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Postgraduate BPH lecture

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  1. 1. Urology Department post-graduate coursesBenign Prostatic Hyperplasia (BPH) Presented By Prof. Dr. Sherine Ragy
  2. 2. For our Lectures and Scientific resourcesvisit our web sites, ©
  3. 3. Gross Anatomy• Average Size 20 gms, depends on age (no correlation between size & symptoms)• Lobes (Clinically)  Two lateral lobes (on either side of the supramontanal urethra) felt by DRE  One median lobe (behind the supramontanal urethra) ©
  4. 4. Zonal anatomy of the prostate (McNeal classification)- The transition zone arise and pass beneath the preprostatic sphincter to travel on its lateral and posterior sides-The central zone arise circumferentially aroundthe openings ofthe ejaculatory ducts-The peripheral zone:(70%)of the prostatic gland.-anterior fibromuscular stroma ©
  5. 5. Zonal anatomy of the prostate
  6. 6. Vascular Supply of prostateArterial Supply• from the inferior vesical artery → prostatic artery/arteries → divides into two main branches:  urethral arteries penetrate the prostatovesical junction posterolaterally and approach the bladder neck in the 1- to 5-o’clock and 7- to11-o’clock positions, (largest branches posteriorly).  They supply the urethra, the periurethral glands, and the transition zone (principal blood supply of the adenoma in BPH)  capsular arteryVenous drainage to periprostatic plexus ©
  7. 7. Pathophysiology of BPH• BPH first develops in the periurethral transition zone of the prostate• BPH is mainly hyperplastic ( increase in the number of cells) and not a hypertrophic (increse in the size of the cells) process.• glandular in character• Small glands demonstrate a predominance of fibromuscular stroma ©
  8. 8. Pathophysiology of BPH:• Active smooth muscle tone is regulated by the adrenergic nervous system.• stimulation of the adrenergic nervous system clearly results in a dynamic increase in prostatic urethral resistance.• α1A is the most abundant adrenoreceptor subtype in the prostate. Distribution of α1-adrenergic receptors in the lower urinary tract ©
  9. 9. Aetiology of BPH- Androgen role• Development of BPH requires the presence of testicular androgens during prostate development, puberty and aging.• Prostate retains ability to respond to androgens throughout life via presence of androgen receptors (AR). In contrast to decreased AR concentration in penis.• Prostate maintains high levels of DHT throughout life, resulting from the conversion of Testosterone to DHT by 5 alpha reductase enzymes types 1 and 2. ©
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  11. 11. Natural history of BPH• Course of BPH may be highly variable• 1- to 5-year period, Patients with clinical BPH  15–50% will have some worsening in symptoms.  15–55%will have no change,  15–30% of patients will have symptom improvement.• 3 to 5 years period:  60–70% will have some worsening.  15–25% of patients will show an increase in flow rates,  15% will have no change,• Placebo responses is reported in 20–40% of patients. ©
  12. 12. BPH Definitions• Benign prostatic hyperplasia(BPH):the typical histopathologic pattern.• Bladder outlet obstruction (BOO): functional term for any cause of infravesical obstruction.• Benign prostatic enlargement (BPE): prostatic enlargement due to a benign cause, generally histologic BPH.• Benign prostatic obstruction (BPO): this is a form of BOO applied when the cause of the outlet obstruction is known to be BPE. ©
  13. 13. BPH Complications• Bladder Stones• Urinary Tract Infections• Hematuria• Acute Urinary Retention• Bladder Decompensation: normal mucosa trabeculation  cellules & sacules diverticulae detrusor muscle failure.• Urinary Incontinence: overflow incontinence or urge incontinence• Upper Urinary Tract Deterioration and Azotemia ©
  14. 14. BPH Diagnosis- HistoryMedical History• history of hematuria, UTI, urinary retention• History of diabetes, nervous system disease (e.g., Parkinson disease or stroke), urethral stricture disease.• Medications aggravation of symptoms:  drugs that impair bladder contractility (anticholinergic agents)  Drugs that increase outflow resistance (α-sympatho- mimetic agents). ©
