of the retained urine in the bladder. Both inflammation and malignancy can significantly increase the PSA, therefore if the PSA is increased above the expected normal level for a patient, then the uro-surgeon generally advises a course of medication like tamsulosin with nitrofurantoin. If the PSA elevation is due to inflammation then the value reverts towards the normal, while in patients with invasive tumours the PSA value keeps increasing.

WHAT IS THE COURSE OF ACTION WHEN THE PSA IS ELEVATED, EVEN AFTER MEDICINES ARE ADMINISTERED FOR TWO WEEKS?

If after two week of such medicines the PSA is still elevated then the surgeon advises trans-rectal tru-cut sampling of the prostate to rule out the presence of malignancy in the prostate. Since if the malignancy is detected in the early stage then it is completely treatable by radical prostatic surgery.

Microsurgical Management Of Prostatic Enlargement

When the prostate is larger than 40 grams and the urine flow has reduced to less than 15 ml per second then the uro-surgeon advises management by microsurgical removal of the prostate.

WHAT IS TURP?

TURP means removal of the prostate gland completely, via the urine passage. The prostate is shaved using electrical energy and removed via the urethra.

How is it performed?
This entire surgery is performed via the normal urine passage. No cut is needed for TURP.

What kind of anesthesia is needed for this?
The patient is best operated under regional surgery anesthesia, spinal anesthesia. General anesthesia is rarely needed.

Is it a no-cut surgery ?
No skin cut or stitch is needed, since the surgery is performed via the urine passage.

How many days hospital stay is needed for this surgery?
Generally a patient is discharged 3 days after the procedure.

How many days catheterization is needed?
Usually the catheter is removed on 3rd day after surgery, but some patients may need catheter removal after 2 weeks.

When can a person resume normal life after TURP?
The usual rest at home period is 3 weeks but generally after 2 weeks the patient can gradually return to his daily routine.

What kind of rest is needed in the first 2 weeks after surgery?
He is advised to walk within his house, while avoiding stair climbing, weight lifting and straining during stool passing.

Is the removed prostate sent for biopsy?
All prostatic tissue must routinely be sent for histopathology exam. This is applicable to all cases and does not mean that cancer is being suspected.

Does it cure prostatic disease?
Since the enlarged prostate is completely removed , therefore disease caused by obstructing prostate is cured by this surgery.

What kind of urination is expected after TURP?
In the first few days patient may have some burning urination and difficulty in holding the urine. This however rapidly improves to good urination within 2-3 weeks.

Is dilatation needed after this procedure ?
If the urethra (urine tube in the male) is narrow then in 1/100 cases dilatation may be recommended. This is performed in the OPD under local anesthesia. The patient usually resumes normal life within 12 hours. The cost borne by the patient is minimal.

Is any long term medicine or follow up needed after the surgery?
TURP is a curative procedure therefore no long term medicine or follow up is usually recommended. Therefore after 2 weeks of rest patient is permanently cured of this ailment.

Advance Therapy (Laser)

HOLMIUM LASER ENUCLEATION OF PROSTATE (HOLEP)

We at national use an AURIGA XL Holmium laser generator. With this energy source the bleeding is minimized to near zero. The procedure entails removal of the entire three lobes of the prostate. These lobes are then detached and delivered from within the bladder using an equipment, called morcellator. The lobes are sucked out of the bladder. Holep allows us to tackle large prostate loads. Also patient’s who are on cardiac bloodthinners, like aspirin and clopidogeal, can undergo laser surgery without stopping medicines, as the laser can safely seal off the bleeding. Therefore laser energy can relieve obstruction even among cardiac patient’s on blood thinning drugs, without the need to stop these drugs thus safe guarding the heart at the same time relieving the urinary obstruction.

This procedure requires the patient to be in hospital for 1-3days and rest at home for 7days. They can then resume normal life.

What is holmium laser?

