Urinary Obstruction

1
Urinary Obstruction Benign Prostatic
Hyperplasia (BPH)

• Xiao Huang, MD PhD
• Department of Urology,1st Affiliated Hospital of
  Zhejiang University, School of Medicine

2
Urinary Obstruction

• Urinary Tract Anatomy
• Urinary Obstruction
• Reason of Urinary Obstruction
• Hydronephrosis

3
Urinary Tract Anatomy
4
Urinary Obstruction
5
Reason of Urinary Obstruction
6
Obstruction Reason Classification

• Dynamic and structural
• Congenital and aquired
• Populations
• Child congenital
• Adults stone, injury, tumor ,TB
• Women pelvic disease
• Old men BPH
• Locations
• Kidney calculus, tumor, infection, TB, UPJ
  stricture, congenital deformity
• Ureter stone, tumor, iatrogenic injury,
  ureteritis,TB , Metastatic carcinoma
• Bladder BPH, bladder neck contracture, tumor,
  calculus, Neurogenic bladder
• Urethral urethral stricture, Phimosis
  ,Congenital Posterior urethral valve ,stone.

7
Hydronephrosis

• What is hydronephrosis?
• Hydronephrosis is a "stretching" or dilation of
  the inside, or collecting part, of the kidney.
• It often results from a blockage in the ureter
  where it joins the kidney that prevents urine
  from draining into the bladder.
• Urine is trapped in the kidney and causes it to
  stretch.
• Hydronephrosis may also be due to abnormal
  backwash or "reflux" of urine into the bladder.

8
Degrees of Hydronephrosis
Kidney function Minimally affected
compensation damage
9
Benign Prostatic Hyperplasia (BPH)
10
Objectives

• What is a BPH
• How to approach a patient with LUTS (lower
  urinary tract symptoms)
• Treatment of BPH

11
Outline

• 1. Definition of BPH
• 2. Anatomy and Physiology
• 3. Microscopic Appearance
• 4. Prevalence of BPH
• 5. Etiology
• 6. Natural History of BPH
• 7. LUTS
• 8. Approach to a patient with BPH
• 9. IPSS
• 10. Differential Diagnosis
• 11. Management of BPH
• 12. Treatment of BPH

12
1.Definition

• BPH is a nonmalignant enlargement of the prostate
  gland caused by cellular hyperplasia of both
  glandular and stromal elements that leads to
  troublesome lower urinary tract symptoms (LUTS)
  in some men
• It is the most common benign tumor in men and is
  not a precancerous condition

13
2.Anatomy and physiology

• The prostate is a compound tubuloalveolar
  exocrine gland of the male mammalian reproductive
  system
• Function is to store and secrete a clear,
  slightly alkaline fluid that constitutes 10-30
  of the volume of the seminal fluid that along
  with the spermatozoa, constitutes semen
• Secret is composed of simple sugars and proteins
  (proteolytic enzymes, acid phosphatase,
  prostate-specific antigen)zinc and citric acid

14
Lower urinary tract
15
2. Anatomy and physiology

• A healthy human prostate is slightly larger than
  a walnut (4cm by 3cm). It surrounds the urethra
  just below the urinary bladder and can be felt
  during a rectal exam. It has anterior, median,
  posterior and two lateral lobes
• Relations Posterior rectal ampulla
  (Denonvilliers fascia)Superior bladder neck
  Anteriorpubic symphysis (retropubic space of
  Retzius) Inferior urogenital diaphragm
• Its work is regulated by androgens which are
  responsible for male sex characteristics

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2.Anatomy and physiology

• Glandular cells produce milky fluid that
  liquefies semen
• Smooth muscle cells, which contract during sex
  and squeeze the fluid from the glandular cells
  into the urethra, where it mixes with sperm and
  other fluids to make semen. The muscle cells are
  stimulated by alpha adrenergic receptors
• Stromal cells (which form the structure of the
  prostate)
• The prostate gland also contains an enzyme - 5
  alpha-reductase that converts testosterone to
  dihydrotestosterone

17
2.1. Zonal Anatomy(McNeal-1972)

• Peripheral Zone 70 of the young adult (60-70 of
  CaP)
• Central Zone 25 (5-10 CaP)
• Transition Zone 5 ( 10-20 CaP) BPH

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Zonal Anatomy
19
3.Microscopic Appearance

• Prostate consists of a thin fibrous capsule under
  which are circulary oriented smooth muscle fibres
  and collagenous tissue. Prostatic stroma lies
  deep to this layer and is composed of connective
  and ellastic tissue and smooth muscle where
  epithelial cells are embeded
• As a male ages, there are more likely to be small
  concretions within the glandular lumina, called
  corpora amylacea, that represent laminated
  concretions of prostatic secretions. The glands
  are normally separated by stroma
• The thin layer of connective tissue that
  surrounds the prostate merges with surrounding
  soft tissues, including nerves

20
4.Prevalence of BPH

• In men 20 to 30 years of age, the prostate weighs
  about 20 g
• however, the mean prostatic weight increases
  after the age of 50.

