Benign Prostatic Obstruction

Bernard S. Tjandra Bedah Urologi

Lower Urinary Tract Symptoms (LUTS)

Storage symptoms = Irritative Voiding symptoms = Obstructive

Epidemiology BPH
Common over 40 yrs of all races & cultures

Prevalence by age 60 = 50 % 70 = 70 % 80 = 90 %
From 40 80 : 10 % chance of undergoing prostatectomies

Number of prostatectomies per year per 1000 men > 55 yrs Belgium USA France Denmark Japan UK 14 13 13 12 9 7

Prostate

Mc Neal 1968 (Zonal concept)

Central gland : transition zone 5 % (origin bpo) periurethral (mid lobe) Peripheral gland : peripheral zone 70 % (origin cancer) central zone 25 % Fibromuscular structures : anterior (smooth muscle) longitudinal preprostatic sphincter postprostatic sphincter (striated)

Functions of Prostatic Gland and Fluid

Reproduction
Citrate Glucose

Antibacterial
Zinc

Pathophysiology
1.

The static component Hyperplastic nodule of transition zone The dynamic component Smooth muscle tone in the prostate, prostatic capsule & bladder neck
The detrusor component Loss of contractile, uninhibited

2.

3.

Histology
Increase in the stromal component, both smooth muscle and connective tissue.

(Chagas et al, BJU International, 2002, 89)

Pathogenesis
1. Dihydrotestosterone hypothesis
(Testo. Bind with TBG & Albumen ; Unbound testo. 1 3 %) formed by 5-alpha reductase isoenzymes type 1 & 2 within the prostate binds to receptors in the nucleus, leads to cell replication epithelial & stromal hyperplasia

2. Oestrogen Testosterone imbalance 3. Stromal Epithelial interaction 4. Reduced cell death

5. Stem cell theory

6. Inflammation *

Risk factors

Age Race Environment and dietary higher in men consuming milk lower in men consuming soya (phytooestrogen) Associated conditions DM, Hypertention (20 30 %), Obesity

Classical symptoms
Obstructive
Weak stream Straining Hesitancy Intermittency Incomplete emptying Terminal dribbling Prolonged micturition Overflow incontinence

Irritative
Frequency Urgency Nocturia Urge incontinence Small voided volume

Other symptoms

Haematuria Dysuria Haematospermia Low back pain (hydronephrosis) Nausea (uremic) Urinary retention Edema

Symptoms fluctuate with time !

Detrusor hypertrophy Trabeculae

Residu Diverticula Infection Stone Renal failure

Diverticulum

Anamnesis

Medical history Disease (CVA, HNP, DM, Tumor, MS) Pelvic surgery Instrumentation Medicine (e.g. phenylpropanolamine) Provocative event (alcohol)

Anamnesis

The severity of the problem can be quantified by asking symptom scores

- Boyarsky (1977)

- Madsen-Iversen (1983) - IPSS (1991) International Prostate Symptom Score AUA

Madsen Iversen score

Obstructive : stream, voiding, hesitancy, intermittency, bladder emptying, incontinence Irritative : urge, nocturia, diuria

Grading 0 4, total score 46 Light Moderate Severe 0 - 8 9 - 20 > 20

IPSS (= AUA)

Self assesment *
Obstructive : incomplete emptying, weak stream, straining, intermittency

Irritative

: frequency, urgency, nocturia

Quality of life * Grade 0 - 5, total score 35 0- 7 8 - 18 > 18

Mild Moderate Severe

Physical examination

Inspection

- meatal stenosis - phimosis

Abdominal palpation

- renal enlargement -bladder distention

Digital rectal examination

The size of a chestnut, 20 grm Firm elastic / rubbery consistency as the tip of the nose

Phimosis

Meatus stenosis

Dilatator / Bougies

Paraphimosis

DRE

Grade 0 : not palpable, < 10 g

Grade 1 : whole prostate palpable < 25 g Grade 2 : enlarge, reach cranial, 25 60 g Grade 3 : reach the top, < 120 g Grade 4 : very big, > 120 g

Diagnosis / Investigations

Urinalysis (ery,leuc,bact) Serum Urea, Creatinine, PSA Uroflowmetry & post-void residual urine *
X-Abdomen & USG Kidney TRUS (Transrectal Ultrasound) of the Prostate

Pressure-flow study (optional)

IVU (cystogram)

Interpretation of Qmax (Uroflow)

flow rate
> 15 ml / sec 10 15 ml / sec < 10 ml / sec

Interpretation
normal equivocal obstructed

Normal Uroflowmetry & BPO

Example of obstructive flows

Transrectale ultrasonography

TRUS of the Prostate

Intrabladder Prostate Protrution

Grade 1 < 5 mm Grade 3 < 10 mm

Residu

Hydronephrosis

Giant Prostate

Interpretation of PSA values (half life = 2.2 3.2 days)

0.5 - 4 ng / ml 4 - 10 ng / ml normal (monoclonal method) 20 % chance of cancer PSA / prostate volume = PSAD normal < 0.15 50 % chance of cancer biopsy !!!

