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Benign Hyperplasia Of Prostate

  1. Most common site is periurethral zone (transitional zone) Q
  2. Medial lobe of prostate is most common lobe involved in BPH. Q
  3. Most common benign tumour in men. Seen in 50% between 50-60 years and 90% in ninth decade.
  4. Pathology: Characterized by adenosis, epitheliosis and stromal proliferations.
  5.  It mainly involves the central part and lateral part gets compressed. With enlarging prostate middle lobe develops, which projects into the base of bladder.
  6. Secondary effects: The urethra gets compressed laterally and is elongated causing bladder outlet obstruction e.g. trabaculation/ secculation/ diverticuli.
  7.  Later on there may be stone formation or Vesico-ureteral reflux.
  8. Clinical presentation: Frequency is the earliest symptom, which initially is only nocturnal. Bladder symptoms are divided in irritative symptoms (e.g. Frequency, urgency, urge incontinence, nocturia) or obstructive symptoms (e.g. hesitancy, thin stream of urine, terminal dribbling and retention).
  9. Other features are recurrent UTI (due to increased residual urine) hematuria, or renal failure due to backpressure changes.
  10. Examination may reveal bladder lump and on PR examination enlarged prostate (feature on BPH are: non nodular enlarged prostate with firm consistency, prominent median sulcus)
  11. In clinical examination one should always exclude presence of CRF e.g. evidence of weight loss or edema, anaemia, tenderness at renal angle and low urine output.
  12. It is important to examine nervous system also to exclude the presence of neurogenic bladder.
  13. Investigations: Complete hemogram and urinalysis, blood urea and serum creatinine. USG is the investigation of choice. Q PSA (prostate specific antigen) is helpful in excluding carcinoma. It is a glycoprotein (mol.wt: 33,000), its normal value is 0- 4 ng/dl.
  14. Urodynamic study (uroflowmetry, cystometrogram, and urethral pressure profile) is also helpful. A value of <10 ml/sec in UFR is suggestive of obstruction. Q
  15. Cystometrogram is helpful in differentiating between BPH and neurogenic bladder (indicated when patient presents with mainly irritative symptoms).   
Treatment Of BPH
MC indication for surgery is symptoms interfering with quality of life (bothersome symptoms and symptoms of BPH).
Absolute indications for surgery in BPH
  1. Refractory urinary retention (failing at least one attempt at catheter removal)
  2. Recurrent UTI
  3. Recurrent gross hematuria
  4. Bladder stones
  5. Renal Insufficiency
  6. Minimal improvement on medical treatment
  • Treatment: 
  1. Medical
    1. Alpha-blockers: (Prazosin, terazosin, doxazosin, tamsulosin, alfuzosin)
      1. MOA - Relaxes smooth muscle and decreases urethral resistance,
      2. Side effects: orthostatic hypotension, dizziness, tiredness, retrograde ejaculation, rhinitis and headache. 
    2. 5-Alpha-reductase inhibitors: (Finasteride, dutasteride, triptorelin pamoate)
      1. Blocks the conversion of testosterone to dihydrotestosterone, affecting the epithelial components of the prostate, resulting in a reduction in the size of gland and improvement in symptoms.
      2. Six months of therapy are required to see the maximum effects on prostate size (20% reduction) and symptomatic improvement. However, symptomatic improvement is seen only in men with enlarged prostates (>40 cm'). 
      3. Side effects: decreased libido, decreased ejaculate volume and impotence.
    3. Combination therapy
      1. The reduction in risk associated with combination therapy (66% risk reduction is greater than that associated with doxazosin or finasteride alone.
      2. Patients most likely to benefit from combination therapy: whom baseline risk of progression is very high, generally patients with larger glands and higher PSA values.
    4. Androgen deprivation with LHRH agonists; Progestational compounds; Antiandrogens
      (cyproterone acetate, flutamide).
  2. Surgical:
    Minimally Invasive Therapy in BPH
    1. Laser therapy: Two main energy sources of lasers have been utilized- holmium:YAG (best)", Nd:YAG.           
    2. Transurethral electro vaporization  
    3. Hyperthermia                      
    4. Transurethral needle ablation
    5. High intensity focused ultrasound
    6. Intraurethral stents
Conventional Surgical Therapy
  1. TURP (Gold standard).
    1. Cystoscopic removal of strips of prostatic tissue using diathermy loop
    2. Best irrigant fluid is 1.5% glycine? (Electrolyte solutions like NaCI are not compatible with electrocautery, so not used).
    3. Glycine is composed of glycolic acid and ammonium, which can cause CNS (visual) toxicity
  2. TURIS: (TUR in saline using bipolar cautery)
    1. Verumontanum is the single most important anatomical landmark in TURP.
    2. Verumontanum lies immediately proximal to external sphincter and serve as the distal landmark for prostate resection to prevent injury to the external sphincter.
    3. Verumontanum: Distal landmark for prostate resection.
    4. Verumontanum: Landmark for proximal limit of external sphincters. 
Risks of TURP:
  1. Retrograde ejaculation (75%), impotence (5-10%) and incontinence (<1%).
