BPH (BENIGN PROSTATIC HYPERPLASIA)

dr Eka Yudha Rahman,M.Kes,SpU

FK UNLAM

ANATOMY• Vaskularisasi : a. vesikalis inferior

• a. hemorrhoidalis media

• a. pudenda interna

• Aliran vena dari prostat plexus periprostatika

• Aliran limfe dari prostat obturator dan iliaka interna

• Persarafan dari plexus pelvicus

ANATOMY• Mc Neal ( 1988 ) :

• Zona transisional, Zona central,Zona peripher ,Zona anterior

fibromuskuler stroma.

Prevalence of BPH

• The Most Frequent Benign Tumor in Men• 20 % of men 41 - 50 years.• 50 % of men 51 - 60 years.• 65 % of men 61 - 70 years• 80 % of men 71 - 80 years.• 90 % of men 81 - 90 years

(autopsy study)

• Indonesia : The Second after Stone

Prevalence of BPH

USA• Above 85 yrs : 90% (Isaac, 1990)

• 80 years : 1 out of 4 male (Barry, 1990, 1995)

• 300.000 TUR yearly (Holtgreve, Mebust, Daud, 1989)

• Expenditure 2 billion Dollar/ year

Patient profile: Age of the patients

Hospital/Author Mean Age

Cipto Mangunkusumo* 65.2 8.0 years

Sumber Waras* 65.2 9.9 years

Kojima et al ** 69.1 6.6 years

*Rahadjo D., Birowo P. MKI 2000 Vol 50 no. 2 : 81-5* *Kojima et al J.Urol.1997; 157 : 2060 - 2065

Hospital Incidence In Jakarta 1995 - 1997

HOSPITAL n

Cipto Mangunkusumo 462

Sumber Waras 602

Rahadjo D., Birowo P. MKI 2000 Vol 50 no. 2 81-5

ETIOLOGY

9

Theory

Dihydrotestosteronhypothesis

Oestrogen-testosteronimbalance

Stromal-epithelialinteractions

Reduced cell death

Stem cell theory

Inflammation

Theories for the cause of BPHCause

5- reductase and androgen receptors

Oestrogens Testosteron

Epidermal growthfactor/fibroblastgrowth factor Transforming growthfactor

Oestrogens

Stem cells

infection

Effect

Epithelial and stromalhyperplasia

Stromal hyperplasia

Epithelial and stromalhyperplasia

Longevity of stromaand epithelium

Proliferation of transitCellsEpithelial and stromalHyperplasia ?

DHT theoryTestosteron

DHT

Inskripsi RNA

Sintesis Protein

Hiperplasia epitel & stroma prostat

Reseptor androgen

5 alpha reductase

Diagnosis I

• Anamnesis Cardinal symptoms:Weak StreamFrequencyNocturia

Storage symptoms, Voiding Symptoms

Scoring System : M.I, IPSS

Symptoms

Storage• Frequency• Urgency• Nocturia• Disuria

Post Voiding• Incomplete

emptying• Terminal

dribbling

Voiding• Weak Stream• Hesitancy• Intermittency • Straining

Symptom Score (symptom profile)

I-PSS Score:

- Mild : 0 – 7

- Moderate : 8 – 19

- Severe : 20 - 35

DIAGNOSIS II

Physical examination:• flanks : kidneys bimanual palpation

ballotement• Supra sympisis: bladderpalpation bladder distention urine `retention

• Genitalia : urethra, testis, epidydimis

Diagnosis II

Physical examination:DRE

TMSABCR

Prostate:1. Size2. Nodule3. Consistency 4. Tenderness5. Symetrical/

asymetrical enlargement

Diagnosis II

Uroflowmetry QmaxVoided volume

Residual urine TAUSCatheter

UROFLOWMETRY CHART

Male 70 years old with LUTS

Lab test

• Blood Count• Serum Electrolyte• Serum Creatinine• Serum PSA (TPSA)• Urine :

Proteinuria Sediment Culture

IMAGING

• TRUS • TAUS• With Indication :

IVP Cystography

TRUS

Hypoechoic lession

TAUS

IVU

CYSTOGRAM

Prostate Volume

* J Urol. 1995 ; 153 (50 : 1550 –5** J urol. 1997 ; 157 : 2160 – 5*** Br J. Urol 1993 ; 71 ; 445 – 50**** JAMA 1993 ; 220 (7) ; 860 - 4

Hospital/Author Mean Prostate Vol (ml)

Cipto Mangunkusumo 57.0 26.5Sumber Waras 44.3 22.4Girman et al 26.4 cc ( median ) *Kojima 30.3 9.8 **Collins et al 32 ***Oesterling et al 29 ****

Indication for Biopsy

Rahardjo D, ST Kamil Gardian, Med J Indones 9(1);35-42

Accepted Standard Proposed standard for Jakarta

4 ng No. biopsy 8 ng

4- 10 ng/mlPSA D > 0.15

Biopsy 8-30 ng/mlPSA D > 0.20

>10 ng/ml Biopsy > 30 ng/ml

Hard Nodule Hypo/hiperchoic lession

BiopsyHard NoduleHypo/hyperechoic lession

Differensial Diagnosis

• Urethral stricture• Bladder neck contracture• Bladder stone• Prostate cancer• Prostatitis• CIS bladder

• Watchful Waiting (IPSS 0-7)• Medical Treatment (IPSS 8 – 19)

- 5 reduktase inhibitor- alpha adrenergic Blockers

1 blocker : Doxazosin Terazosin

1a blocker: Tamsulosin - Phytotherapy

FMUI

Treatment I : Non Surgical

Indication for non surgical treatment

• IPSS score < 20• Residual Urine < 100 ml• PSA < 4 ng/ml• No Hard Nodule• No complication

Indication for surgery(Complication of BPH)

• Chronic retention• recurrent UTI • Decreased Renal Function/Hydronefrosis• Haematuria• With bladder stone• with bladder divertikel

Surgical Treatment

• TUR-P• TUI-P• Open Prostatectomy• Laser Ablation• Laser Resection• Thermo Therapy• Hyperthermia• TUNA

Foto :UniversitatsklinikumTubingen, prof. Bichler,Abt.urologie

TUR-P

33

LASER ND-YAGSIDE FIRING

www.endoscopy.com

Efikasi vs. risiko terapi BPHefikasi

risiko

OPENPROSTATECTOMY

OPENPROSTATECTOMY

TURPTURP

TUNATUNA

THERMOTHERAPYTHERMOTHERAPY

ALPHA BLOCKERSALPHA BLOCKERS5-ALPHAREDUCTASEINHIBITORS

5-ALPHAREDUCTASEINHIBITORS

PHYTOTHERAPYPHYTOTHERAPY

BleedingIncontinenceBladder neck contractureStrictureRetrograde ejac.Impotence

4 (11%) 1 (3%) 0 (0%) 1 (3%)21 (70%) ?

0 (0%)0 (0%)0 (0%)1 (4%)0 (0%)?

8 (8%) 1 (1%) 2 (2%) 3 (3%)62 (62%) 4 (4%)

2 (2%)0 (0%)0 (0%)0 (0%)2 (2%)1 (1%)

Open surg.(n=30)

TUIP

(n=24)

TURP

(n=100)

VILAP

(n=100)

Personal Jakarta Experience Morbidity Associated with Surgery

Complication of Surgery

Alternative Treatment

• Balloon Dilatation

• Stenting

FMUI

FMUI

THANKS FOR ATTENTION