Prostate

The prostate is a gland about the size of a walnut that is only present in men. It is located just below the bladder and surrounds the urethra, the tube through which urine flows from the bladder and out through the penis. One of the main functions of the prostate gland is to produce prostatic fluid, one of the components of semen.
The prostate starts enlarging slowly after the age of 40 and by the age of 70 almost one in every three men have significant symptoms requiring treatment. The enlarged prostate causes compression of urethra.

WHAT IS BENIGN PROSTATIC HYPERPLASIA (BPH) ?

Benign prostatic hyperplasia (BPH) is a condition that affects the prostate gland in men. The prostate is a gland found between the bladder (where urine is stored) and the urethra (the tube urine passes through). As men age, the prostate gland slowly grows bigger (or enlarges). As the prostate gets bigger, it may press on the urethra and cause the flow of urine to be slower and less forceful. "Benign" means the enlargement isn't caused by cancer or infection. "Hyperplasia" means enlargement.

WHAT ARE THE SYMPTOMS OF BPH ?

Most symptoms of BPH start gradually. One symptom is the need to get up more often at night to urinate. Another symptom is the need to empty the bladder often during the day. Other symptoms include difficulty in starting the urine flow and dribbling after urination ends. The size and strength of the urine stream may decrease.
These symptoms can be caused by other things besides BPH. They may be signs of more serious diseases, such as a bladder infection or bladder cancer. Tell your doctor if you have any of these symptoms, so he or she can decide which tests to use to find the possible cause.

HOW WILL MY DOCTOR KNOW IF I HAVE BPH ?

After your doctor takes a complete history of your symptoms, a rectal exam is the next step. This exam allows your doctor to actually feel the size of the prostate gland.
It might not be possible for your doctor to be sure that your prostate problem is benign just by taking a history and performing a physical exam. Your doctor might need to look at a sample of your urine for signs of infection. Your doctor may also do a blood test. An ultrasound exam or a biopsy of the prostate may help your doctor make the diagnosis.

HOW WILL MY DOCTOR TREAT MY BPH ?

Once your doctor is sure that your symptoms are caused by benign growth of the prostate gland, treatment can be recommended. However, your doctor may suggest that you wait to see if your symptoms get better because sometimes mild symptoms get better on their own. If your symptoms get worse, your doctor may suggest another treatment option.
Surgery is considered the most effective treatment and is used in men with strong symptoms. This is also the best way to diagnose and cure early cancer of the prostate. Surgery is usually done through the urethra, leaving no scars. Surgery does have risks, such as bleeding, infection or impotence. These risks are generally small.

ARE THERE ANY DRUG I CAN TAKE ?

Drug treatments are available. Finasteride (brand name: Proscar) makes the prostate shrink, but it does not help all patients. The side effects of finasteride are rare and mild, but they usually have to do with sexual function. They go away when the medicine is stopped. The prostate will enlarge again when the medicine is stopped, so another treatment may have to be tried.
Another kind of medicine, called alpha blockers, also can help the symptoms of BPH. Some of these drugs are terazosin (brand name: Hytrin), doxazosin (brand name: Cardura) and tamsulosin (brand name: Urimax). Alpha blockers have been used for a long time to treat high blood pressure, but they can also help the symptoms of BPH, even in men with normal blood pressure. These medicines may not work in all men. The side effects of alpha blockers are mild and go away if you stop taking the medicine. The side effects include dizziness, fatigue and lightheadedness.

The key symptoms of enlarged prostate are:

• • Weak or intermittent stream of urine
• • Hesitancy or difficulty in starting to pass urine
• • Need for frequent trips to the toilet, including having to get up several times in the night
• • Need to pass urine urgently
• • Feeling that the bladder is not empty after urination
• • Inability to pass urine completely (retention)
• • Repeated urine infection or formation of stone in bladder

At our urology center, 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. We would also like to ensure that the prostate enlargement is age-related (benign) only and not due to cancer.

