Benign prostatic hyperplasia (BPH) is a common benign tumor in older men that results from proliferation of cells in the prostate. It affects the transition zone of the prostate and causes obstruction of urine flow. Common symptoms include hesitancy, weak stream, urgency and frequency. Diagnosis is based on history, physical exam and symptom scoring. Treatment options range from watchful waiting for mild cases to medications, minimally invasive procedures or surgery for more severe cases. Alpha blockers and 5-alpha reductase inhibitors are first line medical therapies that work by relaxing prostate smooth muscle tone.

1. - Dr. Anusha . M

2.  Most Common Benign Tumour in Men.
Histologic Diagnosis is characterized by
Proliferation of Epithelial and Stromal
elements of Prostate.
 Incidence is Age Related.
20% among men aged 41-50 years
50% among men aged 51-60 years
>90% in men aged more than 80 years.
 BPH develops in Transition zone of Prostate.

3.  Normal weight of prostate ranges from 20-25
grams
 According to Mc Neal, gland is divided into 3
zones.

4. Peripheral Zone Central zone Transition Zone
70% of gland; 25% of gland; 5% of gland
Situated
posteriorly
-More prone to
carcinomatous
change
Situated
posteior to
urethral lumen
and above the
ejaculatory
ducts
Periurethral
zone of prostate

5. CAPSULES OF PROSTATE
• True Capsule: formed by condensation of
peripheral part of gland. Fibromuscular and is
continous with stroma of gland.
• False Capsule: lies outside the true capsule;
derived from endopelvic fascia. Prostatic
venous plexus is embeded in between two
capsules.

6. The arterial supply to the prostate is
primarily from the inferior vesical artery,
which originates from the anterior
division of the internal iliac artery. The
inferior vesical artery then branches into
2 main arterial branches to feed the
prostate. The inferior vesical artery
supplies the base of the bladder, the
distal ureters, and the prostate.
• The first arterial branch is the urethral
artery , the main arterial supply for the
adenomas in benign prostatic
hyperplasia
• The capsular artery is the second main
branch of the prostate.This artery
enters the prostate at right angles to
supply the glandular tissue.

7. Venous Drainage
 The veins form a rich plexus around the sides and the
base of the prostate.The plexus communicates with
the vesical plexus and with the internal pudendal
vein which drains into vesical and internal iliac veins.
 Valveless communications exist between the
prostatic and vertbral venous plexuses through which
prostatic carcinoma spreads to vertebral column and
skull.

8. Gland enlargement occurs due to epithelial
and stromal proliferation or impaired pre-
programmed cell death i.e.., Apoptosis or
both.
Prostatic enlargement depends on potent
androgen Dihydrotestosterone (DHT).
In prostate, type 2 5α Reductase metabolises
circulating TST to DHT, which acts locally.
DHT binds to androgen receptors of cell nuclei.

9.  There observed a positive correlation between
levels of free TST, estrogen and volume of
Prostate which suggests that the association
between aging and BPH might result from
increased estrogen levels causing induction of
androgen receptor, which there by sensitizes the
prostate to free TST.
 In men younger than 60 years, may be a
heritable form of disease. In such cases it is of
autosomal dominant pattern of inheritance.
 In First degree male relatives, relative risk is of
approximately fourfold.

10. Pathology:
 BPH virtually always occurs in the inner,
transitional zone of the prostate.
The affected prostate is enlarged, typically
weighing between 60 and 100 g, and contains
many well circumscribed nodules that bulge
from the cut surface.
 As BPH nodules in the transition zone
enlarge, they compress the outer zones of
the prostate, resulting in the formation of a
so-called surgical capsule.
This boundary separates the transition zone
from the peripheral zone and serves as a
cleavage plane for open enucleation of the
prostate during open simple prostatectomies
performed for BPH.

11. The nodules may appear solid or
contain cystic spaces.
The urethra is usually
compressed by the hyperplastic
nodules, often to a narrow slit.
In some cases, hyperplastic
glandular and stromal elements
lying just under the epithelium
of the proximal prostatic urethra
may project into the bladder
lumen as a pedunculated mass,
producing a ball-valve type of
urethral obstruction. Well-defined nodules compress
the urethra into slit like lumen

12. Microscopically
The hyperplastic nodules are
composed of variable proportions of
proliferating glandular elements and
fibromuscular stroma.
The hyperplastic glands are lined by
tall, columnar epithelial cells and a
peripheral layer of flattened
basal cells.

