All posts by Dr Shailendra Goel

Health Tips: Varicocele

Varicocele

Varicocele is the tortuous enlargement of the veins in the scrotum above and around the testis. It is the most common cause of low sperm count and low motility of sperms leading to infertility. It may cause pain in the scrotum and may lead to shrinkage testicles.

What are the symptoms to watch out for?

Varicoceles rarely cause severe pain but when it does, the pain is :

  • Usually dull aching
    • Increase with high exertion or strenuous exercise or when standing for a long time
    • Worsens with time
    • Relieved on lying down

When Varicocele is large, it is felt and sometimes visible as “BAG OF WORMS” above the testicle.

It mostly occurs on the left side, but some time may be on both sides of the scrotum.

How is it caused?

Testes hang in the scrotum by their stalk called spermatic cord. It contains Arteries, veins, lymphatics, and nerves of testes. Arteries bring fresh blood with nutrients to testes and veins clear bad blood and excreta of testes. Blood travels in veins against the gravity toward heart but valves in veins prevent backflow. When valves in veins got damaged, blood backflows and veins in scrotum swell up. Veins no longer able to clear bad blood and excreta of testicles. Hence, testicles do not get proper nutrition and temperature for growth of sperms. Therefore, a patient develops low sperm count and weak sperms. Lack of proper nutrition causes mild pain and ultimately may lead to shrinkage of testicles.

How is the condition diagnosed?

Examination by Urologist in Ghaziabad in lying down and standing condition while the patient holds his breath and strain for stool reveal dilated veins.

Diagnosis can be confirmed by Doppler Ultrasound of Scrotum.

Treatment is necessary only when the varicocele causes the following-

  • Pain
    • Infertility
    •Testicular Atrophy

Treatment options –

Treatment involves tying up of abnormal veins, so that blood flow normalizes. It can be achieved by following methods but Microscopic microsurgical method is best –

  • Conventional Open Surgical Varicocelectomy – It is usually done by a cut in the abdomen. But this method is not accurate as lots of lymphatics are also tied which causes hydrocele. Some dilated veins may be left leading to recurrence or persistence of the problem.
  • Laparoscopic Varicocelectomy –By making 3-4 holes in abdomen main testicular vein is ligated. It is less painful but is associated with high recurrence rates due to patency of other veins of the scrotum.
  • Angio-embolization- A small catheter is inserted into the abnormal veins through the groin area. The main testicular vein is blocked by sclerosant or coil. It is a convenient day care procedure but is associated with high recurrence rates due to patency of other veins of the scrotum.
  • Microscopic Microsurgical Varicocelectomy – It is done by small cut just above the scrotum. All the dilated veins are ligated by examining under a microscope and dissecting finely by the microsurgical method. All types of dilated veins are tied leaving lymphatics & arteries unhurt. This method gives almost 99% success and minimum chance of recurrence or complication.

Understanding Renal Transplantation

Renal transplantation is the definitive treatment for patients with end stage renal disease (ESRD). ESRD can be defined as patients who are suffering with chronic kidney disease (CKD) and require regular dialysis or possibility of permanent dialysis requirement is imminent. Renal transplantation is regularly been done at Max Super Speciality Hospital, Vaishali, by expert team under Dr Shailendra Goel, Urologist in Noida, Ghaziabad, Vaishali. In Kidney transplant in Delhi, Noida, Ghaziabad, donated Kidney is implanted in lower abdomen of patient (Recipient).

How can a patient of ESRD get a kidney?

ESRD patient can get a kidney from either any of his relative (voluntary living kidney donation) or brain dead cadaver. Any relative of patient can donate his/ her one kidney to patient. Donor is medically screened for any disease and fitness for donation. Donor surgery is now routinely been done by Laparoscopy at Max Super Speciality Hospital, Vaishali.

What is Cadaveric Donation?

Brain dead donors are considered dead but donor’s heart continue to beat and maintain circulation to organs. When team of experts declare any hospitalised patient as brain dead, his / her family member can decide to donate his organs (Heart, Liver, Kidneys, Eyes) to patients suffering with end organ damage.

How can any patient opt for Cadaveric Transplantation?

