BENIGN PROSTATIC HYPERTROPHY

what is BPH?
n

Benign Prostatic Hyperplasia

n It is NOT cancer (benign) n Enlargement of the prostate gland

incidence

Half of all men over the age of 60 will develop an enlarged prostate
By the time men reach their 70s and 80s, 80% will experience urinary symptoms

What is the Prostate?

Located between the bladder and the pelvic floor About 20g in size Functions to produce semen

-Walnut-shaped gland -forms part of the male reproductive system

-4x3x2 cms -wt= 8gms

-Surrounds the urethra

5 lobed : anterior posterior median lateral(2 lobes- right and left) 3 zones : peripheral(site of CA) central transition (Prone for BPH)

Zones of prostate

Location of prostate

PROSTATE GLAND

PROSTATE GLAND

BPH-Pathophysiology:
n n n

Nodular hyperplasia of glands and stroma. From normal 20 to 30 50 to 100 gm. Press upon the prostatic urethra.

n
n n n

Obstruction - difficulty on urination

Dysuria, retention, dribbling, nocturia Infections, hydronephrosis, renal failure. Not a premalignant condition*

Physiology of the prostate

-Secretion forms 10-20% of semen -Alkaline in nature -During orgasm, prostate muscles contract and propel ejaculate out of the penis

DHT hypothesis

BPH VIDEO

n Frequent and urgent

need to urinate, especially at night

Dribbling or leaking after urination

Intermittent or weak n stream

-Straining to urinate

-Pain or burning during urination

-Feeling that the bladder never completely empties

Woes of the Prostate

Symptoms of bladder outlet obstruction caused by BPH include: Hesitancy Weakness of urinary stream Intermittent urinary stream A feeling of incomplete bladder emptying and need for repeat voiding Bladder irritability, as manifested by urinary frequency, nocturia, and urinary urgency
n

Nocturia
n

If patient has to void repeatedly in night causing distortion of sleep Many a cases patient passes sleepless nights on chair at the toilet doors

URGENCY
n

Sense of inability to retain urine for long Inflamed mucosa resists stretching by bladder filling & stimulates micturition reflex with little amount of urine in bladder When the condition deteriorates further the patient has the sensation that passing urine in clothes, even more they wet their clothes if not able to find suitable place to void. This is called

Urge incontinence

Bladder outlet obstruction

n

Obstructive symptoms
Hesitancy n Straining n Poor stream n Intermittency n Dribbling n Sense of incomplete voiding n Chronic retention with overflow
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Hesitancy
n

Patient takes time to start the act of voiding Usually for the 1st time Patient realizes that they take very long to void while they stand at public toilets

Straining
n

Patient has to use abdominal muscles to initiate and maintain the urinary stream Due to excessive use of abdominal muscles these patients are prone to develop Hernias

Poor Stream
n

Due to obstruction to urinary out flow there is thin urinary stream which improves on straining ( contrary to bladder neck contracture where stream decreases on straining)

Intermittency
n

When abdominal muscle fatigue there is cessation of micturition which again starts on straining causing intermittent flow of urine When obstruction further increases stream cant be maintained on straining even. So there is on DRIBBLING of urine

Incomplete Voiding
n

Due to persistent outflow obstruction there is always some amount of residual urine left in bladder which cant be voided with any amount of straining So the patient has this sensation and feels like urge to void once again

RESIDUAL URINE

Chronic retention with overflow

Due to persistent increase in residual urine with increasing obstruction there occurs one state when the pressure of retained urine overcomes the obstructing pressure leading to passage to urine It usually happens in night leading to Bed wetting

BPH Constricted urethra

Prostatic enlargement

Benign Prostatic Hypertrophy

BPH proliferation of glandular tissue

COMPLICATIONS OF BPH
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n
n

n
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Urinary retention Renal impairment Urinary tract infection Gross hematuria Bladder stones Bladder decompensation Overflow incontinence as a result of retention

AUA Symptom Score (questionnaire)

Medical history
Physical examination

Prostate exam (digital rectal exam./trucut biopsy)

Urinalysis

PSA blood test

Transrectal ultrasound of prostate

Bladder outlet obstruction

The American Urological Association (AUA) symptom score answer scoring 0-5 (0 for no symptoms, 5 for severe symptoms). The seven questions relate to:
1.
The maximum score is, therefore, 35. Patients can be classed as follows: 0-7 mildly symptomatic 8-19 moderately symptomatic 20-35 severely symptomatic.

2.
3. 4. 5. 6. 7.

Incomplete emptying Frequency Interrupted micturition Urgency Poor stream Straining to begin micturition Nocturia

DIGITAL RECTAL EXAMINATION

TRU CUT BIOPSY

Site selection- sextant,octant etc.

