Prostate Biopsy : How is prostate cancer diagnosed?

A prostate gland  biopsy is a test to remove small samples of prostate tissue to be examined under a microscope.

For a prostate biopsy, a thin needle is inserted through the rectum (transrectal biopsy), through the urethra, or through the area between the anus and scrotum (perineum). A transrectal biopsy is the most common method used. The tissue samples taken during the biopsy are examined for cancer cells.

A biopsy may be done when a blood test shows a high level of prostate-specific antigen (PSA) or after a digital rectal examination finds an abnormal prostate or a lump.

Why It Is Done

A prostate biopsy is done to determine:

·         If a lump found in the prostate gland is cancer.

·         The cause of a high level of prostate-specific antigen (PSA) in the blood.

How To Prepare

Tell your doctor if you:

·         Have had any bleeding problems.

·         Are allergic to latex or any medicines, including anesthetics.

·         Take any medicines regularly. Be sure your doctor knows the names and doses of all your medicines.

·         Are taking any blood-thinning medicines, such as warfarin (Coumadin), heparin,enoxaparin (Lovenox), aspirin, ibuprofen, or other nonsteroidal anti-inflammatory drugs (NSAIDs).

You will be asked to sign a consent form that says you understand the risks of the test and agree to have it done.

Talk to your doctor about any concerns you have regarding the need for the biopsy, its risks, how it will be done, or what the results will mean. To help you understand the importance of the biopsy, fill out the medical test information form.

If a prostate biopsy is done under local anesthesia through the area between the anus and scrotum (perineum), no other special preparation is needed.

If the biopsy is done through the rectum, you may need to have an enema before the biopsy.

If the biopsy is done under general anesthesia, your doctor will tell you how soon before surgery to stop eating and drinking. Follow the instructions exactly about when to stop eating and drinking, or your surgery may be canceled. If your doctor has instructed you to take your medicines on the day of the surgery, please do so using only a sip of water.

During preparation for the biopsy, an intravenous line (IV) is inserted in your arm, and a sedative medicine is given about an hour before the biopsy.

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How It Is Done

This biopsy is done by a doctor who specializes in men's genital and urinary problems (urologist) in the doctor's office, a day surgery clinic, or a hospital operating room.

Before your prostate biopsy, you may be given antibiotics to prevent infection. You may be asked to take off all of your clothes and put on a hospital gown.

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Enlarged Prostate or Benign Prostatic Hyperplasia Treatment in India

Men facing prostate cancer now have several choices when it comes to their treatment. The man’s age, his general health, how much importance he places on preserving sexual function and whether the disease has spread are factors in determining the choice of treatment.

When the disease has not spread further than the prostate gland, there is a high chance of cure with surgical removal of the entire prostate gland or radiation therapy. Complete removal of the prostate gland offers the highest cure rate. Another option for prostate cancer patients is external radiation. Low-dose radiation treatments are given daily for approximately seven to eight weeks.

The newest treatment for men with prostate cancer caught in the early stages is called radioactive seed implantation therapy. This treatment involves implanting approximately 100 tiny radioactive seeds in the prostate gland where they destroy cancerous cells while leaving healthy tissue intact. This FDA-approved procedure has proven as effective as other prostate cancer treatment options, such as surgery or external radiation therapy.

Prior to the implantation procedure, the patient visits the urologist and radiation oncologist for an initial consultation and planning study. The planning information is then used by the radiation oncology physicist and dosimetrist to plan the implant and order the seeds. The actual implantation procedure is done using ultrasound to guide the placement of the seeds in the prostate gland. The seeds are distributed evenly throughout the gland to deliver radiation in a highly-targeted way.

Compared with other methods of treating prostate cancer, the radioactive seed implant therapy has few side effects. Most men can resume normal activities within a day or so, although some may experience side effects, such as more frequent urination or impotence. These symptoms are usually temporary and disappear over time or with medication.

By age 80 a majority of men are found to have a small prostate cancer, if tested. In most of these cases, however, the cancer causes no symptoms and requires no treatment. Since prostate cancer may develop very slowly, these elderly patients may choose "watchful waiting" instead of one of the curative therapies. In patients whose life expectancy is five years or less, the best treatment may be conservative management such as observation or hormonal therapy.

