BENIGN PROSTATIC HYPERPLASIA

PRESENTER DR SHAMPILE SYDNEYMODERATOR DR NENADDATE 4TH FEBRUARY, 2014

Presentation layout

• Relevant anatomy• Etiology• Pathophysiology• Symptoms• Complications of BPH• Diagnosis• Treatment• References

Prostate Gland Anatomy

• Male sex gland • Pear-shape,wt7-16gm• Size of a walnut• Helps control urine flow • Produces fluid component of semen• Produces Prostate Specific Antigen (PSA

Development

• The prostatic part of the urethra develops from the urogenital sinus (endodermal origin).

• It grows into the surrounding mesenchyme• The glandular epithelium of the prostate differentiates

from these endodermal cells• Mesenchyme differentiates into the dense stroma and the

smooth muscle of the prostate• The prostate glands arises by the 9th week of embryonic

life • Condensation of mesenchyme, urethra and Wolffian ducts

gives rise to the adult prostate gland, a composite organ made up of several glandular and non-glandular components tightly fused.

Arterial supply

• From the anterior division of the internal iliac artery

Inferior vesical artery, Middle rectal arteryInternal pudendal artery originates

(hypogastric) artery.

• The capsular artery is the second main branch of the prostate. Supply the glandular tissue.

Venous drainage

• Prostatic plexus of veins• Valveless communication exists between the

prostatic and vertebral plexus through which prostatic carcinoma spread to vertebral column and to skull

• Innervationsfrom pelvic plexuses formed by the parasympathetic,

visceral, efferent, and preganglionic fibers that arise from the sacral

• levels(S2-S4)

sympathetic fibers from the thoracolumbar levels (L1-L2).

The pudendal nerve is the major nerve supply leading to• Somatic innervations of the striated sphincter and the

levator• ani. The preprostatic sphincter and the vesicle neck or

internal sphincter is under alpha-adrenergic control.

Lymphatic drainage

• Obturator and the internal iliac lymphatic channels.

• External iliac, presacral, and the para-aortic lymph nodes.

ETIOLOGYRole of Androgens • Androgens do not cause BPH• The development of BPH requires the

presence of testicular androgens• Patients castrated before puberty or who are

affected by a variety of genetic diseases that impair androgen action or production do not develop BPH.

ETIOLOGYDihydrotestosterone and Steroid 5α-Reductase• Intraprostatic DHT concentrations are

maintained but not elevated in BPH • DHT is a more potent androgen than

testosterone because of its higher affinity for the AR

• Moreover, the DHT-receptor complex may be more stable than the testosterone receptor complex.

• Two types of steroid 5α-reductase have been discovered, each encoded by a separate

Type 1 5α-reductase, the predominant enzyme in extraprostatic tissues, such as skin and liver, is normally expressed in the 5α-reductase deficiency syndrome

Type 2 5α-reductase is the predominant prostatic 5α-reductase, although it is also expressed in extraprostatic tissues

ETIOLOGY

Role of Estrogens • There is animal model evidence to suggest that

estrogens play a role in the pathogenesis of BPH• The role of estrogens in the development of

human BPH, however, is less clear• There are at least two forms of ERER-α is expressed by prostate stromal cellsER-β is expressed by prostate epithelial cells

ETIOLOGY

Regulation of Programmed Cell Death• Programmed cell death (apoptosis) is a

physiologic mechanism crucial to the maintenance of normal glandular homeostasis

• This is impaired in BPH

ETIOLOGY

Stromal-Epithelial Interaction• Prostatic stromal and epithelial cells maintain

a sophisticated paracrine type of communication

• Thus BPH may be due to a defect in a stromal component that normally inhibits cell proliferation, resulting in loss of a normal “braking” mechanism for proliferation

ETIOLOGY

Growth Factors • Interactions between growth factors and steroid

hormones may alter the balance of cell proliferation versus cell death to produce BPH

• GF implicated in prostate growth.bFGF (FGF-2) acidic FGF (FGF-1)Int-2 (FGF-3) KGF, FGF-7)β (TGF-β EGF

• TGF-β (transforming ) is a potent inhibitor of proliferation in normal epithelial cells in a variety of tissues

ETIOLOGY

Other Signaling Pathways• The early growth response gene-1 (EGR1)• α2-macroglobulin• IL-2, IL-4, IL-7, IL-17, interferon-γ (IFN-γ)• Genetic and Familial Factors

PATHOPHYSIOLOGY

• The pathophysiology of BPH is complex • BPH increases urethral resistance, resulting in

compensatory changes in bladder function• Elevated detrusor pressure is required to

maintain urinary flow in the presence of increased outflow resistance

LUTSVoiding (obstructive)symptoms• Hesitancy• Weak stream• Straining to pass urine• Prolonged micturition• Feeling of incomplete

bladder emptying• Urinary retention

Storage (irritative orfilling) symptoms• Urgency• Frequency• Nocturia• Urge incontinence