Low-power photomicrograph
demonstrates a well-demarcated nodule.

Higher-power photomicrograph showing
morphology of the hyperplastic glands,
which are large, with papillary infolding.

13. Pathophysiology
• The symptoms of BPH are related to
1) The obstructive component of the prostate
2) Secondary response of the bladder to the outlet
resistance.
Obstructive: Mechanical or Dynamic
 Mechanical:
As the prostate enlarges, the surrounding capsule prevents it
from radially expanding, potentially resulting in urethral
compression.
Obstruction-induced bladder dysfunction contributes
significantly to LUTS.
 Dynamic component of prostatic obstruction is explained as
follows:
The prostatic stroma, composed of smooth muscle and collagen,
is rich in adrenergic nerve supply. The level of autonomic
stimulation sets a tone to the prostatic urethra.
Use of α-blocker therapy decreases this tone, resulting
in a decrease in outlet resistance.

14. The secondary response of the bladder to the
increased outlet resistance :
• Bladder outlet obstruction leads to detrusor
muscle hypertrophy and hyperplasia as well as
collagen deposition.
• This leads to a decrease in bladder compliance,
detrusor instability is also a factor.
• On gross inspection, thickened detrusor muscle
bundles are seen as trabeculation on cystoscopic
examination.
• If left unchecked, mucosal herniation between
detrusor muscle bundles ensues, causing
diverticula formation.

15. Obstructive
 Hesitancy
 Decreased force and
caliber of stream
 Sensation of
incomplete bladder
emptying
 Double voiding
 Straining to urinate
 Postvoid dribbling
Irritative
 Urgency
 Frequency
 Nocturia
The symptoms of BPH can be divided into
obstructive and irritative complaints.

16.  Special attention to the following features is
essential in making the correct diagnosis and
recommending treatment choices:
 Onset and duration of symptoms
 General health issues (including sexual
history)
 Fitness for any possible surgical interventions
 Severity of symptoms and how they are
affecting quality of life
 Medications
 Previously attempted treatments

17. GRADING:
• The American Urological Association (AUA) developed a self
administered questionnaire which is reliable in identifying the
need to treat patients and in monitoring their response to
therapy.
• The AUA Symptom Score Questionnaire has been extensively
validated and it is now more commonly called the International
Prostate Symptom Score
• This assessment focuses on seven items that will be asked to
patients to quantify the severity of their obstructive or irritative
complaints on a scale of 0–5.
• The score can range from 0 to 35.
IPSS Grade
0-7 Mild
8-19 Moderate
20-35 Severe

19.  A physical examination, Digital rectal
examinaton are performed on all patients.
 The size and consistency of the prostate is
noted, even though prostate size, as
determined by DRE, does not correlate with
severity of symptoms or degree of
obstruction.
 BPH usually results in a smooth, firm, elastic
enlargement of the prostate.

20. Normal prostate –
Grade I (approximately 20g):
Flat or slightly rounded surface,
median sulcus usually unnoticed; with
approximately one fingertip length
anteroposteriorly, and one fingertip
mediolaterally;
Grade I/ II prostate (approximately 30g):
Surface of the prostate between Grade I,
and Grade II

21. Grade II (approximately 40g):
Bilobar rounded surface, well-delimitated
median sulcus; with approximately two
fingertips of length anteroposteriorly, and
one/one and a half fingertip
mediolaterally or one fingertip length
anteroposteriorly, and two fingertips
mediolaterally.

22. Grade II/III (approximately 50g):
Rounded surface, partial
obliteration of the median sulcus;
with approximately the same length
of a Grade II prostate , or an
asymmetric surface with one lobe
Grade II, and the other lobe Grade
III.

23. Grade III (approximately 60g):
Rounded surface, complete obliteration
of the median sulcus; with two fingertips
anteroposteriorly, and two fingertips
mediolaterally
Grade IV (approximately 80g or greater):
Rounded surface, complete obliteration of
the median sulcus;with no accessibility of
the upper limits of the prostate to the tip
of the examining finger.