  15. 15. SYMPTOMS AND SIGNSThe International Prostate Symptom Score (IPSS) grade baseline symptom severity, assess the response to therapy detect symptom progression in those managed by watchful waiting.• AUA S/S Score = Sum Of All 7 Questions  Mild S/S = Score < 7  Moderate S/S = Score 8 – 20  Severe S/S = Score > 20 . ©
  16. 16. IPSSURINARY SYMPTOMS Not < < half > always(SYMPTOM SCORE CRITERIA) at all 1 half the half time the time the in 5 time time1. Weak streamOver the past month, how often have youhad a weak urinary stream?2. IntermittencyOver the past month, how often have youfound you stopped and started againseveral times when you urinate?3. Sense Incomplete emptyingOver the past month, how often have youhad a sensation of not emptying yourbladder completely after you finishedurinating?4. Abdominal Straining None 1 2 3 4 ≥5Over the past month, how often have you timehad to push or strain to begin urination? ©
  17. 17. IPSSURINARY SYMPTOMS Not < < half > always(SYMPTOM SCORE CRITERIA) at all 1 half the half time the time the in 5 time time2. FrequencyOver the past month, how often have youhad to urinate again less than two hoursafter you finished urinating?4. UrgencyOver the past month, how often have youfound it difficult to postpone urination?7. NocturiaOver the past month, how many timesdid you most typically get up to urinatefrom the time you went to bed at nightuntil the time you got up in the morning? A quality of life score 0-6 is added ©
  18. 18. SYMPTOMS AND SIGNS• Storage and Voiding symptoms (assesed by IPSS score)• Retention: Acute retention or Chronic retention or acute-on-chronic retention• Haematuria.• Uraemic symptoms. ©
  19. 19. ExaminationPhysical Examination DRE Focused neurologic examination (anal sphincter tone, saddle area sensation & bulbocavernosus reflex) Examination of the external genitalia Abdominal examinationUrinalysis.Serum Creatinine ©
  20. 20. Serum Prostate-Specific Antigen (PSA)• glycoprotein produced by prostate cells to liquefy semen.• it is specific to the prostate but not to prostate cancer.Indication of serum PSA measurement• Screening asymptomatic men (with DRE)• Staging of CaP (especially, S.V. & L.N. invasion)• follow up after R.prostatectomy & radiotherapy. ©
  21. 21. Additional Diagnostic investigations• Further imaging of UUT. if associated hematuria, stone diseases, or previous urologic operation.• Urethrocystogram. If previous urethral instrumentations or surgeries.• Urodynamic and Pressure/flow study. Indicated only in complicated cases as cases with previous neurologic disease or operation.• Urethro cystoscopy.• TRUS & biopsy If elevated PSA or Suspicious DRE. ©
  22. 22. Sonography of BPH
  23. 23. NON-SURGICAL TREATMENTWatchful Waiting “Self-Help”Indicated When: • the symptoms are not bothersome, • the complications of treatment are greater than the inconvenience of the symptoms • there is a reluctance to take a daily pill owing to side effects and/or the cost of treatment ©
  24. 24. MEDICAL THERAPY α-adrenergic blockers 5α-reductase inhibitors plant extracts (phytotherapy). combinations of these agents. ©
  25. 25. α-ADRENERGIC BLOCKERSCLASS OF α-ADRENERGIC BLOCKER DOSENonselectivePhenoxybenzamine 10 mg bidPrazosin 2 mg bidAlfuzosin IR 2.5 mg tidLong-Acting α1Terazosin 5 or 10 mg qdDoxazosin 4 or 8 mg qdAlfuzosin SR 10 mg qdSubtype SelectiveTamsulosin 0.4 mg qdSilodosin 8 mg qd ©
  26. 26. α-ADRENERGIC BLOCKERSAdverse reactions• asthenia• dizziness• first dose phenomenon• orthostatic hypotension (requiring dose titration) with non-subtype-selective blockers• ejaculatory dysfunction.• intraoperative floppy iris syndrome(IFIS) described with tamsulosin ©
  27. 27. 5α-reductase inhibitors• The development of BPH is an androgen-dependent process mainly dihydrotestesterone (DHT).• Testosterone is converted to DHT by the enzyme 5α- reductase. ©
  28. 28. 5α-reductase inhibitors• 5α-reductase is found in 2 types: type 1 : found in the prostate, liver and skin type 2 : found in the prostate• finasteride is competetive inhibitor for type 2• dutasteride is competitive inhibitor for both types• maximal prostatic volume suppression is achieved after 6 months ©
