BPH- evaluation & management

1. 1

2. 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

3. Male urinary tract - PROSTATE Gland
Location
base of bladder
and surrounds
the urethra
PROSTATE
3
Dept of Urology, GRH and KMC,
Chennai.

4. PROSTATE Gland
• At birth- pea size
• Gradually increase until puberty
• Reaching normal adult size - walnut - third
decade of life
• Size remains same until the age of 40-45
• Increase in the size on or after 45 yrs.
4
Dept of Urology, GRH and KMC,
Chennai.

5. PROSTATE Gland
Prostate cancer commonly occurs in peripheral zone
while BPH occurs in transition zone.
Transitional
Zone
Anterior
Zone
Central
Zone
Peripheral
Zone
5
Dept of Urology, GRH and KMC,
Chennai.

6. Benign Prostatic Hyperplasia
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Dept of Urology, GRH and KMC,
Chennai.

7. Definition & terminology
• Microscopic BPH
• Macroscopic BPH
• Clinical BPH
LUTS ( Paul Abrams)
Detrusor instability
BPH related complications
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Dept of Urology, GRH and KMC,
Chennai.

8. LUTS
BOO
BPE
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Dept of Urology, GRH and KMC,
Chennai.

9. 9
Dept of Urology, GRH and KMC,
Chennai.

10. Initial evaluation
• Medical history
• Physical exam
Gen Exam
DRE & Focused neurologic examination
• Urinalysis
• Sr PSA
10
Dept of Urology, GRH and KMC,
Chennai.

11. Normal
gland 20 gms Chestnut
Minimally perceptible on
DRE
1+ 25 gms Plum <1/4 of the Rectal Lumen
2+ 50 gms Lemon <1/2 of the Rectal Lumen
3+ 75 gms Orange 3/4 of the Rectal Lumen
4+ 100 gms Small grapefruit Fills the Rectal Lumen
11
Dept of Urology, GRH and KMC,
Chennai.

12. Normal gland Encroaches 0-1 cm into Rectal Lumen
1 Encroaches 1-2 cm into Rectal Lumen
2 Encroaches 2-3 cm into Rectal Lumen
3 Encroaches 3-4 cm into Rectal Lumen
4 Encroaches >4 cm into Rectal Lumen
12
Dept of Urology, GRH and KMC,
Chennai.

13. Benign Prostatic Hyperplasia
Patho - physiology of
Bladder Outlet Obstruction
• Mechanical component
• Dynamic component
• Detrusor response
13
Dept of Urology, GRH and KMC,
Chennai.

14. Symptomatology
Symptoms of BPH
Obstructive symptoms Irritative symptoms
• Hesitancy
• Impairment of size and
force of urinary stream
• Interruption of stream
• Terminal dribbling
• Nocturia
• Daytime frequency
urgency
• Dysuria
• Sensation of incomplete
emptying of the bladder/
Sense of incomplete void
Lower urinary tract symptoms
14
Dept of Urology, GRH and KMC,
Chennai.

15. Symptom assessment
• Non validated scoring system
Boyarsky symptom index
Madsen-Iverson symptom index
• Validated scoring system
AUA
• Disease specific QOL scoring system
IPS-S
BPI
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Dept of Urology, GRH and KMC,
Chennai.

16. AUA (1992)
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Dept of Urology, GRH and KMC,
Chennai.

17. If you were to spend the rest of your life with your urinary
condition the way it is now, how would you feel about that?
(Please tick which best describes how you would feel.)
0. Delighted
1. Pleased
2. Mostly satisfied
3. Mixed - about equally satisfied and dissatisfied
4. Mostly dissatisfied
5. Unhappy
6. Terrible
IPSS
• 2nd International consultation on BPH &
WHO (1994)
17
Dept of Urology, GRH and KMC,
Chennai.

18. Additional diagnostic testing
• Optional: Following the initial evaluation of the
patient, urinary flow-rate recording and
measurement of post void residual urine
(PVR) may be appropriate.
• Indications:
– Moderate to severe LUTS
– Bothersome LUTS
– Prior to invasive therapy
– Initial evaluation point to a non prostatic cause
– Patients with complex medical history
18
Dept of Urology, GRH and KMC,
Chennai.

19. Uroflowmetry
• Electronic recording of urinary flow rate through
out the course of micturition
• Simple / non invasive / reproducible
19
Dept of Urology, GRH and KMC,
Chennai.