If any patient is not having suitable living donor in his/ her family, he can opt for cadaveric transplantation. Every transplant hospital maintains a waiting list of suitable end stage organ disease patients. We at Max Super Speciality Hospital, Vaishali, maintain waiting list for kidney transplantation from Cadaver. We have done many cadaveric transplantation recently.

What if patient does not have matching donor in family?

Kidney transplantation is usually done with blood group matching donor and recipient. If matching donor is not available in family or near relatives, then ABO incompatible transplant can be done. In this scenario, recipient’s blood is washed off for antibodies against opposite blood group by plasmapheresis and some medications are given for desensitization. At Max Super Speciality Hospital, Vaishali, we have the facility of ABO incompatible renal transplantation.

What is swap kidney transplantation?

If any two ESRD patients, whose Donors do not have matching blood groups but one patient’s donor blood group matches with other patient’s blood group and other patient’s donor blood group matches with first patient’s blood group. In this scenario, donor kidneys are exchanged among two recipients.

We at Max Super Speciality Hospital, Vaishali are usually doing swap renal transplantation.

9 things you should know as a woman

Urology is a branch of medicine that focuses on the diseases affecting the urinary tract system and male reproductive organs. The organs that come under the scanner here are the kidneys, adrenal glands, ureters, urinary bladder, urethra, and the male reproductive organs (testes, epididymis, vas deferens, seminal vesicles, prostate, and penis). Though there is a prevalent misconception that gynecologists are for women what urologists are for men, urologist in Vaishali, Ghaziabad, Noida also deals with certain women urinary tract related health issues. These include overactive bladder, pelvic organ prolapse, and urinary incontinence. In fact, doctors who specialize in female urology gain detailed knowledge of the female pelvic floor together with intimate understanding of the physiology and pathology. So for woman, gynaecologist is the doctor for menstrual, genital and pregnancy related troubles but UROLOGIST is the doctor who treats urinary problems.

Here are 9 things you should know as a woman

  1. Age related factors affect both men and women: However, women do not have prostate but they suffer similar urinary problems as men at growing age. Right around the time when menopause and andropause strike, changing hormone levels affect the pelvic floor, bladder, urethra and vagina in women causing problems like recurrent urinary tract infection, frequency, nocturia and urinary incontinence. These conditions are effectively treated by a urologist who can also probe for underlying conditions like urethral stenosis, overactive bladder, stone, polyp, or tumor in severe cases.
  2. An overactive bladder is more common than you think: Around 40% women have to hit the bathroom every hour or so owing to this. Simple lifestyle changes like lowering the intake of caffeine and alcohol, in combination with pelvic floor exercises can decrease the problem. However, a urologist can help you to diagnose and treat this condition successfully.
  3. Women must go for urination after sex: Urinary tract infections are very common in sexually active females. During intercourse lot of vaginal bacteria gets entry into urinary bladder. If woman voids after sex, majority of bacteria are thrown out and rest are handled by body immunity. But if you sleep over with all these bacteria, you are more likely to suffer with UTI.
  4. Women sometimes pee in their pants too: A majority of the female population between 40 and 60 suffer from either stress incontinence (when you cough, sneeze or laugh) or urgency incontinence (leaking when you want to go badly). Urologist in Noida, Greater Noida, Ghaziabad can help you to know that there are minimal invasive options and medications available to treat this problem.
  5. Pelvic pain: If it is not gynecology then it is urology. A general pain in the pelvic region triggers a visit to the gynecologist first for most women.From menstrual cramps to ovarian cysts, all of this may well be taken care of by your gynecologist. But when the usual culprits are not the cause for your discomfort, it’s time you get the urological aspect examined thoroughly too by a urologist.
  6. Know the difference between UTI and STI: Because of cross symptoms, one often gets mistaken for the other. So check with your urologist in Ghaziabad, Vaishali, Noida to understand the cause and cure of your particular problem.
  7. Recognize pelvic organ prolapse: This condition is defined by a bit of bladder, rectal, or uterine tissue bulging out of your vagina. An urologist can provide minimal invasive options to deal with this.
  8. Women can get kidney stones too: This is true, especially when you forget to hydrate yourself in hot climates or high temperature situations.
  9. Urology can solve some sexual problems too: Whether it’s sexual dysfunction, low libido or trouble reaching orgasm, urologist can play its part to help you out.

