Benign prostatic hyperplasia (BPH)

PROBLEMS
OF THE PROSTATE GLAND
Presented by----
Mrs. Usha Rani Kandula,
MSc.Nursing, Assistant professor,
Department of Adult Health Nursing,
College of Health Sciences,
Arsi University, Asella, Ethiopia.

ANATOMY OF PROSTATE GLAND
-The prostate gland lies in the pelvic cavity
in front of the rectum and behind the
symphysis pubis, surrounding the first part
of the urethra.

PHYSIOLOGY OF PROSTATE
GLAND
-The prostate gland secretes a thin, milky
fluid that makes up about 30% of semen,
and gives it its milky appearance.
-

DEFINITION
-Benign prostatic hyperplasia (BPH) is a
benign enlargement of the prostate gland.
-It is the most common urologic problem in
male adults.
-About 50% of all men in their lifetime will
develop BPH, almost half of them will have
lower urinary tract symptoms.

HORMONAL CHANGES
 -Hormonal changes associated with the
aging process.

EXCESSIVE ACCUMULATION OF
DIHYDROXYTESTOSTERONE
 Excessive accumulation of di-hydroxy-
testosterone (DHT) (intraprostatic
androgen) in the prostate cells causes
overgrowth of prostate tissue.

INCREASED PROPORTION OF
ESTROGEN
 -Increased proportion of estrogen (as
compared to testosterone) in the blood.
 Men produce both testosterone and small
amounts of estrogen.
 As men age, the amount of active
testosterone in the blood decreases, leaving a
higher proportion of estrogen.
 A higher amount of estrogen within the gland
increases the activity of substances (e.g.,
DHT) that promote cell growth.

RISK FACTORS FOR BPH
 Aging,
 Obesity (in particular increased waist
circumference),
 Lack of physical activity,
 Alcohol consumption,
 Erectile dysfunction,
 Smoking, and diabetes.
 A positive family history

PATHOPHYSIOLOGY OF BPH
Due to etiological factors,
Accumulation of dihydroxytestosterone
(DHT) (intraprostatic androgen) in the
prostate cells,
stimulate cell growth
and an overgrowth of prostate tissue

Con--
This enlargement gradually compresses
the urethra,
leading to partial or complete obstruction,
compression of the urethra,
ultimately leads to the development of
clinical symptoms.

CLINICAL
MANIFESTATIONS OF BPH

CLINICAL MANIFESTATIONS
OF BPH
 -Symptoms associated with lower urinary
tract.
 -The symptoms gradually worsen as the
degree of urethral obstruction increases.

SYMPTOMS CAN BE DIVIDED
INTO TWO GROUPS:
 Symptoms can be divided into two groups:
1.Irritative symptoms
 II. Obstructive symptoms.

I.IRRITATIVE SYMPTOMS
 Nocturia, (night time urination)
 urinary frequency, (No of times)
 urgency, (unable to controle)
 dysuria, (difficulty in urination)
 bladder pain,

 Incontinence, are associated with
inflammation or infection.
 Nocturia is often the first symptom that the
patient notices.

II.OBSTRUCTIVE SYMPTOMS
 These are caused by prostate enlargement
include a decrease in the caliber and force
of the urinary stream,
 Difficulty in initiating voiding, (difficulty in
passing of urine)

 Intermittency (stopping and starting stream
several times while voiding),
 Dribbling at the end of urination. (urine
passes drop by drop)
 These symptoms are due to urinary
retention.

THE AMERICAN UROLOGICAL ASSOCIATION
(AUA) SYMPTOM INDEX FOR BPH
 It is a widely used tool to assess voiding
symptoms associated with obstruction.
 This tool not helps for diagnostic purpose,
 It helps determine the extent of symptoms
only.
 6 Higher scores on this tool indicate
greater symptom severity.

HISTORY AND PHYSICAL
EXAMINATION
 The primary methods used to diagnose
BPH include a
 -History and physical examination.

DIGITAL RECTAL
EXAMINATION (DRE)
 -The prostate can be palpated by digital
rectal examination (DRE) to estimate its
 -size,
 -symmetry, and
 -consistency.

URINALYSIS
 A urinalysis with culture is routinely done to
identify any infection.
 -Bacteria,
 -white blood cells (WBCs), or
 -microscopic hematuria indicate infection
or inflammation.

