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Benign prostatic hyperplasia

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Benign prostatic hyperplasia

  1. 1. SAM, MSIGWA-MD UNIVERSITY OF DODOMA - TANZANIA 04/09/2014 MSIGWA,SAM-MD 1
  2. 2.  The prostate is Greek for "protector“ or “to stand before” .  It is an exocrine gland of the male reproductive system in most mammals  In 2002, female paraurethral glands, or Skene's glands, were officially renamed the female prostate by the Federative International Committee on Anatomical Terminology 04/09/2014 MSIGWA,SAM-MD 2
  3. 3. The prostate is a firm, partly gland and partly muscular body, and is placed immediately below the internal urethral orifice and around the beginning of the urethra. It is situated in the pelvic cavity, below the lower part of the symphysis pubis, above the superior fascia of the urogenital diaphragm, and in front of the rectum. Size of a chestnut and conical in shape 04/09/2014 MSIGWA,SAM-MD 3
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  5. 5.  Consist of a base, an apex, an anterior, a posterior and two lateral surfaces.  The base (basis prostatæ) is directed upward, and is attached to the inferior surface of the bladder, The greater part of this surface is directly continuous with the bladder wall; the urethra penetrates it.  The apex (apex prostatæ) is directed downward, and is in contact with the superior fascia of the urogenital diaphragm 04/09/2014 MSIGWA,SAM-MD 5
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  8. 8.  Vessels and Nerves  The arteries supplying the prostate are derived from the internal pudendal, inferior vesical, and middle hemorrhoidal.  Its veins form a plexus around the sides and base of the gland; they receive in front the dorsal vein of the penis, and end in the hypogastric veins.  The nerves are derived from the pelvic plexus 04/09/2014 MSIGWA,SAM-MD 8
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  12. 12.  The prostate is divided into lobes. The anterior lobe  is the portion of the gland that lies in front of the urethra.  It contains no glandular tissue but is made up completely of fibromuscular tissue. 04/09/2014 MSIGWA,SAM-MD 12
  13. 13. The median or middle lobe is situated between the two ejaculatory ducts and the urethra. The lateral lobes make up the main mass of the prostate.  They are divided into a right and left lobe and are separated by the prostatic urethra. 04/09/2014 MSIGWA,SAM-MD 13
  14. 14. The posterior lobe  is the medial part of the lateral lobes and can be palpated through the rectum during digital rectal exam (DRE).  The prostate is surrounded by the prostatic capsule. Invasion of the capsule changes the stage of disease 04/09/2014 MSIGWA,SAM-MD 14
  15. 15.  Divided into 3 zones : Peripheral zone (PZ). .  The peripheral zone is in the outer most part of the prostate, and the lower peripheral zone is fairly close to the rectal wall. The peripheral zone is the most common site for prostatic adenocarcinoma -70% of CAP originate here. -largest anatomical subdivision. -contains 70-75% of normal prostatic glandular tissue -no contribution to BPH. 04/09/2014 MSIGWA,SAM-MD 15
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  17. 17. Central zone (CZ);  The central zone is in the center of the prostate and cancer does not originate there often.  25% of normal glandular tissue -10% of CAP originate here. Transition zone (TZ); .  The transitional zone is above the central zone and is a common site for benign prostatic hypertrophy, a non-malignant condition of the prostate, but cancer may originate there as well but not as often as in the peripheral zone.  5% of normal glandular tissue. -lies adjacent to prostatic urethra. -site of BPH. -expands to compress the outer PZ to form the false capsule. 04/09/2014 MSIGWA,SAM-MD 17
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  19. 19.  Preprostatic zone;  1% of normal gland. -smallest and most complex. -sphincteric function prevents reflux ejaculation. 04/09/2014 MSIGWA,SAM-MD 19
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  21. 21.  It secretes a slightly alkalic fluid, milky in appearance, that usually constitutes 50–75% of the volume of the semen along with spermatozoa and seminal vesicle fluid.  Prostate secretion in human consist of proteolytic enzymes, prostatic acid phosphatase, beta-microseminoprotein, prostate-specific antigen and zinc (more than 500 times concentration than in blood!)  Spermatozoa which was expelled in prostatic fluid have better motility, longer survival and better protection of the genetic material.  The prostate also contains some smooth muscles that help expel semen during ejaculation 04/09/2014 MSIGWA,SAM-MD 21
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  23. 23.  Testosterone will be transformed into a more active form of the hormone, called dihydrotestosterone (DHT) by 5-alpha-reductase in the prostate.  When men gets older, part of the transition zone in the prostate which grows throughout lifes will still be reacted to the hormone which will cause prostatomegaly.  Adenomatous prostatic growth is believed to begin at approximately age 30 years.  An estimated 50% of men have histologic evidence of BPH by age 50 years and 75% by age 80 years; in 40– 50% of these men, BPH becomes clinically significant. 04/09/2014 MSIGWA,SAM-MD 23
  24. 24.  The growth of the prostate is governed by many local and systemic hormones whose exact functions are not yet known.  The main hormone acting on the prostate is testosterone, which is secreted by the Leydig cells of the testes under the control of luteinising hormone (LH), itself secreted from the anterior pituitary under the control of hypothalamic luteinising hormone releasing hormone (LHRH).  LHRH has a short half-life and is released in a pulsatile manner. This pulsatile release is important, as receptors for LHRH will become desensitised if permanently occupied. 04/09/2014 MSIGWA,SAM-MD 24
  25. 25.  The administration of LHRH analogues in a continuous, non-pulsatile manner exploits the concept of receptor desensitisation and forms the basis for androgen deprivation therapy in prostate cancer.  Testosterone is converted to 1,5- dihydrotestosterone (DHT) by the enzyme 5α-reductase, which is found in high concentration in the prostate and the perigenital skin (type II).  Other androgens are secreted by the adrenal cortex, but their effects are minimal in the normal male.  Oestrogenic steroids are also secreted by the adrenal cortex and, in the ageing male, may play a part in disrupting the delicate balance between DHT and local peptide growth factors, and hence increase the risk of BPH 04/09/2014 MSIGWA,SAM-MD 25
  26. 26.  Increased levels of serum oestrogens, by acting on the hypothalamus, decrease the secretion of LHRH (and hence LH) and thereby decrease serum testosterone levels.  Thus, pharmacological levels of oestrogens cause atrophy of the testes and prostate by means of reductions in testosterone.  Other locally acting peptides are secreted by the prostatic epithelium and mesenchymal stromal cells in response to steroid hormones.  These include epidermal growth factor, insulin-like growth factors, basic fibroblast growth factor and transforming growth factors alpha and beta.  These undoubtedly play a part in normal and abnormal prostatic growth, but as yet their functions are unclear 04/09/2014 MSIGWA,SAM-MD 26
  27. 27.  A role for estrogens in the prostate pathology of the ageing male appears likely with accumulating evidence that estrogens, alone or in combination with androgens, are involved in inducing aberrant growth and/or malignant change.  Animal models have supported this hypothesis in the canine model, where estrogens “sensitize”  the ageing dog prostate to the effects of androgen[40].  The evidence is less clear inhumans.. 04/09/2014 MSIGWA,SAM-MD 27