  29. 29. Combination TherapyCombination Therapy with α-Adrenergic Blockers and 5α-Reductase Inhibitors• combination of dutasteride and tamsulosin was more effective than either drug alone, and reduce the incidence of acute urinary retention.• Alpha blocker should be withdrawn from combination after the response has been established ©
  30. 30. Phytotherapy• The pharmacologic use of plants and herbs (phytotherapy) for the treatment of LUTS associated with BPH is common, e.g. Serenoa Repens, Pygeum africanum,etc.• The mechanisms of action of are generally unknown• Some suggested Mechanisms of Action of Plant Extracts1. Inhibition of 5α-reductase2. Anti-inflammatory3. Antiandrogenic,4. Inhibition of aromatase5. Decrease of sex hormone–binding globulin6. Action on α-adrenergic receptors7. Free radical scavenger ©
  31. 31. Indications of surgical interventionAbsolute indications Relative indications• Upper urinary tract • Moderate symptoms (moderate affection. IPSS score).• Uremia. • Recurrent UTI.• Recurrent attacks of acute • Hematuria. retention. • Stone bladder.• Severe obstructive symptoms (high IPSS score). ©
  32. 32. Open prostatectomyNow rarely used.Indicated in• Patients with symptomatic bladder outlet obstruction due to BPH and markedly enlarged prostate gland,• Patients with a concomitant bladder condition, such as a bladder diverticulum or large bladder calculi• Patients who cannot be placed in the dorsal lithotomy position for TURP
  33. 33. Open prostatectomyRetropubic approach Suprapubic approach
  34. 34. Minimally Invasive & Endoscopic Management of BPH Transurethral Resection of the Prostate(TURP) Transurethral Needle Ablation of the Prostate(TUNA) Transurethral Microwave Therapy(TUMT) Lasers Transurethral Vaporization of the Prostate Transurethral Incision of the Prostate(TUIP) Intraprostatic Stents PKVP (TUVis) and TURis ©
  35. 35. Transurethral Resection of the Prostate(TURP)• TURP is the gold standard for the surgical management of BPH.• All the new therapies are compared to TURP in terms of efficacy and side effects. ©
  36. 36. Nesbit technique for TURP (1943)• resection from proximal to distal  If large middle lobe, start by it first  1st stage: resect BN (superiorly to inferiorly) 12 to 3 O’clock  2nd stage: resect lat. & median lobes (superiorly to inferiorly)  3rd stage: resect apical lobes (inferiorly to superiorly )
  37. 37. TURP (Nesbit technique) 1st stage: resect BN (superiorly to inferiorly)• Resect BN from 12 to 9 oclock (until see circular fibers of BN)
  38. 38. 2nd stage: resect adenoma in quadrants, (superiorly to inferiorly)(until see fibers of prostatic capsule) (a): Rt lobe (12 to 9 o’clock)
  39. 39. 2nd stage: resect adenoma in quadrants, (superiorly toinferiorly) (until see fibers of prostatic capsule) (b): Lt lobe (12 to 3 o’clock)
  40. 40. 2nd stage: resect adenoma in quadrants, (superiorly to inferiorly)(until see fibers of prostatic capsule) (c): Floor(9 to 6 o’clock)
  41. 41. 3rd stage: Apical adenoma removed immediately proximal to EUS,preserving veru (inferiorly to superiorly) (a): begin next to the veru → toward the 12 oclock position
  42. 42. 3rd stage: Apical adenoma removed immediately proximal to EUS,preserving veru (inferiorly to superiorly) (a): Residual tissue is carefully cleared on the patients right side
  43. 43. 3rd stage: Apical adenoma removed immediately proximal to EUS,preserving veru (inferiorly to superiorly) (c): remaining residual tissue is cleared from the patients left side
  44. 44. Another technique• Resection begins at the proximal portion of the middle lobe at the 6- o’clock position.• The resectoscope is placed just proximal to the verumontanum and the resection performed always controlling the end point of each cut.• be aware of the position of the verumontanum to avoid extending below this level or otherwise damage to the sphincter mechanism may occur.
  45. 45. Another technique (cont.):• Resection in smaller adenomas is now carried directly to the side lobe.• It depends on the preference of the surgeon whether to begin on the left and then to resect the other side or vice versa. .
