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BENIGN

PROSTATIC

YPERTROPHY

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Benign Prostatic Hyperplasia

It is NOT cancer (benign)

Enlargement of the prostate gland

what is BPH?

n

n

n

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Half of all men over the age of 60 will develop anenlarged prostate

By the time men reach their 70s and 80s, 80% will

experience urinary symptoms

incidence

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What is the Prostate?

Located

between the

bladder and the

pelvic floor

About 20g in

size

Functions to

produce semen

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-Walnut-shaped gland

-forms part of the male reproductive system

-4x3x2 cms

-wt= 8gms

-Surrounds the urethra

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- 5 lobed : anterior

posterior

medianlateral(2 lobes- right and left)

- 3 zones : peripheral(site of CA)

centraltransition (Prone for BPH)

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Zones of prostate

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Location of prostate

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PROSTATE GLAND

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PROSTATE GLAND

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BPH-Pathophysiology:

n Nodular hyperplasia of glands and stroma.

n From normal 20 to 3050 to 100 gm.

n Press upon the prostatic urethra.n Obstruction - difficulty on urination

n Dysuria, retention, dribbling, nocturia

n Infections, hydronephrosis, renal failure.

n Not a premalignant condition*

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-Secretion forms 10-20%of semen

-Alkaline in nature

-During orgasm, prostate

muscles contract and propelejaculate out of the penis

Physiology of the prostate

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DHT hypothesis

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BPH VIDEO

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Frequent and urgentneed to urinate,especially at night

Dribbling or leaking afterurination

Intermittent or weakstreamn

n

n

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-Straining to urinate

-Pain or burning during urination

-Feeling that the bladder never completelyempties

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Woes of the Prostate

n Symptoms of bladder outletobstruction caused by BPHinclude:

Hesitancy

Weakness of urinary stream

Intermittent urinary stream

A feeling of incomplete bladderemptying and need for repeatvoiding

Bladder irritability, as manifested byurinary frequency, nocturia, andurinary urgency

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Nocturia

n If patient has to void repeatedly in night causingdistortion of sleep

n Many a cases patient passes sleepless nights onchair at the toilet doors

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URGENCY

n Sense of inability to retain urine for long

n Inflamed mucosa resists stretching by bladderfilling & stimulates micturition reflex with little

amount of urine in bladdernWhen the condition deteriorates further the

patient has the sensation that passing urine in

clothes, even more they wet their clothes if notable to find suitable place to void. This is called

Urge incontinence

Bl dd tl t

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Bladder outlet

obstruction

n Obstructivesymptomsn Hesitancy

n Straining

n Poor stream

n Intermittency

n Dribbling

n Sense of incompletevoiding

n Chronic retentionwith overflow

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Hesitancy

n Patient takes time to startthe act of voiding

n Usually for the 1st timePatient realizes that theytake very long to voidwhile they stand at public

toilets

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Straining

n Patient has to useabdominal muscles toinitiate and maintain the

urinary stream

n Due to excessive use ofabdominal muscles

these patients are proneto develop Hernias

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Poor Stream

n Due to obstruction to urinaryout flow there is thin urinarystream which improves on

straining ( contrary to bladderneck contracture where streamdecreases on straining)

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Intermittency

n When abdominal muscle fatiguethere is cessation of micturition

which again starts on straining

causing intermittent flow of urinen When obstruction further

increases stream cant bemaintained on straining even. So

there is on DRIBBLING of urine

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Incomplete Voiding

n Due to persistent outflowobstruction there is alwayssome amount of residualurine left in bladder which

cant be voided with anyamount of straining

n So the patient has thissensation and feels likeurge to void once again RESIDUAL

URINE

Chronic

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Chronicretention with

overflown Due to persistentincrease in residual urine

with increasingobstruction there occurs

one state when thepressure of retainedurine overcomes theobstructing pressureleading to passage to

urinen It usually happens in

night leading to Bedwetting

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BPH Constricted urethra

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Prostatic enlargement

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Benign Prostatic Hypertrophy

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BPH proliferation of glandulartissue

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COMPLICATIONS OF BPH

n Urinary retention

n Renal impairment

n Urinary tract

infectionn Gross hematuria

n Bladder stones

n Bladderdecompensation

n Overflowincontinence as aresult of retention

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AUA Symptom Score (questionnaire)

Medical history

Physical examinationProstate exam (digital rectal exam./trucut biopsy)

Urinalysis

PSA blood test

Transrectal ultrasound of prostate

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Bladder outlet obstruction

The American Urological Association (AUA)symptom score

answer scoring 0-5 (0 for no symptoms, 5 forsevere symptoms).