  28. 28.  Estrogens in the male are predominantly the products of peripheral aromatization of testicular and adrenal androgens  While the testicular and adrenal production of androgens declines with ageing, levels of total plasma oestradiol do not decline.  This has been ascribed to the increase in fat mass with ageing (the primary site of peripheral aromatization) and to an increased aromatase activity with ageing. 04/09/2014 MSIGWA,SAM-MD 28
  29. 29.  However, free or bioavailable estrogens may decline due to an increase in sex hormone binding globulin, which could translate to lower intraprostatic levels of the hormone.  The potentially adverse effects of oestrogens on the prostate may be due to a shift in the intra-prostatic estrogen:androgen ratio with ageing 04/09/2014 MSIGWA,SAM-MD 29
  30. 30.  Prostate-specific antigen (PSA) is a glycoprotein that is a serine protease.  Its function may be to facilitate liquefaction of semen, but it is a marker for prostatic disease.  It is measured by an immunoassay, and the normal range can differ a little from laboratory to laboratory.  There is no real normal upper limit. The levels increase with age, with prostate cancer and with BPH.  There are age-related values but, in general, in men aged 50–69 years, a level of about 3–4 ng ml –1 would prompt a discussion about the need for prostate biopsy. 04/09/2014 MSIGWA,SAM-MD 30
  31. 31.  Its level in men with metastatic prostate cancer is usually increased to > 30 ng ml –1 and falls to low levels after successful androgen ablation.  Men with locally confined prostate cancer usually have serum PSA levels <10–15 ng ml –1  Although PSA is a reliable marker for the progression of advanced disease, it is neither specific nor sensitive in the differential diagnosis of early prostate cancer and BPH, as both diseases are compatible with PSA in the range of 3–15 ng ml–1 04/09/2014 MSIGWA,SAM-MD 31
  32. 32.  PSA measurement has superseded measurement of serum acid phosphatase.  In summary, about 25% of men with a PSA of 4–10 ng ml –1 have prostate cancer (i.e. it is not very specific), and about 15–20% of men with a PSA of 1–4 ng ml –1 have prostate cancer.  In general, one would advise men aged 50–69 years to undergo prostate biopsy if the PSA was more than ~ 3 ng ml–1 . The threshold would be lower in younger men with a strong family history 04/09/2014 MSIGWA,SAM-MD 32
  33. 33.  Benign prostatic hyperplasia (BPH) is the enlargement of the gland .  As the prostate starts to enlarge it exerts pressure on the walls of the urethra. 04/09/2014 MSIGWA,SAM-MD 33
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  36. 36.  This affect most men over the age of 50 but only 10% present with symptoms.  The severity of symptoms depends on the degree of encroachment on the prostatic urethra.  Anatomically, BPH is most strongly associated with the posterior urethral glands (PUG) and transitional zone (TZ) of the prostate.  However, the majority of growth eventually occurs in the TZ.  Since prostatic cancer also occurs in the PZ, BPH nodules in the PZ are often biopsied to rule out cancer 04/09/2014 MSIGWA,SAM-MD 36
  37. 37.  D. Incidence of BPH increases with age 1. Men aged 60 years: 50% 2. Men aged 80 years: 88%  E. Incidence of symptomatic onset is related to ethnicity  1. African American men:onset at age 60 years  2. Caucasian men: onset at age 65 years 04/09/2014 MSIGWA,SAM-MD 37
  38. 38.  Increasing age  Family history of BPH  Diet  Obesity  Lack of physical activity  Erectile dysfunction 04/09/2014 MSIGWA,SAM-MD 38
  39. 39.  The only clearly defined risk factors for BPH are age and the presence of circulating androgens.  BPH does not develop in men castrated before the age of forty .  But other factors may influence the prevalence of clinical disease. These include: 04/09/2014 MSIGWA,SAM-MD 39
  40. 40.  Clinical BPH appears to run in families.  If one or more first degree relatives are affected, an individual is at greater risk of being afflicted by the disorder [54]. In a study  by Sanda et al [55] the hazard-function ratio for surgically treated BPH amongst first  degree relatives of the BPH patients as compared to controls was 4.2 (95% CI, 1.7 to  10.2). The incidence of BPH is highest and starts earliest in blacks than Caucasians and is lowest in Asians [47].  Interestingly, despite having larger prostate glands, the age-adjusted risk of BPH was the same for blacks as for whites  Furthermore, in an Asian population, men presenting with BPH are likely to have higher symptom scores than blacks or Caucasians 04/09/2014 MSIGWA,SAM-MD 40
  41. 41.  Diet has been reported as a risk factor for the development of BPH.  Large amounts of vegetables and soy products in the diet may explain the lower rate of BPH in the orient when compared to westernized countries.  In particular, certain vegetables and soy are said to be high in phyto-oestrogens, such as genestin, that have antandrogenic effects by an as yet determined mechanism on the prostate in vitro [ 04/09/2014 MSIGWA,SAM-MD 41
  42. 42.  It has not been possible to delineate any other risk factors for BPH such as coronary  artery disease, liver cirrhosis or diabetes mellitus.  There is also no causal relationship between prostatic malignancy and benign hyperplasia 04/09/2014 MSIGWA,SAM-MD 42
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  44. 44. BPH is part of the natural aging process, like getting gray hair or wearing glasses BPH cannot be prevented BPH can be treated n n n 04/09/2014 MSIGWA,SAM-MD 44
  45. 45.  Several theories have been proposed to explain the etiology of the pathological phase of BPH.  The major theories include the hypotheses that pathological BPH is due Hormones 1) Dihydrotestosterone (DHT) hypothesis-a shift in prostatic androgen metabolism that occurs with aging, which leads to an abnormal accumulation of dihydrotestosterone, thus producing the enlarged prostate. This is supported by the  fauilure of BPH development in men castrated before puberty. 04/09/2014 MSIGWA,SAM-MD 45
  46. 46.  Serum testosterone levels slowly but significantly decrease with  advancing age; however, levels of oestrogenic steroids are not decreased equally.  According to this theory, the prostate enlarges because of increased oestrogenic effects.  It is likely that the secretion of intermediate peptide growth factors plays a part in the development of BPH . 04/09/2014 MSIGWA,SAM-MD 46
  47. 47.  2) Embryonic reawakening theory- assumes a reawakening of the embryonic induction potential of prostatic stroma. In summary, a change in the prostatic stromalepithelial interaction that occurs with aging occurs, which leads to an inductive effect  on prostatic growth.  3) Stem cell theory featuring an increase in the total prostatic stem cell number  and/or clonal expansion of the stem cells into amplifying and transit cells that  occurs with aging.  4) Inflammatory theory- Prostatic inflammation may contribute to prostate growth  due to the induction of cell growth due to the presence of inflammatory markers and  agents stimulating growth 04/09/2014 MSIGWA,SAM-MD 47
  48. 48.  BPH affects both glandular epithelium and connective tissue stroma to variable degrees.  These changes are similar to those occurring in breast dysplasia (see Chapter 50), in which adenosis, epitheliosis and stromal proliferation are seen in differing proportions. 04/09/2014 MSIGWA,SAM-MD 48
