Laser Treatement for Safer and Faster Management of Benign Prosate

Case highlights
• 81 year old gentleman diagnosed of acute urinary tract infection
• Patient was hypertensive, diabetic and had undergone coronary artery stenting
• Was on blood thinners which makes the conventional prostate resection difficult
• Delay of management of prostate could have allowed bacterial colonization of the coronary artery stent
• Brought to Fortis Hospitals with complications
• Laser TURP was performed to manage the enlarged prostate and urine infection

Bangalore, 19th July, 2010: Fortis Hospitals Bangalore performs a complicated Prostate Surgery on an 81 year old man with latest DIODE laser called Laser TURP wherein laser energy is used for vaporization of prostate tissue without any blood loss. This procedure is ideal for high risk patients who are on blood thinning agents and have the difficulty of undergoing resection of enlarged prostate with the conventional method using electrical energy.

Mr. Venkataswamy Reddy an 81 year old gentleman who had developed acute retention of urine following coronary angiography procedure done 2 weeks prior. He was a known diabetic and hypertensive and had undergone coronary artery stenting about two years ago and was on blood thinning agents – aspirin and clopidogrel. He was advised to undergo conventional TURP (Transurethral resection of the prostate) at a city hospital. Since Mr. Reddy was on blood thinning agents the urologist in the hospital wanted the blood thinners to be stopped a week prior to the procedure. “Stopping of the blood thinners increases the risk of getting a myocardial infarction, commonly known as heart attack and the patient’s hospital stay is longer including the need to stay in coronary care unit postoperatively” said Dr. Mohan Keshavamurthy, Consultant Urologist Fortis Hospitals.

The cardiologist was unwilling to stop the blood thinners because of the obvious cardiac risk but at the same time the doctors were not willing to defer his procedure since the ongoing urinary tract infection could colonise the coronary stent. With these complications Mr. Reddy was referred to Fortis Hospitals Bannerghatta road.

“After a complete workup it was diagnosed that Mr. Reddy had benign enlargement of the prostate with acute urinary tract infection. He was also hypertensive & diabetic. Understanding the cardiac risk Mr. Reddy had along with the acute retention of urine which could lead to further complications, we decided to perform the laser TURP procedure. For laser TURP we don’t need to stop the blood thinning agents and the prostate resection can be done without any blood loss. We performed the procedure without any complication and his post operative recovery has been excellent” said Dr. Mohan.

Benefits of Laser TURP
• No Blood Loss
• Shorter Hospital Stay
• Cardiac patients who are on blood thinning agents
• Patients with renal dysfunction who have a tendency to bleed profusely
• Prostate gland size of more than 60 gm
• Patients with Diabetes, Hypertension & high risk for anesthesia
• Patients who have undergone joint replacement surgery

How Laser TURP is superior to conventional TURP:

In conventional TURP, blood thinning agents have to be stopped a week to 10 days before the procedure. This puts the heart at risk for a second attack. The patient’s hospital stay is longer including the need to stay in coronary care unit postoperatively. In Laser TURP, procedure is done with the blood thinning agents on board which is a revolutionary change in clinical practice guidelines. Conventional TURP surgery is not traditionally performed beyond 60 min because of the risk of irrigant fluid (GLYCINE or DISTILLED WATER) absorption…TURP Syndrome with significant morbidity & mortality. Conventional TURP allows tissue removal at 1gram/min. Hence gland size more than 60 gm is converted from an endoscopic to open procedure. DIODE laser (which Fortis Hospital uses) can vaporize 3-4 grams/min. Here normal saline is used as an irrigant which on absorption does not cause TURP syndrome. Hence prostate gland beyond 100 grams can also be managed endoscopically using laser energy.

Advantages of Laser TURP:

Laser TURP in general is safer and faster than conventional TURP which utilizes electrical energy. Laser TURP is specifically indicated in patients who are on blood thinning agents such as heparin, aspirin, clopidogrel, patients with renal dysfunction, patients whose prostate gland size is more than 60 gm, patients who are at poor risk for anesthesia, are diabetic, have cardiac complications and those who have undergone joint replacement surgery. The benefits of this procedure are that there is no blood loss, involves shorter hospital stay and is ideal for large protate glands.

