Question 1

What operation procedure is ideal for prostate cancer in a 74-year-old elderly patient?

Dr. Anurag Puri · Accepted Answer

Age is not the only barrier. If the patient has a good physiological (not just chronological) age, is fit, has a life expectancy of more than 10 years, has no significant comorbidities, and the disease is limited to the prostate, robotic surgery can still be offered. If the patient is frail with a shorter life expectancy, treatment is tapered to the patient's needs instead, such as relieving urinary obstruction combined with hormone ablation.

Question 2

Which PSA test is more specific for diagnosis: total PSA or free PSA?

Dr. Anurag Puri · Accepted Answer

Total PSA is checked first and should not by itself guide a biopsy decision; if there is doubt, it should be repeated after two to three weeks. When total PSA is borderline (4 to 10) and there is still doubt, a free PSA test helps: a free PSA under 10% of total PSA leans towards malignancy, while over 25% suggests a lower chance of malignancy.

Question 3

Who should perform an ultrasound-guided prostate biopsy: a urologist or an interventional radiologist?

Dr. Anurag Puri · Accepted Answer

Both can perform it, but a urologist is better equipped to manage complications if they occur, such as bleeding in the urine or from the rectum.

Question 4

Is there a specific disease stage for which robotic treatment is used?

Dr. Anurag Puri · Accepted Answer

Robotic radical prostatectomy is used for low-risk and intermediate-risk disease, and can be used for high-risk disease too, provided the lymph nodes are not involved, in which case it is combined with an extended lymph node dissection. If the lymph nodes are already positive, radical surgery is not performed.

Question 5

Should a PSA test be sent for all patients with BPH?

Dr. Anurag Puri · Accepted Answer

It is not mandatory as routine screening, but a baseline PSA is checked before starting an anti-androgen such as dutasteride, which is commonly prescribed for BPH.

Question 6

What is the benefit of alfuzosin in the symptomatic management of BPH, and is there a newer drug?

Dr. Anurag Puri · Accepted Answer

Alfuzosin is a commonly used drug that relieves the urinary symptoms of BPH. Silodosin is a newer, more potent alternative. Alfuzosin is generally preferred in younger, sexually active men, while silodosin is preferred in older patients because of its sexual side-effect profile.

Question 7

Is there really no treatment available for prostate cancer above the age of 80?

Dr. Anurag Puri · Accepted Answer

That is not the case. Between the ages of 80 and 90, up to 80% of men are found to harbour some focus of prostate cancer, but most die of other causes rather than the cancer itself. Because it is often a low-risk, indolent disease in this age group, treatment is sometimes deliberately avoided if the patient is asymptomatic.

Question 8

Does declining male sexual performance with age relate to atherosclerotic changes in penile vessels? Is there a better urological explanation?

Dr. Anurag Puri · Accepted Answer

Yes - this is generally due to atherosclerosis: as blood vessels narrow with age, blood supply to the penis decreases, and this reduced blood flow is the main driver of declining sexual performance.

Question 9

What are the principles of prostate cancer management, the survival rates by stage, and can advanced disease be managed locally?

Dr. Anurag Puri · Accepted Answer

Management is decided by the disease's staging and parameters: PSA level, Gleason score, and clinical stage on digital rectal examination. Survival rates vary sharply by stage - low-risk, early disease has close to a 100% cure rate, and even metastatic (stage four) patients now have meaningfully better life expectancy with appropriate treatment than with many other stage-four cancers.

Question 10

What does a kidney transplant require if the donor's genetic makeup is different, and what can be done to restore a failing transplanted kidney?

Dr. Anurag Puri · Accepted Answer

Kidney transplant is the treatment of choice for renal failure, and results are best with a related, genetically matched donor. Even without a genetic match or matching blood group, plasmapheresis, an advanced technique that lowers the antigenicity of the donor organ, can still allow a transplant to proceed.

Question 11

Is it true that many patients who undergo prostate surgery end up dying, as some patients believe?

Dr. Anurag Puri · Accepted Answer

This is a misconception. The great majority of prostate operations are for benign BPH and are done endoscopically with little morbidity; patients are very satisfied. Even for cancer, with modern robotic surgery, hospital stay is just about three days, and patients are often fit to fly home within two to three weeks without a catheter.

Question 12

Can a combination of tamsulosin and finasteride eradicate BPH?

Dr. Anurag Puri · Accepted Answer

No - this combination provides symptomatic relief rather than eradication. Tamsulosin relaxes the prostate to improve urinary flow, while finasteride can shrink the size of the prostate over time, but neither eliminates the underlying benign enlargement.

Question 13

How do you decide between chemotherapy, radiotherapy, hormone therapy and prostatectomy for a patient?

Dr. Anurag Puri · Accepted Answer

It depends entirely on the stage. Early, organ-confined disease is treated with curative intent using robotic radical prostatectomy or radiotherapy. Locally advanced disease (spread just outside the prostate but not to lymph nodes or bone) may still use surgery or radiotherapy, combined with androgen deprivation therapy. Disease that has spread more widely and is not surgically resectable is treated less aggressively, with radiotherapy plus hormone deprivation. Metastatic disease (spread to bone) is treated with intent to suppress rather than cure, using hormonal suppression (surgical orchidectomy or depot injections). Hormone-resistant disease, where the cancer no longer responds to hormone deprivation, needs chemotherapy (docetaxel) or oral agents such as abiraterone or enzalutamide.

