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    7 prostate lecture 7 prostate lecture Presentation Transcript

    • BENIGN PROSTATIC HYPERPLASIABENIGN PROSTATIC HYPERPLASIABPHBPHAhmad A. Elabbady, MDAhmad A. Elabbady, MDProfessor, Urology Department,Professor, Urology Department,University of AlexandriaUniversity of Alexandria
    • BENIGN PROSTATIC HYPERPLASIABENIGN PROSTATIC HYPERPLASIABPHBPHDefinition• I- Microscopic (BPH) refers to histological proliferation.• II- Macroscopic: senile prostatic enlargement (SPE)refers to organ enlargement due to cellular proliferation.• III-Clinical: refers to the lower urinary tract symptomsthought to be due to BP obstruction.
    • BENIGN PROSTATIC HYPERPLASIABENIGN PROSTATIC HYPERPLASIAIncidenceIncidence- BPH is a disease of the elderly men- The most common benign neoplasm in the aging male- Usually > 60 years Rarely < 40years- Normal prostate is about 18-25 gm
    • BENIGN PROSTATIC HYPERPLASIABENIGN PROSTATIC HYPERPLASIA• BPH arises from the peri-urethral glands in thetransition zone• BPH occurs in almost all men who have normal serumtestosterone level and who lived long enough• Testosterone (T) ---under the effect of 5-alpha reductaseenzyme in the stromal cells is converted toDihydrotestosterone (DHT) which leads to glandularepithelial proliferation.
    • BENIGN PROSTATIC HYPERPLASIABENIGN PROSTATIC HYPERPLASIAPathologyPathologyI- MicroscopyHyperplasia and hypertrophy of the glands + smooth muscles +fibrous tissue stroma• Mainly glandular------- (soft)• Mainly fibrous stroma------ (firm)II- GrossPattern:* Monolobar = Middle lobe*Bilobar = 2 lateral lobes*Trilobar = Middle + 2 Lateral lobesThe hyperplastic lobes outwardly compress the surrounding zones Surgical capsulewith a plane of cleavage in between
    • BENIGN PROSTATIC HYPERPLASIABENIGN PROSTATIC HYPERPLASIAPathophysiology of obstruction:Pathophysiology of obstruction:I- Static component- Bulk of the gland elongation, compression andangulations of the prostatic urethra- Middle lobe obstruction of the bladder neck (ball-valve )II- Dynamic component- Prostatic smooth muscle are innervated by alpha-adrenergic fibers- Atony of the detrusor muscle by long standingobstruction resulting in chronic retention
    • BENIGN PROSTATIC HYPERPLASIABENIGN PROSTATIC HYPERPLASIASymptomsSymptomsI- Lower urinary tract symptoms ( LUTs)A. Obstructive symptoms- Hesitancy- Weak urinary stream- Straining during urination.- Sense of incomplete emptying- Terminal dribblingB. Irritative symptoms- Frequency- Urgency- Urge incontinenceII- HematuriaIII- ComplicationsRetentionInfectionBladder stone.Symptoms of renal failure (in patients with chronic retention).
    • BENIGN PROSTATIC HYPERPLASIABENIGN PROSTATIC HYPERPLASIASignsSigns- Elderly Male- DRE: Size- Shape- Consistency- symmetry- Suprapubic Area (urine retention)- Renal mass ( hydronephrosis)- Hernia orfices (straining)- Neurological examination (S2,3,4)- Signs of renal failure (late).
    • BENIGN PROSTATIC HYPERPLASIABENIGN PROSTATIC HYPERPLASIA• Investigations:• I- Uroflowmetry• - Simple and non-invasive.• - Normal maximum flow rate (Q-Max) >18 ml/second• -Maximum Flow Rate < 10ml/Sec is indicative ofobstruction &/or weak detrusor muscle• II- Laboratory Investigations• - Urinalysis• - Serum creatinine• - Serum PSA ( prostatic specific antigen, <4ng/ml).