Laser TURP procedure is ideal for:

Patients with renal dysfunction have increased tendency to bleed because of platelet dysfunction making conventional TURP risky. This problem is obviated using laser energy. Conventional TURP can only be done through large caliber rigid scopes. Laser TURP can be done through small caliber flexible scopes. Hence standard lithotomy position which is not possible after joint replacement is not mandatory for laser TURP. Laser TURP can be done under short lasting general anesthesia which is ideal in patients who are high risk for anesthesia. Most patients can expect a rapid improvement in their urinary flow rate, and a quick return to normal activities following the procedure.

Fortis Hospitals’ expertise on Laser TURP:
Fortis Hospitals uses DIODE laser which is the fastest & safest laser available in the world. The hospital has the complete laser urology armamentarium under one roof and the Urology team has the largest & most comprehensive experience in performing laser urology procedures.
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Dr. Rehan Sayeed is an alumnus from the prestigious Madras Medical College where he did his basic medical education and went onto to complete his general surgery training. His quest for knowledge and skill took him to the United Kingdom where he graduated to become a Fellow of the Royal college of Surgeons of Edinburgh. He subsequently returned to India to do his Cardiothoracic training  at Chennai under the mentorship of Dr. M R Girinath where he graduated with a Diplomate of the National Board of Examinations.Dr Rehan Sayeed has performed more than 6000 heart surgeries and more than 2500 thoracic surgeries,more than 1500 minimal access valve procddures and more than 50 heart transplants.

Having laid a solid foundation in India he went on to do a Fellowship in Adult Cardiothoracic Surgery at the Boston University Medical Center where he was the chief resident. In 2004 he joined the prestigious Children’s Hospital of Boston, Harvard University as Senior Resident in Pediatric Cardiac surgery training to do complex congenital heart surgery. The last but not the least leg of his training years were spent at The Cleveland Clinic Foundation, Cleveland, Ohio, America’s No.1 heart center for the last 13 years in a row. Here he specialized in Heart failure surgery and Mechanical Assist devices/cardiac transplantation. He is certified in Cardiac Transplantation and was a part of the team that implanted the early Total Artificial hearts ( cardiowest). At the clinic he also trained in minimal access cardiac surgery and valve repair surgery. Today he has to his credit over thousand plus minimal access procedures.

Dr Rehan Sayeed’s  main area of Interests are

• Minimally invasive cardiac surgery
• Valve repair surgery
• OPCAB- Total arterial revascularisation
• Management of Sick Ventricles
• aortic aneurysm repair
• Heart transplantation and Ventricular assist devices
• Thoracic Oncology
• Tracheal reconstructive surgery

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Polycystic Ovarian Syndrome or PCOS is one of the most common female endocrine disorder manifested obesity, Hirsutism (excessive facial or body hair), Alopecia (male pattern hair loss) irregular menstruation, acne associated with enlarged ovaries, Acanthosis Nigricans (brown skin patches), high cholesterol levels, exhaustion or lack of mental alertness, decreased sex drive, excess male hormones and infertility. Other symptoms can include sleep apnea (breathing difficulties during sleeping), thyroid disorders and depression and anxiety.. This complex disorder is characterised by excessive androgen production by the ovaries which interferes with the growth of the ovarian follicles.

1.Causes of Polycystic Ovarian Syndrome The cause of PCOS is uncommon. Most researchers think that more than one factor could play a role in PCOS. Genes are thought to be one factor. Women with PCOS tend to have their mothers or sisters affected with PCOS
2. How common is the syndrome among urban women. Any statistics. Which age group is mainly affected

PCOS is commonly found amongst urban women. The incidence varies from 1 out of 10 women, more common amongst infertile women. It is prevalent in young reproductive period. PCOS are caused by imbalance in the hormones in our brain and ovaries. Many women have higher than normal levels of insulin. PCOS usually happens when a hormone called LH or levels of insulin are too high, which result in extra testosterone production by the ovary.
3. What are the early symptoms that women should watch out for PCOS
Not all women with PCOS have the same symptoms, some of the symptoms are:
• irregular menstrual period / no periods
• infertility
• Increase hair growth on the face, chest, stomach – this condition is called hirutism
• Acne, oily skin or excessive dandruff
• excessive weight gain or obesity
• male pattern baldness or thinning or patching of hair
• dark brown or black skin on the neck, arms, breasts or thighs which is called Acanthosis Nigricans