Bladder cancer know its symptoms

The urinary bladder is the storage organ which holds the urine before it is voided. This organ is a balloon shaped organ which is located in the pelvic area. Like most forms of cancer, bladder cancer also starts off with the cells within the organ, start mutating and not dying resulting in the buildup of abnormal cells.

Symptoms of Bladder Cancer:

  1. Haematuria or the presence of blood in the urine – This is one of the most common symptoms of bladder cancer. The urine may vary in colour from light to dark red although clear urine can also have blood which can only be detected under a microscope. Typically, hematuria is painless and stops on its own. So if anybody who had blood in urine, must get himself investigated by urologist. Stoppage of blood and thinking that it might be just simple infection can be disastrous.
  2. Frequent and painful urination – Changes in the usual pattern of urination along with other symptoms may be signs of bladder cancer. Some of these are:
    • Very frequent urination
    • Having a very weak stream during urination
    • The urge to urinate even when the bladder is not full
    • Painful or burning sensation while urinating

Although these symptoms are common with urinary tract infections, they may also be signs of bladder cancer and it is best for you to go to your doctor to get it checked.

Other Symptoms – Some of the other symptoms may include:

  • Back or pelvic pain in the area surrounding the bladder
  • Being tired or weak without an apparent reason
  • Feet swelling up
  • Painful bones in some cases
  • Inability to urinate in some cases

Types of Bladder Cancer:

Bladder Cancer is primarily of three types and their causes differ. They are:

  1. Transitional Cell Carcinoma – This is the most common type of bladder cancer and is primarily caused by lifestyle problems such as smoking, radiation or chemical exposure.
  2. Squamous Cell Carcinoma – This is a form of cancer that occurs as a reaction to a parasitic infection(schistosomiasis), stoneor foreign body within the bladder.
  3. Adenocarcinoma – A rare form of bladder cancer, this is also caused by radiation or chemical exposure.

Bladder Tumor

The urinary bladder is a hollow purse like storage organ which collects urine from the kidneys and stores it until it can be passed out of the body through the urethra during the process of micturition or urination. It has a thin inner lining of cells called urothelial cells and a thick muscular wall, which exerts pressure to push the urine out of the body.

Causes of Bladder Tumors

In most cases, the bladder tumor develops on the inner layer due to a combination of some of the following factors.

  1. Hereditary: A strong family history of cancer predisposes a person to cancer.
  2. Gender: Men are 3 times more prone for bladder cancer than women.
  3. Ethnicity: White people are more prone for bladder cancer black people.
  4. Smoking / Tobacco use: Smokers develop bladder cancer 2-6 times more frequently than non-smokers. Tobacco contain toxic, carcinogenic substances which reach the kidney and are stored in the bladder, leading to cancerous changes in bladder.
  5. Occupational hazards: Some workplaces have a higher likelihood of causing bladder cancers, especially dye and rubber industries. The effects can be damaging, and the person may develop cancers years after the exposure has happened.
  6. Recurrent bladder infections: In some people, this can also lead to bladder cancer in the long run.

Types of Bladder Tumor

Depending on the extent of the cancerous spread, it can be of two types:

  1. Non-muscle-invasive bladder tumors: The tumor spread is limited to the inner part of the bladder (urothelial cells)
  2. Muscle-invasive bladder tumor: The tumor has spread to the thick muscular outer layer. This is more advanced and prognosis is poor compared to the noninvasive type.

The most common and diagnostic symptom of bladder cancer is the presence of blood in the urine without pain in abdomen, known as painless hematuria. This is usually intermittent and stops on its own. Therefore any person who is more than 40 year old, has blood in urine, must be checked to rule out bladder tumor. If you miss these early warning symtoms by just thinking simple infection, you may miss the tumor and will be diagnosed later when tumor is advanced.

Other symptoms include pain in the lower abdomen and frequent urination.

Diagnosis

From the most non-invasive to the most invasive diagnostic test, these include:

    1. Urine microscopy and cytology to detect blood and cancer cells in the urine
    2. Ultrasound and CT Scan can define the bladder tumor, its size and spread.
    3. Cystoscopy and biopsy – A tube inserted into the urethra to look into the inner wall of the bladder and biopsy is taken from lesion. It is highly diagnostic and confirmatory.