PROSTATE-SPECIFIC ANTIGEN
(PSA)
 A prostate-specific antigen (PSA) blood
test may be done to rule out prostate
cancer.

SERUM CREATININE LEVELS
 Serum creatinine levels
 -may be ordered to rule out renal
insufficiency.

TRANSRECTAL ULTRASOUND
(TRUS) SCAN
 -In patients with an abnormal DRE and
elevated PSA, a transrectal ultrasound
(TRUS) scan is typically indicated.
 This examination allows for accurate
assessment of prostate size and is helpful
in differentiating BPH from prostate cancer.

BIOPSIES,
 Biopsies can be taken during the
ultrasound procedure.

UROFLOWMETRY
 -Uroflowmetry, a study that measures
-the volume of urine expelled from the
bladder per second,
-is helpful in determining the extent of
urethral blockage and thus the type of
treatment needed.

POSTVOID RESIDUAL URINE
VOLUME
 Postvoid residual urine volume is often
measured to determine the degree of urine
flow obstruction.

CYSTOSCOPY
 -Cystoscopy, a procedure allowing internal
visualization of the urethra and bladder,
 -is performed if the diagnosis is uncertain
and in patients scheduled for
prostatectomy.

COLLABORATIVE CARE
 The goals of collaborative care are to
 (1) Restore bladder drainage,
 (2) Relieve the patient’s symptoms, and
 (3) Prevent or treat the complications of
BPH.

MANAGEMENT OF BPH
 -Treatment is generally based on the
degree to which the symptoms bother the
patient or
 - The presence of complications, rather
than the size of the prostate.

DRUG THERAPY.
 Drugs that have been used to treat BPH
with variable degrees of success include
 -5α-reductase inhibitors and
 -α-adrenergic receptor blockers.

5Α-REDUCTASE INHIBITORS.
 These drugs work by reducing the size of
the prostate gland.
 -Ex: Finasteride (Proscar)
 -This drug results in regression of
hyperplastic tissue through suppression of
androgens (DHT).

CON--
 Dutasteride (Avodart) has the same effect
on prostatic tissue
 -The combination of a 5α-reductase
inhibitor (dutasteride) and an α-adrenergic
receptor blocker (tamsulosin) is now
available in a single oral medication
(Jalyn).

Α-ADRENERGIC RECEPTOR
BLOCKERS.
 -These agents selectively block α1-
adrenergic receptors, which are abundant
in the prostate and are increased in
hyperplastic prostate tissue.
 These drugs promote smooth muscle
relaxation in the prostate, facilitating
urinary flow through the urethra.

CON--
 -Several α-adrenergic blockers are currently in
use,
 Silodosin (rapaflo),
 Alfuzosin (uroxatral),
 Doxazosin (cardura),
 Prazosin (minipress),
 Terazosin (hytrin),
 Tamsulosin (flomax).

ERECTOGENIC DRUGS.
 Tadalafil (Cialis) has been used in men
who have symptoms of BPH alone or in
combination with erectile dysfunction (ED).

MINIMALLY INVASIVE
THERAPY.
 -Minimally invasive therapies are becoming
more common as an alternative to watchful
waiting and invasive treatment.
 - They generally do not require hospitalization
or catheterization and are associated with few
adverse events.
 -Many minimally invasive therapies have
outcomes comparable to those of invasive
techniques.

TRANSURETHRAL
MICROWAVE
THERMOTHERAPY
(TUMT).

TRANSURETHRAL MICROWAVE
THERMOTHERAPY (TUMT).
 Transurethral microwave thermotherapy (TUMT) is an
outpatient procedure that involves the delivery of
microwaves directly to the prostate through a
transurethral probe to raise the temperature of the
prostate tissue to about 113° F (45° C).
 The heat causes death of tissue, thus relieving the
obstruction.
 -A rectal temperature probe is used during the
procedure to ensure that the temperature is kept below
110° F (43.5° C) to prevent rectal tissue damage.
 -The procedure takes about 90 minutes.
 -Postoperative urinary retention is a common
complication.

CON--
 patient is generally sent home with an indwelling
catheter for 2 to 7 days to maintain urinary flow and
to facilitate the passing of small clots or necrotic
tissue.
 -Antibiotics, pain medication, and bladder
antispasmodic medications are used to treat and
prevent post procedure problems.
 -The procedure is not appropriate for men with rectal
problems.
 -Anticoagulant therapy should be stopped 10 days
before treatment.
 -Mild side effects include occasional problems of
bladder spasm, hematuria, dysuria, and retention.