Question 14

What can be done to prevent prostate cancer, and in which cases should a patient be referred to India?

Dr. Anurag Puri · Accepted Answer

Prostate cancer is hard to prevent outright, but patients with a family history should undergo more aggressive screening: annual PSA testing and digital rectal examination from age 45 onwards, especially relevant in the African population where incidence and mortality are higher than in Asian populations. This won't necessarily prevent the disease, but it catches it earlier and reduces mortality. On referral: every stage of prostate cancer needs some form of treatment, so it is more useful to ask which patients should NOT be referred - only when a doctor can offer the full, appropriate treatment for that stage locally, or when the patient is too frail to travel, should referral be avoided.

Question 15

Do dieticians and nutrition play a role in prostate cancer care, and are patients referred to dieticians as part of treatment?

Dr. Anurag Puri · Accepted Answer

Dietary factors have been proposed but are not conclusively proven to affect prostate cancer risk. Reduced fat intake, lycopene (found in tomatoes), vitamin E and selenium have all been suggested as protective, though without randomised controlled trial proof. There has admittedly been less emphasis on formal dietician involvement in day-to-day prostate cancer care than there probably should be.

Question 16

How common is hydrocele in prostate cancer patients, and how should it be managed during ongoing therapy?

Dr. Anurag Puri · Accepted Answer

Hydrocele is uncommon in prostate cancer and can occur due to malignancy near the testis. Until treatment is complete and unless the hydrocele becomes very large, it is best managed conservatively rather than with major surgery, since it typically represents distant spread rather than a primary problem needing its own operation.

Question 17

Is there a role for prophylactic prostatectomy to prevent prostate cancer?

Dr. Anurag Puri · Accepted Answer

No - unlike prophylactic mastectomy in breast cancer (as with the well-known case of Angelina Jolie), prophylactic prostatectomy has not been established as a preventive strategy. The recommended approach instead is more aggressive screening of first-degree relatives of prostate cancer patients.

Question 18

How is patient transportation arranged from Nigeria to India, and at what point should a doctor refer a patient through Jivo?

Dr. Anurag Puri · Accepted Answer

Regular direct flights connect Nigeria and India, so transportation itself is straightforward. On referral: all stages of prostate cancer require some treatment, and the earlier a patient is referred, ideally while still asymptomatic, the better the outcome. The Jivo team helps assess whether a specific patient will meaningfully benefit from travelling, rather than the referring doctor needing to make that judgement alone.

Question 19

A 51-year-old man has an established diagnosis of prostate adenocarcinoma, staged T4N0M0 with no metastatic disease on local imaging, and has started on Zoladex ahead of travelling to India for radiotherapy. What is the general outcome for a patient like this?

Dr. Anurag Puri · Accepted Answer

Prostate cancer is one of the slowest-growing cancers in the body. The absence of metastasis is a favourable sign, though it should be reconfirmed with a PSMA PET scan once he arrives in India, since this specific, highly sensitive imaging for prostate cancer spread is often not available locally. If metastasis is later found, the prognosis changes, but if it is confirmed absent, life expectancy can remain good despite the locally advanced (T4) stage.

Question 20

At what stage should a patient with prostate cancer NOT be referred to India?

Dr. Anurag Puri · Accepted Answer

It is more useful to frame it the other way: every stage of prostate cancer requires some form of treatment. If a doctor's local setup can offer the appropriate treatment and full assessment for that stage, it is best handled there. Referral becomes appropriate when treatment modalities such as PET scans, radiotherapy or robotic surgery are not available locally, or when the patient is too frail to safely travel.

Question 21

A cancer patient is very weak and frail, unable to tolerate chemotherapy, and is currently on no medication at all. What should be done?

Dr. Anurag Puri · Accepted Answer

Chemotherapy is not the first-line treatment for prostate cancer; it is a treatment of last resort. The first step should be hormone ablation, either injectable hormone-ablating agents or orchidectomy, before considering chemotherapy at all, since chemotherapy carries its own side-effect burden that could make a frail patient worse rather than better.

Question 22

Why do older men experience urinary incontinence, and why do prostates enlarge with age?

Dr. Anurag Puri · Accepted Answer

Prostate enlargement occurs with age and also has a genetic component. Importantly, prostate size itself does not determine whether treatment is needed - symptoms do. A 100-gram prostate growing outward with no urinary blockage may need no treatment at all, while a much smaller prostate causing obstruction and symptoms does need treatment.

Question 23

Is there a role for HIFU (high-intensity focused ultrasound) in prostate cancer treatment?

Dr. Anurag Puri · Accepted Answer

HIFU is an option for patients who are unfit for major surgery, but it is not the standard of care and is not widely used.

Prostate Cancer: Diagnosis and Latest Treatment Guidelines

Questions Doctors Asked Dr. Anurag Puri