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Procedure
Practice 02/15/98 - Coding
Recommendations
In America, the prostate is probably the gland in a male’s
body that causes the most medical problems. Studies have shown
that 4 out of 10 men over age 55 have an enlarged prostate.
One of four males will have surgery at some time for a prostate
condition. And virtually every man, if he lives long enough,
will develop some degree of prostate cancer.
The prostate gland is a component of the male reproductive
system. In its healthy mature state, it is a solid, walnut-shaped
organ weighing about 25 g. It is located underneath the urinary
bladder and in front of the rectum. It encircles the first
part of the urethra. The prostate is made of a myriad of small
tubules enclosed within a capsule of connective tissue and
muscle fibers. Its inner zone produces secretions to keep
the urethral lining moist. The outer zone produces seminal
fluids to facilitate the passage of semen. The urethra is
a two-stemmed duct leading from the bladder and the prostate
gland into the penis.
The prostate develops from several distinct sets of tubules
that arise from the primitive posterior urethra. Each set
of tubules evolves into a separate lobe: the right and left
lateral lobes, which are the largest, the middle lobe, and
the very small anterior and posterior lobes. The lobes are
made of alveoli lined with a secretory epithelium. The lobes
drain through a series of converging tubules into the prostatic
urethra. Although the lobes arise independently, they are
continuous in the adult with no apparent gross or morphologic
distinctions.
At birth, the prostate is about the size of an almond. It
remains that size throughout childhood. During puberty the
prostate approximately doubles in size and then growth slows.
The prostate is preparing for its main role in life: reproduction.
At about the same time that the testicles are able to produce
sperm, the prostate is sufficiently mature to produce the
seminal fluid that will support the sperm.
At about age 45, the prostate often starts growing again
and, in some cases, can continue to enlarge for the rest of
a man's life. It's generally believed that this growth is
influenced by hormonal changes.
In its role of fluid production to supplement semen volume,
the prostate secretes several proteins including acid phosphatase,
seminin, plasminogen activator, and prostate-specific antigen
(PSA). While the exact roles of most of these proteins are
unknown, they are presumed important for the function of spermatozoa.
Although the function of PSA is not known, an elevated level
of this protein in the blood is often diagnostic of abnormal
prostatic growth such as occurs in cancer of the prostate.
Prostate
Gland Disease
As we have seen, even on the microscopic level, the structure
of the prostate is very complicated. This structure provides
many "hiding places" for infectious organisms and
abnormal cell growth. There are basically three types of disease
conditions that affect the prostate. Benign prostatic hyperplasia
(BPH) is a non-cancerous enlargement of the gland. Prostatitis
is an infection of the prostate, which may be an acute or
chronic condition. The most serious and life-threatening disease
that afflicts the prostate is cancer.
By itself, prostate enlargement (BPH) is not a significant
health problem, but if the prostate continues to enlarge beyond
a certain point, it can squeeze the urethra in an action similar
to pinching a straw. As the urethral lumen is compressed,
the outflow of urine is obstructed. BPH-related operations,
most commonly a transurethral resection of the prostate (TURP),
are the second leading cause of surgery in males (400,000/yr.)
in the United States.
The symptoms commonly associated with an enlarged prostate
are frequent urination, especially at night (nocturia), or
the sudden urge to urinate. In the early phase of prostatic
enlargement, the bladder muscle must force urine through the
narrowed urethra by contracting more forcefully. Over a period
of time, the bladder muscle becomes stronger, thicker, and
overly sensitive, creating a need to urinate more often. The
added pressure on the urethra can also cause a weak, interrupted
urine stream, a sense of incomplete bladder emptying, leakage,
and difficulty in starting urination.
Diagnosis
BPH is suspected on the basis of urinary signs and symptoms.
The initial diagnostic evaluation consists of a digital rectal
examination (DRE) and a screening PSA blood test.
If the results of these initial tests indicate prostate disease,
further work-up may include the following:
Transrectal ultrasound:
Because of its location, the prostate is difficult to visualize
anteriorly. Ultrasound is performed using a small pencil-like
probe placed in the rectum. Ultrasound can aid in measuring
overall prostate size and can detect the presence of prostatic
calculi, infection, and cancer. It is therefore a useful
tool to accurately diagnose any one of the three main prostate
diseases.
Cystoscopy: Urinary
obstructive symptoms generally require further investigation
by means of a cystoscopy. This diagnostic procedure involves
looking into the urethra and bladder with a small, hollow
tube of flexible plastic. If prostatic enlargement is determined
to be the cause of urinary symptomatology, then the next
step is to determine how to remove the obstructing prostatic
tissue.
Treatment
TURP/TEVAP: Transurethral
resection of the prostate is used in 90% of all prostate
surgeries for BPH. In the standard procedure, a metal tube
with a resectoscope wire attached is inserted through the
urethra to reach the prostate and scrape away the tissue.