24.  The American Urological Association (AUA)
has issued a guideline on the management of
benign prostatic hyperplasia.
 Investigations can be grouped into 3
categories:
--Laboratory tests
--Imaging
--Function assessment

26. Urinalysis and Urine Culture
Urine Examination using dipstick methods or via centrifuged
sediment evaluation to assess for the presence of blood,
leukocytes, bacteria, protein, or glucose.
If the initial urinalysis findings indicate an abnormality, a urine
culture may be useful to exclude infectious causes of irritative
voiding.
Electrolytes, BUN, and Creatinine
These evaluations are useful screening tools for chronic renal
insufficiency in patients who have high post-void residual (PVR)
urine volumes.

27. Prostate-Specific Antigen
• Although BPH does not cause prostate cancer, men at risk
for BPH are also at risk for prostate cancer and should be
screened accordingly.
• The current American Cancer Society (ACS) guideline for
early detection of prostate cancer stresses the importance
of involving men in the decision whether to test for
prostate cancer.
• If the patient wishes to proceed with screening ,the ACS
recommends that screening to start at the following ages:
 Age 50 years in men at average risk for prostate cancer
who are expected to live at least 10 more years
 Age 45 years in men at high risk for prostate cancer
(African Americans and men with a first-degree relative
diagnosed with prostate cancer before age 65)
 Age 40 years in men at very high risk (those with more
than one first-degree relative who had prostate cancer at
an early age).

28. Ultrasonography
 Ultrasonography (abdominal, renal, transrectal)
are useful for helping determine bladder and
prostate size and the degree of hydronephrosis
in patients with urinary retention or signs of
renal insufficiency.
 Transrectal ultrasonography (TRUS) of the
prostate is recommended in selected patients, to
determine the dimensions and volume of the
prostate gland.
 In patients with elevated PSA levels, TRUS-
guided biopsy may be indicated to assess for
prostate cancer.

29. Transectal ultrasound showing the volume
of prostate
Transrectal ultrasound probe with
biopsy needle

30.  Imaging of the upper tracts is indicated in
patients who present with any of the
following:
 Concomitant hematuria
 A history of urolithiasis
 An elevated creatinine level
 High PVR volume
 History of upper urinary tract infection
Other imaging studies, such as CT scanning and
MRI, have no role in the evaluation and
treatment of uncomplicated BPH.

31. Cystoscopy
 Cystoscopy is not routinely recommended to
determine the need for treatment.
 It may assist in choosing the surgical approach in
patients opting for invasive therapy.
 When marked obstructive symptoms exist in the
setting of relative minimal prostate
enlargement, cystoscopy may be useful to
identify a high bladder neck, urethral stricture,
or other pathology.
 If BPH is associated with hematuria, then
cystoscopy is mandatory to rule out other
bladder pathology.

32. Normal appearance Moderate benign prostatic
hyperplasia with urethral
obstruction.

33.  Measurement of flow rate, determination of
post-void residual urine, and pressure-flow
studies are considered optional.
 Cystometrograms and urodynamic profiles
are reserved for patients with suspected
neurologic disease or those who have failed
prostate surgery

34.  Options include:
----Watchful waiting
----Medical Therapy
----Minimally Invasive therapy
----Surgery

35. Watchful Waiting or “Self-Help”
• Watchful waiting is the appropriate management of men
with mild symptom scores (0–7). Men with moderate or
severe symptoms can also be managed in this fashion if they
choose.
• A significant proportion of men with LUTS will not choose
medical or surgical intervention because the symptoms are
not bothersome, the complications of treatment are
perceived to be greater than the inconvenience of the
symptoms, and there is a reluctance to take a daily pill
owing to side effects and/or the cost of treatment.
• Self-management could be considered as first-line
treatment for men with LUTS.
• Main Components of Self-Management Program:
- Education and Reassurance
-Fluid Management
-Caffeine and Alcohol avoidance
-Concurrent Medication

36. Education and Reassurance
• The causes of LUTS, including normal prostate and
bladder function; natural history of BPH and LUTS,expected
future symptoms are to be discussed with patient.
• Reassure that no evidence of a detectable prostate cancer has
been found.
Fluid Management
• Advise a daily fluid intake of 1500 to 2000 mL.
• Avoid inadequate or excessive intake on the basis of a
frequency volume chart.
• Advise fluid restriction when symptoms are most inconvenient
i.e.., during long journeys or when out in public.
• Advise evening fluid restriction for nocturia (no fluid for 2 hours
before retiring).