  49. 49.  BPH typically affects the submucous group of glands in the transitional zone, forming a nodular enlargement.  Eventually, this overgrowth compresses the PZ glands into a false capsule and causes the appearance of the typical ‘lateral’ lobes. 04/09/2014 MSIGWA,SAM-MD 49
  50. 50. What is Benign Prostatic Hyperplasia? Peripheral zone Transition zone Urethra 04/09/2014 MSIGWA,SAM-MD 50
  51. 51. Peripheral zone Transition zone Urethra 04/09/2014 MSIGWA,SAM-MD 51
  52. 52.  When BPH affects the subcervical CZ glands, a ‘middle’ lobe develops that projects up into the bladder within the internal sphincter (Fig. 73.3).  Sometimes, both lateral lobes also project into the bladder, so that, when viewed from within, the sides and back of the internal urinary meatus are surrounded by an intravesical prostatic collar 04/09/2014 MSIGWA,SAM-MD 52
  53. 53.  It is important to realise that the relationship between anatomical prostatic enlargement, lower urinary tract symptoms (LUTS) and urodynamic evidence of bladder outflow obstruction (BOO) is complex  Pathophysiologically, BOO may be caused in part by increased smooth muscle tone, which is under the control of α-adrenergic agonists 04/09/2014 MSIGWA,SAM-MD 53
  54. 54. Urethra The prostatic urethra is lengthened, sometimes to  twice its normal length, but it is not narrowed anatomically.  The normal posterior curve may be so exaggerated that it requires a curved catheter to negotiate it.  When only one lateral lobe is enlarged, distortion of the prostatic urethra occurs. 04/09/2014 MSIGWA,SAM-MD 54
  55. 55. Bladder. If BPH causes BOO, the musculature of the bladder  hypertrophies to overcome the obstruction and appears trabeculated (Fig. 73.5).  Significant BPH is associated with increased blood flow, and the resultant veins at the base of the bladder are apt to cause haematuria. 04/09/2014 MSIGWA,SAM-MD 55
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  57. 57.  In both sexes, non-specific symptoms of bladder dysfunction become more common with age, probably owing to impairment of smooth muscle function and neurovesical coordination.  Not all symptoms of disturbed voiding in ageing men should therefore be attributed to BPH causing BOO. 04/09/2014 MSIGWA,SAM-MD 57
  58. 58.  Urologists prefer the term  LUTS and discourage the use of the descriptive term ‘prostatism’.  The following conditions can coexist with BOO, leading to difficulty in diagnosis and in predicting the outcome of treatment: 04/09/2014 MSIGWA,SAM-MD 58
  59. 59. 1• idiopathic detrusor overactivity 2• neuropathic bladder dysfunction as a result of diabetes, strokes, Alzheimer’s disease or Parkinson’s disea 3.Degeneration of bladder smooth muscle giving rise to impaired voiding and detrusor instability; 4• BOO due to BPH 04/09/2014 MSIGWA,SAM-MD 59
  60. 60. • VOIDING  – hesitancy (worsened if the bladder is very full);  – poor flow (unimproved by straining);  – intermittent stream – stops and starts;  – dribbling (including after micturition);  – sensation of poor bladder emptying;  – episodes of near retention. 04/09/2014 MSIGWA,SAM-MD 60
  61. 61. • STORAGE  – frequency;  – nocturia;  – urgency;  – urge incontinence;  – nocturnal incontinence (enuresis) 04/09/2014 MSIGWA,SAM-MD 61
  62. 62.  This is a urodynamic concept based on the combination of low flow rates in the presence of high voiding pressures. It can be diagnosed definitively only by pressure–flow studies.  This is because symptoms are relatively non-specific and can result from detrusor instability, neurological dysfunction and weak bladder contraction.  Even low measured peak flow rates (< 10–12 ml s– 1) are not absolutely diagnostic because, in addition to BOO, weak detrusor contractions or low voided volumes (owing to instability) can be the cause. 04/09/2014 MSIGWA,SAM-MD 62
  63. 63.  Nonetheless, flow rates provide a useful guide for everyday clinical management.  Urodynamically proven BOO may result from:  • BPH;  • bladder neck stenosis;  • bladder neck hypertrophy;  • prostate cancer;  • urethral strictures;  • functional obstruction due to neuropathic conditions. 04/09/2014 MSIGWA,SAM-MD 63
  64. 64.  • Urinary flow rates decrease  (for a voided volume > 200 ml, apeak flow rate of > 15 ml s –1 is normal , one of 10–15 ml s –1 is equivocal and one < 10 ml s –1 is low  • Voiding pressures increase  (pressures > 80 cmH 2 O are high (Fig. 73.8), pressures between 60 and 80 cmH 2 O are equivocal and pressures < 60 cmH 2 O are normal). 04/09/2014 MSIGWA,SAM-MD 64
  65. 65.  1 The bladder may decompensate so that detrusor contraction becomes progressively less efficient and a residual urine develops.  2 The bladder may become more irritable during filling with a decrease in functional capacity partly caused by detrusor overactivity (see Chapter 76), which may also be caused by neurological dysfunction or ageing, or may be idiopathic. 04/09/2014 MSIGWA,SAM-MD 65
  66. 66.  1 Acute retention of urine is sometimes the first symptom of BOO.  Postponement of micturition is a common precipitating cause; overindulgence in beer and confinement to bed on account of intercurrent illness or operation are other causes. 04/09/2014 MSIGWA,SAM-MD 66
  67. 67.  2 Chronic retention.  In patients in whom the residual volume is > 250 ml or so the tension in the bladder wall  increases owing to the combination of a large volume of residual urine and increased resting and filling bladder pressures (acondition known as high-pressure chronic retention).  The increased intramural tension results in functional obstruction of the upper urinary tract with the development of bilateral hydronephrosis 04/09/2014 MSIGWA,SAM-MD 67
  68. 68.  As a result, upper tract infection and renal impairment may develop.  Such men may present with overflow incontinence, enuresis and renal insufficiency.  These symptoms should alert the doctor to the presence of this condition  3 Impaired bladder emptying.  If the bladder decompensates with the development of a large volume of residual urine, urinary infection and calculi are prone to develop. 04/09/2014 MSIGWA,SAM-MD 68
  69. 69.  4 Haematuria. This may be a complication of BPH. Other -causes must be excluded by carrying out an intravenous urography (IVU), cystoscopy, urine culture and urine cytological examination.  5 Other than pain from retention, pain is not a symptom of BOO, and its presence should prompt the exclusion of acute retention, urinary infection, stones, carcinoma of the prostate and carcinoma in situ of the bladder 04/09/2014 MSIGWA,SAM-MD 69
  70. 70. History  Symptom score sheets such as the International Prostate Symptom Score (IPSS) assign a score which gives information regarding the severity of symptoms at the outset and changes over time and following intervention. 04/09/2014 MSIGWA,SAM-MD 70
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  72. 72. Grading Scale (regarding questions below)  Score 0: Not at all  Score 1: Less than 1 in 5 times (<20%)  Score 2: Less than half the time (<50%)  Score 3: About half the time (50%)  Score 4: More than half the time (>50%)  Score 5: Almost always (>80%) 04/09/2014 MSIGWA,SAM-MD 72
  73. 73.  Questions pertaining to the last month of symptoms  1. Incomplete voiding or emptying sensation  2 .Frequency (urination within 2 hours of prior void)  3. Intermittency (stream stops and starts while voiding)  4. Urgency (difficulty postponing urination)  5. Weak urinary stream  6.Straining to begin urination  7. Nocturia (How many times per night of waking to void?) 04/09/2014 MSIGWA,SAM-MD 73
  74. 74.  Interpretation (Add total score for 7 questions above)  Total score <7: Mild BPH Symptoms  Total score 8 to 19: Moderate BPH Symptoms  Total score >20: Severe BPH Symptoms 04/09/2014 MSIGWA,SAM-MD 74
