Benign prostatic hyperplasia (BPH) is a common condition among older men that involves the noncancerous enlargement of the prostate gland. It can cause lower urinary tract symptoms by constricting the urethra. BPH is typically treated through medical management with alpha-blockers or 5-alpha-reductase inhibitors or through surgical procedures like transurethral resection of the prostate (TURP). TURP uses an endoscope inserted through the urethra to surgically remove parts of the prostate. For larger prostates, open prostatectomy techniques like the Millin or Young approaches may be used, removing the prostate through an abdominal incision. Lasers and newer technologies

1. Dr Rahul Mrigpuri

2.  A benign condition in which an
overgrowth of prostate tissue pushes
against the urethra and the bladder,
which may lead to interference with urine
flow, urinary frequency, nocturia, dysuria,
and urinary tract infections.
 a histologic diagnosis associated with
nonmalignant, noninflammatory
enlargement of the prostate, most
common among men over 50 years of age.

3.  Walnut-shaped gland that forms part of the
male reproductive system
 Surrounds the urethra - the tube that
carries urine from the bladder out of the
body

4. BPH is part of the natural aging process,
like getting gray hair or wearing glasses.
It cannot be prevented.
It can be treated.

6. Voiding (obstructive)
symptoms
 Hesitancy
 Weak stream
 Straining to pass urine
 Prolonged micturition
 Feeling of incomplete
bladder emptying
 Urinary retention
Storage (irritative or filling)
symptoms
 Urgency
 Frequency
 Nocturia
 Urge incontinence
LUTS is not specific to BPH – not everyone with
LUTS has BPH and not everyone with BPH has LUTS

7. Total score: 0-7 Mildly symptomatic; 8-19 moderately symptomatic; 20-35 severely
symptomatic.

8. Medical therapies for BPH
include
α-adrenergic blockers
5α-reductase inhibitors

9.  α-ADRENERGIC BLOCKERS
The rationale for α-adrenergic blockers in the treatment of
BPH is based on the hypothesis that the pathophysiology of
clinical BPH is in part caused by BOO, which is mediated by α1-
adrenergic receptors (α1 AR) associated with prostatic smooth
muscle.

10. 5α-REDUCTASE INHIBITORS
-The rationale for androgen suppression is
based on the observation that the
embryonic development of the prostate is
dependent on the androgen
dihydrotestosterone (DHT).
-Testosterone is converted to DHT by the
enzyme 5α-reductase.
-The development of BPH is also an
androgen-dependent process.

11. -It has been demonstrated that androgen
suppression causes regression primarily of the
epithelial elements of the prostate.
-Reducing prostate volume is thought to
decrease the static component of BOO resulting
from BPH
- drugs used commonly are
Finasteride
Dutasteride

13.  Failure of medical management.
 Refractory urinary retention.
 Renal dysfunction.
 Recurrent or persistent urinary infections.
 Recurrent haematuria of prostatic origin
refractory to medical treatment.
Pathophysiologic changes of the kidneys,
ureters, or bladder secondary to prostatic
obstruction.
Bladder calculi secondary to obstruction.

14.  OPEN SURGERIES
 TRANSURETHRAL RESECTION OF THE PROSTATE
 TRANSURETHRAL RETROGRADE ENUCLEATION OF PROSTATE
 TRANSURETHRAL INCISION OF THE PROSTATE
 LASERS
-RESECTION
-POTASSIUM TITANYL PHOSPHATE LASER
-HOLMIUM:YTTRIUM-ALUMINUM-GARNET LASER
-DIODE LASER
-VAPORIZATION
- PHOTO-SELECTIVE VAPORIZATION OF THE PROSTATE (PVP)
 TRANSURETHRAL NEEDLE ABLATION OF THE PROSTATE
 TRANSURETHRAL MICROWAVE THERAPY
 INTRAPROSTATIC STENTS

15.  Open prostatectomy involves the surgical
removal (enucleation) of the inner portion of
the prostate via an incision in the lower
abdominal area.
 open prostatectomy offers the advantages of
a lower retreatment rate and more complete
removal of the prostatic adenoma under
direct vision and avoids the risk of dilutional
hyponatremia (the TURP syndrome), which
occurs in approximately 2% of patients
undergoing TURP.

