Prostate Benign Prostatic Hyperplasia(BPH)- overview

Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai
1

Moderators:
Professors:
• Prof. Dr. G. Sivasankar, M.S., M.Ch.,
• Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
• Dr. J. Sivabalan, M.S., M.Ch.,
• Dr. R. Bhargavi, M.S., M.Ch.,
• Dr. S. Raju, M.S., M.Ch.,
• Dr. K. Muthurathinam, M.S., M.Ch.,
• Dr. D. Tamilselvan, M.S., M.Ch.,
• Dr. K. Senthilkumar, M.S., M.Ch.
Dept of Urology, GRH and KMC, Chennai. 2

BPH-Pathology
• Can be microscopic BPH, macroscopic BPH, or clinical BPH.
• Proliferative process originates in the transition zone and the
periurethral glands .
• Androgens play a passive role in the proliferative process.
• Growth factors such as epidermal growth factor (EGF) are involved
through autocrine and paracrine stromal-epithelial interactions.
3
Dept of Urology, GRH and KMC, Chennai.

BPH-Pathophysiology
4

BPH-Symptoms
• Obstructive LUTS – Straining, Intermittency, Hesitancy, Weak stream,
Incomplete voiding sensation, overflow urinary incontinence
• Irritative LUTS – Frequency, Urgency,
• Nocturia
• Recurrent UTI
• Hematuria
• Acute urinary retention
5

• Rule out other causes of voiding
dysfunction or comorbidities.
• Use of a voiding diary (recording
times and volume) may help
identify patients with polyuria or
other nonprostatic disorders.
BPH-Voiding diary
6

Abdominal examination - to exclude an
overdistended, palpable bladder.
Examination of the external genitalia - to
exclude meatal stenosis or a palpable
urethral mass.
DRE and a focused neurologic
examination should usually be
performed.
BPH-Examination
7

Multiple symptom scores are available.
• AUA-7 Symptom Index (AUASI),
• IPSS,
• Madsen and Iversen,
• Boyarsky and
• International Continence Society
Study on BPH.
BPH-Symptom scores
8

IPSS- Severity of the problem
• Mild symptoms (0 to 7) - assigned to watchful waiting;
• Moderate (8 to 19) or severe (20 to 35) - undergo further testing or
treatment, or both.
IPSS-Current US and International standard
Ideal instrument to grade baseline symptom severity, assess the
response to therapy, and detect symptom progression in those men
managed by watchful waiting.
9

IPSS Scoring system
10

• Urinalysis
• Serum Creatinine
• Serum PSA
• Uroflowmetry
• Post void residual urine
• TRUS
• Upper urinary tract imaging
• Additional studies
BPH-Investigations
11

Assists in distinguishing UTIs and
bladder cancer from BPH.
Urine cytology should always be
requested in men if they have a
smoking history.
BPH-Investigations/Urinalysis
12

• Routine creatinine measurement in the
standard patient is no longer recommended.
• Elevated serum creatinine levels in a patient
with BPH is an indication for imaging studies
(usually ultrasonography) to evaluate the
upper urinary tract.
BPH-Investigations/Sr.Creatinine
13

Performed in patients in whom
the identification of cancer
would clearly alter BPH
management.
BPH-Investigations/Sr.PSA
14

• Inaccurate if the voided volume is <125 to 150
mL.
• The peak flow rate (PFR; Qmax) more specifically
identifies patients with BPH than does the
average flow rate (Qavg).
• PFR >15 mL/sec appear to have somewhat
poorer treatment outcomes after prostatectomy
than patients with a PFR <15 mL/ sec.
• A PFR <15 mL/sec does not differentiate between
obstruction and bladder decompensation.
BPH-Investigations/Uroflowmetry
15

• Does not correlate well with other
signs or symptoms.
• Large PVR urine volumes - slightly
higher failure rate with watchful
waiting.
• PVR urine volume is best viewed
as a “safety parameter.”
BPH-Investigations/PVRU
16

