Question 1

What is the value of PSA to say increased in a catheterized old patient, assuming 60 plus?

Dr. Nitin Shrivastava · Accepted Answer

After catheterization the PSA will be high, and there is no cut-off value for a catheterized patient. A slight increase is expected, perhaps to around 8, 9 or 10, sometimes near 20. You have to rely on clinical judgment and the rectal examination. If the PSA keeps rising, do an MRI to find out what is happening inside the prostate.

Question 2

What is the role of physical medicine and rehabilitation in the treatment of prostate cancer?

Dr. Nitin Shrivastava · Accepted Answer

Rehabilitation is very important after surgery. It does not treat the prostate cancer itself, but it is an integral part of the whole treatment process, because after prostate surgery patients need to do Kegel exercises to regain continence.

Question 3

What factors should we consider when interpreting age-adjusted PSA levels, other than UTI?

Dr. Nitin Shrivastava · Accepted Answer

Other than a urinary infection, there are not many things that raise PSA to a very high level. In a young patient particularly, the other factors to consider are a rise in subsequent PSA readings, PSA velocity and PSA density.

Question 4

What is the time range that should be considered between two PSA measurements during screening?

Dr. Nitin Shrivastava · Accepted Answer

Routine mass PSA screening is not recommended. But high-risk patients, such as those with a family history or African ancestry, should start testing earlier, and a normal PSA needs to be checked every year. There is no need to worry about the genes. If the PSA comes out abnormal, it should be repeated after four to six weeks.

Question 5

What is the best method of managing BPH?

Dr. Nitin Shrivastava · Accepted Answer

First make sure BPH is not causing damage to the kidneys. For mild symptoms, only lifestyle management is needed. For bothersome symptoms, a single alpha blocker is used. There is no one universal method; if it's damaging the kidneys, surgery is needed.

Question 6

Apart from PSA, what other hormones should be monitored in case of prostate cancer?

Dr. Nitin Shrivastava · Accepted Answer

None. PSA is the marker.

Question 7

What are the factors contributing to prostate cancer, and what are the staging parameters?

Dr. Nitin Shrivastava · Accepted Answer

The most important contributing factor is genetics and family history. Researchers point to some role of obesity and possibly a non-vegetarian diet, but these risk factors are not firmly established. Staging is based on the TNM system together with the PSA level and the Gleason grade.

Question 8

What is a neobladder? What is an ileal conduit? How will treatment affect my quality of life?

Dr. Nitin Shrivastava · Accepted Answer

A neobladder and an ileal conduit are treatments for bladder cancer, not prostate cancer. A neobladder is an artificial bladder made from the intestine and stitched in so that the patient continues to pass urine through the natural passage. With a conduit, the urine comes out through a different passage into a bag. We choose a neobladder for a patient who has limited disease and is fit enough to undergo the more complex procedure. On quality of life, once the cancer is out of the body the rest matters far less: even when urine drains into a bag rather than the normal passage, I have seen every patient adjust to it well. What matters is that the cancer comes out of the body completely.

Question 9

Is there a limitation on the number of times TURP can be done on the same patient?

Dr. Nitin Shrivastava · Accepted Answer

After a TURP, about 10 patients out of 100 will need another TURP within the next 10 years. There is no fixed limit. Sometimes the prostate grows back quickly and you have to go in again, and sometimes the procedure is staged, with half the prostate resected in one operation and half in another. The more times TURP is repeated, the higher the risk of complications. The maximum I have done is twice.

Question 10

CT scan is more accessible in our setup than MRI. Is there any place for CT to confirm prostate cancer?

Dr. Nitin Shrivastava · Accepted Answer

CT is not used to look for prostate cancer; MRI is. CT cannot confirm prostate cancer. But if you do not have MRI, CT is very useful for staging: once you know there is a cancer, CT shows whether it has spread outside the prostate. So if MRI is unavailable, do not worry: do the PSA, do the biopsy, do the CT scan, and you will know whether there is a cancer and how far it has spread.

Question 11

What is the value of PSA to consider dangerous: free PSA, total PSA, PSA ratio?

Dr. Nitin Shrivastava · Accepted Answer

The age-adjusted PSA cut-offs are 2.5 for ages 40 to 49, 3.5 for 50 to 59, 4.5 for 60 to 69 and 6.5 for 70 to 79. Two readings above the level for the patient's age are abnormal. A PSA density above 0.15 is suspicious for cancer, and a PSA rising by more than 0.75 per year is also suspicious.

Question 12

In case of BPH, what age range is surgery recommended instead of just urine diversion or catheterization?

Dr. Nitin Shrivastava · Accepted Answer

Whether a patient needs a catheter or surgery depends on his fitness for the procedure, not his age. We have operated on a man who was 100 years old, and there are patients only 60 years old with so many diseases that they are very high risk for a procedure and need to stay on a catheter. Being on a catheter is a difficult decision and very uncomfortable for anyone. If the patient has a very large prostate requiring a long operation and is high risk because of other diseases, it becomes his choice whether to stay on a catheter or to go for surgery, understanding that it is high risk.

Question 13

After removal of prostate cancer, there is urine leakage. What is the remedy?

Dr. Nitin Shrivastava · Accepted Answer

The most practical and best remedy is rehabilitation through Kegel exercises, pelvic floor muscle exercises. If these exercises don't help, an artificial urinary sphincter surgery is available, but that is the last resort.

Question 14

What are the important nutritional considerations for people with BPH and, to a larger extent, prostate cancer?

Dr. Nitin Shrivastava · Accepted Answer

The main risk factor behind prostate cancer is genetics: the chromosomes and the family history. Environmental and dietary factors also play a part, but because so many things drive the disease, no single dietary element has been pinpointed as a cause. Research points towards obesity as a risk factor. Alcohol is controversial. There is some evidence linking red meat and some other kinds of non-vegetarian food to prostate cancer, and some role for vitamin D and lycopene, while vitamin E supplements were linked to a higher risk in a large trial. It is a good idea to have a dietician plan a balanced diet, both for prevention and in the recovery period. Tackling obesity and cutting down on carbohydrates, especially quick sugars, benefits the patient in every way: it is good for the heart, the kidneys and for reducing cancer. Take adequate vitamins, preferably from natural sources, since supplements are controversial. Lycopene comes from tomatoes, which many reports describe as helpful, and phytoestrogens such as soy protein are also reported to help, but none of these are in the recommendations. A balanced diet, adequate vitamins and fewer carbohydrates, planned with a dietician, will help everyone.

Question 15

How can urologists and dieticians work together across facilities to help patients with prostate disease?

Dr. Nitin Shrivastava · Accepted Answer

A dietician should always be part of the urology team, because patients need advice on kidney stones, high uric acid, hypertension and weight reduction. A physical therapist should also be included to encourage patients to exercise. Having a dietician in the team is a good idea.

Live Discussion with Dr. Nitin Shrivastava