  75. 75.  General physical examination  may demonstrate signs of chronic renal impairment with anaemia and dehydration. 04/09/2014 MSIGWA,SAM-MD 75
  76. 76.  Abdominal examination  Abdominal extension is usually normal.  In patients with chronic retention, a distended bladder will be found on palpation, on percussion and sometimes on inspection with loss of the transverse suprapubic skin crease.  The external urinary meatus should be examined to exclude stenosis, and the epididymides are palpated for signs of inflammation. 04/09/2014 MSIGWA,SAM-MD 76
  77. 77.  Normal size is 3.5 cms wide, protruding about 1 cm into the lumen of the rectum.  Consistency: it is normally rubbery and firm with a smooth surface and a palpable sulcus between right and left lobes.  There should not be any tenderness.  There should be no nodularity. 04/09/2014 MSIGWA,SAM-MD 77
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  80. 80.  The posterior surface of the prostate (what we palpate) is in close contact with the anterior rectal wall.  A sulcus runs through the middle of the prostate and divides it into right and left lobes. 04/09/2014 MSIGWA,SAM-MD 80
  81. 81.  Size  Contour  Consistency  Mobility  Protrusion into the rectum  Grade 1, Grade 2, Grade 3, Grade 4  Sulcus present  Pain with palpation 04/09/2014 MSIGWA,SAM-MD 81
  82. 82.  Pencil eraser  Tip of your nose  Thenar pad 04/09/2014 MSIGWA,SAM-MD 82
  83. 83.  Benign prostatic hypertrophy  Prostate carcinoma  Acute prostatitis  Chronic prostatitis  Others: Prostatic calculi or abscesses 04/09/2014 MSIGWA,SAM-MD 83
  84. 84.  The normal tissue is replaced by collagen.  Results in expansion of the capsule, leading to pressure on the urethra; bladder and urinary symptoms (as discussed earlier).  All or part of prostate may enlarge. 04/09/2014 MSIGWA,SAM-MD 84
  85. 85.  The degree of enlargement of the prostate may not be related to symptoms  i.e., a prostate that is markedly enlarged may not obstruct urinary flow 04/09/2014 MSIGWA,SAM-MD 85
  86. 86.  “Acute urinary retention” may occur, and in general symptoms may be aggravated by:  Exposure to cold  Immobilization  Attempts to retain urine  Anesthetics, anticholinergics  Ingestion of alcohol 04/09/2014 MSIGWA,SAM-MD 86
  87. 87.  Size—enlarged  Consistency: boggy, squishy, smooth  Mobility—remains fairly mobile  Protrusion—Grade depends on stage  Sulcus—may be obscured (vs. obliterated)  Should be nontender 04/09/2014 MSIGWA,SAM-MD 87
  88. 88.  In benign enlargement,  the posterior surface of the prostate is smooth, convex and typically elastic, but the fibrous element may give the prostate a firm consistency.  The rectal mucosa can be made to move over the prostate.  Residual urine may be felt as a fluctuating swelling above the prostate. It should be noted that, if  there is a considerable amount of residual urine present, it pushes the prostate downwards, making it appear larger than it is. 04/09/2014 MSIGWA,SAM-MD 88
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  90. 90.  The nervous system  The nervous system is examined to eliminate a neurological lesion. Diabetes mellitus, tabes dorsalis, disseminated sclerosis, cervical spondylosis, Parkinson’s disease and other neurological states may mimic prostatic obstruction.  If these are suspected then a pressure–flow urodynamic study should be carried out to diagnose BOO.  Examination of perianal sensation and anal tone is useful in detection of an S2 to S4 cauda equina lesion 04/09/2014 MSIGWA,SAM-MD 90
  91. 91.  Urinalysis/MCS.  Examination of urine  The urine is examined for glucose and blood; a midstream specimen should be sent for bacteriological examination, and cytological examination may be carried out if carcinoma in situis thought possible. 04/09/2014 MSIGWA,SAM-MD 91
  92. 92.  Blood tests(FBC+ESR, E&U/Cr)  Serum creatinine, electrolytes and haemoglobin should be measured.  PSA: age specific.  However if abnormal, then -PSA velocity- a rise >0.75ng/ml/yr suggests CAP. -PSA density- (PSA/prostatic vol.) results >0.15ng/ml suggests CAP. PSAD is aimed at differentiating rise in PSA due to BPH from CAP. 04/09/2014 MSIGWA,SAM-MD 92
  93. 93.  Upper tract imaging  Most urologists no longer carry out imaging of the upper tract in men with straightforward symptoms.  Obviously, if infection or haematuria is present, then the upper tract should be imaged by means of intravenous urogram or ultrasound scan.  Ultrasound of the testicles, prostate, and kidneys is often performed, to rule out malignancy and hydronephrosis 04/09/2014 MSIGWA,SAM-MD 93
  94. 94. Cystourethroscopy  Inspection of the urethra, the prostate and the urothelium of the  bladder should always be done immediately prior to prostatectomy, whether it is being done transurethrally or by the open route to exclude a urethral stricture, a bladder carcinoma and the occasional non-opaque vesical calculus.  The decision of whether to perform prostatectomy must be made before cystoscopy.  This should be based on the patient’s symptoms, signs and investigations.  Direct inspection of the prostate is a poor indicator of BOO and the need for surgery 04/09/2014 MSIGWA,SAM-MD 94
  95. 95.  Prostatic biopsy. INDICATIONS:  Abnormal DRE  Elevated PSA >10ng/ml  Free PSA percent < 20.  Urine flow rate, post void residual urine, Pressure flow Urodynamics. Indicated in patients with moderate to severe symptoms IPSS 8-20 where decisions have to be taken on modalities of treatment. 04/09/2014 MSIGWA,SAM-MD 95
  96. 96.  URINE FLOW RATE. -Peak Flow Rate (PFR) >15ml/s = normal. 10-15ml/s = equivocal <10ml/s suggests BOO.  POST VOID RESIDUAL VOLUME. -measured by transabd USS. value >200ml indicate need for surgery. 04/09/2014 MSIGWA,SAM-MD 96
  97. 97.  Urethrocystoscopy. Indicated prior to surgery to select the correct operative modalities.  Imaging of upper tract: - IVU -Abdominal USS  TRUS and TRUS-guided biopsy.  Colour doppler imaging of the prostate. 04/09/2014 MSIGWA,SAM-MD 97
  98. 98. • Dipstick urinalysis should be performed in all BPH-LUTS patients to rule out other diagnoses that may cause LUTS. • Abnormal/borderline urinalysis results should be repeated and/or followed with a urine culture 04/09/2014 MSIGWA,SAM-MD 98
  99. 99. Urinalysis result Possible diagnosis Hematuria Kidney stones Bladder cancer Pyuria or nitrates UTI Urethral stricture Proteinuria Underlying renal disease Glucosuria diabetes 04/09/2014 MSIGWA,SAM-MD 99
  100. 100.  BPH does not cause prostate cancer, however men at risk of BPH are also at risk of developing prostate cancer.  It is a sensitive screening test for prostate volume.  Men at age 50 who are expected to live at least 10 more year.  45 years in men who are at high risk ( African American’s or close relative with prostate cancer ) 04/09/2014 MSIGWA,SAM-MD 100
  101. 101.  Help determine prostate and bladder size and degree of hydronephrosis in patients with urinary retention.  Transrectal ultrasonography is recommended in selected patients to determine the dimensions and volume of the prostrate. 04/09/2014 MSIGWA,SAM-MD 101
  102. 102.  It is indicated in patients whom a malignancy or foreign body is suspected. 04/09/2014 MSIGWA,SAM-MD 102
  103. 103. 1-7 = mild 8-19 = moderate 20-35 = severe 04/09/2014 MSIGWA,SAM-MD 103
  104. 104. 04/09/2014 MSIGWA,SAM-MD 104
  105. 105. 04/09/2014 MSIGWA,SAM-MD 105
  106. 106. MODALTIES INCLUDE:  Waitful watching  Medical therapy  Minimally invasive Rx  Surgery. 04/09/2014 MSIGWA,SAM-MD 106
  107. 107.  WATCHFUL WAITING:  Offer to pts with IPSS < or =8 who are not bothered by their symptoms.  Involves regular assessment of IPSS, PSA, PFR, PVR.  Contraindications: AUR, chronic retention, recurrent UTI, dilatation of upper tracts. 04/09/2014 MSIGWA,SAM-MD 107
