Benign prostatic hyperplasia

1. THE PROSTATE & BPH
Dr M.V.SESHA SAI
1ST YEAR PG
DEPT OF GENERALSURGERY
S1 UNIT

2. Objectives :
• Anatomy
• Development and embryology of prostrate
• BPH
Clinical features
Investigations
Medical management
Surgical management
Recent advances

3. • Prostate is a fibromusculoglandular structure situated between the
neck of the bladder and external urethral sphincter and surround the
prostatic urethra, it if conical in shape
• Surface: Had 3 surfaces
Anterior
Posterior
2 infdrolateral surfaces

4. ANATOMY OF THE PROSTATE GLAND
• Will be discussed under the following headings
Surface
Lobes
Relations
Size and weight

5. LOBES
• Has 5 lobes
Anterior
Posterior
Median
Two lateral
SIZE AND WEIGHT:
• 3cm vertically , 4cm transversallyat base and about 2cm antero-
posteriorly
• Weight of about 15-20gms

7. ZONES OF PROSTATE
• Central zone- contains short unbranched glands
• Transitional zone[most effected by BPH] -contains short unbranched
glands
• Peripheral zone- contains long branched glands

9. FASCIAL RELATIONS OF PROSTATE
• Capsule
• True capsule formed by condensation of the prostate at periphery
• False capsule fromed by the visceral layer by the pelvis fascias
• Surgical capsule fromed by non adenomatous tissue of the prostate
which is pushed by the hypertrophied gland to the periphery
• Fascia behind the prostate is also known as
RECTOVESICAL/DENIVILLER’S fascia

10. STRUCTURES IN AND AROUND PROSTATE
• Urethra is divided into three parts
Prostatic urethra (widest and most dilatable part)
Membranous urethra (shortest and least dilatable part)
Spongy urethra

11. RELATIONS
BASE Neck of UB
INF External urethral sphincter
POST Denovilliars fascia
LATERAL Levator ani
• Blood supply by Internal Iliac artery
• Venous drainage by post venous plexus and to some extent to
vertebral plexus
• Lymphatic drainage to Internal Iliac Lymph nodes

12. DEVELOPMENT AND EMBRYOLOGY
• The prostate is a derivative of the primitive endoderm (gut tube)
which is further divided into foregut,midgut and hindgut
• Caudal to hind gut the is a sac called as Cloaca
• Cloaca divides into urinary and intestinal tracts during embryogenesis
• The ventral urinary compartment called Primary urogenital sinus is
divided cranially to form urinary bladder and caudally the urethra
• Differentiation of urogenital sinus is dimorphic and in males divided
prostatic and membranous urethra, prostate, and bulbourethral gland

13. BUDDING OF PROSTATE
• In males, the prostate develops just caudal to the bladder neck via the
proliferation of epithelial buds extending out from the urogenital
sinus epithelium.
• Androgen exposure of the urogenital sinus directly or indirectly
initiates the first stage, prostate lineage commitment of regions of the
urogenital sinus epithelium
• In the second stage, solid cords epithelial cords, or prostate buds,
form and invade urogenital sinus mesenchyme at stereotyped
locations

14. • These regions prepare for epithelial bud invasion by “mesenchymal
condensation,” a process in which urogenital sinus mesenchymal cells
become closely packed together
• This condensation occurs in males and females and is therefore
androgen independent
• epithelial budding is strictly androgen dependent
• In the third stage of prostate organogenesis, prostate buds elongate
and branch to form the mature prostate network
• Finally, the ducts canalize, and cytodifferentiation of the epithelium
results in mature prostate glands.

15. • The wolffian ducts develop into the seminal vesicles, epididymis, vas
deferens, ampulla, and ejaculatory duct. The developmental growth
of this group of glands is stimulated by fetal testosterone and not
DHT.
• The developing urogenital sinus mesenchyme and epithelium have
been shown take role in prostate development
• Androgen acts on the mesenchyme to indirectly induce prostate
epithelial outgrowth during development

16. • The prostatic epithelium in the human is composed of
two major cell compartments: epithelial cells and stromal
cells.
• The epithelial cell types include mature secretory and
terminally differentiated cells, neuroendocrine cells,
intermediate cells, and basal cells.
• Prostatic stem cells reside in the basal compartment and
are enriched in the proximal portions of prostatic ducts.