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4.Prevalence of BPH

• 20 of men age 41-50
• 50 of men age 51-60
• 65 of men age 61-70
• 80 of men age 71-80
• 90 of men age 81-90
• lower urinary tract symptoms associated with
  BPH increase with age.

22
Pathophysiology of Clinical BPH Predictive Risk
Factors

• Increasing age
• Prostatic enlargement
• Lower-urinary-tract symptoms (LUTS)
• Decreased urinary flow rate
• Elevated prostate-specific antigen (PSA)

Slide I.4
23
5.Etiology of BPH

• Androgens
• Estrogens
• Lifestyle
• Hereditary(genetic)/Race

24
5.1 Androgens

• Testosterone and related hormones play a
  permissive role in BPH
• Androgens have to be present for BPH to occur
• Administering exogenous testosterone is not
  associated with a significant increase in the
  risk of BPH symptoms
• Didhydrotestosterone (DHT), a metabolite of
  testosterone is a critical mediator of prostatic
  growth. DHT is synthesized in the prostate from
  circulating testosterone by the action of the
  enzyme 5a-reductase, type 2. This enzyme is
  localized principally in the stromal cells
  hence, these cells are the main site for the
  synthesis of DHT
• DHT can act in an autocrine fashion on the
  stromal cells or in paracrine fashion by
  diffusing into nearby epithelial cells. In both
  of these cell types, DHT binds to nuclear
  androgen receptors and signals the transcription
  of growth factors that are mitogenic to the
  epithelial and stromal cells. DHT is 10 times
  more potent than testosterone because it
  dissociates from the androgen receptor more
  slowly
• the active androgen, DHT, is important in
  promoting growth of prostate that would
  eventually lead to symptomatic BPH.

25
Regulation of Prostate Growth Intrinsic and
Extrinsic Factors
Extrinsic factors
Testicular Androgens Estrogens
Nonandrogenic
Intrinsic factors(prostate)
Epithelium Luminal Basal
Neuroendocrine
Stroma Fibroblast Smooth muscle
Extracellular matrix
Nontesticular Endocrine organs
Neurotransmitters Immunologic
Genetic Homeobox genes
Hereditary diseases
Urethra Urine Testis-epididymal
fluid
Environmental Dietary Micro-organisms (
immune response)
Extrinsic factors
Adapted from Lee C et al. In Benign Prostatic
Hyperplasia. Plymouth, United Kingdom Health
Publication, 200179-106.
Slide III.1
26
Regulation of Prostate GrowthRole of
Androgens

• DHT is the principal androgen responsible for
  prostatic growth and BPH
• 5?-reductase mediates the conversion of
  testosterone to DHT

OH
OH
5?-reductase
O
O
H
Testosterone
Dihydrotestosterone
Adapted from Bartsch G et al Eur Urol
200037(4)367-380.
Slide III.2
27
5.2 Estrogen

• BPH occurs when men generally have elevated
  estrogen levels and relatively reduced free
  testosterone levels
• Prostate tissue becomes more sensitive to
  estrogens and less responsive to DHT
• Cells taken from the prostates of men who have
  BPH have been shown to grow in response to high
  estradiol levels with low androgens present
• Estrogens may render cells more susceptible to
  the action of DHT
• Androgen/estrogen ratio change

28
5.3 Lifestyle

• On a microscopic level, BPH can be seen in the
  vast majority of men over the age of 70 years,
  around the world
• Men who lead a western lifestyle have a much
  higher incidence of symptomatic BPH than men who
  lead a traditional or rural lifestyle

29
6.Natural History of BPH

• Pathological or first phase of BPH -asymptomatic
  and involves a progression from microscopic to
  macroscopic BPH
• Clinical or second phase of BPH - progression
  from pathological to clinical BPH development
  of LUTS
• Mechanical and dynamic components are responsible
  for the progression from pathological to clinical
  BPH
• In clinical BPH, the ratio of stroma to
  epithelium is 5 1
• Asymptomatic hyperplasia the ratio is 2.71

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Pathophysiology of Clinical BPH Overlapping but
Independent Features
Adapted from Nordling J et al. In Benign
Prostatic Hyperplasia. Plymouth, United Kingdom
Health Publication, 2001107-166.
Slide I.2
31
7. Lower Urinary Tract Symtoms-LUTS

• 7.1.Voiding/Obstructive symptoms
• Hesitancy
• Intermittency
• Incomplete voiding
• Weak urinary stream
• Straining to pass urine
• Prolonged micturition
• Terminal dribbling