  2. Complications: Bleeding, urethral stricture or bladder neck contracture, perforation of the prostate capsule with extravasation, and if severe, TUR syndrome.
  3. TUR syndrome (Dilutional hyponatremia or water intoxication)
    1. TUR syndrome (Dilutional hyponatremia or water intoxication)  resulting from a hypervolemic, hyponatremic state due to absorption of the hypotonic irrigating solution.
    2. Clinical Features: Nausea, vomiting, confusion, hypertension, bradycardia, and visual disturbances.
    3. The risk increases with resection times >90 minutes or gland size >75 gm.
    4. Treatment includes diuresis (furosemide) and in severe cases, hypertonic saline (3%) administration.
    5. Late Complications of TURP
    6. Bladder neck stenosis (4%) >Urethral stricture (3.6%)
    7. Bladder neck stenosis is seen more often with small «30 gm) fibrotic prostates.
  1. Transurethral incision of the prostate (TUIP):
    1. For posterior commissure hyperplasia (elevated bladder neck), involves two incisions using the Collins knife at the 5- and 7-0'clock positions.
    2. The incisions are started just distal to the ureteral orifices and are extended outward to the verumontanum.
    3. TUIP lowers the incidence of bladder neck contracture when compared to TURP, so TUIP should be strongly considered in patients with smaller gland in place of TVRP.
    4. TUIP is used for smaller (20 gm) prostate, young patients.
    5. Decreased incidence of retrograde ejaculation as compared to TVRP.
    6. Open simple prostatectomy: Glands >75 gm, concomitant bladder diverticulum or a bladder stone or if dorsal lithotomy positioning is not possible. 
      1. Suprapubic prostatectomy: Performed transvesically (Frayer's) and operation of choice in dealing with concomitant bladder pathology (Bladder stones or diverticulum.
      2. Retropubic prostatectomy (Millin's); Transverse incision is made in surgical capsule of prostate and enucleation is done.
      3. Perineal prostatectomy (Young’s): Abandoned now  
    7. Carcinoma prostate originates in peripheral zone of prostate, so prostatectomy for BPH confers no protection for subsequent cancers.
Extra edge:
  • Verumontanum is the single most important anatomical landmark in TURP.
  • Verumontanum lies immediately proximal to external sphincter and serve as the distal landmark for prostate resection to prevent injury to the external sphincter.
  • Verumontanum: Distal landmark for prostate resection.
  • Verumontanum: Landmark for proximal limit of external sphincter.
Most common site of stricture following long lasting TURP? (AIPG 2011)
A. Bladder neck                                                               
B. Navicular fossa
C. Mid bulb                                                       
D. Prostatomembranous region
Ans. B Navicular fossa > C Mid bulb
During TURP, while dissecting around the verumontenum, the surgeon should specifically take care to avoid
injury to which of the following? (AIPG 2011)
A. Urethral crest                                             
B. Sphincter vesicae
C. Trigone of the bladder                              
D. External urethral sphincter
Ans. D External urethral sphincter
Agent Action Mechanism Side Effects
GnRH analogue: Leuporalide,
Goserelin, nefralin
Blocks pituitary LH secretion, Decreases level of T & DHT. Loss of libido, hot flashes, gnaecomastia
Antiandrogen: Flutamide,
Kasadex, Nilutamide
5-alpha reductase inhibitor:
Finastride(proscar), Epristride.
Blocks nuclear androgen
receptor. Does not decrease
level of T or DHT.
Blocks conversion of T to DHT.
Dose not decrease level of T.
Impotency, Diarrhoea,
Headache, No impotency,
Minimal loss of libido.
Combined agents:
antiandrogenic and
gonadotripic effects;
cyproterone acetate,
magestrol acetate
Blocks LH release and nuclear
androgen receptor.
Impotency, loss of libido (100%)
Aromatase inhibitors:
testolactone, atamestane.
Blocks peripheral conversion of
T to estrogen
Occasional headache. No
impotency or loss of libido.
Alpha 1 sympathetic blockers:
terazocine, prazocine
Relaxes bladder neck. Postural hypotension
The indications for TURP or open (simple) prostatectomy include the following:
  1. Acute urinary retention
  2. Persistent or recurrent urinary tract infections
  3. Significant hemorrhage or recurrent hematuria
  4. Bladder calculi secondary to bladder outlet obstruction
  5. Significant symptoms from bladder outlet obstruction not responsive to medical or minimally invasive therapy
  6. Renal insufficiency secondary to chronic bladder outlet obstruction
    1. Consider open (simple) prostatectomy, using either the retropubic or suprapubic approach, when the prostate is larger than 75 g or larger than the surgeon can resect reliably with TURP in 60-90 minutes.
    2. In patients with concomitant bladder pathology that complicates their outlet obstruction (eg, a large or hard bladder calculus, symptomatic bladder diverticulum), open prostatectomy remains the procedure of choice. 

Recent Advances: Newer minimal invasive Procedures for BPH:-

  1. TUMT – transurethral microwave therapy
  2. TUNA – transurethral needle ablation
  3. VLAP technique involving Nd; YAG loser
  4. Photosensitive vaporization (PVP) of prostate with green light (KTP) loser.
  5. Holmium laser ablation of prostate.

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