Benign Prostatic Hyperplasia (BPH)

What is a prostate?

The prostate gland is part of the male reproductive system. It is about the size and shape of walnut. As pictured in the diagram, the prostate is located below the bladder and in front of the rectum. The prostate surrounds a tube called the urethra that carries urine from the bladder out through the penis. The main function of prostate is to produce fluid for semen.

Benign prostatic hyperplasia is a nonmalignant enlargement of the prostate and is the most common benign tumor in males, requiring 1.7 million physician office visits each year and results in more than 300,000 prostatectomies.

The prostate weighs only a few grams at birth but undergoes two different growth cycles during the life span of the average male. First at puberty the prostate undergoes androgen-mediated growth and reaches approximately 20g by age 20 . It remains this size until about the fifth decade of life when it undergoes a second increase in size in the majority of males.

BPH  will affect men starting in their forties and will increase so that by the time men are in their seventies, 90% will have some degree of prostatic  hyperplasia.

Etiology

The exact cause of prostratic hyperplasia is not known. However, two clear criteria necessary  for the occurrence of prostatic hyperplasia are an increase in age and the presence in testes. The androgen that mediates the growth of the prostate at all ages is dihydrotestosterone (DHT), which is formed within the prostate from plasma testosterone. As men age, the production of estradiol increases in relation to other androgens.

Symptoms

The symptoms of BPH are those associated with obstruction or irritation of the posterior urethra. These symptoms may include frequency, nocturia, dysuria , hesitancy in initiating voiding , dribbling after voiding, diminution of the caliber and force of the urinary stream, the sensation of incomplete emptying , and finally urinary  retention. Early on in the disorder the symptoms may be minimal due to the compensatory effect of the musculature of the bladder. However, as the disorder progresses symptoms will worsen.

Diagnosis

The initial evaluation of a patient with these symptoms should include a detailed history focusing on the urinary tract. Symptoms may also be quantified with the use of the AUA Symptom Index. A digital rectal exam should also be performed at this time for characterization of the size, consistency , and shape of the gland . It should be noted that the size of the prostate does not always correlate with obstruction of the urethra and often a seemingly small prostate can produce symptomatic obstruction.

There are a variety of tests available to the practitioner in the evaluation of prostatic hyperplasia. It should be noted however that although these tests may help to quantify a patient’s condition they are often not indicative of symptoms.

Treatment

Current treatment strategies for BHP  are dependent on the severity of the patient’s symptoms . Patients with mild disease benefit most from conservative monitoring . If symptoms progress patients may receive medical therapy for there symptoms. Patients with mild diseases benefit mostly from conservative monitoring. If symptoms progress patients may receive medical therapy for their symptoms .

What are the various Treatment Choices

Treatment choices for Benign Prostatic Hyperplasia

Watchful waiting: If you have no symptoms are not bothered by your symptoms or have moderate or severe symptoms but have not developed other urinary tract problems you may choose to visit your doctor once a year or sooner if you conditions changes. If your symptoms  becomes worse talk to your doctor about other treatments

Medical Treatments for Benign Prostatic Hyperplasia :

Two types  of medications may help relieve the symptoms of BPH . In some cases these medications may be combined together

Drugs that help relax the muscles of the prostate .These drugs are called alpha blockers .They include Tamsuloson, Alfuzosin,Doxazosin and Teraosin .Although all four drugs work equally well there are slight differences in the side effects of each one

Drugs that hep the prostate to shrink. These drugs are inhibitors of the 5  Alpha reductase  enzyme and include finasteride and dutasteride .,Your Doctor  may recommend this type of drug if you have an enlarged prostate . You will need to see your doctor on a regular basis if you take this drug. Because these drugs change as a result of your PSA test by lowering it about 50% (for example from 4 to about 2 or from 6 to about 3) this test may need to be repeated while you take this drug

Combination therapy; if you have an enlarged prostate and bothersome symptoms of BPH,you may be treated with combination fo both alpha blockers and drugs that shrink the prostate.

Minimally Invasive Treatments:

These treatments  are performed as outpatient procedures and may cause pain and discomfort that are relieved with the administration of an anesthetic .

After the treatment a catheter is placed in the bladder and remains for a few days while you are at home . In general these treatments are better at relieving symptoms than medical therapies but are less effective that surgical procedures

Surgery :

Symptoms may be selected as initial treatments if you have symptoms are particularly bothersome or you have developed other serious problems because of BHP.   You may also select surgery if you have tried medical or minimally invasive treatments and they have not been successful .The choice of surgery should be decided based  on your levels of discomfort, your medical tests results and your doctors suggestions

Transurethral resection of the prostate ( TURP )

This is the most common surgical procedure to treate symptoms of BPH. The procedure involves surgically removing inner portion of the prostate. Under anesthesia the surgeon uses a scope through the Urethra, so that there is no external scan

6. Disorders of  the pancreas

The Pancreas is located at the rear of the abdomen  and is necessary for production of various hormones and its digestive enzymes. Among the important hormones secreted is Insulin.The  Digestive enzymes it secretes are essential for digestion of carbohydrates proteins and fat.