The seven questions relate to:

1. Incomplete emptying2. Frequency3. Interrupted micturition4. Urgency

5. Poor stream6. Straining to begin micturition7. Nocturia

The maximum

score is,

therefore, 35.

Patients can be

classed as

follows:0-7 mildly

symptomatic

8-19 moderately

symptomatic

20-35 severely

symptomatic.

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DIGITAL RECTAL

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DIGITAL RECTAL

EXAMINATION

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TRU CUT BIOPSY

Sit l ti t t t t

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Site selection- sextant,octantetc.

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What is PSA?

n PSA starts out in the fluid that carries sperm. PSA is a proteinnormally made in the prostate gland in ductal cells. These cellsmake some of the semen that comes out of the penis duringsexual climax (orgasm). PSA helps to keep the semen liquid.

n Three main conditions with elevated PSA

1. Prostatitis and Lower Urinary Tract symptoms (LUTS)

2. BPH3. Prostate cancer.

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PSA test - values

n 0 to 2.5 ng/mLis low.

n 2.6 to 10 ng/mLis slightly to moderately elevated.

n 10 to 19.9 ng/mLis moderately elevated.

n 20 ng/mL or moreis significantly elevated.n There is no specific normal or abnormal PSA level. The

higher a mans PSA level, the more likely it is that

cancer is present.

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PSA Velocity

PSA VELOCITY

The rate at which PSA rises after

prostatectomy or radiation therapy.

-a significant factor indetermining how aggressivethe cancer is

-indicative of how aggressively

treatment is required.

PSAVelocity values

n 0.25 ng/ml/yr- for menages 40 to 59

n 0.50 ng/ml/yr for ages60 to 69

n 0.75 ng/ml/yr.)for men age 70 andolder

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PSA Density

this test measures the size of the prostate gland(via TRUS) andrelates it to the level of (PSA).

n used to identify men who are more likely to have prostatecancer.

n Indication: Men with a slightly high standard PSA test value, whohave a normal rectal exam

Results: Normally, a man with a large prostate gland will have ahigher PSA density value than men with a smaller prostate gland,assuming neither has cancer of the prostate.

The standard PSA value is often proportional to the size of theprostate gland.

http://health.discovery.com/encyclopedias/illnesses.html?article=2574http://health.discovery.com/encyclopedias/illnesses.html?article=2574http://health.discovery.com/encyclopedias/illnesses.html?article=2574http://health.discovery.com/encyclopedias/illnesses.html?article=2574

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Pre-operative Assessment

n 3 parameters that consistently predict need forintervention;

n IPSS Scoren Flow Rate

n Post Void Residual

n In addition, PSA (as an indicator of prostatevolume) indicates increased risk of acute retention,disease progression and requirement for surgery

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IPSS Score

n 0 to 5, symptoms relate to within the last month:n Incomplete emptying

n >2 hourly daytime frequencyn Intermittent flow

n Urinary urgency

nWeak stream

n Straining during urination

n Nocturia

n QoL score

IPSS score. Max 35

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IPSS Score

n AUA-7 / IPSS Scoren Score 0 - 7 Mild Symptom score

n Score 8 - 19 Moderate Symptom score

n Score 20 - 35 Severe Symptom score

n IPSS score is not diagnostic for BOO/BPH

n An IPSS score >17 pre-TURP, predicts a >7 pointimprovement in 87% of patients post TURP