  108. 108.  Suitable for patients where: - low risk of progression - sx not particularly bothersome  Regular monitoring using IPSS score will objectively identify deterioration  Education  Lifestyle advice  Reassurance 04/09/2014 MSIGWA,SAM-MD 108
  109. 109. Lifestyle Patients should decrease fluid intake before bedtime, moderate the consumption of alcohol and caffeine-containing products, and follow timed voiding schedules. 04/09/2014 MSIGWA,SAM-MD 109
  110. 110.  Alpha-blockers are a first-line option for men with symptomatic bother who desire treatment  5ARI’s are an effective option for symptomatic patients with demonstrable prostatic enlargement  Combination alpha-blocker and 5-ARI therapy improves symptom score and peak urinary flow vs. monotherapy; appropriate for patients with LUTS associated with prostatic enlargement  A PDE5 inhibitor can be used once-daily in men with moderate to severe symptoms and bother, to effectively reduce symptoms of BPH-LUTS while maintaining sexual function  Phytotherapy is not recommended by the CUA 04/09/2014 MSIGWA,SAM-MD 110
  111. 111.  Prostate smooth muscle tone is mediated via a1-adrenergic receptor  Blockage of the receptor leads to improvement of flow rate and LUTS1  Central a-receptors and the effect of agents on these receptors likely play an additional role  Density of adrenergic receptors changes with prostate size and age  Three a1-adrenergic receptor subtypes have been identified (A, B, D) Schwinn DA. BJU Int. 2000;86(suppl 2):11-22. 04/09/2014 MSIGWA,SAM-MD 111
  112. 112. 04/09/2014 MSIGWA,SAM-MD 112
  113. 113. 04/09/2014 MSIGWA,SAM-MD 113
  114. 114.  Nonselective  Phenoxybenzamine  Short-acting selective a1-blocker  Prazosin, Alfuzosin  Long-acting selective a1-blockers  Terazosin  Doxazosin  Long-acting selective a1A-subtype  Tamsulosin  Alfuzosin-SR 04/09/2014 MSIGWA,SAM-MD 114
  115. 115.  All currently available a1-blockers induce fast improvement in LUTS and flow rate parameters with similar efficacy  They are all well tolerated; however, the adverse event spectrum differs between the agents  Terazosin and doxazosin induce more dizziness, fatigue, and asthenia  Tamsulosin induces more ejaculatory disturbances  None of the a1-blockers alter urodynamic parameters, prostate volume or serum PSA  None have been shown to alter the natural history of the disease or prevent AUR / Surgery 04/09/2014 MSIGWA,SAM-MD 115
  116. 116. • Selective antagonist of α1-adrenoceptors located in: • Prostate • Prostatic capsule • Bladder base • Bladder neck • Prostatic urethra • Help relax smooth muscle in the bladder neck and prostate; allow urine to flow more freely • Selective and non-selective alpha-blockers exist • Non-selective alpha-blockers are not commonly used for BPH-LUTS 04/09/2014 MSIGWA,SAM-MD 116
  117. 117. • First line options include Selective :- Alfuzosin Tamsulosin Silodosin Non selective: Doxazosin Terazosin • Equal clinical effectiveness for LUTS secondary to BPH • Do not alter the natural progression of the disease • Choice of agent should depend on comorbidities, side effect profile and tolerance 04/09/2014 MSIGWA,SAM-MD 117
  118. 118.  Retrograde ejaculation  Erectile dysfunction  Asthenia •  Dizziness  Orthostatic hypotension  Nasal congestion 04/09/2014 MSIGWA,SAM-MD 118
  119. 119.  Prostatic differentiation & growth depend on androgenic stimulation  Testosterone is converted to dihydrotestosterone (DHT) within the prostatic stromal & basal cells facilitated by 5a-reductase enzyme  5a-reductase inhibitor: deprive the prostate of its testosterone support  5a-reductase enzyme: Type I: skin & liver Type II: stromal & basal cells of prostate, seminal vesicle, epididymis Kirby RS et al. Br J Urol. 1992;70:65-72 Tam0m4/e0la9 /T2L0J1 e4t al. J Urol. 1993;149:342-344 MSIGWA,SAM-MD 119
  120. 120. Serum testosterone (T) Serum Dihydrotestosterone (DHT) DHT DHT-androgen receptor complex Growth factors Unbalanced T 5AR (1 and 2) Prostate cell Increased Cell growth Cell death 04/09/2014 MSIGWA,SAM-MD 120
  121. 121. OH O O OH H 5 a-reductase type 1 and 2 NADPH NADP Testosterone Dihydrotestosterone Avodart (dutasteride) - Dual (type 1&2) 5ARI Proscar(finasteride) - Only type 2 5ARI 04/09/2014 MSIGWA,SAM-MD 121
  122. 122. • Indicated as first-line therapy for men with enlarged prostates: • Finasterideinhibits 5α-reductase Type 2 (prostate) • Dutasterideinhibits 5α-reductase Type 1 AND 2 (liver, skin and prostate) • Blocks the conversion of testosterone to DHT (responsible for prostate growth) • Treatment with 5-ARIs reduce: • Prostate size • PSA • Long-term risk of acute urinary retention • Need for surgery 04/09/2014 MSIGWA,SAM-MD 122
  123. 123.  Reduced libido  Erectile dysfunction  Decreased ejaculate volume  Breast tenderness 04/09/2014 MSIGWA,SAM-MD 123
  124. 124. 04/09/2014 MSIGWA,SAM-MD 124
  125. 125.  Alpha blockers relax the smooth muscle of bladder neck and prostatic capsule/adenoma, thereby improving symptoms and flow rates, relieving obstruction  5 ARIs reduce the action of androgens in the prostate, inducing apoptosis, atrophy, and, by shrinking the prostate improve symptoms, relieve obstruction and prevent AUR & prostate surgery 5ARIs Arrest disease progression a1-adrenergic blockers Rapidly relieve symptoms ? 04/09/2014 MSIGWA,SAM-MD 125
  126. 126. Medical Therapy of Prostatic Symptoms (MTOPS) 04/09/2014 MSIGWA,SAM-MD 126
  127. 127.  Combined alpha-blocker and 5-ARI therapy is effective for LUTS associated with prostatic enlargement  Improves symptom score and peak urinary flow greater than either monotherapy option  Delays symptomatic disease progression  Decreased risk of urinary retention and/or prostate surgery 04/09/2014 MSIGWA,SAM-MD 127
  128. 128.  Promote smooth muscle relaxation.  Improve LUTS.  Improves quality of life.  Effective in men with or without erectile dysfunction.  Tadalafil is the only approved PDE5 inhibitor for BPH-LUTS. 04/09/2014 MSIGWA,SAM-MD 128
  129. 129.  Single arm therapy with alpha blocker  Improve symptoms and prevent symptom progression  Does not alter natural history or cross over to invasive therapy  Single arm therapy with 5 ARI  Treats symptoms only when LUTS associated with BPH (ie enlargement or high PSA)  Alters natural history in pts at risk (large gland, high PSA)  Combination (doxazosin+finasteride) therapy is the most effective form of treatment for LUTS and BPH  Improve symptoms and flow rate  Prevent AUR and/or surgery  Alter the natural history of the disease 04/09/2014 MSIGWA,SAM-MD 129
  130. 130.  Headache  Facial flushing  Dyspepsia 04/09/2014 MSIGWA,SAM-MD 130
  131. 131. Drug class Time for symptom improvement Alpha blockers 2-4 weeks 5 alpha reductase inhibitors Atleast 6 months PDE5 inhibitors 4 weeks 04/09/2014 MSIGWA,SAM-MD 131
  132. 132. Case description Recommendation Moderate – severe bother (PSA 1.3ng/ml) Alpha blocker Diabetes Alpha blocker hypertension Alpha blocker Erectile dysfunction Alpha blocker or PDE5 Enlarged prostate + PSA > 1.5ng/ml 5-ARI Enlarged prostate + PSA > 1.5ng/ml + ED 5-ARI and/or PDE5 Bothersome sexual side effects with α-blocker or 5-ARI PDE5 04/09/2014 MSIGWA,SAM-MD 132
  133. 133. A. Indications  1. Failed medical therapy  2. Refractory urinary retention  3. Recurrent urinary tract infections  4. Persistant haematuria  5. Bladder stones  6. Renal Insufficiency 04/09/2014 MSIGWA,SAM-MD 133
  134. 134.  Acute urinary retention  Gross hematuria  Frequent UTI  Vesical stone  BPH related hydronephrosis or renal function deterioration  Obstruction IPSS≧8, prostate size, image study, UFR cystoscopic findings, residual urine 04/09/2014 MSIGWA,SAM-MD 134