20. Contd…
• Q max - Maximal flow rate
• Q ave - Average flow rate
• TQ max - Time lapsed from onset to
maximal flow
• Flow time - Time over which measurable
flow actually occurs
• Voided Vol - Total volume of urine actually
voided
20
Dept of Urology, GRH and KMC,
Chennai.

21. Contd…
Gender Age (Yr) Flow rate (ml/sec)
Males
<40 >22
40 - 60 >18
>60 >13
Females <50 >25
>50 >18
Flow rate (ml/sec) Interpretation
> 15 unlikely to be obstructed
10 - 15 Equivocal
< 10
Either obstructed or weak
bladder contractility 21
Dept of Urology, GRH and KMC,
Chennai.

22. 22
Dept of Urology, GRH and KMC,
Chennai.

23. Guidelines
• Qmax is more specific than Qave
• Qmax decreases with advancing age & decreasing
voided volume
• Qmax of > 15 ml/sec – Poor outcome after surgery
• Qmax of < 15 ml/sec – does not differentiate
between obstruction and poor bladder contractility
• Uroflow is not needed in patients who elect
watchful waiting therapy
23
Dept of Urology, GRH and KMC,
Chennai.

24. PVR
• Volume of urine remaining in the bladder
immediately after the completion of urination
• Normal range 0.09 to 2.24 ml
• Mean 0.53 ml
• 78% of normal men - < 5 ml
• 100% of normal men - < 12 ml
• Measurement
– USG
– Catheterization
24
Dept of Urology, GRH and KMC,
Chennai.

25. UDE
• Pressure flow studies (PFS)
– Is the only test directly measures the relative contributions of bladder,
outlet and prostate to lower urinary tract function, dysfunction or
symptoms
– Differentiate between pts with low Qmax due to obstruction or nerogenic
dysfunction
• Indications
– Uroflow is equivocal
– Bothersome LUTS with high Qmax
– Evaluation of men with LUTS who have failed prior invasive
therapy
– Pts with history / examination suggestive of concomitant
neurologic diseases (CVA,Parkinsons,Neuropathy)
25
Dept of Urology, GRH and KMC,
Chennai.

26. Urethrocystoscopy
• H/O microscopic or gross hematuria
• H/O stricture disease
• H/O bladder cancer
• H/O prior lower urinary tract surgery
• To select specific technique in pts choosing
invasive therapy
26
Dept of Urology, GRH and KMC,
Chennai.

27. Size Intraurethral lateral Intraurethral middle or
dorsal portions of lateral
Intravesical middle
or dorsal portion of
lateral
Normal Concave lateral
prostatic urethral walls
1-2 cm between veru and
prostatic border
Does not cover
trigone
Gr I Lobes bulge inwards
but do not touch in
midline
2-3 cm between veru and
prostatic border
Covers upto ½ of
trigone
Gr II Lobes touch in the
midline
3-4 cm between veru and
prostatic border
Covers from ½ to
all trigone
Gr III Lobes touch in the
midline for 2-3 cm
4-5 cm between veru and
prostatic border
Covers more than
trigone
Gr IV Lobes touch in the
midline for > 3 cms
>5 cm between veru and
prostatic border
Extends up into
fundus
27
Dept of Urology, GRH and KMC,
Chennai.

28. Management Options
• Watchful waiting.
• Medical Management.
• Surgical Management.
28
Dept of Urology, GRH and KMC,
Chennai.

29. Watchful waiting
• 85% of men will be stable on WW at 1 year.
• 65% of men will be stable on WW at 5 years.
• Reason why some men deteriorate and others do not is not
understood.
• Education ,reassurance ,and periodic monitoring is a must.
EAU Update 2004
29
Dept of Urology, GRH and KMC,
Chennai.

30. • Patients with mild symptoms and patients
with moderate to severe symptoms without
bother should be managed using watchful
waiting
• Patients with bothersome moderate to
severe symptoms include medical,
minimally invasive, or surgical therapies
30
Dept of Urology, GRH and KMC,
Chennai.

31. Surgery in BPH
Absolute Indications
 Refractory retention of urine
 Persistent hematuria
 Persistent UTI with BPH
 Vesical calculi with BPH
 Bladder diverticulae with BPH
 Renal failure in BPH
 Severe symptoms
31
Dept of Urology, GRH and KMC,
Chennai.

32. MEDICAL TREATMENT
• Alpha blockers
• 5 alpha reductase inhibitors
• Combination therapy( alpha blocker and 5
alpha reductase inhibitor)
• Phytotherapy
32
Dept of Urology, GRH and KMC,
Chennai.

