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Cancer of Prostate

The prostate is a pear shaped gland about the size of a small lime. It situated at the outlet of the bladder and the water passage passes through this gland. It is thus very deep in the pelvis with the pubic bone lying in front and the rectum behind it. The gland can be examined by your doctor through the back passage across the rectum. The urine control muscles, called sphincters are closely related to this gland.The function of the prostate is to add secretions to the semen to maintain the health of the sperms.

Incidence

The incidence of Prostate Cancer increases with age with three quarters of the cases occurring in men above 65 years of age.The incidence of prostate cancer shows wide variations across countries. The highest rates of 104.2/100,000 are seen across Australia/New Zealand , Western and Northern Europe, and North America . The estimated age-adjusted incidence rates of prostate cancer in India as a whole was 3.7/100,000 persons during the year 2008 . Wide variations of incidence are also reported between different regions within India. Higher incidence is present in metro cities and in North India compared to South India. However, the incidence of prostate cancer is showing an increasing trend in India. It was 17.76% in 2007 reaching 28.9% in 2010. Globally, studies have shown that prostate cancer is the second most frequently diagnosed cancer in men and the fifth most common cancer overall.

References

1 Ferlay J, Shin HR, Bray F, et al. GLOBOCAN 2008 v 1.2, Cancer Incidence and Mortality Worldwide: IARC Cancer Base No. 10. Lyon, France: International Agency for Research on Cancer; 2010.   2.Chatterjee A. Risk of prostate cancer in Eastern India. Int J Can Res 2012;8:63-8.

Diagnosis of Prostate Cancer

Early prostate cancer can be totally asymptomatic. When symptoms set in they can be similar to non cancerous enlargement. The most frequent complaint is difficulty with urination, increased frequency, pain on urination and occasionally, blood in urine . More advanced stage of the disease may present with urinary retention. Prostate cancer can spread to bone and cause back pain.

Screening for Prostate Cancer

The three important aspects of screening for prostate cancer is by examination by Urologist, PSA blood test and when required by Trans Rectal Ultrasound scan. Screening is done typically for population above 50 years of age and 40 years in first blood relations. The advantage of screening is to be able to diagnose the disease at a stage when cure is possible. The disadvantage is that it will diagnose some prostate cancers which may not have in anyway affected the health of the patient as some prostate cancers are extremely slow growing. However, research is still on to reliably distinguish this group of patients.

Tests

Besides examination of the gland by your Urologist, blood tests and sometimes high resolution multi parametric MRI scan may be advised by your doctor.

Biopsy

In the event of high suspicion for prostate cancer, the definitive diagnosis will require a biopsy. Biopsy of the prostate can be done without much discomfort using a transrectal ultrasound scan. We admit the patient on the day of biopsy and discharge the next day.

Treatment Options at Early Diagnosis

The three important aspects of screening for prostate cancer is by examination by Urologist, PSA blood test and when required by Trans Rectal Ultrasound scan. Screening is done typically for population above 50 years of age and 40 years in first blood relations. The advantage of screening is to be able to diagnose the disease at a stage when cure is possible. The disadvantage is that it will diagnose some prostate cancers which may not have in anyway affected the health of the patient as some prostate cancers are extremely slow growing. However, research is still on to reliably distinguish this group of patients.

Screening for Prostate Cancer.

When diagnosed early, curative treatment is possible in a good number of patients.

1. Surgery

Radical Prostatectomy – Open surgery, Laparoscopic surgery, Robot assisted laparoscopic Surgery.

In Radical Prostatectomy the prostate gland is removed completely. This involves division of the bladder neck at the proximal part of the prostate and urethra at the distal end liberating the prostate completely. The gland is then separated from the rectum preserving if possible the nerves that supply the erectile function and the sphincters that control the uncontrolled leakage of urine (continence).

All types of surgery – Open , Laparoscopic or Robot assisted laparoscopic surgery gives the same results. However, Laparoscopy has several advantages over open surgery. As the visibility of the prostate gland in the depth of the normal male pelvis is much better during laparoscopy, there is less blood loss and greater accuracy in repair of the bladder and urethra. Hence removal of the catheter in the water passage can be done much earlier and the incidence of incontinence of urine may be lesser after laparoscopy. The post operative pain from laparoscopic keyholes will of course be far less than the open surgical wound. In Robot assisted surgery the laparoscopic surgery can be performed faster.

As cost is an important criteria in choosing treatment in India, the most cost effective surgical technique is pure laparoscopic. Robot assisted surgery requires the use of a Rs 20 crore robot increasing the treatment cost to be more by several multiples.

2. Radical Radiotherapy -

When the patient is not medically fit to undergo a major surgery radical radiotherapy is an alternative effective curative therapy.

Palliative Treatment

In some cases. For example - When the diagnosis of cancer is not early the disease progression can be delayed by hormone treatment. This can be done with equivalent results by either simple surgery, regular injections or tablets.

A Pre Operative Check up & Preparation.

After the doctor does the necessary investigations regarding the stage of the prostate cancer he will tell you the treatment most suitable for you.

  • You will be send to the physician for a complete medical check up. This will include blood tests, grouping, ECG and chest X ray.
  • Stop smoking, walk for 1 hour every day and have a healthy diet while you are awaiting surgery.
  • Surgery is done 6 weeks after biopsy or 12 weeks after any previous prostate surgery
  • You will have to arrange 3 units of blood.
  • You will be admitted the day before surgery. A strong purgative will be used in the afternoon to clear your bowels. After this only light easily digestible food should be taken.

On the Day of Surgery & Immediately After

  • Surgery may last from 4 to 8 hours.
  • After surgery bystanders will be informed by phone and one person can visit you in the surgical ICU.
  • Normally you will be shifted back to your room the next day afternoon.
  • You will be able to sit up with very little pain on the first post operative day itself.
  • There will be a urethral catheter in your water passage and a drain which is brought out through one of the keyhole used during surgery..
  • You will have to abstain from taking any food or drink for 1 or 2 days - this instruction will be given to you by the surgeon.
  • The drain is removed when all drainage stops - usually on the 5th day.
  • Usually you will be allowed to go home on the 6th or 7th post operative day. The urethral catheter is not removed. It will be connected to a bag.

Re Admission for Catheter Removal

  • You will be re admitted after 1 to 3 weeks for catheter removal.

Urinary Continence After Catheter Removal

When the prostate is removed or ablated by radiotherapy, part of the urethral sphincter ( the muscle that controls urinary continence) will be destroyed as this part is in the gland itself. The remaining sphincter therefore has to do the work of the part that was removed (or destroyed by radiotherapy). This may take time. Hence statistically about 50% of patients after surgery will be continent on removal of the catheter and 90% after 3 months. Continence improves up to 2 years.

If there is still incontinence - surgical correction is possible to a certain extent. In the meantime the alternatives are - adult diapers and penile clamps..

Potency After Treatment

The nerves that control penile erection are microscopic and intimately attached to the prostate gland. Great care is taken during surgery to prevent damage to them. However, impotence is a complication for this surgery (or radiotherapy)

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