    • BENIGN PROSTATIC HYPERPLASIABENIGN PROSTATIC HYPERPLASIAIII- Diagnostic ImagingA. U/S Abdominal- Gives an idea about kidneys, post voiding residual, size of theprostate and other pathology ,e.g. bladder stone, diverticulumB. Plain KUB and IVUStonesUpper tract affectionSmooth basal filling defectFish hook of the lower uretersBladder trabeculations, cellules, and diverticulaPost-voiding film
    • BENIGN PROSTATIC HYPERPLASIABENIGN PROSTATIC HYPERPLASIA
    • BENIGN PROSTATIC HYPERPLASIABENIGN PROSTATIC HYPERPLASIAIV- Cystourethroscopy ( prior to surgery)Degree of middle &/or lateral lobe enlargement HematuriaBladder stoneAssociated pathologyUrethral stricture
    • BENIGN PROSTATIC HYPERPLASIABENIGN PROSTATIC HYPERPLASIADifferential DiagnosisDifferential DiagnosisMeatal stenosisUrethral strictureProstatic cancerBladder neck fibrosisDrugs ( parasympatholytic and sympathomimetics)Neurologic lesions
    • BENIGN PROSTATIC HYPERPLASIABENIGN PROSTATIC HYPERPLASIATreatmentTreatmentI- Medical TreatmentWatchful waitingPhytotherapy e.g. pumpkin seed oilAlpha-blockers e. g. doxazosin, Terazocin, Tamsolucin5-alpha reductase inhibitors e. g. finastride, Dutasteride.
    • BENIGN PROSTATIC HYPERPLASIABENIGN PROSTATIC HYPERPLASIAII- Surgical treatmentA. Transurethral resection of the prostate(TURP):This is the gold standard option.B. Open prostatectomy:Retropubic, transvesical and perineal routesN.B. Histopathological examination.
    • III- Less invasive methods (Still inferior to TURP):- Laser,- hyperthermia,- Incisions,- Balloon dilatation.
    • BENIGN PROSTATIC HYPERPLASIABENIGN PROSTATIC HYPERPLASIAIndications of surgeryIndications of surgery1. Repeated attacks of acute urine retention2. Chronic retention, hydronephrosis3. Hematuria (repeated significant)4. Recurrent UTI5. Bladder stone6. Severe obstructive symptoms7. Poor response to medical therapy8. Side effects of medical treatment.
    • Complications of prostatectomyComplications of prostatectomyA- Complications of anesthesiaB- intra-operative- Bleeding- TUR syndrome- Trauma (urethra, B.N., bladder)C- Immediate post-operative- Bleeding primary, reaction- Problems with catheters- Re-retentionD- Delayed post-operative- Bleeding secondary- Infection UTI, Wound- Urine leak- Urine incontinence- Urethral stricture
    • BENIGN PROSTATIC HYPERPLASIABENIGN PROSTATIC HYPERPLASIA- 20% of post-adenectomy biopsies have prostate cancer.- The peripheral zone (surgical capsule) may still at risk ofdeveloping cancer after TURP or Open prostatectomy;Follow up is essential by PSA & clinical evaluation.
    • Prostate CancerProstate CancerAhmad A. Elabbady, MDProfessor, Urology Department,University of Alexandria
    • PROSTATE CANCERPROSTATE CANCERNormal prostate is about 18-25 gm- Is a disease of the elderly men- One of the most common neoplasm in the aging male
    • Prostate CancerProstate Cancer• P Ca is the most common non-skin cancer among men.• Common in USA & Europe.• Men have 1 in 6 life time risk of developing P Ca.• Pathologic prevalence > clinical incidence• About 30% of men > 50 years have P Ca at autopsy.• Specimens from men > 80 years show 80% P Ca
    • Prostate cancerProstate cancerRisk FactorsRisk Factors- Age- Family history- Race- Dietary fats- Hormones- Geography- Genetics
    • Prostate CancerProstate Cancer• It is a Heterogeneous, wide spectrum disease.• Often, It is a slowly progressive disease.
    • Prostate CancerProstate Cancer• P Ca rarely causes symptoms early in thecourse of the disease.• The majority of adenocarcinomas arise in theperiphery of the gland distant from the urethra.