33. LUTS
• Dynamic component - managed by alpha
blockers
• Static component - managed by 5 alpha
reductase inhibitors
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Dept of Urology, GRH and KMC,
Chennai.

34. Alpha receptors
Alpha 1
• Alpha 1a – prostatic smooth muscle
• Alpha 1b – blood vessels
• Alpha 1d - detrusor
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Dept of Urology, GRH and KMC,
Chennai.

35. Alpha blockers
• Drugs used
Non selective
Alpha 1
Long acting alpha 1
Alpha 1a , 1d
• Phenoxybenzamine
• Prazosin
• Terazosin ,Doxazosin
Alfuzosin SR
• Tamsulosin
35
Dept of Urology, GRH and KMC,
Chennai.

36. 36
Dept of Urology, GRH and KMC,
Chennai.

37. 5ALPHA REDUCTASE
INHIBITORS
• Foundation therapy for BPH
• 5AR enzyme in 2 forms
type 1 –in skin,liver
type 2 – prostate
• Drugs available – Finasteride , Dutasteride
• Mech. of action – inhibits 5AR enzyme
which converts testosterone to DHT
• DHT –active form
37
Dept of Urology, GRH and KMC,
Chennai.

38. COMBINATION THERAPY
• Indicated when prostate vol >40gm or PSA >1.5ng/ml
• The best tested combination is doxazosin and
finasteride
• Reduces the risk of progression, reduces the risk of
surgery, reduces the risk of acute urinary retention
• 0.5mg of Dutasteride + 0.4mg of Tamsulosin provides
rapid symptomatic relief
• Withdrawal of alpha blocker after 6 months maintains
symptomatic relief in 77% of patients
38
Dept of Urology, GRH and KMC,
Chennai.

39. Assess prostate size
Digital rectal exam
Ultrasound optional
40g or less >40g
Alpha blocker
Alpha blocker+/or
5 alpha reductase inhibitors
Reassess Reassess
Improvement No improvement Improvement No improvement
Continue indefinitely Surgery Continue indefinitely Surgery
39
Dept of Urology, GRH and KMC,
Chennai.

40. When to switch over ?
• Progression in symptoms/ IPSS
• No change in the PFR
• Progressively increasing PVR
• Intolerance / C.Indications to
medical treatment
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Dept of Urology, GRH and KMC,
Chennai.

41. Surgical Options
• Open prostatectomy
• TURP
• Newer modalities and minimally invasive
techniques
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Dept of Urology, GRH and KMC,
Chennai.

42. TURP
• TURP is the gold standard in treating patients with BPH
• Surgical therapy(TURP) betters the symptom score
compared to other modalities
• Only limitation is its morbidity and associated high costs
42
Dept of Urology, GRH and KMC,
Chennai.

43. TURP
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Dept of Urology, GRH and KMC,
Chennai.

44. The prostate "chips" seen here are the firm, rubbery fragments obtained from transurethral
resection of prostate (TURP) performed for symptomatic nodular hyperplasia 44
Dept of Urology, GRH and KMC,
Chennai.

45. BPH – OPEN
PROSTATECTOMY
• Transvesical
• Retropubic
• Perineal
45
Dept of Urology, GRH and KMC,
Chennai.

46. BPH – MINIMALLY INVASIVE PROCEDURES
• Trans Urethral Inscision of Prostate.
• Transurethral needle ablation
• Laser Ablation
• Electrovaporization
• Transurethral microwave therapy
• Transurethral baloon dilatation
• Intra prostatic stents
46
Dept of Urology, GRH and KMC,
Chennai.

47. Trans Urethral Incision of Prostate
• Small gland ( <30gms) causing obstruction
• Associated BNE without middle lobe
hyperplasia.
• Results comparable with TURP.
• Less complications than TURP especially
retrograde ejaculation.
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Dept of Urology, GRH and KMC,
Chennai.

48. TUIP
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Dept of Urology, GRH and KMC,
Chennai.

49. Trans Uethral Needle Ablation
• RF energy delivered into prostate
producing temperature > 60 degree C
• Localized necrotic lesion in hyperplastic
tissue without damaging urethra.
• RF generator attached to TUNA catheter
(Pro Vu system).
• Lateral lobes <60 gms without median
lobe enlargement & bladder neck
hypertrophy are best suited.
49
Dept of Urology, GRH and KMC,
Chennai.

50. TUNA
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Dept of Urology, GRH and KMC,
Chennai.

51. TRANSURETHRA NEEDLE
ABLATION (TUNA)
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Dept of Urology, GRH and KMC,
Chennai.