16. Surgical approaches to open
prostatectomy are
-freyer’s prostatectomy
-Millin’s prostatectomy
-Young’s prostatectomy

17. INDICATIONS OF OPEN PROSTATECTOMY
 Open prostatectomy is the treatment of
choice for large glands over 80-100ml.
 associated complications such as large
bladder stones.
 If resection of the bladder diverticulum is
indicated.
 Patients with ankylosis of the hip or other
orthopedic conditions, preventing proper
positioning for transurethral resection.
Patients with recurrent or complex urethral
conditions, such as urethral stricture or
previous hypospadias repair, to avoid the
urethral trauma associated with transurethral
resection.

18. CONTRAINDICATIONS OF OPEN PROSTATECTOMY
- a small fibrous gland
-previous prostatectomy or previous
pelvic surgery that may obliterate
access to the prostate gland
-Carcinoma of prostate

19. ADVANTAGES OF OPEN PROSTATECTOMY
-With open enucleation of the adenoma there is
more complete removal of adenoma
-Thus a lower retreatment rate
-TUR syndrome is completely avoided.
DISADVANTAGES OF OPEN PROSTATECTOMY
- a midline incision
- longer hospital stay
- more intra-operative and peri-operative bleeding

20. This approach to open prostatectomy was
first carried out by Eugene Fuller in New
York in 1894
 It was later popularized by Peter Freyer
in London, who described the procedure
in 1900

21. Suprapubic prostatectomy or transvesical
prostatectomy consists of the enucleation
of the hyperplastic prostatic adenoma
through an extraperitoneal incision of the
lower anterior bladder wall.
The major advantage of this suprapubic
procedure over the retropubic approach
is that it allows direct visualization of the
bladder neck and bladder mucosa.

22. INDICATION OF FREYER’S PROSTATECTOMY
-A suprapubic approach is ideal for a large
median lobe protruding into the bladder
-clinically significant diverticulum
-large bladder calculi as it allows direct
access to the bladder neck and bladder
mucosa
- It may also be preferable for obese men,
in whom it is difficult to gain direct access
to the prostatic capsule and dorsal vein
complex

23. DISADVANTAGES OF FREYER’S
PROSTATECTOMY
-With this approach direct visualisation of
the apical prostatic adenoma is limited
- This factor may affect postoperative
urinary continence
-Apical enucleation is less precise
-Haemostasis may be more difficult due to
inadequate visualisation of the entire
prostatic fossa after enucleation.

24. This approach to open
prostatectomy was popularized by
Terrence Millin, who reported the
results of the procedure in 20
patients in Lancet in 1945.
The retropubic approach permits
enucleation of the hyperplastic
adenoma through a direct incision of
the anterior prostatic capsule.

25. There is excellent anatomical exposure of
the adenoma for complete removal.
 The urethra can be transected precisely
distal to the adenoma for preserving
continence.
 Clear visualisation of the prostate bed is
possible for haemostasis, and there is
minimal to no surgical trauma to the
bladder.

26.  The advantages of this procedure over the suprapubic
approach are
 (1) excellent anatomic exposure of the prostate,
 (2) direct visualization of the prostatic adenoma during
enucleation to ensure complete removal,
 (3) precise transection of the urethra distally to
preserve urinary continence,
 (4) clear and immediate visualization of the prostatic
fossa after enucleation to control bleeding,
 (5) minimal to no surgical trauma to the urinary
bladder.
 The disadvantage of the retropubic approach compared
with the suprapubic prostatectomy, is that direct
access to the bladder is not achieved.

27. This procedure was first introduced by
Buchler in 1869
 Hugh Hampton Young described the
first radical perineal prostatectomy in
1905
The perineal approach offers unmatched
visualization of the urethral dissection
and anastomosis, resulting in excellent
urinary continence.

28. The proximity of the prostate to the
perineum allows for an easier
vesicourethral anastomosis, as compared
with any retropubic approach.
A more precise dissection of the prostatic
apex is possible via direct visualization
through the perineal approach.
Can be performed in obese patients

29.  The exaggerated lithotomy position required
during RPP may not be feasible in all patients
 Rectal injury has been reported to be more
frequent in RPP than with the retropubic
approach.

31. Open prostatectomy should be
considered when the obstructive tissue
is estimated to weigh more than 75 g or
sizable bladder diverticula or calculi
exist.
 Before performing an open
prostatectomy, the presence of
prostate cancer should be excluded.