In some people, the pancreas may become inflamed, giving rise to a condition known as ‘Pancreatitis’. Improper  functioning of Pancreas  can lead to disorders such as Diabetes, Malabsorbition.

Chronic pancreatic : Symptoms

Symptoms such as Abdominal Pain which  is intermittent and persistent

This  paid can be of two types ; one is persistemt mid abdominal pain which varies in intensity .In the other type there is intermittent flare ups(bout or attacks of pain ), . This pain is severe and lasts for several hours a day

As the diseases slowly destroys the enzyme producing cells, symptoms may arise such as

Weight Losss

Symptoms of  Diabetes; Frequent urination and tiredness

Bulky smelling stools (steatorrhea)

Diagnosis of Chronic Pancreatitis :

If you visit a Doctor with the above mentioned complaints,  he will suspect Chronic Pancreatitis, even if there is no history of alcohol intake .  He will advise  one  or  more  of  the  following:

Blood Tests :

To check the levels of blood sugar and enzymes such as lipase and amylase.

Computed Tomography : CT scan which reveals the changes in the pancreas.

Magnetic Resonance Imaging : a special MRI called M R C P ( M a g n e t i  c   R e s o n a n c e  Cholangiopancreatography) which shows the structure of pancreas  more clearly than a CT.

What is a Risk?

Other than conditions  such a Diabetes and Malabsportion , people with Chronic Pancreatitis are at an increased risk of developing Pancreatic Cancer.

Treatment:

Lateral Pancreaticojejunostomy

Patients with disabling abdominal pain due to chronic pancreatitis, who have pancreatic ductal dilatation with strictures and calcifications , are best managed by ductal decompression, with special attention to coring out the head of pancreas- Frey procedure

Partial Pancreatic Resection :

Although preservation of pancreatic tissue is desired to maintain both exocrine and endocrine function, partial pancreatic resection( such as distal pancreatectomy or even pancreaticoduodenectomy) is at times the preferred treatment . While alternative procedures such as endoscopic  sphincterotomy and pancreatic  ductal stenting  may provide  short- term relief of symptoms, long –term results are not as good as surgery.

At  Fortis Hospitals, partial pancreatic ressections  are done Laparoscopically  in suitable patients.

In this method, after the anesthestist administers general anesthesia, the surgeon makes a few tiny incisions  in the abdomen. The Abdomen is inflated with Carbon Dioxide to create room for easy maneuvering  of instruments. A miniature video camera  and a laparoscope are  inserted through these holes. The  camera sends a magnified image from  inside  the body  to a video monitor, giving the surgeon a close-up view of the organs and tissues. The affected part of the pancreas is removed while preserving as much of the healthy tissue as possible.

In cases od cancer of distal body and tail of pancreas, Laparoscopic distal pancreatectomy with splenectomy can be done.

Advantages of a Laparoscopic Surgery:

• Less pain than open surgery.
• Preservation of healthy pancreatic tissue
• Better cosmetic results as the incisions are very small.
• Reduced hospital stay and faster healing post surgery.

Effect post pancreatectomy:

Post operatively, diabetes and steatorrhea (lost light colored stools) may occur in a minority of patients, depending upon the amount of the pancreas that has been removed and the condition of the remaining pancreas. Your doctor will explain it to you based on the results of investigations and biopsies. It can be very difficult  to distinguish between chronic pancreatitis and pancreatic  cancer. Marked elevation of serum CA 19-9 in a patient without jaundice is highly suggestive of pancreatic cancer.

Sleep apnea is a sleep disorder that interrupts breathing while sleeping. There are three distinct forms of sleep
apnea: central, obstructive, and complex.

In the first, breathing is interrupted by the lack of respiratory effort. Obstructive sleep apnea is caused, when breathing is interrupted by a physical block in the airflow, and, complex sleep apnea displays a combination

of the symptoms of the first two. If ignored, it can become life-threatening.
Here are some of the symptoms:

• Increasing your awareness on Heart Care
• Frequent breaks in breathing while sleeping;
• Choking or gasping during sleep;
• Loud snoring;
• Waking up abruptly or in sweat to restart breathing;
• Daytime sleepiness due to frequent sleep interruptions during the night

Sleep apnea is not difficult to rid yourself of. All you need to do is:

Reduce weight, if obese;
Give-up alcohol, tobacco, Sedatives, and anything that relaxes throat muscles and encourages snoring;
Sleep on your side;
Raise the head of your bed by about 4 – 6 inches to make
breathing easier;
Maintain regular sleeping hours;
Use a nasal dilator/ breathe-right strips/ saline nasal spray to open nasal passages

Healthy Heart Diet:

Eating your way to a healthy heart is possible only if you eat the right things. Consult your doctor for an eating plan that suits your dietary needs. Meanwhile, here’s what you should be mindful of, irrespective of your diet plan:

Fat. Your fat consumption should be no more than 30 per cent of total calories per day.
Saturated fatty acid. Your saturated fatty acid consumption should not exceed 30 per cent of your total daily calories.
Mono-unsaturated fatty acid. Consumption below 10 to 15 per cent of total calories per day is the optimal limit.
Cholesterol. Consumption should never exceed 300 milligrams per day.
Sodium. Do not consume more than 3000 milligrams in a day. Avoid foods containing chemicals and food preservatives.