LUTS is not specific to BPH – not everyone withLUTS has BPH and not everyone with BPH has LUTS

Common Symptoms

decrease in the urinary stream

Dribbling or leaking after urination

Intermittency

Hesitancy

Pain or burning during urination

Feeling that the bladder never completely empties

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Complications

Mortality• 10 per 100,000Bladder Stones• bladder stone development is smallUrinary Tract Infections• 0.1/100 patient-yearsBladder Decompensation• progression from normal mucosa to advancing

trabeculation, diverticula and detrusor muscle failure

Complications

Urinary Incontinence• complications from surgical intervention for BPH • secondary to overdistention of the bladder

(overflow incontinence) • Due to detrusor instability (urge incontinence)Acute Urinary Retention • Long-term outcome resulting from BPH

Diagnosis of BPH

• History and Examination• Digital rectal examination(DRE)

• inaccurate for size but can detect shape and consistency• Ultrasonography• Urodynamic analysis• Measurement of prostate-specific antigen (PSA)

– high correlation between PSA and PV, specifically TZV– men with larger prostates have higher PSA levels

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– PSA is a predictor of disease progression and screening tool for CaP

– as PSA values tend to increase with increasing PV and increasing age, PSA may be used as a prognostic marker for BPH

Other investigations

• Serum Creatinine Measurement• Urinalysis• Postvoid Residual Urine Volume• Pressure-Flow Studies• Filling Cystometry (Cystometrography)• Urethrocystoscopy

TREATMENT

BPH needs to be treated ONLY IF:The symptoms are severe enough to bother patient and affect the quality of life

Renal insufficiency

Frequent urinary tract infections

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TREATMENT

• Medical • Minimally Invasive and Endoscopic• Surgical approaches

TREATMENT

•First line of defense against bothersome urinary symptoms

–Manage the condition - don’t fix it

•Two major types:

•(Alpha-1-blocker) - relax the prostate and provide a larger urethral opening (prazosin,terazosin)

•Shrink the prostate gland (5-alpha reductase inhibitor) (finasteride)

TREATMENT

• Combination therapy with both an α-adrenergic receptor blocker and a 5α-reductase inhibitor has been demonstrated to be the most effective

• Antimuscarinic agents are useful adjuncts for patients with “storage” symptoms or ED

Minimally Invasive and Endoscopic

Temporary Stents• Temporary stents are tubular devices that are

made of either a nonabsorbable or a biodegradable material

• designed for short-term use, to relieve bladder outlet obstruction (BOO)

Temporary Stents

• Spiral Stents- e.g Urospiral,stent should remain in the prostatic urethra for longer than 12 months

• Polyurethane Stents • Biodegradable Stents

Permanent Stents

• were introduced as a definitive treatment for prostatic obstruction, particularly for patients unfit for prostatic surgery

• Patients were able to void satisfactorily in most cases, but complications were relatively high

• UroLume endourethral prosthesis

TRANSURETHRAL NEEDLE ABLATION OF THE PROSTATE (TUNA)

• Heat treatment inducing necrosis of prostatic tissue

• The aim is to increase prostatic temperature to in excess of 60° C

• Uses low-level radiofrequency (RF) energy that produces localized necrotic lesions in the hyperplastic tissue.

Deployment of radiofrequency needles in transurethral needle ablation

TRANSURETHRAL MICROWAVE THERAPY

• These cover heat changes and differential blood flow in the prostate

• Damages the sympathetic nerve endings• Induction of apoptosis

The Prostatron antenna, treating the prostatic transition zone.

LASERS

• “laser” stands for light amplification by the stimulated emission of radiation

• There are four types of laser that can be used to treat the prostate

1. Neodymium : Yttrium-Aluminum-Garnet Laser2. Potassium-Titanyl-Phosphate Laser 3. Holmium : Yttrium-Aluminum-Garnet Laser 4. Diode Laser

LASERS

The energy from lasers can be delivered as follows: • End firing Bare tip Sculptured tip Sapphire tip • Side firing Metal or glass reflector Prismatic internal reflector

TRANSURETHRAL RESECTION OF THE PROSTATE (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

TURP• Operation is performed through a modified cystoscope

• Prostatic tissue is resected using an electrically energized wire loop

• Prostatic capsule is usually preserved.

• Continuous irrigation is necessary to distend the bladder and to wash away blood and dissected prostatic tissue.