Hakenberg OW. J Urol. 1997 Jul;158(1):94-9

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Use of PSA

n Elevated PSA is related to BOO

n PSA > 4 ng/ml 89% obstructed on CMG

n PSA < 2 ngml 33% not obstructed

n PLESS and MTOPS studies

n PSA / prostate volume are powerful predictors ofacute urinary retention and the need for surgery

Laniado ME et al. BJUI 2004

1 McConnell et al. N Engl J Med. 1998 Feb 26;338(9):557-63

2 McConnell et al. NEJM 349(25): 2387-98

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Pressure Flow Studies

n Indications for Urodynamics pre-op:n Age < 55 years

n Equivocal or Normal flow rates with significant symptoms(IPSS)

n Neurological disorders e.g. parkinsons

n Symptoms suggestive of OAB (incontinence)

n Previous TURP

n Previous pelvic surgery

Aim is to differentiate between obstruction and detrusordecompenastaion as the cause of a low Qmax

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ALTERNATIVE line of defence

2 MAJOR groups:

1.Alpha blockers2.5-alpha reductase inhibitors

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INDICATIONS FOR SURGERY

Surgery is recommended in patientsin whom BPH causes:n Renal insufficiencyn Urinary retentionn Recurrent urinary tract infectionn Bladder calculin Hydronephrosisn Post void residual volume >500 mL

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nOpen procedures

nScopic procedures

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n Retropubic prostatectomy(Millins)

n Suprapubic prostatectomy(Freyers)

n Perineal prostatectomy(Youngs)

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nTURP

nTUNA

n

TUIP

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OPEN PROSTATECTOMY

Reserved for men withlarge prostates

(>100 g) and those withbladder cancer

Positives: Follow-upsurgery rarely necessary Negatives: Abdominalincision, longer

convalescence vs.transurethral approaches,hemorrhage potential

RETROPUBIC

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RETROPUBICPROSTATECTOMY(MILLINS)

PERINEAL PROSTATECTOMY(Youngs

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Procedure)

INDICATIONS OF MINIMAL

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INDICATIONS OF MINIMAL

INVASIVE TECHNIQUES

Minimally invasive

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Minimally invasivetechniques for BPH

n Transurethral needleablation(TUNA)

n Transurethralmicrowavetherapy(TUMT)

n Laser resection orablation

n Electrovaporizationn Transurethral incision

of the prostate(TUIP)n Water-Induce

Thermotherapy*n Ethanol Invection*n Intraprostatic stents

(veryuncommon

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Destroy prostate tissue with heat

Tissue is left in the body and is expelled over

time (called sloughing)Transurethral Microwave Therapy (TUMT)

Transurethral Needle Ablation (TUNA)

Interstitial Laser Coagulation (ILC)

Water Induced Thermotherapy (WIT)

heat therapies

n

n

n

n

n

n

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possible side effects of

Urinary Tract Infection

Impotence

Incontinence

Retrograde ejaculation

heat therapies

n

n

n

n

h h i

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heat therapies

Benefits

Office treatments

Local anesthesia

Minimally invasiveReduced risk ofcomplications ascompared to invasive

surgical TURP

Disadvantages

Bothersome symptoms willpersist for up to 3 months

Cannot predict who willrespond

Limited by prostate size orlength

May require prolongedcatheterization

n

n

n

n

n

n

n

n

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Transurethral needle

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Transurethral needleablation (TUNA)

Response rate: 70%

Average of 30%

improvement in BPH

symptoms

10% recurrence within

4 years; retreatment

required

I di i f TURP

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Indications for TURP

n Absolute

n Recurrent Episodes ofUrinary Retention

n Recurrent UTI

n Gross Prostatic

Haematurian Bladder Stones

n Obstructive Uropathy

n Relative

n Moderate to SevereSymptoms (IPSS)

n Bother / QoL

n Increasing PVR

n

Low Flow raten Failure of medical

therapy / clinicalprogression

R

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Resectoscope

Light tower

Lens (30o)

Continuous flow

irrigation

Bipolar

Resctoscope

loopRotatable

Sheath

T h i l Ad

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Technical Advances

n Irrigation Fluid: Glycine v Saline

n 1.5% Glycine is a non-haemolytic (not isotonicsolution 200 mOsm/l) solution. Conducts current to

diathermy pad in monopolar modeln Saline may only be use with a bipolar resectoscope.