BPH-Investigations/TRUS
• Transrectal Ultrasonography of
Prostate.
• Provides most accurate volume of
the prostate.
17

Recommended in presence of one or
more of the following:
1. Hematuria,
2. UTI,
3. Renal insufficiency
(ultrasonography recommended),
4. History of urolithiasis, or
5. History of urinary tract surgery.
BPH-Investigations/
Imaging of Upper Urinary tract
18

1. Urodynamic study: Detrusor hypocontractility, if suspected.
2. Cystoscopy- Prudent before operative procedure.
BPH-Investigations/Additional studies
19

BPH- TREATMENT OPTIONS
WATCHFUL WAITING
MEDICAL THERAPY
SURGERY
20

21

Patient driven treatment of choice.
Indications:
1. Absence of absolute indication for
intervention.
2. If the complications of treatment are
greater than the inconvenience of the
symptoms,
3. Reluctance to take a daily pill owing to
side effects and/or the cost of
treatment.
Watchful Waiting or “Self-Help”
22

Watchful waiting-Methods
1. Decreasing total fluid intake especially
before bedtime,
2. Moderating the intake of alcohol and
caffeine-containing products, and
3. Maintaining timed voiding schedules.
23

24

Medical Therapy-Treatment Goals
1. Relieving LUTS,
2. Decreasing BOO,
3. Improving bladder emptying,
4. Ameliorating detrusor instability,
5. Reversing renal insufficiency, and
6. Preventing disease progression.
25

Medical Therapy-Agents
1. Αlpha adrenergic blockers
2. 5α-reductase inhibitors
3. Aromatase inhibitors
4. Antimuscarinic drugs
5. Phosphodiesterase inhibitors
6. Plant extracts
26

Alpha blockers
Efficacy is mediated by α1 receptor
Toxicity is mediated by α2 receptor
Adverse effects:
1. Dizziness,
2. Asthenia,
3. Orthostatic hypertension,
4. Retrograde ejuculation.
27

Alpha blockers
1. Terazosin- Caution of hypotension needed in poorly controlled
hypertension patients.
2. Doxazosin- Longer half life than terazosin (22 vs. 12 hours).
3. Tamsulosin- Most commonly employed α1 antagonist. Exhibits
some degree of specificity for the α1A-adrenergic receptor .There is
no need of dose titration.
4. Alfuzosin- Multiple doses is its primary limitation. Uroselective drug
with no blood pressure changes.
28

Alpha blockers
5. Silodosin- Minimal effects on the cardiovascular system, retrograde
ejaculation is most common.
6. Naftopidil- A relative selective α1D-adrenergic receptor antagonist.
Decreases IPSS for storage symptoms.
29

1. Finasteride-
• Competitive inhibitor of the enzyme 5α-reductase type 2 isozyme.
• Side effects- Decreased libido, ejaculatory disorder, and
impotence.
• Prevents recurrent gross hematuria secondary to BPH &
• Effective in post prostatectomy hematuria.
2. Dutasteride- Dual inhibitor of 5αreductase types 1 and 2.
3. Zanoterone- steroidal competitive androgen receptor antagonist.
Associated with severe breast pain & gynecomastia
Androgen manipulation
30

4. Flutamide- orally administered nonsteroidal antiandrogen, inhibits
the binding of androgen to its receptor.
5. Cetrorelix- a gonadotropin-releasing hormone (GRH) antagonist.
Primary disadvantage is its injectable form and high cost.
6. Atamestane- highly selective aromatase inhibitor. Use suspended
because of negative clinical findings
Androgen manipulation
31

Combination Therapy with α-Adrenergic Blockers and 5α-Reductase
Inhibitors
• Combination of doxazosin and finasteride exerts a clinically relevant,
positive effect on rates of disease progression.
Combination versus Avodart or Tamsulosin (CombAT) Trial
• Combination of dutasteride and tamsulosin was more effective than
either drug alone.
Combination Therapy
32