  135. 135. 1. Transurethral Resection of the Prostate (TURP) 2. Open Prostatectomy (rarely used nowadays for BPH alone)  a. Very large prostate size  b. Large median prostate lobe protruding into bladder  c. Urethral diverticulum 04/09/2014 MSIGWA,SAM-MD 135
  136. 136. Very large ( 80-100g ) Large ( 30-80g ) Small ( <30g ) Open prostatectomy TURP TURP Laser prostatectomy -holium -greenlight Laser prostatectomy -holium -greenlight Minimally Invasive - TUMT - TUNA 04/09/2014 MSIGWA,SAM-MD 136
  137. 137.  Excessive bleeding requiring blood transfusion  TUR syndrome  Permanent sexual side effects:  Retrograde ejaculation  Erectile dysfunction (less common)  Urinary tract infections  Urinary incontinence  Need for retreatment:  Prostate regrowth  Bladder/urethral strictures 04/09/2014 MSIGWA,SAM-MD 137
  138. 138. TURP (transurethral resection of the prostate) “Gold Standard” of care for BPH Uses an electrical “knife” to surgically cut and remove excess prostate tissue Effective in relieving symptoms and restoring urine flow n n n 04/09/2014 MSIGWA,SAM-MD 138
  139. 139.  “Gold standard” of surgical treatment for BPH  80~90% obstructive symptom improved  30% irritative symptom improved  Low mortality rate 0.2% 04/09/2014 MSIGWA,SAM-MD 139
  140. 140.  Done using a Resectoscope  Used to Remove the Obstructing tissue in all but the most enormous tissue,thereby carving a passage way from the bladder  Hospital stay is short 04/09/2014 MSIGWA,SAM-MD 140
  141. 141.  Gold Standard” of care for BPH  Uses an electrical “knife” to surgically cut and remove excess prostate tissue  Effective in relieving symptoms and restoring urine flow 04/09/2014 MSIGWA,SAM-MD 141
  142. 142.  Operation is performed through a modified cystoscope  Prostatic tissue is resected using an electrically energized wire loop  Prostatic capsule is usually preserved.  Continuous irrigation is necessary to distend the bladder and to wash away blood and dissected prostatic tissue. 04/09/2014 MSIGWA,SAM-MD 142
  143. 143. • 04/09/2014 MSIGWA,SAM-MD 143
  144. 144. Ideally the irrigation solution should be: • Isotonic • electrically inert • Nontoxic • Transparent • inexpensive • Nonhemolytic • Nonmetabolized
  145. 145.  Prostate <60g.  LUTS not responding to change in lifestyle/medical therapy  Recurrent acute urinary retention.  Renal impairment due to BOO  Recurrent hematuria due to BPH  Small bladder stones due to BPH. 04/09/2014 MSIGWA,SAM-MD 145
  146. 146. Benefits Widely available Effective Long lasting Disadvantages Greater risk of side effects and complications 1-4 days hospital stay 1-3 days catheter 4-6 week recovery n n n n n n n 04/09/2014 MSIGWA,SAM-MD 146
  147. 147.  Immediate complication bleeding capsular perforation with fluid extravasation TUR syndrome  Late complication urethral stricture bladder neck contracture (BNC) retrograde ejaculation impotence (5-10%) incontinence (0.1%) 04/09/2014 MSIGWA,SAM-MD 147
  148. 148.  Hemorrhage; primary and secondary.  Urinary incontinence; maybe due to pre existing detrusor instability +/- sphincter weakness. Stress incontinence maybe due to sphincter damage 04/09/2014 MSIGWA,SAM-MD 148
  149. 149.  Retrograde Ejaculation; usually during ejaculation there is reflex closure of the internal sphincter when semen enters the prostatic urethra.  Urethral stricture; common sites--- ext urethral meatus, bladder neck and penoscrotal jxn. 0ccurs 4-10 months post surgery. 04/09/2014 MSIGWA,SAM-MD 149
  150. 150. • TURP syndrome: • constellation of signs and symptoms caused by the absorption of large volumes of isotonic irrigating fluids through prostatic veins or breaches in the prostatic capsule. • The syndrome is characterized by • hypervolemia, • hyponatremia • hypo-osmolarity
  151. 151. Manifest as confusion Seizures visual disturbance bradycardia. Central to this syndrome is dilutional Hyponatremia. Can be prevented thus;limit Resection time, 04/09/2014 MSIGWA,SAM-MD 151
  152. 152.  Avoid aggressive resection near the the capsule  Use a continous irrigating cystoscope-this provides low pressure irrigation 04/09/2014 MSIGWA,SAM-MD 152
  153. 153. TURP syndrome is more likely to occur: 1. The hydrostatic pressure of the irrigation solution is high. 2. An excessively distended bladder 3. Prostatic gland is large. 4. The Prostatic Capsule is violated during surgery. 5. Duration of surgery (>60mins) 04/09/2014 MSIGWA,SAM-MD 153
  154. 154.  Two types  Retropubic  Transvesical  Indications  Prostate gland 70-100g  Bladder diverticulum  Large Hard ca stone  Marked ankylosis of the Hip preventing lithotomy position 04/09/2014 MSIGWA,SAM-MD 154
  155. 155.  It is the most effective method of treating BOO due to BPH  PFR inceasesto>20mls/s,symptoms improve markedly.  Likelyhood of px requiring further surgery is 0.4%,compaared to TURP 3.4%  Complication rate 31.7% compared to TURP 16.1% 04/09/2014 MSIGWA,SAM-MD 155
  156. 156.  Haemorrhage-Follows inadequate haemostas  Clot Retention,folows severe bleed and inadequate nursing care  UTI  Epididymo-orchitis-Arise from retrograde spread of infxn from prostatic fossa along the vas to the Epididymis  Erectile Dysfxn-carvenosal nerve controlling erection may be destroyed during prostatectomy  Damage to the ureters 04/09/2014 MSIGWA,SAM-MD 156
  157. 157.  Retrograde ejaculation-bladder neck is removed in prostatectomy  Infertility  Incontinence of urine-Due to mech effect of the urethral catheter on the int sphincter of the bladder neck  DVT 04/09/2014 MSIGWA,SAM-MD 157
  158. 158. Contraindications  small fibrous gland  The presence of prostate cancer  Previous prostatectomy  Pelvic surgery that obliterate access to the prostate gland 04/09/2014 MSIGWA,SAM-MD 158
  159. 159.  Post-op Mx  Measure output input  Bladder irrigation  Effective pain mx  1st p.o.day fluid diet, ambulation ,deflate balloon(10ml↓) & irrigate residual clot  2nd p.o.day regular diet  3rd p.o.day remove retro pubic  4th p.o.day discharge with catheter  5- 7 pod day remove catheter 04/09/2014 MSIGWA,SAM-MD 159
  160. 160.  Complications  Bleeding -urethral catheter traction with 50ml of saline to compress the bladder neck & prostatic fossa -bladder irrigation to prevent clot formation -the inflow through urethral catheter &out flow through the suprapubic tube -if the bleeding persist cystoscopic inspection of the prostatic fossa &bladder neck -if marked bleeding continue to persist →open re-exploration 04/09/2014 MSIGWA,SAM-MD 160
  161. 161.  Perforation of the bladder & prostatic capsule (IN TURP)  Incontinency (if damaged external sphincter mechanism)  Retrograde ejaculetion(80-90%) & impotence (3-6% due to damage of the nerves associated with erection)  Bladder neck contracture  Urethral stricture  Sepsis  Death(0.2 to 0.3%) 04/09/2014 MSIGWA,SAM-MD 161
  162. 162.  TUR-syndrome  In 2% of all TURP  Due to absorption irrigating fluid through cut open veins  Characterized by (hyponatremia →↓Na+ ,HPT,nauesa& vomiting,bradicardia,visual disturbance,mental confusion)  Risk factors (gland>45gm,↑resection time >90mnt & much fluid for irrigation  RX diuretics &correct electrolytes 04/09/2014 MSIGWA,SAM-MD 162
  163. 163.  Two types  Retropubic  Transvesical  Indications  Prostate gland 70-100g  Bladder diverticulum  Large Hard ca stone  Marked ankylosis of the Hip preventing lithotomy position 04/09/2014 MSIGWA,SAM-MD 163
  164. 164.  Proper Positioning of the Patient  Once anesthesia has been induced the patient is positioned on the operating table in a supine position  Trendelenburg position without extension 04/09/2014 MSIGWA,SAM-MD 164
  165. 165. 04/09/2014 MSIGWA,SAM-MD 165