17. BENIGN PROSTATIC HYPERPLASIA[BPH]

19. • Defined as “non cancerous increase in size of prostate gland which
involves hyperplasia of prostatic stromal and epithelial cell resulting in
formation of fairly discrete nodules in trasitional zone of prostate,
which push and narrow the urethra resulting in increased resistance”
• Mostly seen in elderly males , in whom the prostate extends upwards
towards the bladder and causes outlet obstruction
• About 50% of men intheir life time by age 50 years develops BPH and
among then half may have bothersome urinary tract symptoms.
• 75% develops BPH by 80 years

21. Risk factors
• Age
• Family history
• Race – less common in Asian men than in white and black men
• Diabetes and patients on B blockers
• Life style[obesity]

22. Clinical manifestations
• Hesitency in start of urination
• Increased frequency of urination
• Nocturia
• Urgency to pass urine
• Abdominal straining
• Dribbling of urine
• Decrease in volume and force of urine
• Sensation of incomplete empyting of bladder

23. • Recurrent UTI’S
• Pelvic discomfort and pain
• Azatemia
• Renal failure as a result of chronic urinary retention and large
residual volumes
• Hematuria

24. How to diagnose?
• Proper history collection
• Physical examination including DRE
• Complete urine analysis for UTI and blood cells
• PSA if the life expectancy of patient is more than 10 years
• Urodynamic studies
• Urethrocystoscopy
• Usg KUB to know volume of prostate and post voidal urinary volume

25. MANAGEMENT
• Depends on severity of obstruction and condition of patient
• Medical management
• Surgical management

27. Medical management:
• If the patient cannot void urine immediately catheterize the patient
• Sometimes SPC may be required
• If there is less severe symptoms ‘WAIT AND WATCH POLICY’ adopted

28. Alpha blockers:
• MOA: These agents relax bladder neck muscles and muscle fibres in
prostate making urination easier
• Ex Alfuzosin, tamsulosin, doxazosin, silodosin
• Alpha blockers usally advised in people with relatively small prostate

29. 5 alpha reductase inhibitors:
• MOA: Shrink prostate by preventing hormonal changes that cause
prostate growth
• Ex Finasteride , dutasteride
• The above drugs take 6 months to show their action
• When individual drugs are not effective combination therapy can be
tried.
• Tadalafil generally given in men who have erectile dysfuntion along
with BPH

30. SURGICAL MANAGEMENT
• 1 Minimally invasive therapy
• 2 Invasive therapy

31. Minimally invasive therapy
• These are becoming more popular than wait and watch policy and
invasive surgery

33. Transurethral microwave thermotherapy
• TUMT is an outpatient procedure that involves the delivery of
microwaves directly to the prostate through a probe to raise the temp
pf prostate to about 113 F .
• The heat causes death of tissue, thus the obstruction relieved.
• Rectal temp probe is used to make sure temp is less than 110F to
prevent rectal tissue damage

34. • Duration of procedure 90min
• Most common post op complication Urinary retention
• Catheterization for 2to 7 days usally done post op
• Antibiotics, painkillers and antispasmodics are usually given post op

35. TRANSURETHRAL NEEDLE ABLATION:
• Process is similar to that of TUMT , the only difference is low wave
radio frequency is used
• Only tissue contact with the needle is ablated
• Had accurate precision over target tissue
• Duration of procedure is 30min , so usually done as a outpatient basis
• Complications: urinary retention, irritative voiding symptoms,
hematuria.

36. LASER PROSTATECTOMY
• Laser therapy is used as a alternative to TURP
• Laser beam delivered per urethrally through fiber instrument and is
used for cutting, coagulation and for vapourization.

37. PHOTOVAPORIZATION
• PVP uses high power green laser light to vaporize tissues
• Obstructive symptoms got relieved immediately
• Bleeding is very minimal
• Pvp works for large prostate glands

38. INTERSTITIAL LASER COAGUALTION
• Prostate is viewed through a cystoscope
• Laser is used to quickly treat precise areas of the enlarged gland

39. INTRAPROSTATIC URETHRAL STENTS
• Patients unfit for surgery can be relieved by the stents
• Stents are placed directly into prostatic tissue
• Complications chronic pain, infection, encrustation

40. INVASIVE SURGERIES
• TURP -Transurethral resection of prostate
• TUIP- Transurethral Incision of prostate

41. TURP -Transurethral resection of prostate
• A resectoscope is passed through the urethra and prostate tissue
removed
• TURP is considered as gold standard in treatment of BPH
• In recent year due to advances in minimal invasive surgeries the
usage of TURP decreased
• Done under SA/GA
• Foleys is placed in situ after procedure and bladder is irrigated
continuously or intermittently to avoid blocking of bladder by mucus /
clots

43. TUIP- Transurethral Incision of prostate
• Done under LA
• Several incisons are given on prostate that causes expansion of
urethra and thus relieving the symptoms
• Generally advised in patients with small to moderately enlarged
prostate
• Post operative complications include hemorrhage, clot retention,
dilutional hyponatremia

44. COMPLICATIONS OF BPH
• Acute urinary retention
• Involuntary bladder contractions
• Bladder diverticula
• Cystolithiasis
• VUR
• Recurrent UTI
• Gross hematuria
• Hydro ureter and hydronephrosis