TRANSURETHRAL
NEEDLE ABLATION
(TUNA).

TRANSURETHRAL NEEDLE
ABLATION (TUNA).
 Transurethral needle ablation (TUNA) is another procedure
that increases the temperature of prostate tissue, thus causing
localized necrosis.
 TUNA differs from TUMT in that low-wave radiofrequency is
used to heat the prostate.
 Only prostate tissue in direct contact with the needle is
affected, thus allowing greater precision in removal of the
target tissue.
 -The extent of tissue removed by this process is determined
by the amount of tissue contact (needle length), amount of
energy delivered, and duration of treatment.
 -This procedure is performed in an outpatient unit or
physician’s office using local anesthesia and IV or oral
sedation.

CON--
 The TUNA procedure lasts approximately 30
minutes.
 -The patient typically experiences little pain with an
early return to regular activities.
 -Complications include urinary retention, UTI, and
irritative voiding symptoms (e.g., frequency,
urgency, dysuria).
 -Some patients require a urinary catheter for a
short time.
 -Patients often have hematuria for up to a week.

LASER PROSTATECTOMY.
 -The use of laser therapy through visual or
ultrasound guidance is an effective
alternative to transurethral resection of the
prostate (TURP) in treating BPH.
 -The laser beam is delivered trans
urethrally through a fiber instrument and is
used for cutting, coagulation, and
vaporization of prostatic tissue.

VISUAL LASER ABLATION
OF THE PROSTATE
(VLAP),

VISUAL LASER ABLATION OF THE
PROSTATE (VLAP),
 One common procedure is visual laser
ablation of the prostate (VLAP), which uses
the laser beam to produce deep coagulation
necrosis.
 -The affected prostate tissue gradually
sloughs in the urinary stream.
 -It takes several weeks before the patient
reaches optimal results after this type of laser
therapy.
 -At the completion of VLAP, a urinary catheter
is inserted to allow for drainage.

CONTACT LASER TECHNIQUES
 Contact laser techniques involve the direct
contact of the laser with the prostate tissue,
producing an immediate vaporization of the
tissue.
 -Blood vessels near the laser tip are
immediately cauterized.
 -Thus bleeding during the procedure is rare.
 -A three way catheter with slow-drip irrigation
is placed immediately after the procedure for
a short time.

CON--
 Typically the catheter is removed within 6
to 8 hours after the procedure.
 -Advantages of this procedure over TURP
include minimal bleeding both during and
after the procedure, faster recovery time,
and ability to perform the surgery on
patients taking anticoagulants.

PHOTOVAPORIZATION
OF THE PROSTATE
(PVP)

PHOTOVAPORIZATION OF THE
PROSTATE (PVP)
 Photovaporization of the prostate (PVP)
uses a high-power green laser light to
vaporize prostate tissue.
 Improvements in urine flow and symptoms
are almost immediate after the procedure.
 -Bleeding is minimal, and a catheter is
usually inserted for 24 to 48 hours
afterward.
 - PVP works well for larger prostate glands.

INTERSTITIAL LASER
COAGULATION
(ILC).

INTERSTITIAL LASER
COAGULATION (ILC).
 Another approach to laser prostatectomy is
interstitial laser coagulation (ILC).
 -The prostate is viewed through a
cystoscope.
 -A laser is used to quickly treat precise
areas of the enlarged prostate by
placement of interstitial light guides directly
into the prostate tissue.

INTRAPROSTATIC
URETHRAL STENTS.

-INTRAPROSTATIC URETHRAL
STENTS.
 -Symptoms from obstruction in patients
who are poor surgical candidates can be
relieved with intra prostatic urethral stents.
 -The stents are placed directly into the
prostatic tissue.
 -Complications include chronic pain,
infection, and encrustation (tissue
hardness).
 - The long-term effects are not known.

-INVASIVE THERAPY (SURGERY).
 Invasive treatment of symptomatic BPH
involves surgery.
 The choice of the treatment approach
depends on the size and location of the
prostatic enlargement and patient factors such
as age and surgical risk.
 -Invasive therapy is indicated when the
decrease in urine flow is sufficient to cause
discomfort, persistent residual urine, acute
urinary retention because of obstruction with
no reversible precipitating cause, or hydro
nephrosis.