32.  Advantages of open prostatectomy over
TURP are a lower retreatment rate, more
complete removal of the prostatic adenoma
under direct vision, and no risk of TURP
syndrome.
Disadvantages of open prostatectomy over
TURP are a lower midline incision, longer
hospitalization, and increased potential for
perioperative hemorrhage.
Suprapubic prostatectomy is ideal for men
with a large median lobe, clinically
significant bladder diverticulum, or large
bladder calculi

33. Gold standard surgery for BPH
TURP comprises 95% of all
surgical procedures done for
BPH.
Obstructive symptom are
improved
Irritative symptom are improved

34.  Low mortality rate 0.1%
 Treatment of choice for prostate sized 30-100
ml.

35.  It involves the surgical removal of the
prostate’s inner portion via an endoscopic
approach through the urethra, with no
external skin incision

37.  conventional
 electrical current passes through the patient from
the active electrode (connected to the resectoscope
loop) to a grounding pad attached to the patient
POTENTIAL RISKS
 skin burns
 excessive heating of deep tissues
 nerve damage
 inadvertent nerve stimulation (e.g. obturator reflex)
and cardiac pacemaker malfunction.
 Requires nonhemolytic, hypo-osmolar irrigation fluids
(e.g. glycine), which, if absorbed in high volumes,
may lead to TUR syndrome

38. The standard monopolar TURP is now
being challenged by the use of
bipolar resection.
 The rationale for the introduction of
this system is that the complications
of standard monopolar TURP need to
be reduced to improve acceptability
by patients.
It consists of a 17 mm-long, gold-
plated, crescent-shaped cutting tool

39.  The diameter of the bipolar
resection loop is, however, a
little smaller than that of the
conventional monopolar
instrument.
 The positive and negative poles
are on the same axis and are
isolated from each other by a
ceramic connecting piece.

40. The Plasmakinetic Generator (Gyrus
Medical) generates strong, pulsatile,
bipolar energy, which generates the
working temperature on the cutting
tool, permitting maximum tissue
dissection with minimum collateral
damage.
It has been constructed to achieve
optimum hemostasis and prevent
adherence to the tissue.

41. One principal advantage of the
bipolar instrument is that it is
possible to use normal saline
solution (NaCl 0.9%) as irrigating
fluid.
The absence of reverse current
is intended to decrease the risk
of burns and subsequent
stricture formation

42.  Immediate complication
bleeding
clot retention
capsular perforation with fluid extravasation
TUR syndrome
 Late complication
urethral stricture
bladder neck contracture
retrograde ejaculation
impotence
incontinence (0.1%)

43. The syndrome was characterized by mental
confusion, nausea, vomiting, hypertension,
bradycardia, and visual disturbance.
Usually, the patients do not become
symptomatic until the serum sodium
concentration reaches 125 mEq/dL.
The risk is increased if the gland is larger
than 45 g and the resection time is longer
than 90 minutes.
TUR syndrome is secondary to dilutional
hyponatremia

44. Prostate is enucleated
retrogradely,same as in laser
prostatectomy,using a bipolar
cautery.
Adenoma is pushed into bladder
enmass.
Avascular adenoma is resected
indide bladder.

45.  Using a Collin’s knife an incision is made at 5 &
7 o’clock positions or on one side of the midline
only.
 It starts just distal to the
ureteric orifice and ends
just proximal to the
verumontanum.
 One or two cuts are made in the prostate and
the prostate capsule, reducing constriction on
the urethra.
 In appropriate patents TUIP results in similar
symptomatic improvement as TURP.

46. INDICATIONS OF TUIP
 Smaller prostates 30ml or less with no median lobe
ADVANTAGES OF TUIP
 In appropriate patents TUIP results in similar
symptomatic improvement as TURP.
 Lower incidence of complications
 minimal risk of bleeding and blood transfusion,
decreased risk of retrograde ejaculation
 shorter operating time and hospital stay

47. Operating principle of lasers
In the laser, a flashlamp gives out high-intensity light,
which then bombards a resonator cavity with photons.
These excite electrons in the resonator cavity to higher
energy status.
The electrons in the resonator cavity, which are excited
by the bombardment of photons, are caused to jump to
higher or “excited state” orbitals. Because of the
instability of these excited state orbitals, there is a
very rapid decay of the electrons, which emit a photon.
This process is known as spontaneous emission of
radiation.

48. However, the emitted photon has
the energy required to interact with
other excited state atoms. If this
interaction happens, further
electron orbital decay and photon
emission are induced. This photon
has the same characteristics and
travels in the same direction as the
incident photon. This is known as
stimulated emission of radiation.