37. Caffeine and Alcohol
• Avoid caffeine by replacing with alternatives.
• Avoid alcohol in the evening if nocturia is bothersome.
• Replace large-volume alcoholic drinks with small-volume alcoholic
drinks .
Concurrent Medication
• Adjust the time when medication with an effect on the urinary
system is taken, to improve LUTS at times of greatest
inconvenience.
• Replace antihypertensive diuretics with suitable alternatives with
fewer urinary effects.
Types of Toileting and Bladder Retraining
• Advise men to double-void.
• Advise urethral milking for men with postmicturition dribble.
• Advise bladder retraining. Using distraction techniques,
aim to increase the minimum time between voids to 3 hours
(daytime) or the minimum voided volume to between 200 and 400
mL (daytime). The urge to void should be suppressed for 1 minute,
then 5 minutes, then 10 minutes, and so on, increasing on a weekly
basis. Use frequency-volume charts to monitor progress.
Miscellaneous
• Avoid constipation in men with LUTS

38. MEDICAL THERAPY:
• Medical therapies extensively investigated for LUTS and BPH
include α-adrenergic blockers, 5α-reductase inhibitors and
numerous plant extracts.
Selecting Candidates for Medical Therapy:
The ideal candidate for medical therapy should have symptoms
that are bothersome and negatively affect quality of life so that
the patient is willing to make a long-term commitment to
medical therapy, providing the drug is effective and adverse
experiences are minimal.
• Patients with absolute indications for intervention should be
discouraged from selecting medical therapy.
• If informed patients are willing to accept potential risks,
medical therapy may be offered with a provision for careful
follow-up and future prostatectomy if medical therapy proves
ineffective.

39. Alpha Blockers
 The rationale for α-adrenergic blockers in the treatment of
LUTS is based on the hypothesis that the pathophysiology of
LUTS is in part caused by BOO, which is mediated by α1
adrenoceptors associated with prostatic smooth muscle.
 The human prostate and bladder base contains α1
adrenoreceptors, and the prostate shows a contractile
response to corresponding agonists.
 The contractile properties of the prostate and bladder neck
seem to be mediated primarily by the subtype α1a-receptors.
α-Blockade has been shown to result in both objective and
subjective degrees of improvement in the symptoms and signs
of BPH in some patients.

40.  Phenoxybenzamine and
prazosin are the prototypical
nonselective and selective α-
blockers, but today, they are
not recommended.
 Long-acting α1-blockers make
once-a-day dosing possible,
but dose titration is still
necessary.
 Terazosin is initiated at 1 mg
daily for 3 days and increased
to 2 mg daily for 11 days and
then to 5 mg/d. Dosage can be
escalated to 10 mg daily if
necessary.

41. Doxazosin:
• The half-life of doxazosin is longer than that of terazosin
(22 vs. 12 hours).
• Therapy with doxazosin is started at 1 mg daily for 7 days
and increased to 2 mg daily for 7 days, and then to 4 mg
daily. Dosage can be escalated to 8 mg daily if necessary.
• Possible side effects of long acting alpha 1 blockers
include orthostatic hypotension, dizziness, tiredness,
retrograde ejaculation, rhinitis, and headache.
 Selective blockade of the α1a-receptors, which are
localized in the prostate and bladder neck, results in
fewer systemic (particularly cardiovascular) side effects,
thus obviating the need for dose titration with these
agents (tamsulosin, alfuzosin, and silodosin).
 Other side effects such as retrograde ejaculation still can
occur.

42. Tamsulosin is currently the most widely used α1 antagonist
investigated for LUTS and BPH .
• One of the features of tamsulosin is that it exhibits some
degree of specificity for the α1A adrenoceptors.
• Dose to be started at 0.4 mg and can be increased to 0.8
mg per day.
 Adverse events include mild and included dizziness,
rhinitis, and abnormal ejaculation which increase in dose
dependent manner.

43. Alfuzosin was safe and effective for the treatment of LUTS
and BPH.
• The primary limitation of alfuzosin was a requirement for
multiple daily doses (2.5 mg three times a day or 5 mg twice
a day).
• ER or SR alfuzosin is a new formulation that allows for a
once-daily dosing regimen without dose titration.
• Because of the lack of adverse effects and blood pressure
changes, alfuzosin has been described as a uroselective drug

44. Silodosin, a selective α1-adrenergic receptor antagonist, is
the LUTS-BPH market leader.
• Silodosin was shown to increase urine flow in 2 to 6 hours after
the initial dose.
• Improvement of symptoms was realized in 3 to 4 days, with the
majority of patients, including men on concomitant
cardiovascular medications, achieving at least a three-point
improvement in IPSS score, regardless of age or severity of
symptoms.
• It was associated with a low incidence of orthostatic hypotension
and syncope, fainting, and dizziness.
• The most common drug-related side effect was retrograde
ejaculation.The second most commonly reported adverse event
was dizziness.