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.
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.

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.

4. 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.

5. 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 30 ml generally indicates adequate bladder emptying and measurements of 100 to 200 ml or higher often indicate blockage.

For enlarged prostate, the key treatments are:

• 1. Medical Treatment
• 2. Holmium Laser for Enlarged Prostate
• 3. TURP

1. Medical Treatment

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.

2. Holmium Laser for Enlarged Prostate (HoLEP)

At our Urology Centre, we offer Holmium Laser Prostatectomy, the operation aimed to remove the central part of prostate gland that enlarges due to ageing and causes pressure on the urine passage (urethra).
The procedure is performed with a special endoscope passed through the urethra. With the help of Holmium Laser, the central part of prostate is separated from the surrounding fibrous covering (capsule) and pushed into urinary bladder. Then it is cut by a special machine (Morcellator) into smaller pieces and sucked out of the body and sent for biopsy.
This technique was developed by Peter Gilling (New Zealand) and is being carried out successfully in the US, UK and Europe over last 10 years with excellent results, but the high level of expertise required for this technique has resulted in being available only in selected centres in the world.

Why Us?

Dr Paruliya gained 2 years (2008 – 2009) of specialised training and experience in various laser treatments at world-renowned hospitals.

Advantages of HoLEP (Holmium Laser) vs. TURP (Endoscopy)

	HoLEP	TURP
Size of Gland	Any Size	Not greater than 70 grams
Hospitalisation	1-2 Days	3-4 Days
Catheter	Less than 24 hours	48-72 hours
Irrigation	Not needed	Usually needed
Blood Loss	1 in 10,000	10-15 in 100
Patients on anticoagulants, aspirin and with heart valves and coronary stents	Safe	High Risk
Recovery	Very soon	Few weeks
Risk of stricture, bladder neck contracture & impotence	Insignificant	High Risk

Advantages of HoLEP (Holmium Laser) vs. Other Lasers

	HoLEP	Other Lasers(Greenlight PVP, Thulium, etc.)
Biopsy to detect Prostate Cancer	Possible	Not Possible
Published Laser RCT	8	2 (Greenlight); 0 (Thulium)
Amount of Enlarged Prostate Removed	82 - 91%	32 - 51 %
Treatment Cost	Economical	Expensive

3. TURP (Transurethral resection of the prostate)

Commonly known as a TURP, plural TURPs, and rarely as a transurethral prostatic resection, TUPR) is a urological operation. It is used to treat benign prostatic hyperplasia (BPH). As the name indicates, it is performed by visualising the prostate through the urethra and removing tissue by electrocautery or sharp dissection. This is considered the most effective treatment for BPH. This procedure is done with spinal or general anaesthetic. A triple lumen catheter is inserted through the urethra to irrigate and drain the bladder after the surgical procedure is complete. Outcome is considered excellent for 80-90% of BPH patients

• Plasmakinetic Resection

• PK or Button resection uses ionized vapor that heats up by low voltage electricity a semi-spherical button to vaporize the prostate tissue from inside. This is considered to be the least intrusive of all current techniques. It also features fewer post-op complications and shorter healing time.

• Bipolar TURP

• A newer technique, Bipolar TURP uses bipolar current to remove the tissue. Because it allows for saline irrigation (instead of nonconducting glycine as in monopolar TURP) it reduces complications such as TUR syndrome. This allows for longer procedure length. This is the standard technique for the removal of enlarged prostate gland. In this technique, telescope is passed from urethra and small pieces of prostate are cut with the help of electric current passed through a metal loop. All pieces are washed out from the bladder. After being trained in the SMS, Jaipur, Dr. Paruliya doing TURP in Agra in 2008 and has performed over 1000 TURP surgeries with gratifying results. He has trained many urologists and surgeons over the years. We still continue to offer TURP to patients who prefer this technique, as we have over the years.