    • PROSTATICPROSTATIC SymptomsSymptomsI- Lower urinary tract symptoms ( LUTs)A. Obstructive symptoms- Hesitancy- Weak urinary stream- Straining during urination.- Sense of incomplete emptying- Terminal dribblingB. Irritative symptoms- Frequency- Urgency- Urge incontinence
    • PROSTATICPROSTATIC SymptomsSymptomsII- Hematuria More common with BPHIII- ComplicationsRetentionUT InfectionBladder stone.Symptoms of renal failure (in patients with chronic retention).IV- Symptoms of Mets (with cancer)Bone painGeneral symptoms
    • PROSTATICPROSTATICSignsSigns- Elderly Male- DRE: Size- Shape- Consistency- symmetry- Suprapubic Area (urine retention)- Renal mass ( hydronephrosis)- Hernia orfices (straining)- Neurological examination (S2,3,4)- Signs of renal failure (late).
    • Diagnosis of prostate CancerDiagnosis of prostate CancerEarly diagnosisEarly diagnosis- DRE Asymmetry, hard nodules- Serum PSA 0-4 ng/ml- TRUS-directed prostatic Bx.
    • Early detection of prostate CancerEarly detection of prostate CancerPSAPSAPSA is organ-specificbut not cancer specific
    • Early detection of prostate CancerEarly detection of prostate CancerPSAPSAPSA elevations-Prostate disease (BPH, prostatitis, P Ca)-prostate manipulation (massage, Bx).
    • Diagnosis of prostate CancerDiagnosis of prostate CancerAdvanced diseaseAdvanced disease• DRE hard irregular prostateDistortion of local anatomyUrine retention (acute, chronic)• PSA very high figures e.g. >100 ng/ml• MetastasisL.N.Bone (pain, neurologic symp., fractures)
    • Diagnosis of P CaDiagnosis of P CaTRUS-BxTRUS-BxThe major role of TRUS is to ensureaccurate wide-area sampling of prostatetissue.
    • Prostate cancerProstate cancerPathologyPathology• Commonly: adenocarcinoma . 95%• Other types: 5% e.g. TCC- Sarcoma
    • • The 2002 TNM staging for Ca P• TX Primary tumor cannot be assessed• T0 No evidence of primary tumor• T1 Clinically inapparent, not palpable or visible by imaging• T1a incidental histological finding in 5% or less of tissue• T1b incidental histological finding in > 5% of tissue• T1c identified by needle biopsy (because of elevated PSA)• T2 Tumor confined within the prostate• T2a involves one half of one lobe or less• T2b involves > half of one lobe, but not both lobes• T2c Tumor involves both lobes• T3a tumor penetrate capsule unilateral or bilateral• T3b tumor involve S.V.• T4a Tumor invades bladder neck, externalsphincter, and/or rectum• T4b Tumor invades levator muscle and/or fixed to pelvic wall
    • TNM staging for Ca PTNM staging for Ca P
    • Prostate cancerProstate cancergradinggrading• Gleason grading systemDepends on architectural patternGrades 1-5 for the primary and secondary patternGleason sum: primary + secondary grades
    • Prostate cancerProstate cancer• Pattern of spread• Direct• Inward > outward• Lymphatic• Obturator• Hypogastric• Distant• 90% to bones• Lung,liver
    • Prostate cancerProstate cancerDiagnosisDiagnosis• D.R.E : 50% of cases• Serum marker P.S.A ( Normal: 0-4 ng/ml)• T.R.U.S : Needle biopsy 6 each lobe• Bone Scan Tc labeled phosphate• CT• MRI• IVU• Bilateral pelvic lymphadenctomy (laparoscopic)
    • BENIGN PROSTATIC HYPERPLASIABENIGN PROSTATIC HYPERPLASIA
    • Prostate cancerProstate cancerTreatment OptionsTreatment Options• 1- Watchful Waiting Old age- Low grade•• 2- Radical prostatectomyT1,T2, Young patient-• Retropubic, perineal, laparoscopic•• 3- Radiotherapy• *Curative = Localized cancer• *Palliative = Metastatic••• Types:• - External beam• - Interstitial irradiation• I-123, Gold 198•
    • Prostate cancerProstate cancerTreatment OptionsTreatment Options• 4- Hormonal Therapy (Metastatic Tumors)Types:• Bilateral orchiectomy Best• Estrogen: DES• Anti-androgen : Bicultamide, Flutamide• LHRH agonists: Leupron, ZoladexCord compression Laminectomy, Ketoconazole, orchiectomyUreteral obstruction: Ureteric catheter, PCN, KetoconazoleRetention TUR
    • Thank you