Laser is a focused light beam where in all the energy within the light beam travels in a straight path and does not spread and dissipate the energy. Since the light beam carries very high energy therefore the tissue where the beam is focused is vaporized. The holmium laser is absorbed by water therefore the laser has a penetration of only 1mm and therefore the deep tissue damage is very limited. Compare to this, in case of TURP electrical resection the deep tissue damage is five times higher with a 5mm depth of dead tissue zone being created. Therefore the chance of bleed and pain and infection is much higher in TURP electrical cutting against laser precision cutting.

What is difference between holmium laser and electrical resection of TURP?

Holmium laser allows the surgeon to create a plane between the capsule of the prostate and the adenoma the obstructing lobes are therefore removed intact and then delivered to within the bladder. Therefore complete removal of the prostate is possible only in laser enucleation of the prostate. In TURP the prostate is shaved piece by piece and therefore the chance of residual tissue is very high, generally enough prostate is resected to allow a good channel for urination, however in laser enucleating of the prostate complete removal of the enlarged prostate is performed.

How many stitches are needed for this procedure?

This is a no cut surgery and therefore no incision is placed and no stitches are needed. The access to the prostate is gained via the natural urine opening of the male.

What is the duration of stay in hospital needed after HOLEP?

Generally the patient can be discharged within two days after the catheter is removed. However I prefer to retain the patient after catheter removal for one more day so that the patient is comfortable while passing urine and then can be discharged.

What size prostate gland can be safely removed by HOLEP?

Prostate of any size can be removed safely by this procedure. Since the prostate lobes are enucleated therefore the lobe size is immaterial to the removal process. The plane between the capsule of the prostate and the lobe is developed therefore the size of the prostatic lobe does not matter. I have removed safely 250-300 gram prostates in a single sitting by this technique.

What is the TUR syndrome?

When electrical resection TURP is performed water is used to irrigate the operation field to give the surgeon a clear view. This water is absorbed directly into the blood and increases the pressure on the heart to pump this extra volume. In elderly people this can cause serious problems. However in the case of laser HOLEP saline is used as an irrigation fluid therefore the chance of this syndrome is very rare. Even in very large prostates I have not seen this problem in HOLEP. However in case of TURP this is quite common and can cause serious complications.

Why is TURP difficult with very large prostate load in elderly patients with poor cardiac status?

Since these patients have a weak heart therefore these patients are better not to be subjected to TURP. As the water load increases on the heart the heart may fail to pump the additional load. It is essential that these patients are operated only by lasers HOLEP.

Is blood transfusion needed in cases after laser prostatic enucleation?

I have as yet not needed to transfuse blood to any of my operated cases after laser HOLEP since the blood loss is very minimal. This is due to the superior bleed control achieved by the holmium laser compared to the electrical resection in TURP.

What is the difference between laser enuclation and electrical resection of TURP?

Laser vaporizes tissue of the prostate to a depth of 1mm only therefore the resection is very clean and the bleed is minimal. The patient, in TURP after electrical energy is used to resect the prostate develops deeper dead zone of tissue which is 5 times deeper. Therefore these patients have more bleed and infection. Therefore the laser resection is better than TURP in all aspects.

What is morcellation?

Once the lobes of the prostate are delivered within the bladder then a separate suction cutter is introduced again via the natural urine passage. This then sucks and cuts the prostate lobe into very small pieces. These are then sucked out through the urine passage. Therefore no cut or stitches are applied and the patient can recover faster while very large prostates can also be cleared.

How much rest is needed after holmium laser enucleation of the prostate?

Generally the patient can resume normal life after ten days, but we advise two weeks of rest and then gradual resumption of normal life in these patients.

Is biopsy sent after HOLEP?

Biopsy is routinely sent in all cases after tissue is removed in laser, since the final diagnosis is very important in all cases.

What is the follow up after holmium laser enucleation and morcellation of the prostate?

These patients are all advised for one year follow up after this surgery. The prostate is always completely removed in laser HOLEP. But the urethra, that is the passage for urination in the male , is checked for normal calibre, this is performed generally in the first year three times. One in a 100 patient may require longer follow up in case the urine passage is tight These patients are kept on dilatation of the urine passage till the urine passage stabilizes.