Antimuscarinics
• Useful for patients with coexisting OAB (Overactive bladder)
symptoms.
• Theoretical risk of increase in urinary retention in patients with
significant obstruction due to antimuscarinic effect on detrusor.
• Combination therapy with α1-adrenoceptor antagonists in carefully
selected men is effective.
• Men with significant obstruction and PVRU >200ml, antimuscarinics
are better avoided.
33

Sildenafil, Tadalafil, Vardenafil and Udenafil are used.
PDEIs improve urinary symptoms scores. Useful in men with LUTS and
significant Erectile dysfunction.
Possible candidate mechanisms of action include:
1. Smooth muscle relaxation in prostatic, bladder or erectile tissues,
2. Autonomic hyperactivity,
3. Calcium-independent Rho-kinase activation pathway
4. Reduced nitric oxide (NO) levels
5. Pelvic atherosclerosis theory
Phosphodiesterase Inhibitors
34

Combination therapy:
Concomitant use of α-adrenergic blockers and PDEIs may lead to
symptomatic hypotension.
Coadministration of doxazosin (4 and 8 mg daily) and tadalafil (5
mg/day or 20 mg as a single dose intermittently) leads to further
lowering of blood pressure, and this combination is not recommended
by the manufacturers.
Phosphodiesterase Inhibitors
35

• Phytotherapeutic products are not the actual plant but are extracts
derived from either the roots, the seeds, the bark, or the fruits of the
various plants used.
• Composition is very complex. Contains phytosterols, plant oils, fatty
acids and phytoestrogens.
• Serenoa Repens (Saw Palmetto Berry) extract is commonly used.
• Three mechanisms of action: anti-inflammatory effects, 5α-reductase
inhibition, and growth factor alteration.
Phytotherapy
36

• Is a Complication associated with BPH
• May be “spontaneous” or
• May be “precipitated” by:
• Medications Eg:anticholinergic or sympathicomimetic agents,
• Urinary infection,
• excessive fluid intake, and
• the consequences of surgery (postoperative pain or the effects of
anesthesia or analgesia or loss of mobility) may precipitate AUR.
Acute Urinary Retention (AUR)
37

• Risk factors:
• Presence of LUTS,
• Low PFR, and
• Raised PSA
• If AUR is due to increased sympathetic activity, an α-adrenergic
blocker may cause spontaneous voiding after catheter removal.
• In the MTOPS trial, finasteride or combination therapy of finasteride
with doxazosin, but not doxazosin alone, reduced the incidence of
AUR
Acute Urinary Retention (AUR)
38

39

Indications for BPH surgery
1. Refractory urinary retention
2. Recurrent UTI
3. Recurrent gross hematuria
4. Bladder stones
5. Renal insufficiency or
6. Large bladder diverticula
40

Endoscopic Procedures
• Intraprostatic stent placement
• TUNA
• TUMT
• TVP
• TURP
• TIP
Open prostatectomy
• Retropubic prostatectomy
• Transvesical prostatectomy
Surgical Treatment Options
41

Intraprostatic stents
• Useful in patients unfit for surgery, in either the short or the long
term
• Better alternative for indwelling urethral catheterization.
Can be of two types:
1. Temporary stents
2. Permanent stents
Endoscopic Procedures/Stenting
42

Tubular devices, made of either a nonabsorbable
or a biodegradable material.
1. Spiral Stents
• First-Generation Stents Eg: Urospiral (Porges)
and Prosta Kath (Pharma-Plast).
• Complications: hematuria with clot retention
(5%), stent migration (15%), recurrent urinary
tract infections (10%), and encrustation (4%).
• Second-Generation Stents. To overcome the
problems of the first-generation. Eg:
Memokath and the Prosta Coil
Endoscopic Procedures/Stenting/
Temporary Stents
43

2.Polyurethane stents are also known
as intraurethral catheters. There are
three types:
a. Intraurethral catheter,
b. Barnes stent, and
c. Trestle stent.
3.Biodegradable Stents do not need to
be removed, and eventually they
disappear by biodegrading .
Temporary Stents
44