  46. 46. TURP intra-op complications• Overall rate is about 3%  Haemorrhage 2 -10%  Hemorrhage needing Transfusion 8%  Urethral injury 0 - 2%  Bladder injury 0 - 2%  TUR syndrome 1-7 %  Extraperitoneal perforation 0.25%  Recta perforation < 0.25%  Mortality < 0.2%
  47. 47. Early post-op complications• Overall rate is about 7-43%  Urinary retention (Failure to void) 2-8%  Clot retention 3-20%  UTI 6-20%  Epididymo-orchitis 3-5%  Septicaemia 0-5%  Mortality < 0.2%
  48. 48. Late post-op complications• Overall rate is about 8 % – Bladder neck stenosis 1-3% – Urethral Stricture 1-2% – Secondary Haemorrhage 1.4% – Incontinence 1-3% – Retrograde Ejaculation 85 - 100% – Erectile Dysfunction 2 - 13 % – Mortality • 30 day post-op 0.3% • 90 day post-op 1.7% • Re-operation rate (within 5 years) 3-8%
  49. 49. TURP in motion
  50. 50. Transurethral radiofrequency needle ablation of the prostate (TUNA)• Low-level radiofrequency is transmitted to the prostate via a transurethral needle delivery system• The resultant heat causes localized necrosis of the prostate.
  51. 51. Transurethral radiofrequency needle ablation of the prostate (TUNA)Side-effects• bleeding in 1/3 of patients• Short-term urinary retention in 10-40%.• UTI in 10% and urethral stricture in 2%.• Irritative urinary symptoms can last for a month or more.• No adverse effects on sexual function have been reported.
  52. 52. Transurethral radiofrequency needle ablation of the prostate (TUNA)Efficacy• TUNA is a successful minimally invasive treatment option for symptoms associated with prostatic enlargement.• However, Concerns remain with regard to long-term effectiveness.
  53. 53. Transurethral microwave thermotherapy (TUMT)• Microwave energy is delivered to the prostate via an intraurethral catheter which incorporates a microwave generator (antenna), a temperature measurement system, and a cooling system to prevent damage to the adjacent urethra.
  54. 54. Transurethral microwave thermotherapy (TUMT)• The microwave energy produces prostatic heating and coagulative necrosis.• Subsequent shrinkage of the prostate and thermal damage to adrenergic neurons (i.e. heat-induced adrenergic nerve block) relieves obstruction• Cavities can be demonstrated 3 months post- treatment by TRUS.• Low-energy, high-energy, and high-intensity protocols are available.
  55. 55. Transurethral microwave thermotherapy (TUMT)Side effects• Perineal discomfort is common after TUMT, as is urgency, but these symptoms usually resolve in a few days.• Sexual side-effects after TUMT (e.g. impotence, retrograde ejaculation) are less frequent that after TURP,• a catheter may be required for 1-2 week because of urinary retention in up to 25% of patients especially with higher-energy protocols.
  56. 56. HIFU• A focused ultrasound beam can be used to induce a rise in temperature in the prostate, or indeed in any other tissue to which it is applied.• A transrectal probe is used for HIFU treatment of the prostate• There are no randomized trials comparing its effectiveness against other treatment modalities.
  57. 57. TUVP• This technique vaporizes and dessicates the prostate.Advantages• TUVP is as effective as TURP for symptom control and relief of bladder outlet obstruction.• Requirement for blood transfusion may be slightly less after TUVP than after TURP.•
  58. 58. TUVPSide effects• Retrograde ejaculation occurs 70-100% of patients and impotence in 0-15%.• Irritative symptoms seem to be more troublesome than after TURP and can last for 4-6 weeks.• TUVP does not provide tissue for histological examination, and so prostate cancers cannot be detected.
  59. 59. LASER• Light• Amplification by the• Stimulated• Emission of• Radiation
  60. 60. LASER• Penetration depends on wavelength.• Shorter wavelengths (600nm-700nm) are absorbed within a couple of mm by hemoglobin.• Longer wavelengths (1,000nm + ) are absorbed by fat and water.
  61. 61. Laser TherapyMechanism of action of Laser in prostatectomy:• Ablation (coagulation necrosis).• Resection.• Vaporization.These mechanisms are employed through1) Visual laser ablation of the prostate.2) Laser vaporization of the prostate.3) Laser resection of the prostate.4) Laser enucleation of the prostate (with tissue morcellation).5) Laser incision of the prostate.6) Interstitial laser coagulation of the prostate.
  62. 62. Laser delivery system
  63. 63. Laser TherapyThere are four types of laser for the prostate:1) Neodymium: Yttrium-Aluminum-Garnet (Nd:YAG) laser: utilizes wavelengths of 1064 nm causing coagulative necrosis of the prostate.2) Potassium Titanyl Phosphate (KTP) laser:  Doubling the frequency of pulsed (Nd:YAG) laser energy with a KTP crystal has led to the creation of a 532 nm wavelength selectively absorbed by Hb.  The 60-W KTP laser has proved that a higher-power laser beam could speed up vaporization.  So, the 80-W KTP laser was introduced (Green light photoselective vaporization laser system).