Treatment

TURBT:Once the tumor is diagnosed, first step of the treatment is endoscopic surgery known as transurethral resection of the bladder tumor (TURBT). The cancerous bladder lesion is resected and removed through a cystoscope. Muscle tissue from the base of tumor is also resected to check the spread of tumor in the muscle. The bladder is then flushed with chemotherapy agent to kill any residual cancer cells in the bladder.

Intravesical BCG Therapy: If muscle is not involved with tumor, this is called superficial tumor. As there is high chance that this tumor may recur or progress, bladder is treated with BCG injection therapy repeatedly for at least 6 weeks to many months. Check cystoscopy is usually done thereafter to check for any recurrence at frequent intervals.

Radical Cystectomy with Ileal conduit or Neo-Bladder: If tumor is involving muscle layer of bladder then whole urinary bladder is removed surgically and urine passage is made at abdominal wall using part of intestine called Ileal conduit. Patient has to wear a bag on abdomen to urine collection and discharge. Now-a-days, artificial bladder is made by patients own intestine which functions like normal bladder and patient passes urine per urethra.

Radical Radiotherapy: This is also an alternative treatment for muscle invasive bladder cancer where bladder is preserved and treated by radiotherapy. Repeated check cystoscopy is required thereafter to check for recurrence.

Chemotherpy: If tumor has advanced to lymph nodes and other body organs, then treatment is chemotherapy where anticancer drugs are injected into veins.

In Summary,

Bladder cancer is usually caused by Tobacco consumption.

Blood in urine even if it stops on its own or by medications, in person over 40 years of age must be evaluated for bladder cancer.

In early stage it can be treated by cystoscopy.

If it involved muscle, bladder is removed and neo-bladder is made.

Hematuria Causes

Presence of blood in urine is called Hematuria. It can be gross hematuria which is visible blood in urine by naked eye. It can be Microscopic Hematuria which is diagnosed by laboratory microscopic examination of urine.

Blood in urine (Hematuria) can never be normal. It is 100 % related to some abnormality in body especially urogenital system. It usually stops on its own or sometimes after taking some medications. But stoppage of blood in urine does not mean that problem has cured. Therefore, it is always important to investigate the cause of blood in urine by Urologist. Thinking that it was because of minor infection can be detrimental as it can be an early sign of cancer.

Common Causes of Hematuria

    1. Stones in Urinary Tract: Commonest reason of Hematuria in Young people is stone disease. It usually is associated with pain in one side of abdomen.
    2. Prostate Enlargement: In males, more than 40 years of age, prostate enlargement causes difficulty in urination. Hematuria can a presentation if prostate problem remains untreated for long.
    3. Bladder Cancer: It is one of the commonest reason of painless hematuria in people above 40 years of age. In bladder cancer hematuria initially is episodic and stops on its own or with minor medications. So, it is very important to investigate the cause of hematuria in every individual despite the fact it stopped with minor medication or its own. Otherwise we may lose the opportunity to diagnose cancer at an early stage.
    4. Urinary Tract Infections: Sometime urinary tract infection may lead to hematuria. But even if it stops after a course of antibiotic, it is important to establish why urinary tract infection occurred. Therefore, even if infection is treated, it should by checked and investigated by urologist for its cause.
    5. Kidney & Prostate Cancer: Cancer of any part of urogenital system like kidney, ureter, urinary bladder or prostate may give rise to blood in urine. It can be first indication of cancer.
    6. 6. Blood Thinners: Cardiac patients do take blood thinners usually. High doses of these antiplatelet or anticoagulant medicines may cause hematuria.

Treatment

      1. Antibiotics: This form of treatment is administered when the cause of hematuria is a urinary tract infection.
      2. Other Medications: There are several other medications to help stop hematuria. But primary treatment is directed toward the cause of hematuria. Symptomatic treatment includes hemosatic medications.

Therefore, it is very important to establish the cause of hematuria. It can be detrimental if we ignore it.

Urinary Tract Infection Causes and Symptoms

Infection caused in the kidneys, ureters, bladder, urethra or prostate gland is known as urinary tract infection(UTI). According to urologist in Noida, Ghaziabad, Vaishali, Greater Noida, sexually active women are generally more at risk of suffering from this condition. Females other than sexually active age group and men are otherwise immune for urinary tract infections. If they got UTI, they should be thoroughly investigated for its cause by a urologist.