51. LASER THAT CAN BE USED TO TREAT THE PROSTATE
-RESECTION
-POTASSIUM TITANYL PHOSPHATE LASER
-HOLMIUM:YTTRIUM-ALUMINUM-GARNET LASER
-DIODE LASER
-VAPORIZATION
- PHOTO-SELECTIVE VAPORIZATION OF THE PROSTATE
(GREEN LASER)

52.  Uses a KTP crystal to double the frequency of
an Nd:YAG laser
 Produces a 532-nm wavelength.
 This provides an intermediate level of
coagulation and vaporization. Only half the
depth of tissue penetration is reached
compared with that of the Nd:YAG laser.
 However, the consequent higher energy per
unit tissue volume produced may increase
tissue vaporization and desiccation.
 Advantage: prostate and bladder neck may be
incised with the KTP laser

53.  Emits light at a wavelength of 1064 nm, and its
active medium consists of neodymium atoms in
an yttrium-aluminum-garnet rod.
 This light is poorly absorbed by water and body
pigments, it can penetrate tissues relatively
deeply.
 This poor absorption in a fluid medium causes
thermal coagulation of the surface tissue and
of areas just under the surface.
 The tissue that has been coagulated becomes
white, and hemostasis is total. Subsequently,
the coagulated tissue sloughs, and this may
occur over a period of some weeks.
 It may take up to 3 months to achieve
complete healing.

54.  Emits light at a frequency of 2100 nm.
 The energy is emitted in a series of rapid pulses
over a few milliseconds, the Q-switched laser.
 This is unlike the continuous wave of the KTP
laser.
 Disadvantage:
-Because it produces a cutting effect by
vaporization of the tissue water, its hemostatic
properties are less than those of the continuous
wave lasers.

55.  With conventional lasers, less than 5% of the
electrical input is converted into laser light, and
this inefficiency means that conventional lasers
require high-energy cooling devices and radiators,
thus increasing the size of the machine.
 ADVANTAGES:
-The high gain of the diode laser allows the more
efficient use of the photons that are generated.
-The available diode lasers used for medical
purposes are
small and
portable, and
special connections are not required

56.  MECHANISM OF ACTION
With TUVP, two electrosurgical effects are
combined:
vaporization and desiccation.
-vaporization steams tissue away using high heat
-coagulation uses lower heat to dry out tissue.

57.  DIFFERENCE FROM TURP
Whereas TURP removes tissue by resection of
prostatic tissue and causes hemostasis by
fulguration, transurethral vaporization of the
prostate (TUVP) is brought about by
combining the concepts of vaporization and
desiccation

58.  Uses a very high powered green laser and a
thin, flexible fiber
 Fiber is inserted into the urethra through a
cystoscope

59. Quickly and precisely vaporizes and removes
the enlarged prostate tissue
The green laser energy is hemostatic, so
there is almost no bleeding.
Advantage: patients on anticoagulants and
high surgical risk can be treated
Disadvantage: no tissue is available for
analysis.

60. Enlarged Prostate
Urethra is open
Normal urine flow is
restored
Urethra is obstructed
Urine flow blocked
After GreenLight PVP

62. Good haemostasis,almost no
need of blood transfusion.
Shorter cateterization time.
Shorter hospital stay.

63. High cost of equipment and
treatment.
Steep learning curve.

64.  Heat treatment of whatever kind, to the prostate,
is intended to reduce outflow resistance and the
volume of the obstruction by, increasing the
temperature within the prostate and inducing
necrosis of prostatic tissue.
 The aim is to increase prostatic temperature to in
excess of 60° C.
 Transurethral needle ablation of the prostate
(TUNA) uses low-level radiofrequency (RF) energy
that is delivered by needles into the prostate and
that produces localized necrotic lesions in the
hyperplastic tissue.

65. The TUNA system consists of a special
catheter attached to a generator.
 At the end of the catheter are two
adjustable needles that are withdrawn
into two adjustable shields made from
Teflon.
The needles are advanced into the
prostatic tissue and can be placed
accurately into the required position.