  166. 166.  A 2-0 chromic suture on a 58-inch circle-tapered needle is passed in the avascular plane between the urethra and the dorsal vein complex at the apex of the prostate.  A tie is grasped and tied around the dorsal vein complex. B, With 2-0 chromic suture material on a CTX needle, a figure-of-eight suture is placed through the prostatovesicular junction just above the level of the seminal vesicles to control the main arterial blood supply to the prostate gland.  When placing this suture, care must be taken to avoid entrapment of the neurovascular bundles located posteriorly and slightly laterally 04/09/2014 MSIGWA,SAM-MD 166
  167. 167.  Retropubic prostatectomy. A, With the superficial branch of the dorsal vein complex secured proximally and distally, a No. 15 blade on a long handle is used to make the transverse capsulotomy. B, Metzenbaum scissors are used to develop the plane anteriorly between the prostatic adenoma and the prostatic capsule. 04/09/2014 MSIGWA,SAM-MD 167
  168. 168. 04/09/2014 MSIGWA,SAM-MD 168
  169. 169.  Retropubic prostatectomy. A, With blunt dissection with the index finger, the prostatic adenoma is dissected free laterally and posteriorly. B, Metzenbaum scissors are used to divide the anterior commissure to visualize the posterior urethra and verumontanum. C, The index finger is then used to fracture the urethral mucosa at the level of the verumontanum. With this last maneuver, extreme care is taken not to injure the external sphincteric mechanism 04/09/2014 MSIGWA,SAM-MD 169
  170. 170. 04/09/2014 MSIGWA,SAM-MD 170
  171. 171. 04/09/2014 MSIGWA,SAM-MD 171
  172. 172.  Retropubic prostatectomy. A, View of the prostatic fossa and posterior urethra after enucleation of all the prostatic adenoma. Note that the verumontanum and a strip of posterior urethra remain intact. B, After placement of a urethral catheter and, if needed, a Malecot suprapubic tube, the transverse capsulotomy is closed with two running 2-0 chromic sutures. The two sutures are tied first to themselves and then to each other across the midline to create a watertight closure of the prostatic capsule. 04/09/2014 MSIGWA,SAM-MD 172
  173. 173. 04/09/2014 MSIGWA,SAM-MD 173
  174. 174.  Proper Positioning of the Patient  After anesthesia has been induced, the patient is positioned on the operating table in a supine position.  The table is placed in a mild Trendelenburg position without extension  22-Fr catheter is inserted into the bladder. After residual urine is drained, 250 mL of saline is instilled into the bladder and the catheter is clamped. 04/09/2014 MSIGWA,SAM-MD 174
  175. 175. This image cannot currently be displayed. 04/09/2014 MSIGWA,SAM-MD 175
  176. 176. 04/09/2014 MSIGWA,SAM-MD 176
  177. 177.  Starting at the bladder neck posteriorly, Metzenbaum scissors are used to develop the plane between the prostatic adenoma and the prostatic capsule (lateral view). B, Anterior view of the same maneuver 04/09/2014 MSIGWA,SAM-MD 177
  178. 178. 04/09/2014 MSIGWA,SAM-MD 178
  179. 179.  Using the index finger, the prostatic adenoma is enucleated from the prostatic fossa (lateral view). B, Anterior view of the same maneuver. With extreme large prostate glands, the left, right, and median lobes should be removed separately 04/09/2014 MSIGWA,SAM-MD 179
  180. 180. 04/09/2014 MSIGWA,SAM-MD 180
  181. 181.  After enucleation of the entire prostatic adenoma, a 0-chromic suture is used to place two figure-of-eight sutures to advance bladder mucosa into the prostatic fossa at the 5- and 7- o’clock positions at the prostatovesicular junction to ensure control of the main arterial blood supply to the prostate. 04/09/2014 MSIGWA,SAM-MD 181
  182. 182. 04/09/2014 MSIGWA,SAM-MD 182
  183. 183.  suprapubic tube, the cystotomy is closed in two layers using a running 2-0 Vicryl suture, enforced by tying of multiple interrupted 3-0 Vicryl stay sutures. A closed Davol suction drain is placed on one side of the bladder and exits via a separate stab incision 04/09/2014 MSIGWA,SAM-MD 183
  184. 184. 04/09/2014 MSIGWA,SAM-MD 184
  185. 185.  It is the most effective method of treating BOO due to BPH  PFR inceasesto>20mls/s,symptoms improve markedly.  Likelyhood of px requiring further surgery is 0.4%,compaared to TURP 3.4%  Complication rate 31.7% compared to TURP 16.1% 04/09/2014 MSIGWA,SAM-MD 185
  186. 186.  Haemorrhage-Follows inadequate haemostas  Clot Retention,folows severe bleed and inadequate nursing care  UTI  Epididymo-orchitis-Arise from retrograde spread of infxn from prostatic fossa along the vas to the Epididymis  Erectile Dysfxn-carvenosal nerve controlling erection may be destroyed during prostatectomy  Damage to the ureters 04/09/2014 MSIGWA,SAM-MD 186
  187. 187. MINIMALLY INVASIVE TREATMENT.  indicated in pts with IPSS 8-19  Pts unfit for major surgery-pulmonary dxs, liver dxs, MI etc.  CONTRAINDICATIONS:  Recurrent episodes of haematuria  Bladder stone due to BPH  Upper tract dilatation  Recurrent UTI  Renal insufficiency. 04/09/2014 MSIGWA,SAM-MD 187
  188. 188.  OPTIONS:  High intensity focused ultrasound (HIFU)  Transurethral vapourisation of prostate  Transurethral laser therapy (TULIP)  Intra-urethral stents  Transurethral needle ablation of prostate (TUNA)  Transurethral balloon dilatation. 04/09/2014 MSIGWA,SAM-MD 188
  189. 189.  1. Transurethral Incision of the Prostate  2. Transurethral Laser Induced Prostatectomy (TULIP)  a. Ultrasound-guided Nd-Yag laser  b. Shorter procedure and fewer complications than TURP  c. No tissue samples for histopathology testing 04/09/2014 MSIGWA,SAM-MD 189
  190. 190.  3. Transurethral Microwave Thermotherapy (TUMT)  a. Microwave probe heats to over 45 C  b. Safe, effective method for urinary retention relief  4. Transurethral Vaporization of the Prostate (TUVP)  5. Transurethral Electrovaporization Prostate (TVP)  6. Transurethral Needle Ablation of Prostate (TUNA)  7. Hot Water Ballon Thermoablation  a. Experimental procedure with good outcomes  b. Minimal discomfort 04/09/2014 MSIGWA,SAM-MD 190
  191. 191.  8. Urethral Stent  a. Risk of infection and re-blockage  b. Indications  i. BPH patients with high surgical risk  ii. Short life expectancy  9. Transurethral Balloon Dilation  a. Rarely used due to high rate of symptom recurrence. 04/09/2014 MSIGWA,SAM-MD 191
  192. 192. Temporary Stents  Temporary stents are tubular devices that are made of either a nonabsorbable or a biodegradable material  designed for short-term use, to relieve bladder outlet obstruction (BOO) 04/09/2014 MSIGWA,SAM-MD 192
  193. 193.  Spiral Stents- e.g Urospiral,stent should remain in the prostatic urethra for longer than 12 months  Polyurethane Stents  Biodegradable Stents 04/09/2014 MSIGWA,SAM-MD 193
  194. 194.  were introduced as a definitive treatment for prostatic obstruction, particularly for patients unfit for prostatic surgery  Patients were able to void satisfactorily in most cases, but complications were relatively high  UroLume endourethral prosthesis 04/09/2014 MSIGWA,SAM-MD 194
  195. 195.  Heat treatment inducing necrosis of prostatic tissue  The aim is to increase prostatic temperature to in excess of 60° C  Uses low-level radiofrequency (RF) energy that produces localized necrotic lesions in the hyperplastic tissue. 04/09/2014 MSIGWA,SAM-MD 195
  196. 196. 04/09/2014 MSIGWA,SAM-MD 196
  197. 197.  These cover heat changes and differential blood flow in the prostate  Damages the sympathetic nerve endings  Induction of apoptosis 04/09/2014 MSIGWA,SAM-MD 197
  198. 198. 04/09/2014 MSIGWA,SAM-MD 198
  199. 199.  “laser” stands for light amplification by the stimulated emission of radiation  There are four types of laser that can be used to treat the prostate 1. Neodymium : Yttrium-Aluminum-Garnet Laser 2. Potassium-Titanyl-Phosphate Laser 3. Holmium : Yttrium-Aluminum-Garnet Laser 4. Diode Laser 04/09/2014 MSIGWA,SAM-MD 199