Some of the causes which contribute to the development of this infection are:

  1. Females have short urethra: Due to short length of urethra, lot of bacteria got entry into urinary bladder from vagina, during sexual intercourse. Therefore, it is wise for females to urinate after intercourse so that bacteria flush out in urine. If not, these bacteria will lead to UTI.
  2. Prostatitis is very common in young males: Infection of prostate gland is very common in young males. Semen is naturally produced. If a young male does not ejaculate regularly, this stocked up semen leads to prostatitis. That’s why, regular ejaculation is very important for males. Therefore, Masturbation is healthy, not harmful.
  3. Urination after ejaculation in males is harmful: If male urinates immediately after ejaculation, then some urine refluxes into open mouth of prostate glands. Urinary chemicals cause prostatitis. Therefore, males should not void immediately after ejaculation.
  4. Phimosis: In male children, if prepuce does not open properly, it may cause infection.
  5. Unprotected sexual intercourse: Unprotected intercourse may transmit infections to other partner if one partner has infection.
  6. Uncontrolled diabetes
  7. Kidney, ureteric and bladder stones
  8. Prostate Enlargements
  9. Urethral stricture
  10. Congenital disorders in children

Some of the symptoms of urinary tract infection are:

  1. A nagging urge to urinate: One of the most predominant symptoms of urinary tract infection is a persistent, nagging urge to urinate.
  2. There is a burning sensation when you urinate: If you feel a burning sensation while urinating, chances are extremely high that you are suffering from urinary tract infection.
  3. Red colored urine: Sometimes your urine may contain perceptible amount of blood in them.
  4. Foul smelled urine: An internal infection in the urinary tract manifests itself in different ways. One of the chief symptoms of this infection is discharging foul smelling urine.
  5. Pain in the pelvic area: Women who suffer from urinary tract infection experience excruciating pain near the pelvic area, sometimes extending to the pubic bone.
  6. Fever with chills: severe infection may lead to fever with chills and rigors.
  7. Frequent urge for urination: Frequent urination may be a sign of infection.

Symptoms of Prostatic disease

What menstrual problems are to women, prostate problems are to men. The prostate is a gland in the lower abdomen that aids in the production of semen. The prostate is walnut sized in a young man, but can get enlarged with age. As it grows bigger, it can cause a number of problems. These are commonly seen after a man celebrates his 50th birthday.

There are three common prostate problems faced by men. Some of the symptoms that can tell if a man has a prostate problem are:

  1. Difficulty faced while urinating.
  2. The urge to urinate frequently at night.
  3. Constant feeling of a full bladder.
  4. Pain while urinating.
  5. Blood in urine.

Prostatitis

This can be defined as inflammation of the prostate gland. In most cases the cause of this inflammation is unknown. However, there are two types of prostatitis; bacterial and nonbacterial. While the former reacts well to antibiotics, the latter is more difficult to control. Symptoms of this disease vary from one person to the next. Some of the factors that could trigger this disease are:

  1. Chemical irritants
  2. Past bacterial infection
  3. Dysfunctional pelvic floor muscles
  4. Sexual abuse
  5. Chronic anxiety

Enlarged prostate

As mentioned earlier, as men get older, the prostate gland tends to grow in size. This growth is benign, but can block the bladder neck and prostatic urethra. This can cause problems urinating and lead to acute urinary retention. This can be very painful. Inserting a catheter can provide temporary relief and help release stored urine. Chronic retention is much less common and is associated with high bladder pressure and can damage the kidneys.

Prostate cancer

Advancing age and family genetic history are said to be the main triggers of prostate cancer. This type of cancer can remain restricted to the prostate gland in its early stages but may spread to the other glands as the cancer advances. This can also cause the growth of secondary tumors in the bones.

The only way to correctly diagnose a prostate problem is with a thorough physical examination. This includes a digital rectal exam where the doctor will insert a gloved finger into your rectum to check the size of your prostate, a blood test, mid stream urine tests and ultrasounds. In some cases a biopsy of the prostate may also be required. Depending on the diagnosis, urologist in Ghaziabad, Vaishali, Noida may prescribe antibiotics, surgery, radiotherapy or hormone therapy to manage your prostate.