SURGICAL PROCEDURE•

Ideally the irrigation solution should be:

• Isotonic• electrically inert• Nontoxic• Transparent• inexpensive • Nonhemolytic• Nonmetabolized

IRRIGATION FLUID

COMPLICATIONS •TURP can be associated with a number of complications:

•TURP Syndrome (2%) •Hemorrhage •Bladder perforation (1%) •Hypothermia •Septicemia (6%) •DIC

•The main challenges are blood loss and TURP Syndrome due to excessive absorption of irrigant fluid

TURP SYNDROME

• TURP syndrome: constellation of signs and symptoms caused by the absorption of large volumes of isotonic irrigating fluids through prostatic veins or breaches in the prostatic capsule.

• The syndrome is characterized by • hypervolemia, • hyponatremia • hypo-osmolarity

TURP SYNDROME: RISK FACTORS

TURP syndrome is more likely to occur:

1.The hydrostatic pressure of the irrigation solution is high.

2.An excessively distended bladder

3.Prostatic gland is large.

4.The Prostatic Capsule is violated during surgery.

5.Duration of surgery (>60mins)

Retropubic Prostatectomy

• Proper Positioning of the Patient • Once anesthesia has been induced the patient

is positioned on the operating table in a supine position

• Trendelenburg position without extension

Retropubic prostatectomy. The space of Retzius has been opened and the periprostatic adipose tissue has been dissected free from the superficial branch of the dorsal vein complex. The endopelvic fascia is incised

bilaterally

A 2-0 chromic suture on a 58-inch circle-tapered needle is passed in the avascular plane between the urethra and the dorsal vein complex at the apex of the prostate. A tie is grasped and tied

around the dorsal vein complex. B, With 2-0 chromic suture material on a CTX needle, a figure-of-eight suture is placed through the prostatovesicular junction just above the level of the seminal

vesicles to control the main arterial blood supply to the prostate gland. When placing this suture, care must be taken to avoid entrapment of the neurovascular bundles located posteriorly and

slightly laterally

Retropubic prostatectomy. A, With the superficial branch of the dorsal vein complex secured proximally and distally, a No. 15

blade on a long handle is used to make the transverse capsulotomy. B, Metzenbaum scissors are used to develop the

plane anteriorly between the prostatic adenoma and the prostatic capsule.

Retropubic prostatectomy. A, With blunt dissection with the index finger, the prostatic adenoma is dissected free laterally and posteriorly. B, Metzenbaum scissors are used to divide the anterior commissure to visualize the posterior urethra and verumontanum. C, The index finger is then used to fracture the urethral mucosa at the level of the verumontanum. With this last maneuver,

extreme care is taken not to injure the external sphincteric mechanism

Retropubic prostatectomy. A, After removal of the left lateral lobe of the prostate, the right lateral lobe is excised with the aid of a tenaculum and Metzenbaum scissors. B, Lastly, the median lobe is removed under direct

vision

Retropubic prostatectomy. A, View of the prostatic fossa and posterior urethra after enucleation of all the prostatic adenoma. Note that the verumontanum and a strip of posterior urethra

remain intact. B, After placement of a urethral catheter and, if needed, a Malecot suprapubic tube, the transverse capsulotomy is closed with two running 2-0 chromic sutures. The two sutures are tied first to themselves and then to each other across the midline to create a

watertight closure of the prostatic capsule.

Suprapubic Prostatectomy

• Proper Positioning of the Patient • After anesthesia has been induced, the patient is

positioned on the operating table in a supine position.

• The table is placed in a mild Trendelenburg position without extension

• 22-Fr catheter is inserted into the bladder. After residual urine is drained, 250 mL of saline is instilled into the bladder and the catheter is clamped.

Suprapubic prostatectomy. A, A lower midline incision is made from the umbilicus to the pubic symphysis. B, After developing the prevesical space, a small, longitudinal cystotomy is made

with an electrocautery

With adequate exposure of the bladder neck, a circular incision in the bladder mucosa is made distal to the trigone, using an

electrocautery

Starting at the bladder neck posteriorly, Metzenbaum scissors are used to develop the plane between the prostatic adenoma and the prostatic capsule (lateral view). B, Anterior view of the

same maneuver

Using the index finger, the prostatic adenoma is enucleated from the prostatic fossa (lateral view). B, Anterior view of the same maneuver. With extreme large prostate glands, the left, right,

and median lobes should be removed separately

After enucleation of the entire prostatic adenoma, a 0-chromic suture is used to place two figure-of-eight sutures to advance bladder mucosa into the prostatic fossa at the 5- and 7-o’clock positions at the prostatovesicular

junction to ensure control of the main arterial blood supply to the prostate.

suprapubic tube, the cystotomy is closed in two layers using a running 2-0 Vicryl suture, enforced by tying of multiple

interrupted 3-0 Vicryl stay sutures. A closed Davol suction drain is placed on one side of the bladder and exits via a separate stab

incision

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