66.  The generator produces a monopolar RF signal
of 490 kHz, which allows excellent penetration
and uniform tissue distribution. The patient has
a grounding pad placed over the sacrum, and
the current passes toward this through the
prostatic tissue.
 In other words, tissue heating is created
because of tissue resistance to the current as it
flows from the active to the return electrode.
 The size of the lesion caused by RF relates to
the position and depth of insertion of the
electrode as well as the power used and the
duration of the treatment

69.  The patient most likely to benefit from TUNA
would be one who had lateral lobe enlargement
 A prostate of 60 g or less

70. The patients having severe lower
urinary tract symptoms, the mean I-
PSS at entry being greater than 20.
The effect of TUNA is to halve the
mean I-PSS at 1 year
Sexual dysfunction is rare after
TUNA
 Urinary incontinence has not been
reported in any series

71. Most common complication :Post-
treatment urinary retention,
occurring at a rate between 13.3%
and 41.6%
Second most common adverse event
reported is that of irritative voiding
symptoms

72.  Studies have shown that there may be several
factors involved in the mode of action of TUMT.
 High temperatures cause necrosis of prostatic cells,
whereas lower temperatures for longer periods of
application induce programmed cell death or
apoptosis.
 Newer TUMT devices seek higher temperatures
(thermotherapy) as well as a transurethral approach
to target the transitional zone.

73.  Prostatron operates at 1296MHz and is capable of
generating up to 80W.
 Prostalund is the only device to use an interstitial
probe with three sensors to monitor intraprostatic
temperature, thereby providing a mechanism to
control and adjust the volume of tissue ablation.
It operates at a frequency of 915MHz with three
different length catheters and can deliver up to
100W.
 High energy TUMT is associated with improved
objective results compared with low energy TUMT,
but with increased morbidity.

74.  The symptomatic improvement that occurs after
TUMT seems to be energy related.
 TUMT is effective in partially relieving LUTS
secondary to BPH.

76.  ADVANTAGES
Day care surgery
Mild sedation required
Lack of sexual side effects
 DISADVANTAGE
Post operative urinary retention is frequent
TUMT is not as effective as TURP in improving
the objective signs of outflow obstruction

77.  One of the earliest attempts to find less
traumatic methods of treating symptomatic
BPH
 they are still being used
 patients who were unfit for surgery
 stents are now available in different lengths,
diameters, materials, and designs

78.  Temporary stents are tubular devices that
are made of either a non-absorbable or a
biodegradable material.
 They are designed for short-term use, to
relieve bladder outlet obstruction, and to act
as an alternative to an indwelling urethral or
suprapubic catheter.

79.  Success rates have been reported as lying in
the range of 50% to 90%.
 They are easy to reposition or replace
 Used in high-risk patients considered unfit
for surgery

80.  Catheterization or cystoscopy cannot be
performed while the stent is in place.
 Complications such as
encrustation
migration
breakage
stress incontinence
bacteriuria

81.  Temporary stents are receiving widespread
attention, but the original idea that they should be
used as a temporary expedient to overcome
outflow problems in the medically unfit is being
modified.
 The newer stents, whether biodegradable or not,
are being viewed as possible methods of
overcoming the temporary retention that can
occur secondary to treatments such as laser
therapy or high-energy transurethral microwave
therapy.

82. Detrusor-sphincter dyssynergia
Post-brachytherapy bladder
outlet obstruction
Anastomotic strictures
Complex urethral strictures

83.  UROLUME ENDOURETHRAL PROSTHESIS
-is a woven tubular mesh
-maintains its position in the urethra by outward external
pressure, thus maintaining the patency of the prostatic
urethra.
 MEMOTHERM
-is a heat-expandable stent of nickel-titanium alloy
- when it is cooled, it can easily be compressed and
distorted, but, when warmed to body temperature, it
expands to a flexible cylinder and does not shorten
-It is made from a woven single wire

84.  The surgical procedures of TURP, TUIP and open
prostatectomy are all efficacious and result in
improvement of LUTS exceeding 70%
 Need for blood transfusion is in the range of 2-
5%, more following open and less following TUIP.
 Stress incontinence following TURP is 2.2%,
TUIP 1.8% and open 10%
 Risk of bladder neck contracture is 1.8% after
open, 4% after TURP and 0.4% after TUIP
 Retrograde ejaculation occurs in 80% after
open 65-70% after TURP and 40% after TUIP

85.  TURP is GOLD STANDARD : safe and effective way of
treating BPH
 TUIP are also effective as TURP, particularly for small
prostates.
 THE HOLMIUM LASER and the HIGH-POWER PVP LASER
are the most popular instruments in technology
section. Benifits are comparable to TURP. Long-term
studies are required
 TRANSURETHRAL NEEDLE ABLATION and
TRANSURETHRAL MICROWAVE THERAPY have a
significant beneficial effect. Limited availability and
limited studies keeps them at backfoot.
 INTRAPROSTATIC STENTS are confined to alternative
therapy for BPH for patients unfit for surgery.