52. Trans Urethral Microwave Therapy
• Urethral microwave device to heat
prostatic tissue > 45 degrees.
• Damage to urethra prevented by
conductive cooling system.
• Commonly used systems – Prostatron &
Targis.
• Mechanism – Tissue necrosis, induction of
apoptosis & damage to intraprostatic
nerve endings and alpha receptors.
52
Dept of Urology, GRH and KMC,
Chennai.

53. TUMT
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Dept of Urology, GRH and KMC,
Chennai.

54. TUMT Catheter
• Catheter tip and balloon (A).
• Thermosensing unit and microwave antennae (B) are located just
proximal to the balloon.
• Coolant-circulating ports (C).
• Thermosensor port(D).
• Drainage port (E)
• Microwave ports (F and G)
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Dept of Urology, GRH and KMC,
Chennai.

55. TUMT
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Dept of Urology, GRH and KMC,
Chennai.

56. Patient undergoing TUMT
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Dept of Urology, GRH and KMC,
Chennai.

57. Trans Urethral Vaporization of prostate
• Combination of 2 electrosurgical effects –
vaporization & desiccation.
• Grooved roller ball electrode made of
nickel-silver & insulated with Teflon.
• Vaporization occurs at leading edge &
desiccation occurs at trailing edge.
• Trans urethral vaporization-resection of
protate (TURVP) using vaporizing loops.
57
Dept of Urology, GRH and KMC,
Chennai.

58. TUVP – ROLLER BALL
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Dept of Urology, GRH and KMC,
Chennai.

59. TUVP – ENDOSCOPIC VIEW
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Dept of Urology, GRH and KMC,
Chennai.

60. Lasers in BPH
• Types of Lasers
Nd:YAG Laser.
KTP Laser.
Holmium:YAG Laser.
• Mechanism – Desication,
coagulation,carbonization&vaporization of
prostatic tissue.
60
Dept of Urology, GRH and KMC,
Chennai.

61. Methods of Delivery
• End firing Laser.
• Side firing Laser.
• Interstitial Laser.
61
Dept of Urology, GRH and KMC,
Chennai.

62. Side firing Laser probe
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Dept of Urology, GRH and KMC,
Chennai.

63. Interstitial Laser Therapy
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Dept of Urology, GRH and KMC,
Chennai.

64. KTP Laser
• Wavelength 532 nm.
• High absorption in hemoglobin limits penetration
of the KTP laser beam to a depth of 0.8mm.
• Vaporization occurs from within the tissue where
vapor bubbles form and burst the collagen.
• Highly hemostatic.
• Treatment of patients on anti-coagulants is
feasible due to the hemostatic properties of the
KTP laser.
• Known as Green light PVP or Photoselective
Vaporization of the Prostate.
64
Dept of Urology, GRH and KMC,
Chennai.

65. Holmium:YAG Laser
• Wavelength 2100 nm.
• Depth of penetration is only 0.4 mm.
• The tissue volume heated by the laser is
very small, which limits vaporization
speed, coagulation depth and hemostasis.
• Energy emitted in a series of rapid pulses.
• Permitts actual tissue resection.
• HoLAP for glands <40gms & HoLEP for
>40 gms.
65
Dept of Urology, GRH and KMC,
Chennai.

66. 66
Dept of Urology, GRH and KMC,
Chennai.

67. LASER PROSTATECTOMY
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Dept of Urology, GRH and KMC,
Chennai.

68. Post op Results
68
Dept of Urology, GRH and KMC,
Chennai.

69. Protatic Stents
• Restricted to patients unsuitable for
surgical procedures.
• First generation stents – Prosto Kath.
• Second generation – Memokath,Prostocoil
• Polyurethane Stents.
• Biodegradable Stents
• Permanent Stents – Urolume,Memotherm.
69
Dept of Urology, GRH and KMC,
Chennai.

70. TEMPORARY STENTS
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Dept of Urology, GRH and KMC,
Chennai.

71. MEMOKATH STENT
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Dept of Urology, GRH and KMC,
Chennai.

72. TRANSURETHRAL BALLOON
DILATATION
72
Dept of Urology, GRH and KMC,
Chennai.

73. Conclusion
• BPH is one of the most common diseases
of aging men.
• TURP is the gold standard for BPH.
• Newer modalities – short term efficacy
comparable with TURP.
• Less morbidity & minimal complications.
• Long term efficacy under evaluation.
73
Dept of Urology, GRH and KMC,
Chennai.

74. 74
Dept of Urology, GRH and KMC,
Chennai.