2 year old baby with complex heart deformity undergoes major open heart surgery at Fortis Hospitals without blood transfusion

A team of cardiac experts led by Dr. N S Devananda, Consultant Cardiac Surgeon, Fortis Hospitals has performed a major open heart surgery on a 2 year old baby from Nigeria. Baby Brendan was suffering from congenital heart defect called – Tetralogy of Fallot or complex blue baby syndrome.

“Baby Brendan was brought to us in a condition which was complicated and need surgical intervention to correct the anomaly. In this syndrome the pure and impure blood gets mixed in the heart and the amount of blood flow to the lungs is decreased. It is the most common complex heart defect, representing 55-70%, and the most common cause of blue baby syndrome. It can prove fatal if it is not treated in time,” said Dr. N S Devananda, Consultant Cardiac Surgeon, Fortis  Hospitals.

The other bigger challenge which came before the surgery was the fact that the baby’s parents belonged to the Jehovah Witness community and as per their religious belief they oppose to any form of transfusion of blood and any blood products however they could accept other from of treatment. This made the case all the more complicated.

“Babies with Tetrology of Fallout have two treatment options – the first is palliative where no open heart surgery is done and the defect is treated with shunt operation. The second is complete repair – which is definitive treatment where the patient undergoes an open heart surgery with a heart lung machine. In the case of Baby Brendan we obviously chose the second option due to its curative value. But the problem we faced was that the heart lung machine requires 500 ml of blood by itself to drive away the air and still haemoglobin at acceptable level. The challenge was with the baby weighed only 11 kgs and his blood volume was 800 – 900 ml and to conduct an open heart proved difficult without additional usage of blood” said Dr. Devananda.

The team devised many things technically to make operative time shorter and do the best possible ways so that re-operation or re-exploration can be avoided and the ICU stay is reduced. The heart lung machine circuit was modified in such a way that total priming volume was reduced to the least possible; the haemo-filteration technique was used in such a way that excess water from the body is removed and it gives back the RBC’s to the body. We also had to reduce the sampling to the least possible for various tests.

“We did everything technically possible to reduce the requirement of blood. With all these modifications the baby underwent the open heart surgery and was out of ICU within 24 hours and is flying back to his native on the 7^th post operative day. In an era where a lot of talking is happening around blood transfusion and adults have been undergoing surgery without blood transfusion, the same thing on a child is quite complicated. However with technical modification and surgical skills it is definitely possible and should be encouraged so that no child from the community remains untreated” said Dr. Devananda.

Brendan can live an active life like any other child of his age as this is a one time complete correction and his post op ECHO is satisfactory.

Brendan’s mother Ettieh’s faith in Jehovah has strengthened after this incident. She says, “Everybody should give proper attention to their child and keep monitoring the health of the baby time and again. Till one year when Brendan was not keeping too well and was not gaining weight we got very concerned and kept taking to the local physicians in Nigeria. However nobody could give us a proper answer to his continuous ill health until last year August, 09 Brendan complained of breathlessness and pain on his left chest. A thorough examination indicated that my baby has some heart complication which needed to be treated immediately. Being a member of the Jehovah Witness community our challenge was to take Brendan to the right hands where surgery was possible without using blood transfusion. That’s when one of our friends at Nigeria who knew about Fortis Hospitals and their expertise in performing surgery without blood transfusion suggested us and we finally decided to fly Brendan down here for treatment. Initially when we decided to come to India for treatment I was engulfed with mixed feelings, but with the kind of care and response we received here I was quite confident that I have brought my baby to the right place.”

To know more about our heart care department at Fortis Hospitals,visit our website

Levels of Brain and Spine Surgery at Fortis Hospitals,Bangalore

Level 7

Brain Tumor Supra Major

Aneurysms supra major

Spine procedures supra major

AVMS Supra major

Level 6

Brain tumor excision complex

AVMS complex

Aneurysm Complex

Combined surgeries Complex

Level 5

Brain tumor excision intermediate

Spine Fusion Multilevel

Spine Decompression Complex

Aneurysms Simple

AVMS simple

Spine Tumor excision intermediate

Level 4B

Spine fusion simple

Spine Tumor excision simple

Spine Decompression  intermediate

Brain Tumor excision Simple

Vascular Decompression simple

Level 4A

Haematoma head trauma

Carotid Endarterectomy

Haematoma Intracranial

Endoscopic Spine surgery intermediate

Level 3

Microlumbular discectomy simple

Spine decompression simple

Anterior cervical discectomy simple

Meningomyeloce Repair

Level 2

VO Shunt Simple

TP Shunt

Head Injury Simple

Burr Hole

Endoscopic Percutaneous release

Level 1A

Nerve/Muscle Operations

Biopsy Brain

RF lesion

Twist Drill

Level1

Suturing of wounds

CSF Drainage external

Biopsy Nerve/Muscle Simple

Levels of Brain and Spine Services