Renal Stones

Our kidneys act as filters which constantly flushes out toxins and excess minerals with water in form of urine. Urine contains lots of minerals which may precipitate and form stones. Urine has lots of pro-precipitating agents and anti-precipitating agents. When their balance disturbs due to some disease, stones start forming.These stones may often lead to abdominal pain which is referred to as renal colic.

What exactly is renal colic?

Renal or ureteric colic is the term used for typical pain in one side of abdomen in flank region starting from back and radiating forward towards lower abdomen up to scrotum. This is usually associated with nausea, vomiting and urinary discomfort. There may be blood in urine.

How kidney stones are related to renal colic?

Kidney stones usually forms inside kidney and lies there without causing any pain. But whenever they are dislodged and stuck at mouth of kidney (pelvis) or anywhere in ureter, they block the passage of urine of that kidney. This causes swelling in kidney termed as hydronephrosis. This swelling in kidney causes renal / ureteric colic.

This colic is protective phenomenon and tries to push out the stones. Small stones do come out in urine by this natural process. This spontaneous expulsion of small stones is common and many local practitioners used to get credit of it feigning benefit of their medicine. However large stones need some form of intervention to come out. Otherwise they do harm to kidneys in long term.

Symptoms of kidney stones along with renal /ureteric colic

  1. Most stones which are lying in calyces of kidney are asymptomatic
  2. Nausea & vomiting
  3. Frequent urinary tract infections
  4. Fever with chills
  5. Foul smelling urine
  6. Hesitency, frequency and burning in urination
  7. Blood in urine (urine with a reddish, pink or brownish hue)
  8. Passage of small stones in urine

Treatment of renal colic

Kidney stone treatment in Noida, Ghaziabad, Vaishali, involve control of symptoms and stone removal.

  1. Expectant Treatment or Medical Expulsion Therapy: Small stones of less than 4 mm size usually passes on its own and some medicines like alpha-blockers and steroid hasten up their expulsion. Medium size stone (4-6 mm), sometimes passes with aid of these medications. But stones larger than 6 mm usually require intervention.
  2. Lithotripsy: This method involves breaking of stones by shock waves into small dusty particles which passes through urine on its own. This is usually suitable for stones upto 1.5 cm and lying in kidneys. This is non operative treatment which can be done by a urologist in Ghaziabad, Noida, Vaishali, on OPD or Day care basis.
  3. Ureteroscopy (URS): This method involves entry of very thin semirigid scope through urethra into ureter. Stone is broken by LASER and removed. This involve single day admission and spinal anaesthesia.
  4. RIRS – Retrograde Intra Renal Surgery: In this method very thin flexible scope in maneuvered through urethra into the upper ureter and pelvi-calyceal system of kidney. Stones in kidney or upper ureter are broken by LASER and removed. This is also done under anaesthesia and require a day admission.
  5. Mini – PCNL: This method is suitable for large renal stones. In this technique, a small hole is made into the kidney through back and tiny scope is entered into the kidney. Stones are broken by LASER and removed. This is done under anaesthesia and require two to three days admission.

Prostate Cancer

Prostate gland is a small walnut sized gland situated below urinary bladder and produces part of semen. In older age groups, enlargement of prostate gland is the commonest urological problem. This enlargement can be benign (BPH – benign enlargement of prostate) or malignant (prostatic carcinoma).

Prostate cancer is second most common cancers in males. Although prostate cancer can be a slow-growing cancer, it is a leading cause of death.Most of the cases in India present in advance stages leading to high death rates.The last two decades in particular have witnessed an upsurge in its incidence attributed to changing lifestyles and increased proportion of elderly populations.

Old age, repeated prostatic infections, obesity and smoking habits heightens the risk of cancer prostate. Races like African-American are at highest risk than whites. Positive family history also increases the risk.

Clinical presentation

Most patients with early prostate cancer are asymptomatic. Presence of symptoms suggests advance stage. Patient may have urinary symptoms likes poor flow, urinary frequency, blood in urine, urinary leakage, unable to hold urine, waking up multiple times in night for urination and feeling of incomplete urination after voiding. If the disease has spread to bones, it may cause bone pain. Involvement of spine may lead to weakness of lower limbs and paralysis.