45. 5α-reductase Inhibitors
• Finasteride is a competitive inhibitor of the enzyme 5α-
reductase Finasteride lowers serum and intraprostatic DHT levels.
• Two isozymes (types 1 and 2) of 5α-reductase exist .
• Finasteride is a selective inhibitor of the type 2 isozyme.
• Finasteride does not reduce DHT levels to castrate levels because
circulating testosterone is converted to DHT by type I isozymes
that exist in skin and liver.

46. • Prostate volume regression was maximal at 6 months.
The greatest change in symptom scores and PFR occurred
within the first 2 months of initiation of active
treatment.
• Adverse effects include decreased libido, ejaculatory
disorder, and impotence.
• Because of the variable effect on PSA, men who are
candidates for early detection of prostate cancer should
have their PSA level determined before beginning
finasteride therapy. A biopsy should be considered if the
PSA level is elevated or for progressively rising PSA levels
after initiation of therapy.
The Prostate Cancer Prevention Trial showed that
finasteride reduced the incidence of diagnosed prostate
cancer . There was an increased incidence of high-grade
disease, possibly because of the volume change effect,
which was also seen with dutasteride.

47. Dutasteride
Dutasteride is a dual inhibitor of 5α-reductase 1 and 2 and
therefore has a greater impact on suppressing serum DHT
levels.
• The symptom score was improved by 4.5 points.
• Long-term treatment with dutasteride results in continuing
improvements in both symptoms and urinary flow
• Similar to finasteride, the principal side effects were loss of
Libido and ED, but these were most frequently seen at the
start of therapy and declined over time with treatment.

48. Combination therapy
Combination of alpha blockers and 5-alpha reductase
inhibitors:
 The risk of overall clinical progression—defined as an
increase above baseline of at least four points in the IPSS,
acute urinary retention, urinary incontinence, renal
insufficiency, or recurrent urinary tract infection—was
significantly reduced by doxazosin (39% risk reduction) and
finasteride (34% risk reduction), as compared with placebo.
 The reduction in risk associated with combination therapy
(66% risk reduction) was significantly greater than that
associated with doxazosin or finasteride alone.
 Patients most likely to benefit from combination therapy
are those in whom baseline risk of progression is very high,
generally patients with larger glands and higher PSA
values.

49. PHYTOTHERAPY
 The pharmacologic use of plants and herbs (phytotherapy)
for the treatment of LUTS and BPH is common.
 These agents are popular in Europe, particularly in France,
Austria, and Germany.
 Although α-blocker monotherapy was the most frequently
prescribed treatment; phytotherapy was very popular
followed by 5α-reductase inhibitor monotherapy.
 Phytotherapeutic products are not the actual plant but are
extracts derived from the roots, the seeds, the bark, or the
fruits of the various plants used.
 The composition of plant extracts is very complex. They
contain a wide variety of chemical compounds, which
include phytosterols, plant oils, fatty acids, and
phytoestrogens.

51. S. repens (also known by its
botanical name of
S.serrulata), is the most
popular phytotherapeutic
agent consumed for LUTS
and BPH.The extract of the
berry of the plant is used.

52. Suggested Mechanism of Action of
Phytotherapeutic Agents:
 Inhibition of 5α-reductase
 Anti-inflammatory action
 Interference with growth factors
 Antiandrogenic effects
 Estrogenic effects
 Inhibition of aromatase
 Decrease of sex hormone–binding globulin
 Alteration of cholesterol metabolism
 Action on α-adrenergic receptors
 Free radical scavenging
 Alteration of lipid peroxidation
 Modulation of prolactin-induced prostatic growth
 Protection of bladder and detrusor function
 Placebo effect

53. Surgical Therapy
Transurethral resection of the prostate
Current indications for transurethral
resection of the prostate.
Moderate (8–19) to severe (20–35) lower urinary tract
symptoms (LUTS) not responding to medical treatment
●● Refractory urinary retention with at least one failed
attempt at catheter removal
●● Chronic retention with back pressure changes, leading
to:
––Hydronephrosis
––Renal insufficiency
●● Complications of benign prostatic hyperplasia (BPH),
including:
––Recurrent urinary tract infection
––Recurrent gross hematuria
––Bladder diverticula
––Bladder stones