Con--
 - Intermittent catheterization or insertion of
an indwelling catheter can temporarily
reduce symptoms and bypass the
obstruction.
 -However, avoid long term catheter use
because of the increased risk of infection.

TRANSURETHRAL
RESECTION OF THE
PROSTATE
(TURP)

TRANSURETHRAL RESECTION OF THE
PROSTATE (TURP)
 Transurethral resection of the prostate
(TURP) is a surgical procedure involving
the removal of prostate tissue using a
resecto scope inserted through the urethra.
–
 TURP has long been considered the gold
standard for surgical treatments of
obstructing BPH.

Con--
 TURP is performed under a spinal or general
anesthetic and requires a 1- to 2-day hospital
stay.
 No external surgical incision is made.
 -A resecto scope is inserted through the
urethra to excise and cauterize obstructing
prostatic tissue .
 -A large three-way indwelling catheter with a
30-mL balloon is inserted into the bladder
after the procedure to provide hemo stasis
and to facilitate urinary drainage.

Con--
 The bladder is irrigated, either continuously
or intermittently, usually for the first 24
hours to prevent obstruction from mucus
and blood clots.
 -The outcome for 80% to 90% of patients is
excellent, with marked improvements in
symptoms and urinary flow rates.

Con--
 Quality of life is also improved.
 -TURP is a surgical procedure with a relatively
low risk.
 -Postoperative complications include
bleeding, clot retention, and dilutional
hyponatremia associated with irrigation.
 -Because bleeding is a common complication,
patients taking aspirin, warfarin (Coumadin),
or other anticoagulants must discontinue
these medications several days before
surgery.

TRANSURETHRAL INCISION
OF THE PROSTATE
(TUIP).

TRANSURETHRAL INCISION OF THE
PROSTATE(TUIP).
 -Transurethral incision of the prostate
(TUIP) is a surgical procedure done under
local anesthesia for men with moderate to
severe symptoms.
 Several small incisions are made into the
prostate gland to expand the urethra,
which relieves pressure on the urethra and
improves urine flow.

Con--
 TUIP is an option for patients with a small
or moderately enlarged prostate gland.
 - TUIP has similar patient outcomes to
TURP in relieving symptoms.

NURSING ASSESSMENT
 Subjective and objective data that should
be obtained from a patient with BPH.

NURSING DIAGNOSES
preoperatively may include,
 Acute pain related to bladder distention
secondary to enlarged prostate
 Risk for infection related to an indwelling
catheter, urinary stasis, or environmental
pathogens

PLANNING
The overall preoperative goals for the patient
having invasive procedures are to have
 (1) restoration of urinary drainage;
 (2) treatment of any UTI; and
 (3) understanding of the upcoming
procedure, implications for sexual function,
and urinary control.

Con--
The overall postoperative goals are to have
 (1) no complications,
 (2) restoration of urinary control,
 (3) complete bladder emptying,
 (4) satisfying sexual expression.

NURSING IMPLEMENTATION
 HEALTH PROMOTION.
 Health promotion focuses on early
detection and treatment.
 The American Cancer Society, along with
the AUA, recommends a yearly medical
history and DRE for men over 50 years of
age in an effort to detect prostate problems
early.

 When symptoms of prostatic hyperplasia
are present, further diagnostic screening
may be necessary .
 -Some men find that the ingestion of
alcohol and caffeine tends to increase
prostatic symptoms because the diuretic
effect increases bladder distention.

Con--
 -Advise patients with obstructive symptoms
to urinate every 2 to 3 hours and when
they first feeling the urge.
 -This will minimize urinary stasis and acute
urinary retention.
 -Fluid intake should be maintained at a
normal level to avoid dehydration or fluid
overload.

PREOPERATIVE CARE (TURP).
 -Urinary drainage must be restored before
surgery.
 -Prostatic obstruction may result in acute
retention or inability to void.

 - A urethral catheter may be needed to
restore drainage.
 -In many health care settings, 10 mL of
sterile 2% lidocaine gel is injected into the
urethra before insertion of the catheter.

 - The lidocaine gel not only acts as a
lubricant, but also provides local
anesthesia and helps open the urethral
lumen.
 -Aseptic technique is important at all times
to avoid introducing bacteria into the
bladder.