Choosing a Treatment

When faced with prostate cancer, men should discuss all of the treatment options -- radioactive seed implantation, surgery, hormonal therapy, external radiation and watchful waiting -- with a specialist. It is sometimes helpful for prostate cancer patients to bring a family member along for the initial visit with the urologist and to consider obtaining a second opinion from a radiation oncologist to discuss treatment options. At that visit, the patient and/or family might wish to ask the following questions:

• Is the cancer localized to the prostate gland or has it spread to other organs?
• Will there be a biopsy of the tumor? If so, what does this show?
• What are the options for treatment? What are the potential risks and complications of each? What are the benefits of each?
• Given the patient’s age and other medical conditions, what does the doctor feel is the best option?

By discussing these and other issues, the patient, his family and his physician can make a decision that best suits his specific circumstances, concerns and needs.

 Laser Prostatectomy : is the latest trend in BPH and prostate cancer surgeries because they have lesser blood loss and quicker recovery period. But long term effects of this surgery are yet to be determined. 

There are four Types of Laser Surgeries: 
1. Green Light PVP Laser : This procedure uses green light to vaporize the prostate and useful for majority of patients with enlarged prostate. A tube with light and lens called the cystoscope is inserted into the penis. The laser beam is introduced through the cystoscope and directed towards the prostate. It creates high energy which vaporizes the excess tissue and relieves the urethral blockage. The procedure is done in a short time and the patient can go home the same day and resume daily non strenuous activities within a couple of days.
The image on the left shows an enlarged prostate constricting bladder flow. The image on the right shows the prostate after laser PVP surgery. 
2. Holmium Laser : This is the most commonly used technique and is performed under general anaesthesia. The laser of 2140nm wavelength and 0.4mm penetration is introduced through the cystoscope that is inserted into the penis at the start of the procedure. The laser cuts and vaporises the enlarged prostate tissue and relieves urinary blockage. Some tissue pieces are directed to the bladder from where they are flushed out. The procedure is done in a short time and the patient can go home the same day or the next day and resume daily non strenuous activities within a couple of days. The procedure is relatively bloodless. 
3. VLAP : This procedure has many disadvantages and has become virtually obsolete with the coming of Holmium Laser. The technique uses neodymium:yttrium-aluminum-garnet (Nd:YAG) laser which has a wavelength of 1064nm. The laser beam is directed towards the prostate gland via the cystscope. The beam generates a lot of heat which coagulates the gland tissue. The surgery is performed under regional or general anaesthesia. The technique was not popular among patients as the coagulated portion caused irritation. Also the urine catheter had to be kept for long. Soon this was replaced by Holmium Laser. 
4. ILC : Interstitial Laser coagulation therapy was used to coagulate tumours which could not be cut and removed especially in the brain, neck, liver, pancreas etc. in this procedure the laser probe is in direct contact with the prostatic tissue and generates temperature of 60 degrees Celsius which destroys the cell protein. The destroyed cells are absorbed in due course of time and a shrunken prostate gland remains. The urethra is not affected. The procedure is performed under general or regional anaesthesia. The rigid laser probe is inserted through the cystoscope and pushed till it enters the prostate after which it is activated to produce the heat. The effect is localised to the prostate tissue only.
d) Robotic Prostatectomy : This procedure is carried out using the computer and is an advanced form of minimally invasive surgery. In this technique, small incisions are made in the lower part of the abdomen and the entire surgery is carried out using Tele-manipulator. The surgeon performs actions, which moves the Tele-manipulator which in turn is connected to the robot’s arms which replicate the surgeons hand movements and perform the surgery. The surgery is controlled remotely but involves great precision because of which it is soon becoming very popular. The procedure has resulted in favourable outcome as there is less blood loss, faster recovery and shorter hospital stay. 
Surgeons also perform laparoscopic robot assisted surgeries using the Da Vinci system which uses miniature surgical tools to carry out the surgery through the keyhole incisions. This method is gradually gaining popularity in treatment of prostatic cancers as there is great precision involved while removing the prostate gland without affecting the other tissues. 
e) HIFU : High intensity focused ultrasound is the new treatment approach that has evolved for the treatment of prostate cancer. The focused high energy ultrasound beam is targeted towards the cancerous cells which may be very small or very big which results in intense heating up of these cells causing their death. Since this treatment does not involve any side effects that are seen with chemo and radiotherapy, it is fast gaining popularity among the patients. The patients can go home after a single night stay in the hospital. The surgery is carried out under general or spinal anesthesia. The ultrasound probe is inserted through the rectum and emits high energy ultrasound towards the prostate gland which destroys the cancer tissue. The chance of recurrence is very less and side effects like erectile dysfunction and urinary incontinence are rarely seen. Hifu has been used successfully in Europe but is still in the clinical trial stage in United States. 
After surgery, the patient is advised not to lift heavy weights or do strenuous work for 2-3 weeks and drink plenty of water. Regular physician checkup should be done as advised. Patients attain their pre-surgery status sooner in laparoscopic, laser assisted or robotic surgeries as compared to traditional open surgeries.