  200. 200. The energy from lasers can be delivered as follows:  End firing  Bare tip  Sculptured tip  Sapphire tip  Side firing  Metal or glass reflector  Prismatic internal reflector 04/09/2014 MSIGWA,SAM-MD 200
  201. 201.  Retrograde ejaculation-bladder neck is removed in prostatectomy  Infertility  Incontinence of urine-Due to mech effect of the urethral catheter on the int sphincter of the bladder neck  DVT 04/09/2014 MSIGWA,SAM-MD 201
  202. 202.  Prostatitis  Bladder obstruction  Bladder cancer  Neurogenic bladder 04/09/2014 MSIGWA,SAM-MD 202
  203. 203.  This is the commonest cancer in men. 52% of tumours at presentation are localized to the prostate gland. It is rare below the age of 50.  Most prostate cancers are slow growing; however, there are cases of aggressive prostate cancers. The cancer cells may metastasize (spread) from the prostate to other parts of the body, particularly the bones and lymph nodes.  Spread occurs to adjacent organs, e.g. bladder, urethra and seminal vesicles.  Spread to the rectum is rare. Lymphatic spread is to the iliac and para-aortic nodes. Blood spread occurs early, especially to the pelvis, spine and skull (osteosclerotic lesion).  Prostate cancer may cause pain, difficulty in urinating, problems during sexual intercourse, or erectile dysfunction. 04/09/2014 MSIGWA,SAM-MD 203
  204. 204. Genetic  Men who have a first-degree relative (father or brother) with prostate cancer have twice the risk of developing prostate cancer, and those with two first-degree relatives affected have a fivefold greater risk compared with men with no family history.  Mutations in BRCA1 and BRCA2, important risk factors for ovarian cancer and breast cancer in women, have also been implicated in prostate cancer. Other linked genes include the Hereditary Prostate cancer gene 1 (HPC1), the androgen receptor, and the vitamin D receptor. 04/09/2014 MSIGWA,SAM-MD 204
  205. 205. Dietary  Evidence supports little role for dietary fruits and vegetables in prostate cancer occurrence.  Red meat and processed meat also appear to have little effect in human studies. Higher meat consumption has been associated with a higher risk in some studies.  Lower blood levels of vitamin D may increase the risk of developing prostate cancer.  Taking multivitamins more than seven times a week may increase the risk of developing the disease.  A 2009 study on folic acid supplements showed an association with an increased risk of developing prostate cancer.  Obesity and elevated blood levels of testosterone may increase the risk for prostate cancer. 04/09/2014 MSIGWA,SAM-MD 205
  206. 206. Others  Use of the cholesterol-lowering drugs ( statins )may also decrease prostate cancer risk.  Infection or inflammation of the prostate (prostatitis) may increase the chance for prostate.sexually transmitted infections chlamydia, gonorrhea, or syphilis seems to increase risk.  There is an association between vasectomy and prostate cancer however more research is needed to determine if this is a causative relationship. 04/09/2014 MSIGWA,SAM-MD 206
  207. 207.  Asymptomatic  Hard craggy mass and nodule in prostate on rectal examination - the median sulcus between the lobes may be obliterated  Incontinence  Dysuria  Haematuria  Hesitancy  Dribbling  Retention  Bone pain - pathological fractures  Sciatica  Anaemia  Weight loss  Palpable bladder  Tenderness over bone  Hepatomegaly 04/09/2014 MSIGWA,SAM-MD 207
  208. 208.  Hb-FBC  ESR  U&Es  Creatinine  PSA - PSA Density (PSAD) - the blood PSA level divided by the size of the prostate, as determined by TRUS - can help distinguish between BPH and prostate cancer. Basically, with BPH, the PSA level should not be more than 15 percent of the size of the prostate. PSA levels exceeding 15 percent of the size of the prostate are more likely to indicate the presence of prostate cancer -- and the need for a biopsy.  Transrectal Ultrasound (TRUS) scan and guided biopsy  CXR : metastases in lungs or ribs  Bone radiograph : sclerotic deposits in pelvis, spine or skull  Bone scan is sensitive indicator of early metastases  Ultrasound Spectral (USS) : residual urine, upper urinary tract obstruction, and useful in prostate Ca grading. Grade I - 3.0 to 3.8 cms 30 Gms. Grade II - 3.8 to 4.5 cms 30- 50 Gms. Grade III- 4.5 to 5.5 cms 50- 80 Gms. Grade IV - 5.5. cms 85 Gms 04/09/2014 MSIGWA,SAM-MD 208
  209. 209.  Is used to help evaluate the prognosis of men with prostate cancer.  It grades tumors on a scale of 1-5. You may have different grades of ca in one biopsy sampel.  The 2 main grades are added together. - The higher the score,the higher the probability of the ca to spread past the prostate.  Scores 2-5 : Low grade prostate  Scores 6-7 : Intermedieate (most prostate fall into this group)  Scores 8-10:High grade ca 04/09/2014 MSIGWA,SAM-MD 209
  210. 210. Mainly TURP to relieve obstructive symptoms Other treatment for Prostatic Cancer depends on staging.  For cancer localized to prostate - observation with routine monitoring of PSA, external beam radiotherapy or radical prostatectomy.  For metastatic disease, hormonal manipulation is used, such as Luteinizing releasing hormone releasing hormone (LHRH) agonist E.g. cyproterone acetate or bicalutamide and silboestrol,which is rarely used nowadays (causes gynaecomastioa and fluid retention)  Local radiotherapy is used for bony metastatic pain PROGNOSIS : Variable - Depends on stage at presentation. Patients with clinically localized tumor treated radically may expect a normal life expectancy. Those with metastatic disease at presentation have a median 3-year survival. 04/09/2014 MSIGWA,SAM-MD 210
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  213. 213.  This occurs most commonly in young adults.  Acute bacterial prostatitis ususally presents as an acute febrile illness.  Chronic prostatitis presents with recurrent UTIs.  If there is a past history of TB anywhere in the body, suspect TB prostatitis. 04/09/2014 MSIGWA,SAM-MD 213
  214. 214. Acute Bacterial Prostatitis :  Fever  Low back pain  Perineal pain  Bladder irritation  Outflow obstruction  Enlarged tender prostate Chronic Prostatitis :  Sx of UTI - but mild or sometimes absent  Dull perineal ache  Normal or indurated irregular prostate 04/09/2014 MSIGWA,SAM-MD 214
  215. 215. Acute Prostatitis :  FBC - TWC (raised)  Mid -stream urine (MSU) - shows growth.  Blood C&S Common bacterias are: Echerichiacoli, Klebsiella, Proteus, Pseudomonas, Enterobacter, Enterococcus, Se rratia, andStaphylococcus aureus Chronic Prostatitis :  Prostatic massage may yield secretions containing white cells and occasionally orgasms  Culture for TB in chronic prostatitis 04/09/2014 MSIGWA,SAM-MD 215
  216. 216. Acute Prostatitis :  Bed rest  Hydration  Antibiotics (I.V) eg. Ciprofloxacin, Co-trimoxazole and tetracyclines such as doxycycline  Analgesics  Patients with urinary retention are best managed with a suprapubic catheter or intermittent catheterization. Chronic Prostatitis :  Long term antibiotics eg. Ciprofoloxacin for 4-8weeks  Escherichia coli extract and cranberry have a potentially preventive effect  Prostatic massage (may be effective) TB Prostatitis :  Anti - TB 04/09/2014 MSIGWA,SAM-MD 216
  217. 217.  What is prostate?  What prostate does?  What are the causes for enlargement of prostate?  How do we differentiate between each cause?  What are the treatment of BPH, Prostate Ca and Prostatitis? 04/09/2014 MSIGWA,SAM-MD 217
  218. 218.  Bailey and love’s surgery  Churchill’s Surgery  Dr.Mwashambwa , M.Y lecture notice  Oxford Clinical Surgery  World Wide Web  Salman Bangash 2014 ppt  Dr. Shampile sydney ppt 04/09/2014 MSIGWA,SAM-MD 218
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