  64. 64. Laser Therapy3) Holmium: Yttrium-Aluminum-Garnet (Ho:YAG) laser: • The Ho:YAG utilises wavelength of 2140 nm. • It causes vaporization rather than coagulation. • can be used for resection (HoLRP) or enucleation (HoLEP).4) Diode laser: has 3 components: 1. portable diode laser unit, 2. specialized fiber optic delivery system that allows optical monitoring of tissue temperatures, 3. laser.
  65. 65. Visual laser ablation of the prostateIt is based on the principle of laser coagulation.Surgical technique: The laser energy is delivered to the prostate gland with a side-firing, noncontact, free-beam laser. The most widely used laser energy is the Nd:YAG. The obstructive tissue then starts to slough during the next 4 to 8 postoperative weeks, leading to a patent prostatic urethra.Adverse effects: Prolonged irritative voiding symptoms which may last for weeks and sometimes months.
  66. 66. Laser vaporization of the prostate The Green Light company improved the power of the 532 nm laser up to 80 W KTP and 120 W high-performance system (HPS) with lithium triborate (LBO). Photoselective vaporization of the prostate (PVP) is considered an easy technique creating prostatic fossa resembling TURP. Indications of PVP: 1) Prostates larger than 80 ml can be done. 2) Patients with a high risk. 3) Elderly aged 80 years or more. 4) Anticoagulant users .
  67. 67. Laser vaporization of the prostateSurgical technique: Vaporization is started at the 6 oclock position or at one of the two lateral lobes of the prostate. Effective lasing makes many air bubbles. A Foley catheter is placed for less than 24 hours before a voiding trial is done.Advantages No significant blood loss or fluid absorption was noted during or immediately after PVP.Side effects transient hematuria (8.6%), dysuria (9.3%) and urinary retention (5%).
  68. 68. Laser resection of the prostateIt is based on the principle of laser vaporization.Holmium: YAG is the most widely used laser for this technique.Surgical techniquethe laser fiber cuts the prostatic lobes into pieces small enough to be evacuated through the resectoscope sheath to create a TUR-like cavity.
  69. 69. Laser enucleation of the prostate (with tissue morcellation)Indication: Alternative to open prostatectomy in large prostates.Surgical technique Bilateral bladder neck incisions from orifices to veru. The median lobe is enucleated then the lateral lobes. Prostate tissues in the bladder are fragmented and aspirated with the morcellator.Adverse effects: Recatheterization (2.9%), UTI (2.3%), urethral stricture or bladder-neck contracture (3.2%) and reoperation (2.8%).
  70. 70. Laser incision of the prostate• based on the principle of tissue vaporization• a contact-tip laser fiber is used to deliver high energy along the prostatic urethra, causing a linear tract of tissue vaporization.• It is performed on relatively small glands (< 30 g).
  71. 71. INTERSTITIAL LASER COAGULATION  A standard cystoscope is used to insert the laser fiber transurethrally into the prostate gland.  The intraprostatic temperature reaches 100°C within a few seconds and is maintained for150 seconds resulting in tissue coagulation. Adverse Effects Retreatment rate in 16% and UTI in 20% of patients.
  72. 72. Plasmakinetic vaporesection of the prostate (PKVP)A new technique based on creating aplasma arc, vaporizing tissue and achievinghemostasis to a predictable depth.
  73. 73. Plasmakinetic vaporesection of the prostate (PKVP)• current is passed through the active electrode of the device that approaches boiling point and a plasma corona is formed, creating very high resistance between the active and return electrodes.• Tissue entering the corona (lower resistance) is vaporized and adjacent tissue is sealed up to 0.5 mm.
  74. 74. Plasmakinetic vaporesection of the prostate (PKVP) Advantages of PKVP1) The bipolar current and the use of saline irrigation eliminates the risk of TUR syndrome.2) Hemostasis is achieved to a predictable depth.3) The working element is the return electrode , thus, eliminating the risk of skin burns and obturator jerk.4) Safe to be used in patients with cardiac pacemakers.5) used in high risk patients, patients with bleeding disorder and patients receiving anticoagulative therapy. Disadvantages of PKVP It does not provide histopathological specimens which may miss incidental cancers.
  75. 75. Trans-urethral resection in saline (TURis)• Using a bipolar electrode this technique allows working with saline medium.• The technique offers familial technique with minimal bleeding and use in high risk patients with cardiac pacemakers and arrhythmias.
  76. 76. TURis and TUVis (PKVP) in motion
  77. 77. Thank You