> 10 ng / ml

Effect of prostate manipulation on PSA

procedure
DRE TRUS Massage Cystoscopy TURP Biopsy

effect
none none 1.9 X 4.1 X 53 X 57 X

Treatments

Watchful waiting
for patients with minor symptoms and no objective signs of complications

Relative
- Severe haematuria - Socially disabling symptoms - Disturbance of sleep, rest

Absolute
- Obstructive uropathy - Overflow incontinence - Repeated retention - Vesicle stone - Severely decompensated bladder - Chronic / recurrent infection

Option for treatment

Medical therapy Alpha-1 blockers (Prostate tone) - Doxazosin - Alfuzocin - Terazosin - Tamsulosine (selective) 5-alpha reductase inhibitors (Prostate volume) - Finasteride (type 2) - Dutasteride (type 1 & 2)

Distribution of alpha receptors

Alpha 1 A prostate Alpha 1 D bladder neck Alpha 1 B vascular

Effects of medical therapy

Alpha-1 blockers
- improve flow by 3-5 ml/sec - effective 60 % - drowsiness, headaches - postural hypotention - discontinuation before cataract surgery !!!

Finasteride
- reduced prostate volume - improve flow by 2.7 ml/sec - reduced libido - reversible impotence - decreases PSA by 50 %

Phytotherapy (plant extracts)

Antiandrogenic Proapoptotic Anti-inflammatory

Serenoa repens

Option for treatment

Surgical therapy Open prostatectomy Transvesical (Hrynchack, Freyer 1901) Retropubic subcapsule (Millin 1947)
- prostate volume > 100 grm - hospital stay 10 12 days - mortality rate 1 %

Retropubic subcapsule prostatectomy

Option for treatment

Surgical therapy Transurethral resection of the Prostate (= TURP)

- hospital stay 3 days - succes rate 71 % - re-treatment rate after 5 yr 8 % - mortality rate 0.1 0.2 %

Pre and Post TURP

3 way catheter

T.U.R. Prostate

Post-operative complications Retrograde ejaculation 60 % Haemorrhage 15 % Impotence 15 % Urethra stricture 5% Bladder-neck sclerosis 5% Epididymitis 4% TUR syndrome 2% Incontinence 1%

Stricture urethra

Bladder neck sclerosis

Option for treatment

Technological intervention - Laser enucleation (Holmium/YAG) - Vaporization (GreenLight laser/KTP)

GreenLight Laser
120 -W

Photoselective Vaporization of the Prostate GreenLight HPS Laser

120 -W

use saline or aqua

GreenLight Laser Prostatectomy Photoselective Vaporization Prostate

Less Bleeding Less Pain No Erectile Dysfunction No TUR Syndrome Stay one night Quick recovery

Vaporization

Advantages of GreenLight laser

Bloodless procedure Less pain No risk of water intoxication Short catheterization (< 24 hours) < 1 % cases of erectile dysfunction Rapid urine flow improvement Quick return to normal activities Definitive and long lasting treatment No pathology specimen

New Finding

Anti-inflammatory Antioxidants

Differential diagnosis

Teratoma

Chordoma

How to insert a catheter and What you need

Suprapubic cystostomy

The TUR syndrome

As result of absorption of irrigant Sodium < 120 mmol / l Widening QRS complex ST depression

Mean volume of irrigant absorbed during TURP 900 ml 30 % absorbed by intravascular route
(venous pressure 6 cm H20)

70 % absorbed by retroperitoneal (capsular breaches)

Pathophysiology TUR syndrome

Circulatory distress Hypervolaemia - elevate CVP Diffusion interstitial - plasma (transient) follow leakage of water from plasma - interstitial - Hypotention
Dilution of protein Lowers oncotic pressure - pulmonary oedema

Classic syndrome

bradycardia hypotention tachypnoea restlessness

Confusion Convulsions Coma Vascuvar collapse death

Prevention / Management

good surgical technique avoid overfilling the bladder limit resection time (90 min.) routine administration of Furosemide

inducing diuresis (10 % Mannitol) hypertonic saline (500 ml 3 %)

The concept of balance

The extracellular water Plasma (3 li) Interstitial-lymp (11 li)

14 li

The intracellular water 28 li ---------------------------------------------------Total body water 42 li