Minimally Invasive Robotic Prostate Surgery in India

Robotic Prostate Surgery Service - where a minimally invasive robot assisted radical prostatectomy technique eradicates prostate cancer with minimal post surgery complications

The mission of “Minimally Invasive Robotic Prostate Surgery Program” is to leverage latest technology to and treat prostate disease through small incision and great precision resulting in:

·  Shorter hospital stay, Faster recovery and return to normal activities

· Less pain and scarring , Reduced blood loss and need for blood transfusion

·  Reduction in the use of pain medicines, Decreased postoperative pain

Usually in conventional approach surgeons make decisions using tactile and visual cues to identify a phenomenon, which is actually microscopic which is likely to damage nerves or to leave some cancer behind.  Sometimes it is difficult for surgeons to find a precise plane between the cancer and urinary sphincter or the nerves and err on the side of cancer safety leading to incontinence or Impotence

Highly trained Indian surgeons who have worked for decades at some of the global centres of excellence now use Advanced Robotic technique gives surgeon a sophisticated master slave robot that seamlessly translates the surgeon's movements at the computer console into precise, real-time movements of the surgical instruments inside the patient. This ensures that the Prostate is removed excellent outcomes and minimal chances of cancer left behind after the surgery.

If you're young and in good health, the short-term risks of this surgery are low. The hospital stay is usually 2 to 3 days, with the catheter left in place for 2 to 3 weeks. You're usually able to go back to work in about 1 month. You shouldn't have severe pain with this surgery. Most men regain bladder control a few weeks to several months after the surgery.

The main advantage of surgery is that it offers the most certain treatment. That is, if all of the cancer is removed during surgery, you are probably cured. Also, the surgery provides your doctor with accurate information about how advanced your cancer is, since the nearby lymph nodes are taken out along with the tumor.

 Surgery does have risks. The main risks of radical prostatectomy are incontinence (loss of bladder control) and impotence (loss of the ability to get or keep an erection long enough to have sex). Most bladder and impotence problems improve with time.

 

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Green Light PVP Surgery of Prostate in India

This lasertreatment of the prostate is a new, minimally invasive surgical technique for treating Benign Prostatic Hyperplasia (BPH), or enlargement of the prostate. Greenlight HPS utilizes a specially designed laser light source and fiber optic delivery system developed by Laserscope in concert with researchers from the Mayo Clinic and other institutions around the world. The PVP procedure combines the immediate symptom relief and the dramatic flow rate improvements of the current "gold standard" procedure (called TURP or Trans-Urethral Resection of the Prostate) with minimal side effects, fast operative and recovery times, and usually no need for a catheter after surgery.

No other BPH treatment option has been shown to clinically provide such dramatic and immediate symptom relief while concurrently providing significant uroflow results and minimal, if any, side-effects. The PVP technique is a fast, outpatient treatment that will satisfy both the subjective (symptom relief) and objective (uroflowometry results) outcomes of a successful BPH treatment. Other minimally invasive BPH treatment options (such as TUMT, microwave, TUNA, thermotherapy) require compromises to be made by the patient and/or the physician. With PVP, there are no compromises, patient's symptoms are drastically reduced and flow rates are significantly improved.