Con--
 Any infection of the urinary tract must be
treated before surgery.
 -Restoring urinary drainage and
encouraging a high fluid intake (2 to 3
L/day unless contraindicated) are also
helpful in managing the infection.
 -Patients are often concerned about the
impact of the impending surgery on sexual
function.

POSTOPERATIVE CARE.
The main complications after surgery are
 Hemorrhage,
 Bladder spasms,
 Urinary incontinence,
 Infection.

Con--
 -After surgery the patient will have a
standard catheter or a triple-lumen
catheter.
 -Bladder irrigation is typically done to
remove clotted blood from the bladder and
ensure drainage of urine.

 -The bladder is irrigated either manually on
an intermittent basis or more commonly as
continuous bladder irrigation (CBI) with
sterile normal saline solution or another
prescribed solution.

Con--
 -If the bladder is manually irrigated (if
ordered), instill 50 mL of irrigating solution
and then withdraw with a syringe to
remove clots that may be in the bladder
and catheter.
 -Painful bladder spasms often occur as a
result of manual irrigation.

Con--
 With CBI, irrigating solution is continuously
infused and drained from the bladder.
 -The rate of infusion is based on the color
of drainage.
 -Ideally the urine drainage should be light
pink without clots.
 -Continuously monitor the inflow and
outflow of the irrigant.

 -If outflow is less than inflow, assess the
catheter patency for kinks or clots.
 -If the outflow is blocked and patency
cannot be reestablished by manual
irrigation, stop the CBI and notify the
physician.

Con--
 -Use careful aseptic technique when irrigating
the bladder because bacteria can easily be
introduced into the urinary tract.
 -To prevent urethral irritation and minimize the
risk of bladder infection, secure the catheter to
the leg with tape or a catheter strap.
 -The catheter should be connected to a
closed-drainage system.

 -Do not disconnect unless it is being
removed, changed, or irrigated.
 -Proper care of the catheter is important.
 On a daily basis, cleanse the secretions
that accumulate around the meatus with
soap and water.

NURSING ASSESSMENT
 Blood clots are expected after prostate
surgery for the first 24 to 36 hours.
 However, large amounts of bright red blood
in the urine can indicate hemorrhage.
 -Postoperative hemorrhage may occur
from displacement of the catheter,
dislodgment of a large clot, or increases in
abdominal pressure.

 -Release or displacement of the catheter
dislodges the balloon that provides counter
pressure on the operative site.

Con--
 - Traction on the catheter may be applied
to provide counter pressure (tamponade)
on the bleeding site in the prostate,
thereby decreasing bleeding.
 -Such traction can result in local necrosis if
pressure is applied for too long.

Con--
 Therefore pressure should be relieved on a
scheduled basis by qualified personnel.

 -Activities that increase abdominal
pressure, such as sitting or walking for
prolonged periods and straining to have a
bowel movement , should be avoided in
the postoperative recovery period.

Con--
 Bladder spasms are a distressing
complication for the patient after
transurethral procedures.
 -They occur as a result of irritation of the
bladder mucosa from the insertion of the
resectoscope, presence of a catheter, or
clots leading to obstruction of the catheter.

 -Instruct the patient not to urinate around
the catheter because this increases the
likelihood of spasm.

Con--
 - If bladder spasms develop, check the
catheter for clots.
 -If present, remove the clots by irrigation so
that urine can flow freely.
 -Belladonna and opium suppositories or
other antispasmodics (e.g., oxybutynin
[Ditropan]), along with relaxation
techniques, are used to relieve the pain
and decrease spasm.

 -The catheter is often removed 2 to 4 days
after surgery.
 - The patient should urinate within 6 hours
after catheter removal.
 -If he cannot, reinsert a catheter for a day
or two.

Con--
 - If the problem continues, instruct the
patient to perform clean intermittent self-
catheterization.
 -Sphincter tone may be poor immediately
after catheter removal, resulting in urinary
incontinence or dribbling.

 -This is a common but distressing situation
for the patient.
 -Sphincter tone can be strengthened by
having the patient practice Kegel exercises
(pelvic floor muscle technique) 10 to 20
times per hour while awake

Con--
 Encourage the patient to practice starting and
stopping the stream several times during
urination.
 -This facilitates learning the pelvic floor
exercises.
 -It usually takes several weeks to achieve
urinary continence.
 -In some instances, control of urine may never
be fully regained.

 -Continence can improve for up to 12
months.
 -If continence has not been achieved by
that time, refer the patient to a continence
clinic.
 -A variety of methods, including
biofeedback, have been used to achieve
positive results.