54. • TURP involves an endoscopic approach via the
patient’s urethra to surgically remove the inner
portion primarily the transition zone of the prostate
that encircles the urethra.
• An electrified wire loop is used to remove the portion
of the prostate between the bladder neck and the
verumontanum to a depth of the surgical capsule.
• The current is carried from the cutting loop through
the tissue to the return electrode in the grounding
pad.
• This requires the use of a nonionic irrigant (water,
glycine, sorbitol) to allow electroresection of the
prostate.
• The use of an ionic solution (i.e., normal saline) leads
to dissipation of the cutting current and poor cutting
efficacy.
• These nonionic solutions are hypo-osmolar and can be
problematic when absorbed through open prostate
sinuses into the systemic circulation.

55. • Irrigation fluid must be non-conductive that the diathermy
current is concentrated at the cutting point.
• Irrigation fluid has to be non-haemolytic so that haemolysis
does not occur if it enters the circulation.
• Irrigation fluid must have neutral visual density so that the
surgeon‘s view is not distorted.
• Most commonly used irrigants are glycine1.5% in water ( 230
mOsm/L) or Cytal a mixture of 2.7% sorbitol and 0.54% mannitol
( 195 mOsm/L).
• During a TURP - procedure 20 ml/min irrigant solution is
normally absorbed .This is a total of 1 - 1.5 litres for the
average case.

56. Procedure:
Anaesthesia: General / spinal/ regional
• Regional anesthesia is a desirable choice in patients
undergoing transurethral prostatic surgery. Excellent
skeletal and smooth-muscle relaxation allows easy filling of
the bladder and reduces bladder spasms.
• Once adequate anesthesia has been initiated,the patient is
placed in the modified lithotomy position.
• Care is taken to avoid overextension at the hip joint, and
adequate padding is used for bony prominences.
• Cystourethroscopy is done as the first step to assess the
distal urethra, position of verumontanum, size and
configuration of the prostate, bladder neck, urinary
bladder, and both ureteric orifices.

57. • Fluid level may be raised during the procedure if visualization
becomes obscured because of bleeding.
• The opening of the procedure should start with resection of
any impediment to movement of the irrigating fluid.
• A 24 or 26 Fr size resectoscope, the continuous irrigation
variety is the most commonly employed equipment.
• The presence of a middle lobe should lead the surgeon to
start the resection there.
• Once a median lobe has been removed, the lateral lobes of
the prostate may then be tackled.
• Irrigating fluid should be maintained at body temperature
and placed at the lowest height relative to the patient to
provide adequate visualization.

58. • Some surgeons use a modification of the
Nesbit“encirclement” approach .
• In the Nesbit approach, resection is initiated at the 11 o’clock
to 9 o’clock and the 1 o’clock to 3 o’clock positions.
• The resection exposes but does not resect the bladder neck
fibers and carries the resection proximally to the base of the
verumontanum,avoiding any injury to the external sphincter.

60. • Surgeons starting with the prostatic floor usually start by resecting
a “channel” at either the 5 or 7 o’clock position and resecting down
to the surgical capsule of the prostate.
• By finding the surgical capsule early in the procedure, the depth of
the resection is set.
• The channel is then widened (usually laterally) and then carried up
the lateral walls toward the anterior aspect of the prostate,
following the surgical capsule as the depth of resection.

61. • The area between the 5 and 7 o’clock positions is then resected
at the final stages of the procedure to smooth out the prostatic
floor and finish the procedure without undermining the bladder
neck during multiple movement of the scope.
• The initial stages of the resection should involve long, smooth
tissue cuts. The produced prostate chips should be long and
canoe-like in appearance, with a length equivalent to the
extended resection loop.
• Over-resection in any area before the major portion of the
adenoma has been removed may expose large venous sinuses.
Exposing these sinuses will predispose to bleeding and fluid
extravasation and absorption and compromise the resection and
patient outcome.
• The prostate apex is best resected at the end of the procedure
in a bloodless field where resection can be done precisely to
avoid injury to the external sphincter.