Diagnosis

DRE & PSA

Digital rectal examination by urologist involves feeling of prostate gland through anal opening. Any hardness in prostate gives suspicion of cancer.

Raised value of a simple blood test of PSA (prostate specific antigen) can also suspect prostate cancer. It is advisable to all healthy males to go for PSA test after 40 years of age and repeat test at frequency depending on its result.

Multiparametric MRI of prostate

If DRE or PSA suspects cancer prostate, Multiparametric MRI provides non-invasive localization of cancer. This uses multiple parameters like hypoechogenecity, contrast enhancement, ADC value, spectroscopy and cystine – choline ratio to decide nature of lesion. This new modality is highly accurate in suspecting cancer and differentiating it from infection but still not confirmatory.

Prostate Biopsy

If DRE, PSA or MRI suspects cancer prostate, biopsy is required to prove it. This involves taking of prostatic tissue by needle placed through anal opening guided by ultrasound probe. The tissue taken in biopsy is examined by pathologist to confirm the prostate cancer.

Staging and risk assessment

MRI and Bone scan (if very high PSA) are done accordingly to decide the stage of the cancer. The Stage of cancer means about the level of spread of the tumor in the body. Cancer may be confined inside the prostate gland within its capsule (Localised disease), may spread locally outside capsule (Locally advance disease) or may spread to bones, lymph nodes, liver, lungs or brain (Metastatic / advanced disease). Further treatment depends upon the stage and grade of cancer.

Treatment

Early Disease

Options for the patients with early / localised disease are wathchful waiting, surgery and radiotherapy. Watchful waiting is an option for patients with low grade disease (gleason score6 or less and low PSA) or very old patients with other diseases or poor life expectancy. However they will need definitive treatment in case of progression of disease.

Surgery in form of Radical Prostatectomy is an option for patients with good life expectancy (more than 10 years) and age less than 75 years with localised disease. It involves removal of entire prostate gland through abdomen and it cures the cancer. Person will have the normal life span after surgery. It can be performed by open method, Laparoscopic method or with Robotic assistance. It has the side effect of temporary urinary leakage.

Radiotherapy is indicated in patients with localised or locally advanced disease who are elderly, unfit or unwilling for surgery. This also completely cures the cancer and gives normal life span to the patient. With the advances in machines and technology, side effects of radiotherapy due to the burning of adjoining tissues have reduced significantly. Its side effects include burning, frequency and blood in urination, diarrhoea and blood in stool.

Advanced / Metastatic Disease

Hormonal manipulations– Prostate cancer cells growth depend upon the availability of Testosterone hormone which is produced in the testis. If both testes are removed surgically or blocked medically by hormonal blocking injections and tablets, cancer stops to grow and regresses. Even in case of advance prostatic cancer, this manipulation gives years of trouble free life. Its side effects include loss of vigour and bony weakness. Calcium supplementation and bisphophonates are given to prevent and control these side effects.

However, after some years of hormonal manipulations, some smart cancer cells learn to grow on other feeds rather than Testosterone hormone or produce their own hormone and leads to CRPC (Castration Resistant Prostate cancer)condition. Here comes the role of chemotherapy i.e. drugs which are given via intravenous routes to kill these cancer cells. These are toxic but in this way some months are available to the patient. Vacccination therapy can also provide some months to life of the patients of CRPC.

Supportive / palliative treatment– The patients of advance cancer with urinary retention can be relieved by endoscopic scrapping of prostate (TUR Channelling). Obstruction of ureter and renal failure by cancer can be treated by ureteral stenting or tube drainage of kidneys (PCN). Bony pain due to metastasis can be controlled by calcium supplementation, Bisphosphonates and localised radiotherapy.

Conclusion

Prostate cancer is one of the most common cancers affecting the aging males. It is slow growing but due to late presentation it leads to debility, suffering and death. It can be diagnosed in early stage by easily available tests. If treated in early stage it gives 100% life expectancy. Even in advance stage effective treatment options are available to give the patients “useful years” of life.

Dr. Shailendra Kumar Goel

M.S., M.Ch., D.N.B., M.B.A., M.N.A.M.S.

Principal Consultant Urologist, Andrologist & Renal Transplant surgeon

Max Super Speciality Hospital, Vaishali& Noida