Green Light PVPSurgery of Prostate 

The PVP (Photoselective Vaporization of the Prostate) Procedure that uses the Green Light PV laser system offers a unique and simple solution to Benign Prostatic Hypertrophy (BPH) because it combines the effectiveness of TURP, the surgical "gold standard" with the safety, comfort and ease of a minimally invasive treatment.

The PVP Procedure uses a very high powered laser to immediately vaporize and precisely remove enlarged prostate tissue. PVP (Photo-Selective Vaporization of the Prostate) is performed with the KTP laser by Laserscope (Greenlight PVP). This laser treatment of the prostate is a new, minimally invasive surgical technique for treating Benign Prostatic Hyperplasia (BPH), or enlargement of the prostate. 

Greenlight PV utilizes a specially designed laser light source and fiber optic delivery system.

The PVP procedure combines the immediate symptom relief and the dramatic flow rate improvements of the current "gold standard" procedure (called TURP or Trans-Urethral Resection of the Prostate) with minimal side effects, fast operative and recovery times, and usually no need for a catheter after surgery.

No other BPH treatment option has been shown to clinically provide such dramatic and immediate symptom relief while concurrently providing significant uroflow results and minimal, if any, side-effects. The PVP technique is a fast, outpatient treatment that will satisfy both the subjective (symptom relief) and objective (uroflowometry results) outcomes of a successful BPH treatment. Other minimally invasive BPH treatment options (such as TUMT, microwave, TUNA, thermotherapy) require compromises to be made by the patient and/or the physician. With PVP, there are no compromises, patient's symptoms are drastically reduced and flow rates are significantly improved.

The PVP procedure is performed in an outpatient setting, typically a hospital or surgical center, with average operative times normally less than 60 minutes. The GreenLight PV surgical laser system, which is used to perform the KTP laser PVP treatment, delivers laser light pulses through a specially designed fiber optic delivery device that is inserted through a standard cystoscope. The light pulses are directed towards the prostate tissue. The laser quickly vaporizes and removes the prostatic obstruction without significant bleeding.

Once the procedure is completed, patients have immediate post-operative symptom relief and dramatic improvements in symptoms, urinary flow rates, and bladder emptying.

Cost Estimate for Laser ProstateSurgery in India

Cost Estimate for Laser Prostate Surgery is $5000 US Dollars - Cost Estimate for above include stay in a Private Room for 4 days at the hospital, More accurate treatment cost estimates can be provided if medical reports are emailed to us or after the patient is examined by doctors after arrival at hospital in India and medical tests are done after admission. For more information visit:          http://www.medworldindia.com                           https://www.facebook.com/medworld.india Please scan and email your medical reports  to us at care@medworldindia.com and we shall get you a Free Medical Opinion from India’s Best Doctors. Call Us : +91-9811058159 Mail Us : care@medworldindia.com

Advantages of Robotic Surgery for Prostate Cancer in India

Robotic laparoscopy prostatectomy offers several advantages. Although experts do not agree as to whether robotic or open surgery is best, the majority of prostate cancer surgeries in the U.S. are being done with the laparoscopic/robotic approach, particularly at high volume medical centers that specialize in prostate cancer treatment. The post-operative goals for treating prostate cancer are the same regardless of whether the operation is done with an open or laparoscopic approach.

Da Vinci master slave robotic system is used to completely eradicate cancer with minimal side effects for treating Prostate Cancer. Through this system a minimally invasive robot assisted radical prostatectomy technique has been developed in which doctors evolved a unique sequence of surgical steps.

The Da Vinci is a sophisticated master-slave robot that incorporates 3-D high definition visualization, scaling of movement, and wristed instrumentation. The operations with the Da Vinci System are performed with no direct mechanical connection between the surgeon and the patient. The surgeon is working a few feet away from the operating table, while seated at a computer console with a three-dimensional view of the operating field.

Less Scaring

The first advantage to robotic surgery is that it is an application of advance technology and is minimally invasive. Instead of having a 5 or 6” incision to the skin and abdominal fascia (See image below, left), patients have a series of small “band-aid” incisions.

A Shorter Hospital Stay

With smaller incisions, the postoperative pain is significantly less, which means your length of hospitalization is shorter - as is the time to return to usual activity.