62. • Strict hemostasis should be maintained througout the
procedure.
• Before the operation is terminated, all tissue must be
removed from the bladder, with careful attention paid to
make sure prostatic chips have not fallen into any bladder
diverticuli that may exist.
• An Ellik or Toomey syringe may help facilitate removal of any
tissue.
• The prostatic fossa should be examined again as one of the
final steps, with control of any arterial bleeding.
• A large-bore catheter should be carefully placed into the
bladder with the use of a wire catheter guide if required.
• The amount of fluid placed in the balloon should be tailored
to the volume of resected tissue to avoid the catheter
balloon falling into the excavated prostatic fossa.
• The use of continuous bladder irrigation (CBI) is not
compulsory but can be used if the irrigant is not clear at the
end of the procedure.

63.  Early:
Haemorrhage
Resection Errors
TURSyndrome
Obturator Nerve Stimulation
Intraoperative Priapism
Sepsis

64.  Late:
Bladder Neck Contracture
Urethral Stricture
Incontinence
Impotence

65. TUR syndrome
 This is a complex syndrome of fluid overload, dilutional
hyponatremia, and hemolysis due to systemic absorption of
large amounts of irrigant, especially in patients with a gland
size larger than 45 g and a resection time of more than 90
minutes.
 TUR syndrome occurrs in 2% of patients .
 The syndrome may occur as quickly as 15 minutes after the
resection starts or up to 24 hours postoperatively.
 It is characterized by confusion, nausea, vomiting,
hypertension, bradycardia, and visual disturbances.
 Monitoring the serum sodium concentration is important as the
syndrome does not occur until the serum sodium falls below 125
mEq/dl.
 Intravenous hypertonic saline, diuretics, and termination of the
procedure may be required when this happens.
 Limiting the height of the irrigation bottle to 60 cm above the
prostate reduced the intravascular fluid absorption.
 Leaving a rim of tissue on the capsule until the end of the
procedure, where it can be left if signs of TUR syndrome are
evident, may reduce the risk of absorption due to opening of
prostatic sinuses.

66. Transurethral incision of
the prostate:
 Men with moderate to severe
symptoms and a small prostate
often have posterior
commissure hyperplasia .
• These patients will often
benefit from an incision of the
prostate.
• This procedure is more rapid
and less morbid than TURP.
• The technique involves two
incisions using the Collins knife
at the 5- and 7-o’clock position.
The incision
is started at the ureteral orifice
and carried through the bladder
neck up to the verumontanum.
This procedure is done bilaterally

67. Transurethral vaporization
of the prostate
 This ablative techniques uses
photo- or electroevaporation to
ablate obstructing prostate tissue.
 The two most commonly used
devices for these procedures are
the neodymium-doped yttrium-
aluminum-garnet (Nd:YAG) KTP
“GreenLight” laser, which is
preferentially absorbed by
hemoglobin, and the plasma
vaporization “Button” electrode.
The latter works with a standard
contemporary bipolar generator
used for bipolar TURP.
 The goal of the procedure in either
case is to produce a central
prostate defect comparable with
traditional TURP, but with less
bleeding and lower risk of
perforation.

68. Holmium laser enucleation of
the prostate (HoLEP)
HoLEP denotes an anatomic dissection
in the plane between the central and
peripheral zones of the prostate.
This approach is felt to provide the
largest defect and perhaps the
longest durability,
but entails a longer learning curve
than TURP or TUVP.

69. Simple (subtotal) prostatectomy
Indications:
--Glands >100 g
--Concomitant bladder diverticulum
--large bladder stone
--dorsal lithotomy positioning is not possible.
Open prostatectomies can be done with either a suprapubic or
retropubic approach.
• A simple suprapubic prostatectomy is performed transvesically.
After the bladder is opened, a semicircular incision is made in the
bladder mucosa, distal to the trigone.
• The dissection plane is initiated sharply, and then blunt dissection
with the finger is performed to remove the adenoma.
• The apical dissection should be done sharply to avoid injury to
the distal sphincteric mechanism.
• After the adenoma is removed, hemostasis is attained with suture
ligatures, and both a urethral and a suprapubic catheter are
inserted before closure.

70. • In a simple retropubic prostatectomy, the bladder is
not entered. Rather, a transverse incision is made in
the surgical capsule of the prostate, and the adenoma
is enucleated as described earlier.
• Only a urethral catheter is needed at the end of the
procedure.
Transurethral microwave thermotherapy
Microwave hyperthermia is most commonly delivered with a
transurethral catheter.
Some devices cool the urethral mucosa to decrease the risk of
injury. If temperatures are not >45°C, cooling is unnecessary.