What is PSA?
n

PSA starts out in the fluid that carries sperm. PSA is a protein normally made in the prostate gland in ductal cells. These cells make some of the semen that comes out of the penis during sexual climax (orgasm). PSA helps to keep the semen liquid.

Three main conditions with elevated PSA

Prostatitis and Lower Urinary Tract symptoms (LUTS)

1.

2.
3.

BPH
Prostate cancer.

PSA test - values

n

n
n n n

0 to 2.5 ng/mL is low. 2.6 to 10 ng/mL is slightly to moderately elevated. 10 to 19.9 ng/mL is moderately elevated. 20 ng/mL or more is

significantly elevated.

There is no specific normal or abnormal PSA level. The higher a mans PSA level, the more likely it is that cancer is present.

PSA Velocity
PSA VELOCITY The rate at which PSA rises after prostatectomy or radiation therapy. -a significant factor in determining how aggressive the cancer is -indicative of how aggressively treatment is required.

PSAVelocity values n 0.25 ng/ml/yr- for men ages 40 to 59 n 0.50 ng/ml/yr for ages 60 to 69 n 0.75 ng/ml/yr.) for men age 70 and older

PSA Density
this test measures the size of the prostate gland(via TRUS) and
relates it to the level of (PSA).
n n

used to identify men who are more likely to have prostate cancer. Indication: Men with a slightly high standard PSA test value, who
have a normal rectal exam
Results: Normally, a man with a large prostate gland will have a higher 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 the prostate gland.

Pre-operative Assessment
n

3 parameters that consistently predict need for intervention;

n

n
n

IPSS Score Flow Rate Post Void Residual

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

IPSS Score
n

0 to 5, symptoms relate to within the last month:

Incomplete emptying n >2 hourly daytime frequency n Intermittent flow n Urinary urgency n Weak stream n Straining during urination n Nocturia n QoL score
n

IPSS score. Max 35

IPSS Score
n

AUA-7 / IPSS Score

n
n n

Score 0 - 7 Score 8 - 19 Score 20 - 35

Mild Symptom score Moderate Symptom score Severe Symptom score

IPSS score is not diagnostic for BOO/BPH An IPSS score >17 pre-TURP, predicts a >7 point improvement in 87% of patients post TURP
Hakenberg OW. J Urol. 1997 Jul;158(1):94-9

Use of PSA
n

Elevated PSA is related to BOO

PSA > 4 ng/ml 89% obstructed on CMG n PSA < 2 ngml 33% not obstructed
n
Laniado ME et al. BJUI 2004

PLESS and MTOPS studies

n

PSA / prostate volume are powerful predictors of acute urinary retention and the need for surgery
1 McConnell et al. N Engl J Med. 1998 Feb 26;338(9):557-63 2 McConnell et al. NEJM 349(25): 2387-98

Pressure Flow Studies

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Indications for Urodynamics pre-op:

n n n n n n

Age < 55 years Equivocal or Normal flow rates with significant symptoms (IPSS) Neurological disorders e.g. parkinsons Symptoms suggestive of OAB (incontinence) Previous TURP Previous pelvic surgery

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

ALTERNATIVE line of defence

2 MAJOR groups:
1.Alpha

blockers 2.5-alpha reductase inhibitors

INDICATIONS FOR SURGERY

Surgery is recommended in patients in whom BPH causes: n Renal insufficiency n Urinary retention n Recurrent urinary tract infection n Bladder calculi n Hydronephrosis n Post void residual volume >500 mL

nOpen

procedures

nScopic

procedures

n Retropubic

prostatectomy(Millins) prostatectomy(Freyers)

n Suprapubic

n Perineal

prostatectomy(Youngs)

n TURP

n TUNA

n TUIP

OPEN PROSTATECTOMY
Reserved for men with large prostates (>100 g) and those with bladder cancer Positives: Follow-up surgery rarely necessary Negatives: Abdominal incision, longer convalescence vs. transurethral approaches, hemorrhage potential

RETROPUBIC PROSTATECTOMY(MILLINS)

PERINEAL PROSTATECTOMY(Youngs

Procedure)

INDICATIONS OF MINIMAL INVASIVE TECHNIQUES

Minimally invasive techniques for BPH

Transurethral needle ablation(TUNA) n Transurethral microwave therapy(TUMT) n Laser resection or ablation n Electrovaporization n Transurethral incision of the prostate(TUIP) n Water-Induce Thermotherapy* n Ethanol Invection* n Intraprostatic stents (very uncommon)
n

heat therapies
n Destroy
n Tissue

prostate tissue with heat

is left in the body and is expelled over time (called sloughing)

n Transurethral

Microwave Therapy (TUMT)