Examples are Urolume &Memotherm.
UroLume is a woven tubular mesh that maintains its position in the
urethra by outward external pressure.
Memotherm is a stent of nickeltitanium alloy that is expandable to 42 Fr
with heat.
Permanent Stents
45

TUNA- Transurethral needle ablation of prostate.
Increases the temperature within the prostate
and induces necrosis of prostatic tissue. The aim
is to increase prostatic temperature to in excess
of 60° C.
Uses low-level radiofrequency (RF) energy of
490kHz that is delivered by needles into the
prostate and that produces localized necrotic
lesions in the hyperplastic tissue
Lateral lobe enlargement and a prostate of 60 g or
less patients are mostly benefited.
Endoscopic Procedures/TUNA
46

Adverse Effects:
• Posttreatment urinary retention (13.3-41.6%)
• Irritative voiding symptoms (40%)
• Urinary tract infection to (3.1%).
• Sexual dysfunction is rare after TUNA.
• Urinary incontinence has not been reported in any series.
Endoscopic Procedures/TUNA
47

TUMT- Transurethral Microwave Therapy
Eg: Prostatron, Targis
Mechanism of Action
• Tissue exposed to a minimum of 45° C for about 60
minutes suffered hemorrhagic necrosis with
uniform extirpation
• Thermal damage to the adrenergic fibers
• Induction of Apoptosis
TUMT does not outperform TURP.
Endoscopic Procedures/TUMT
48

LASERs used:
Nd:YAG
KTP
Holmium
Diode
Mechanism of action:
1. Coagulation or
2. Vaporization.
Endoscopic Procedures/
LASER Prostatectomy
49

• Neodymium : Yttrium-Aluminum-Garnet Laser (wavelength of 1064
nm):
• Active medium consists of neodymium atoms in an yttrium-
aluminum-garnet rod.
• Causes thermal coagulation of the surface tissue and of areas just
under the surface.
• Relatively inefficient way because of the high power required.
LASER Prostatectomy/Nd:YAG
50

• Potassium-Titanyl-Phosphate Laser (532-nm wavelength):
• 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.
LASER Prostatectomy/KTP LASER
51

• Photoselective vaporization of the prostate
(PVP) uses a 80-W KTP laser (Greenlight PV
Laser System)
• KTP/532 laser energy is delivered by a side-
firing glass fiber.
• Sterile water irrigation is used.
• Complete vaporization produces aTURP-like
cavity.
• Less bleeding with larger coagulation zones.
• Useful in patients on anticoagulant therapy or
with severe bleeding disorders.
LASER Prostatectomy/PVP
52

• Holmium : Yttrium-Aluminum-Garnet Laser (2100 nmwavelength):
• The energy is emitted in a series of rapid pulses
• Less hemostatic properties than those of the continuous wave lasers.
• The Ho : YAG laser beam is absorbed by water (unlike the Nd : YAG
beam) at a wavelength of 2140 nm and causes considerable tissue
vaporization.
• Can also be applied to large prostates.
LASER Prostatectomy/Holmium Laser
53

• TURP- Transurethral resection of the
prostate
Gold standard for the surgical management of
BPH.
Indications:
1. Moderate to severe symptoms,
2. Acute urinary retention,
3. Recurrent infection,
4. Recurrent hematuria, and
5. Azotemia.
TURP
54

Antibiotic Usage:
No Bacteriuria and no Catheter in situ:
Single dose of Ist generation Cephalosporin + Gentamicin before
surgery.
Bacteriuria or Catheter in situ:
Antibiotic continued till catheter removal.
Traditional monopolar technology has been replaced with Bipolar
resection known as Gyrus Plasma Kinetic System.
TURP
55

• Gyrus bipolar system consists of a
generator with 200-W capability, an RF
range of 320 to 450 kHz,
• Resection should be performed in a
routine step by-step manner.
TURP
56