4. Are women with PCOS more prone to developing diabetes
Women with PCOS have great chances of developing type II diabetes. More than 50% of women with PCOS will have diabetes or pre-diabetes before the age of 40
5. What is the treatment procedure
There is no specific cure for PCOS. It needs to be managed to prevent the problem
Birth Control pill:
For women who does not want to get pregnant birth control pill can control menstrual cycle, it may reduce male hormone levels and help to clear acne. Only progestrogen pill or better known as mini pill, can be taken.
Metformin -a drug which is used to treat diabetes is found to help women with PCOS symptoms. Abnormal hair growth will slow down and ovulation may return after few months of use
If a woman wants to get pregnant – lack of ovulation is usually the reason for fertility problem in PCOS. Several medication that stimulate ovulation can help women PCOS to get pregnant. For most patient Clomiphene Civate is the first choice of therapy to stimulate ovulation. If this fails Metformin is taken with Clomiphene is usually tried
Gonadotropin can also be used to stimulate ovulation. These are given as injection.
For hair growth or extra male hormone – anti androgen may reduce hair growth and clear acne. Spironolactone (Aldactone) has been used to reduce the impact of male hormone
Anti androgens are often combined with oral contraceptives

Incidence of Polycystic Ovarian Syndrome

Polycystic ovarian syndrome (PCOS) accounts for 90% of women with oligomenorrhoea (infrequent periods) and 30% of women with amenorrhoea (absent of periods) and over 70% of women with anovulation.

Diagnosis of Polycystic Ovarian Syndrome

Laparoscopy

Laparoscopy allows direct inspection of the ovaries; the ovaries are enlarged and polycystic. However, polycystic ovaries may appear normal at laparoscopy.

Vaginal ultrasound scan (better than abdominal)

The vaginal ultrasound may show the typical PCOS appearance but reliability varies with expertise.

Surgical Treatment
Ovarian drilling – is a surgery that brings in ovulation. It is done when a women does not respond to fertility medicines. This is done through laparoscopy. This surgery can lower male hormone levels and in ovation. But these affects may only last for few months.
Lifestyle Modification
Keeping a healthy weight by eating healthy food and exercise is another way of helping to manage PCOS. Many women with PCOS are overweight or obese. Even a 10% loss in body weight can restore a normal period and make a women’s cycle more regular.

Kidney cancer is one of the most common cancers affecting males in the middle age group, especially those who smoke. Smoking is one of the most important causative factors. These cancers are best treated with surgery wherein the cancer bearing organ is removed along with the cancer and the surrounding layers so that cancer recurrence can be reduced maximally. However this also means that the unaffected portion of the kidney also has to be sacrificed with the cancer. Nephron sparing surgery allows the surgeon to remove the cancer bearing area of the kidney while at the same time preserving the rest of the unaffected parts of the kidney thereby preserving as many functioning nephron units as possible.

This surgery can be performed by laparoscopic approach which the additional advantage of rapid recovery and rapid return to work. At the Fortis Kidney Hospital we have performed many such procedures to remove the cancer bearing tissue and at the same time preserve the rest of the kidney.

This surgery can however be only offered to those who present in the earlier stage of the cancer, and the tumor has as yet not affected the main blood supply of the kidney. These cancers can easily be detected in early stage by a simple abdominal ultrasound evaluation and can routinely be done in individuals above the age of 50 years. After the tumor is suspected then the surgeon will usually advise for CT angiography to assess the relationship of the blood vessels of the kidney with the tumor. Once it is detected that the cancer is in the early stage and has not yet attacked the main central vessels then the uro-surgeon can decide in favor of removal of the main tumor while at the same time preserve the rest of the nephrons.

This surgery performed by minimal invasive technique at Fortis Kidney hospitals. The patient needs to be admitted for five to six days and can return to work after two weeks of rest.

This treatment can be offered to most patients if the cancer is detected in the early stage of the disease and therefore the importance of regular kidney check up and ultrasound examination after age pf 50 years.

Dr Avishek Mukherjee ,Consultant Uro surgeon, Fortis Hospital & Kidney Institute