Improved cut at reduced power. Eliminates TURsyndrome and obturator kick.

n Continuous Flow irrigation

S i l T h i

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Surgical Technique

n Nesbit Technique (1943)

n First stage: resection of bladder neck from 12oclock down to 6.

n Second stage: Adenoma is resected in quadrantsbeginning at 12 oclock so that the lateral lobes fall

in. The right followed by left lateral lobes.

nThird Stage: resection of tissue at the apex

S i l T h i

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Surgical Technique

n Blandy Technique 1a. Resection of middle lobe initially

b.

Resect each lateral lobe from 12 oclock down to6 oclock

n Blandy Technique 2a. Resection of middle lobe initiallyb. Work on lateral lobe from 6 to 12 oclock and

continue clock-like from 12 to 6 on other lobe

TURP f

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TURP-steps of surgery

n Create a channel at 5 and 7 oclock frombladder neck back to veru

n Deepen the channel to capsule so that youknow how deep and how far to go

nTake each lateral lobe seperately from 12 to 6

oclockn Resect the median lobe last to avoid

undermining of the bladder neck/trigone

TURP f

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TURP-steps of surgery

n On last look, check:n Veru and UOs intact, No Chips in bladder and

satisfactory haemostasis is achieved

n Insert 22 3way reinforced PTFE catheter - spigottirrigation channel. Irrigate bladder.

n Place catheter on traction secured to right thigh with

adhesive dressing.n If clotting - 3 lt bladder washout +/- overnight

saline irrigation.

n Check bloods mane. Remove UC in 48 hours.

TURP(transurethral resection of the prostate)

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TURP

Gold Standard of care for BPH

Uses an electrical knife to surgically cut

and remove excess prostate tissue

Effective in relieving symptoms and

restoring urine flow

( a su e a esec o o e p os a e)

n

n

n

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Benefits

Widely available

Effective

Long lasting

Disadvantages

Greater risk of side effects andcomplications

1-4 days hospital stay

1-3 days catheter

4-6 week recovery

n

n

n

n

n

n

n

TURP

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Impotence

Incontinence

Bleeding

May require blood transfusion

Electrolyte imbalance (TUR Syndrome)

May result in ICU (Intensive Care Unit)

TURP

n

n

n

n

n

n

INCIDENCE OF EARLY

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COMPLICATIONS

n Complications: Early (7-43%)

n Haemorrhage

nTransfusion 2-10%n Failure to void 6.5%

n Clot retention 3%

n Infection/Septicaemia 2%

nTUR Syndrome 2%

n Epididymo-orchitis 1%

.

INCIDENCE OF LATE

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COMPLICATIONS

n Complications: Laten Retrograde Ejaculation 25 - 99%

n Secondary Haemorrhage

n Erectile Impotence 4 - 14 %n Bladder neck stenosis

n Urethral Stricture

n Incontinence 0.6 - 1.4%

n Mortalityn 30 day post-op 0.3%

n 90 day post-op 1.7%

n 9% Re-operation rate within 5 years

0.6 - 10%

TURP VIDEO

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TURP VIDEO

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how does PVP

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Uses a very high powered green laser and a thin,flexible fiber

Fiber is inserted intothe urethra through a

cystoscope, an

instrument that allows

the doctor to see thebladder and urethra

how does PVP

work?n

n

how does PVP work?

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Quickly and precisely vaporizes and

removes the enlarged prostate tissue

The green laser energy is hemostatic, so

there is almost no bleeding

how does PVP work?

n

n

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DA VINCI PROSTATECTOMY

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DA VINCIPROSTATECTOMY

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DA VINCI VIDEO

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DA VINCI VIDEO

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You dont realize how something like this

(BPH) affects your quality of life -

until you get it back

QUESTIONS ?

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QUESTIONS ?

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Thanks.