Hemorrhage
• Arterial bleeding is controlled by electrocoagulation.
• After surgery if arterial bleeding suspected, resectoscope is reinserted
to achieve hemostasis.
• Venous bleeding can be controlled by filling the bladder with 100 mL
of irrigating fluid and placing the catheter on traction for 7 minutes at
the operating table. The balloon of the catheter is overinflated to 50
mL of fluid.
TURP-Intraop Complications
57

Extravasation, or perforation of prostatic capsule
Occurs in about 2% of patients.
Symptoms of extravasation are restlessness, nausea, vomiting, and
abdominal pain
Pain is usually localized to the lower abdomen and back.
Operation should be terminated as rapidly as possible but hemostasis
must be secured.
Over 90% of these patients can be managed simply by urethral catheter
drainage and cessation of the operative procedure
TURP-Intraop Complications
58

Intraoperative Priapism
Managed by injecting an α-adrenergic agent (Ephedrine or
Phenylephrine) directly into the corpora cavernosa.
Post Op complications
Failing to void (6.5%),
Bleeding requiring transfusion (3.9%), and
Clot retention (3.3%).
TURP- Complications
59

• TUR syndrome occur in 2% of the patients.
• TUR syndrome is secondary to dilutional hyponatremia.
• Amount of fluid absorbed were dependent on the height of the fluid
by the patient. This could not be achieved when the fluid level was
below 60 cm H2O.
• Usualy serum sodium concentration reaches below 125 mEq/dL.
• Risk is increased if the gland is larger than 45 g
• resection time is longer than 90 minutes.
• Clinical Features: mental confusion, nausea, vomiting, hypertension,
bradycardia, and visual disturbance.
TUR Syndrome
60

• Effective in treating patients with LUTS caused by
BOO.
• Useful in younger patients, especially if the prostate
is smaller than 30 g.
• Efficacy is comparable in such patients with TURP.
• Simple technique and low morbidity.
• With a Collings knife, an incision is made at the 5-
and 7-o’clock positions or on one side of the midline
only. It starts just distal to the ureteral orifice and
ends just proximal to the verumontanum.
TUIP-Transurethral Incision of Prostate
61

Advantages:
1. Lower re-treatment rate and
2. More complete removal of the prostatic adenoma
3. No risk of TUR syndrome
Disadvantages:
1. Need for a lower midline incision
2. Longer hospitalization and convalescence period.
3. Increased potential for perioperative hemorrhage.
Open Prostatectomy
62

1. All indications for endoscopic procedures apply for open procedure
also.
2. Prostate weighing more than 75 gms
3. Associated large bladder diverticula requiring diverticulectomy
4. Ankylosing conditions of the hip
5. Large bladder calculi not amenable to endoscopic removal
6. Recurrent and complex urethral conditions, Eg.Stricture,
hypospadias repair
7. Associated inguinal hernia
Open Prostatectomy- Indications
63

1. Small fibrous gland
2. Presence of prostate cancer and
3. Previous prostatectomy or pelvic surgery
Open Prostatectomy-
Contraindications
64

1. Urinary incontinence
2. Erectile dysfunction
3. Retrograde ejaculation
4. Urinary tract infection
5. Bladder neck contracture
6. Urethral stricture
7. Need for a blood transfusion
8. Deep vein thrombosis and pulmonary embolus
Open Prostatectomy-Potential Risks
65

Retropubic Prostatectomy-Millin’s
66

67

68

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
Retropubic Prostatectomy-
Advantages
69

Transvesical Prostatectomy- Freyer’s
70

71

72

Advantages
1. A suited for large median lobe protruding into the bladder
2. Clinically significant bladder diverticulum
3. Large bladder calculi
4. Preferable for obese men
Disadvantages
1. Less direct visualization of the apical prostatic adenoma.
2. Apical enucleation is less precise
3. May affect postoperative urinary continence
4. Hemostasis is more difficult
Transvesical Prostatectomy
73

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Prostate Benign Prostatic Hyperplasia(BPH)- overview

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