The result is similar to hollowing out a pumpkin and leaving
the shell intact. The outer capsule of the prostate and
some prostate tissue remain after the procedure, so the
prostate may grow again. Usually, though, it will seldom
grow enough to cause recurrent voiding problems. Transurethral
electrovaporization of the prostate (TEVAP) does essentially
the same thing as a TURP, but uses electric current to destroy
the prostate tissue.
TUIP: Another
surgical procedure is called transurethral incision of the
prostate (TUIP). Instead of removing tissue, as with TURP,
this procedure widens the urethra by making a few small
cuts in the bladder neck where the urethra joins the bladder
and in the prostate gland itself.
VLAP/ ILC: This
procedure is a laser variation of a TURP. It may be referred
to as a VLAP (visual laser ablation of the prostate) or
an ILC (interstitial laser coagulation of the prostate).
In this procedure, the tissue is lasered rather than surgically
scraped away. The procedure is less invasive than a TURP
and can be done on patients who may not be healthy enough
to tolerate a TURP. One of the disadvantages, however, is
that not all prostates respond equally well to laser treatment.
Transurethral Microwave Thermotherapy:
In May 1996, the Food and Drug Administration approved a
device that uses microwaves to heat and destroy excess prostate
tissue. The Prostatron sends computer-regulated microwaves
through a catheter to heat selected portions of the prostate
to at least 111 degrees Fahrenheit. A cooling system protects
the urinary tract during the procedure.
Prostatitis is a bacterial infection of the glandular tissue
of the prostate and is almost always preceded by a cystitis.
Bacteria are always present in the urethra and bladder, thriving
in the warm, moist environment. Usually only known "gut"
bacteria like E. coli, are present, and these are quite harmless.
They are useful bacteria that help digest the food in the
intestines. These bacteria get into the urethra and bladder
all the time, but are washed away with urine before their
numbers can grow. The bladder is used to this constant invasion
of friendly bacteria and can handle it most of the time.
The number of bacteria can, however, increase and a bladder
or prostate infection may result, for example, if urine production
is decreased due to excessive sweating, resistance is low
during a bout of flu, or if the bacteria involved are unusually
aggressive. Often the bladder cures itself by flushing out
urine and bacteria, but the prostate is less fortunate. While
urine does flow past the prostate, it does not flow through
it, so it does not really clean the glandular tissue.
Usually, prostatitis is a rather mild disease, and a lot
of men may not notice their infection. It may cause a waxing
and waning type of pain low in the abdomen, in the groin,
or in the back. Urinary symptoms include increased frequency,
pain, and burning. The symptoms are caused by the prostate
lying close to the bladder and irritating it. Additionally,
often bacteria are "seeded" from the prostate to
the urinary bladder or the urethra, causing additional irritation.
In some cases, bacteria can go upstream into the vas deferens,
causing groin pain or an infection of the epididymis. As with
many other infectious processes, prostatitis can also be accompanied
by chills and fever.
Diagnosis
As with any prostate disease, a digital rectal examination
and a PSA test are generally the first tests done to detect
prostatitis. A transrectal ultrasound may also be useful.
To make an accurate diagnosis, however, the one test that
should always be performed when prostatitis is suspected
is prostate stripping, during which prostatic fluid is collected.
While performing the digital examination, the physician
massages the prostate to force prostatic fluid out of the
gland and into the urethra. The fluid is then analyzed for
bacteria so that effective antibiotic treatment can begin.
Treatment
Antibiotics generally are prescribed to cure prostatitis.
After recovery, some scar tissue may remain, which increases
the chance of getting a repeat infection. Although usually
a specific cause for prostatitis cannot be found, the presence
of BPH or prostatic cysts may increase the risk of infection.
Prostatic cysts are small, fluid-filled spaces within the
prostate. Bacteria, once inside these cysts, can survive
despite adequate treatment with antibiotics.
Far more serious than infections are malignant growths in
the prostate gland. Prostate cancer is the most often diagnosed
cancer in American males, the number of incidences now exceeding
even those of lung cancer. The diagnosis of prostate cancer
is aided by detecting the presence of the prostate-specific
antigen (PSA) protein in serum. If the prostate is damaged
by the abnormal cell growth of BPH or cancer, the PSA protein
inadvertently enters the serum where detection of greater
than 4 mg/ml. indicates a prostate problem such as BPH or
cancer.
Although it is unknown how prostate cancer develops, it has
been established that it is not caused by prostatitis or BPH
and that testosterone is necessary for its existence. Usually
the cancer cells are found at a different location than the
benign enlargement cells. BPH is found around the urethra,
while prostate cancer will generally develop at the outskirts
of the prostatic gland. This feature, fortunately, makes it
easier to detect the cancer during a screening rectal examination.