Con--
 You can also instruct the patient to use a
penile clamp, a condom catheter, or
incontinence pads or briefs to avoid
embarrassment from dribbling.
 - In severe cases, an occlusive cuff that
serves as an artificial sphincter can be
surgically implanted to restore continence.

 -Assist the patient in finding ways to
manage the problem that allow him to
continue socializing and interacting with
others.

Con--
 Observe the patient for signs of
postoperative infection.
 -If an external wound is present (from an
open prostatectomy), assess the area for
redness, heat, swelling, and purulent
drainage.

 -Special care must be taken if a perineal
incision is present because of the proximity
of the anus.
 -Avoid rectal procedures, such as taking
rectal temperatures and administering
enemas.

Con--
 -The insertion of well-lubricated belladonna
and opium suppositories is acceptable.
 -Dietary intervention and stool softeners
are important in the postoperative period to
prevent the patient from straining while
having bowel movements.

 -Straining increases the intra abdominal
pressure, which can lead to bleeding at the
operative site.
 -A diet high in fiber facilitates the passage
of stool.

EVALUATION
 The expected outcomes are that the
patient with BPH who has
 surgery will--
 • Report satisfactory pain control
 • Report improved urinary function with no
pain or incontinence

AMBULATORY AND HOME
CARE.
 Discharge planning and home care issues
are important aspects of care after prostate
surgery.
 Instructions include
 (1) caring for an indwelling catheter (if one
is left in place);
 (2) managing urinary incontinence;
 (3) maintaining adequate oral fluid intake;

Con--
 (4) observing for signs and symptoms of
urinary tract and wound infection;
 (5) preventing constipation;
 (6) avoiding heavy lifting (more than 10 lb
[4.5 kg]); and
 (7) refraining from driving or intercourse
after surgery as directed by the physician.

INSTRUMENTS USED IN
OPEN PROSTECTOMY

 Left to right: 2 Bard-Parker knife handles #4;
 1 Bard-Parker knife handle #3, long;
 2 Mayo dissecting scissors, curved and
straight;
 2 Metzenbaum dissecting scissors, 7 inch and
extra long;
 2 Snowden- Pencer scissors, straight and
curved;
 1 Jorgenson dissecting scissors;

 Left to right: 2 Adson tissue forceps (1 × 2), front view
and side view;
 2 Ferris Smith tissue forceps (1 × 2), front view and
side view;
 2 Russian tissue forceps, front view and side view; 2
thumb tissue forceps with teeth (1 × 2), long, front
view and side view;
 2 DeBakey vascular Autraugrip tissue forceps, long,
front view and side view;
 2 DeBakey vascular Autraugrip tissue forceps, extra
long, front view and side view.

 Hemoclip-applying forceps, 2 medium, 2
large.

 1 Gil-Vernet retractor;
 2 Goelet retractors, front view and side
view;
 2 Gelpi retractors.

 2 Greenwald suture guides, 24Fr and
28Fr;
 3 Deaver retractors: narrow, side view;
medium, front view; and wide, side view;
 2 Harrington splanchnic retractors, small
and large, side view.

 Top: 2 Balfour abdominal retractor fenestrated
blades, large.
 Left to right: 1 Balfour abdominal retractor frame; 2
Balfour abdominal retractor fenestrated blades,
small;
 2 Balfour abdominal retractor center blades, large
and small;
 2 Richardson retractors, medium and large;
 3 Ochsner malleable retractors, narrow (side
view), medium, and large.

 Left to right: Paper drape clip;
-Halsted hemostatic forceps, straight;
-Mayo dissecting scissors,
-straight; Crile hemostatic forceps,
-straight; paper drape clip.

 Resectoscopes: 30-degree telescope;
obturator; inner sheath; outer sheath;
working element.
Top to bottom: 1 red port cap; 1 gray
nipple; stopcock; 2 metal tubing
connectors; bridge; and 2 peg clamps.

 Top, left to right: Plastic tubing; spoon.
 Bottom, left to right: inner sheath;
obturator; outer sheath; light cord; van
Buren urethral male sounds, 30Fr to 22Fr.

 Left to right: A, cutting electrode with
pointed end and tip;
 B, coagulating electrode with ball end
and tip;
 C, cutting electrode with round wire and
tip.

Benign prostatic hyperplasia (BPH)

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