After the laparoscopic/robotic prostatectomy patients typically do not require an inpatient hospital stay over one night. Surgery is done in the morning and they typically go home after lunch on the first operative day.  Comparitively, after the open prostatectomy patients spend at least two nights in the hospital primarily for pain control, nausea and difficulty getting out of bed and getting back to an activity level that would be appropriate for them to be discharged home. .

Postoperative Catheterization

The third advantage of robotic surgery over open surgery is a reduction in the required postoperative catheterization time. After open surgery, foley catheters are left to drain the urine for usually two or more weeks. After the robotic approach, the catheter typically remains in place 5 to 7 days. The reason for this difference is unclear but may be related to the increased precision and visibility the robotic approach offers and also maybe that a running anastamosis (bringing the bladder neck and urethral sphincter back together) may be done in a water-tight fashion compared to the open approach.

Erectile Function

The fourth advantage of robotic prostatectomy is the (at least theoretical) improved ability to preserve the erectile nerves. During an open prostatectomy through an incision on the anterior abdominal wall, the nerves that provide erection are hidden behind the prostate. The approach taken using the surgical robot, enters the abdomen and the robotic arms are positioned posterior to the prostate with the nerves directly in front of the robotic/laparoscopic camera. In this way, the nerves maybe preserved, primarily because the anatomy can be seen more clearly compared to open surgery.

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Laser Treatment and Diagnosis for Enlarged Prostate (BPH)

Diagnosis for Enlarged Prostate (BPH)

Clinical symptoms and physical examination provide the basis for diagnosis of Enlarged Prostate or Benign Prostatic Hyperplasia. The physical examination includes a digital rectal examination (DRE). 

Digital Rectal Examination (DRE)
DRE typically takes less than a minute to perform. 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, like the fleshy tissue of the hand where the thumb joins the palm. Malignant tissue is firm, hard and often asymmetrical or stony like the bridge of the nose. If the examination reveals the presence of unhealthy tissue, additional tests are performed to determine the nature of the abnormality.

PSA Test

Blood test to check the levels of prostate specific antigen (PSA) in a patient who may have BPH helps the doctor to eliminate the diagnosis of prostate cancer.

Uroflowmetry Test
This is a simple test which records the urine flow to determine how quickly and completely the bladder can be emptied. With a full bladder, the patient urinates into a device that measures the amount of urine, the time taken, and the rate of urine flow. Patients with stress or urge incontinence usually have a normal or increased urinary flow rate, unless there is an obstruction in the urinary tract. A reduced flow rate may indicate BPH.

Post-Void Residual (PVR)
This test measures the amount of urine that remains in the bladder even after urination. The patient is asked to urinate immediately prior to the test and the residual urine is determined by ultrasound. PVR less than 50 ml. generally indicates adequate bladder emptying and measurements of 100 to 200 ml or higher often indicates blockage.

Laser Treatment for Enlarged Prostate (BPH)

Holmium Laser Enucleation of the Prostate (HoLEP)

Holmium Laser Enucleation of the prostate (HoLEP) is a modern alternative to the standard Transurethral Resection of the Prostate (TURP) procedure for bladder outflow obstruction due to BPH. It requires a short period of hospitalisation and an anaesthetic.  A catheter (a tube which drains the bladder) is also needed for 1-2 days until the urine clears. Patients are advised to take life quietly and to avoid straining or heavy lifting for four weeks after the surgery.

Holmium Laser Enucleation of the prostate (HoLEP) is a modern alternative to the standard Transurethral Resection of the Prostate (TURP) procedure for bladder outflow obstruction due to BPH. It requires a short period of hospitalisation and an anaesthetic.  A catheter (a tube which drains the bladder) is also needed for 1-2 days until the urine clears. Patients are advised to take life quietly and to avoid straining or heavy lifting for four weeks after the surgery.

What are the advantages of HoLEP

• There is no upper size limit of prostate that can be dis-obstructed – traditionally men with prostates over 100ml in size needed major open surgery
• There is often less bleeding than after a TURP
• Discharge is often quicker than after TURP at 1-2 days
• The chance of recurrence requiring further surgery is very low
• Unlike greenlight laser operations, large quantities of prostate tissue are sent for pathological analysis
• The PSA generally drops to very low levels after HoLEP operations

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