Needle Ablation (TUNA)

n Transurethral
n Interstitial n Water

Laser Coagulation (ILC)

Induced Thermotherapy (WIT)

possible side effects of heat therapies

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Urinary Tract Infection Impotence Incontinence Retrograde ejaculation

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heat therapies
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Benefits Office treatments Local anesthesia Minimally invasive

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Disadvantages
n

Reduced risk of complications as compared to invasive surgical TURP

Bothersome symptoms will persist for up to 3 months Cannot predict who will respond Limited by prostate size or length May require prolonged catheterization

Transurethral needle ablation (TUNA)

Response rate: 70% Average of 30%

improvement in BPH symptoms 10% recurrence within 4 years; retreatment required

Indications for TURP

n

Absolute
n

Relative
n

n n

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Recurrent Episodes of Urinary Retention Recurrent UTI Gross Prostatic Haematuria Bladder Stones Obstructive Uropathy

Moderate to Severe Symptoms (IPSS)

n n n

Bother / QoL Increasing PVR Low Flow rate

Failure of medical therapy / clinical progression

Resectoscope
Continuous flow irrigation

Light tower
Bipolar Resctoscope loop

Rotatable Sheath

Lens (30o)

Technical Advances
n

Irrigation Fluid: Glycine v Saline

1.5% Glycine is a non-haemolytic (not isotonic solution 200 mOsm/l) solution. Conducts current to diathermy pad in monopolar model n Saline may only be use with a bipolar resectoscope. Improved cut at reduced power. Eliminates TUR syndrome and obturator kick.
n

Continuous Flow irrigation

Surgical Technique
n

Nesbit Technique (1943)

First stage: resection of bladder neck from 12 oclock down to 6. n Second stage: Adenoma is resected in quadrants beginning at 12 oclock so that the lateral lobes fall in. The right followed by left lateral lobes. n Third Stage: resection of tissue at the apex
n

Surgical Technique
n

Blandy Technique 1
a. b.

Resection of middle lobe initially Resect each lateral lobe from 12 oclock down to 6 oclock

Blandy Technique 2
a. b.

Resection of middle lobe initially Work on lateral lobe from 6 to 12 oclock and continue clock-like from 12 to 6 on other lobe

TURP-steps of surgery
n n n

Create a channel at 5 and 7 oclock from bladder neck back to veru Deepen the channel to capsule so that you know how deep and how far to go Take each lateral lobe seperately from 12 to 6 oclock Resect the median lobe last to avoid undermining of the bladder neck/trigone

TURP-steps of surgery
n

On last look, check:

n

Veru and UOs intact, No Chips in bladder and satisfactory haemostasis is achieved

n n

n
n

Insert 22 3way reinforced PTFE catheter - spigott irrigation channel. Irrigate bladder. Place catheter on traction secured to right thigh with adhesive dressing. If clotting - 3 lt bladder washout +/- overnight saline irrigation. Check bloods mane. Remove UC in 48 hours.

TURP(transurethral resection of the prostate)

n n

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

Benefits
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Disadvantages
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Widely available

Effective
Long lasting
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Greater risk of side effects and complications 1-4 days hospital stay 1-3 days catheter 4-6 week recovery

TURP
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Impotence
Incontinence

Bleeding
n

May require blood transfusion

Electrolyte imbalance (TUR Syndrome)

n

May result in ICU (Intensive Care Unit)

INCIDENCE OF EARLY COMPLICATIONS

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Complications: Early (7-43%)

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Haemorrhage
n

Transfusion

2-10%

Failure to void n Clot retention n Infection/Septicaemia n TUR Syndrome n Epididymo-orchitis

n
.

6.5% 3% 2% 2% 1%

INCIDENCE OF LATE COMPLICATIONS

n

Complications: Late
n n n

n
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Retrograde Ejaculation 25 - 99% Secondary Haemorrhage Erectile Impotence 4 - 14 % Bladder neck stenosis 0.6 - 10% Urethral Stricture Incontinence 0.6 - 1.4% Mortality
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30 day post-op 90 day post-op

0.3% 1.7%

9% Re-operation rate within 5 years

TURP VIDEO

how does PVP work?

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

Fiber is inserted into the urethra through a cystoscope, an instrument that allows the doctor to see the bladder and urethra

how does PVP work?

Quickly and precisely vaporizes and removes the enlarged prostate tissue
The green laser energy is hemostatic, so there is almost no bleeding

DA VINCI PROSTATECTOMY

DA VINCI VIDEO

You dont realize how something like this (BPH) affects your quality of life until you get it back.

QUESTIONS ?

Thanks.