While prostate cancer can occur in men of all ages, it is
most commonly found in men older than 40 years of age. Initially
prostate cancer causes little or no symptoms. It is usually
detected during a routine digital rectal exam or by the use
of a screening PSA test. Since the abnormal growth begins
at the periphery of the gland, urinary symptoms are not present
until the cells have invaded the prostate more deeply. Prostate
cancer is also not a painful disease in its early stages.
Pain generally arises only when it has spread to other parts
of the body. The tumor cells spread via the lymphatic system
or the bloodstream, or both simultaneously.
Bone is the most common metastatic site. More than 30,000
men die annually from this disease. Because of its prevalence,
a number of techniques have been developed to diagnose and
treat prostate cancer.
Diagnosis
As previously mentioned, prostate cancer is often detected
initially during a digital rectal examination. The most telling
diagnostic test, however, is the blood test done to measure
PSA levels. An elevated PSA is a clear marker for prostate
disease. If the PSA level is determined to be high, additional
diagnostic tests may then be done. Transrectal ultrasound
and cystoscopy are two of these tests and are reviewed under
the previous discussion on benign prostatic hyperplasia. Other
tests include the following:
Transrectal prostate biopsy:
The biopsy retrieves prostatic tissue samples for
microscopic analysis. A rectal ultrasound probe is often
used to correctly locate the biopsy site and several small
pieces of prostate are removed with a very thin needle.
This is usually done with an instrument called a biopsy
gun, which looks like a small spring-loaded pistol.
Diagnostic scans: CT
scans are done if metastatic disease is suspected. A contrast
medium may be injected intravenously to better highlight
the area under study. Bone scans are also used to determine
disease spread. A radioactive isotope is injected into the
blood. The isotope then essentially "sticks" to
possible prostate cancer cells in the bones.
Treatment
Watch and wait! In
the case of prostate cancer, "to do nothing" may
be an appropriate form of treatment. In some case, even
if the cancer has not spread, the treatment can be worse
than the disease. Especially in the elderly, it is often
improbable to expect the cancer to do much harm in the short
lifetime left; treating the cancer would then cause damage
without the benefit of an extended or better life.
Hormone therapy: The
very existence of the prostate is due to the presence of
male hormones, chiefly testosterone, which the prostate
and most prostate cancers require to grow. This observation
led urologists to the use of hormone reduction to treat
prostate cancer in the 1940s and, except for administering
newer drugs, the principle of hormone reduction still stands
today. Hormone reduction is accomplished either with a monthly
shot (Lupron or Zolodex) or by surgical removal of the testicles
(orchiectomy). Oral medication may also be used with either
therapy to maintain testosterone reduction.
Radical prostatectomy:
Surgical removal of the prostate is considered to
be the standard therapy for localized prostate cancer. Simply,
the entire prostate is removed and the bladder is reconnected
to the urethra. Pelvic lymph node sampling may be done at
the time of surgery to determine whether the cancer cells
have invaded the local lymph nodes. The two approaches to
this procedure are via the perineum (perineal prostatectomy)
and via the lower abdomen (retropubic prostatectomy).
External beam radiation:
External beam radiation therapy is by far the simplest
of therapies. Over a 6 to 7-week period, the patient receives
radiation treatment lasting about 15 minutes, 5 days a week.
The radiation is aimed at the prostate from many different
angles in an attempt to reduce the dosage to the surrounding
tissues while maximizing the dosage to the prostate and
the cancer. The advantages of external radiation therapy
lie in the ease of its administration: neither surgery,
nor anesthesia is necessary, and the patient does not encounter
any no blood loss. The biggest disadvantage is that the
cancer is left in place, and only time will tell if the
amount of radiation delivered effected a cure.
Implant therapy (brachytherapy):
Radioactive implants are ultrasound-guided radiation
treatments done under anesthesia. Some implants are permanently
left in place (Iodine, Palladium, Gold) and some are temporary
(Iridium). Implants allow for higher doses of radiation
to the prostate while sparing the surrounding tissues and
decreasing urinary tract side-effects such as incontinence
and dysuria. A major disadvantage to this therapy is that
any cancer cells lying outside the prostate will not be
destroyed.
Combined Precision Irradiation
(CPI): This treatment, also sometimes
referred to as prostRcision, uses both prostate implants
and external irradiation. It is based upon the use of radioactive
iodine seeds. Implantation is usually done as an outpatient
procedure under anesthesia. Under transrectal ultrasound
guidance, approximately 25 very thin hollow needles are
inserted into the prostate via the perineum. A radiation
oncologist then injects 3-6 radioactive iodine seeds per
needle into the prostate. Three weeks following the seed
implant, external beam radiation is applied to the prostate
and surrounding region. The iodine seeds are used as a target
so that the radiation is given very precisely.
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