• 7.2.Storage/Irritative symptoms
• Frequency of urination
• Nocturia
• Urgency (compelling need to void that can not be
  deferred)
• Urge incontinence

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7. Obstructive and irritative symptoms origin

• Obstructive symptoms-mechanical obstruction due
  to glandular enlargement as well as dynamic
  obstruction secondary to contraction of the
  smooth muscle of the prostate, urethra and
  bladder neck. This dynamic obstruction is a
  result of sympathetic nervous system mediated
  stimulation of alpha-1adrenoceptors
• Irritative symptoms - detrusor instability
  related to detrusor muscle changes in response to
  obstruction, such as bladder wall hypertrophy and
  collagen deposition in the bladder
• Adrenoceptors may be further sub-divided into
  alpha1A and alpha1D subtypes, with alpha1A
  predominant in the prostate and alpha 1D in the
  bladder. Thus blockade of alpha1A may be
  necessary for reduction of obstruction whereas
  the blockade of alpha1D may be required to
  relieve storage symptoms

33
8. Differential Diagnosis

• 10.2. Prostatic
• Prostatitis
• Prostate Cancer

• 10.1. Pre-prostatic
• Urethral stricture
• Bladder neck contracture
• Bladder tumors
• Neurogenic bladder
• Bladder calculi
• Urinary tract infections

34
9. Approach to a patient with BPH

• History (LUTS, previous surgery in the GU tract,
  STD and Hx of urethral stricture, prescription
  meds and over the counter meds). Use IPSS
• Physical Examination digital rectal exam ( R/O
  Canodules, asymmetry, hardened ridges,
  induration R/O prostatitis tenderness,
  bogginess R/O anal malignancy and detect
  undiagnosed neurologic conditions by evaluating
  the sphincter tone and perianal
  sensationAbdomianl exam-distended bladder)
• Urinalysis- by dipstick and routine microscopy,
  urine culture and sensitivity to R/O infections
  and hematuria
• Serum PSA-optional to R/O Prostate Cancer

35
9. Approach to a patient with BPH (contd)

• Upper tract imaging (IVP,CT, U/S) only in
  presence of concomitant urinary tract disease or
  complications-hematuria, UTI, renal
  insufficiency, Hx of stone disease
• Cystoscopy- only for patients who dont respond
  to medical Trx to determine the need for surgical
  approach
• Cystometrograms and urodynamic profile -for
  patients with suspected neurologic disease or
  those who failed prostate surgery
• Flow rate, post-void residual urine determination
  and pressure flow- optional

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10. IPSS

• Mild (score 0-7)
• Moderate (score 8-19)
• Severe (score 20-35)

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11. Management of BPH

• Goal- rapid and sustained relief of symptoms
• Decrease bladder outlet obstruction
• Improve bladder emptying
• Lower detrusor instability
• Reverse renal insufficiency
• Prevent future episodes of gross hematuria, UTI
  and urinary retention
• Quality of life and sexuality
• Management depends on severity

38
12. Treatment of BPH

• Lifestyle modification
• Watchful Waiting
• Medical Therapy
• Phytotherapy (alternative)
• Surgical Treatment Conventional Surgical or
  Minimally Invasive Treatment

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12. Treatment Algorithm
40
12.1. Lifestyle Changes

• Enriched diet with ample amounts of fresh fish,
  fruits and vegetables
• Reduce stress
• Exercise on a regular basis
• Weight within normal limits
• Limit fluid intake, decrease bladder
  irritants-caffeine, alcohol avoid
  anticholinergic drugs, narcotics and skeletal
  muscle relaxants
• See your doctor if you develop nocturia
• Be aware of interaction of botanical and medical
  treatment

41
12.2. Watchful Waiting

• The risk of progression or complications is
  uncertain
• In men with symptomatic BPH, progression is not
  inevitable and some men undergo spontaneous
  improvement or resolution of their symptoms
• Retrospective studies on the natural history of
  BPH are inherently subject to bias, related to
  patient selection and the type and extent of
  follow-up. Very few prospective studies
  addressing the natural history of BPH have been
  reported. A large randomized study compared
  finasteride with placebo in men with moderately
  to severely symptomatic BPH and enlarged
  prostates on DRE (McConnell et al, 1998).
  Patients in the placebo arm of the study had a 7
  risk of developing urinary retention over 4 years
  
• Appropriate management of men with mild symptom
  scores (0-7)
• Men with moderate or severe symptoms can also be
  managed in this fashion if they so choose
• Neither the optimal interval for follow-up nor
  specific endpoints for intervention have been
  defined

42
12.3. Medical Treatment

• Alpha blockers
• 5a-Reductase inhibitors
• Combination Therapy

43
12.3. Medical Treatment
Alpha blockers

• Initially used for treatment of high blood
  pressure
• The human prostate and bladder base contain
  alpha-1-adrenoreceptors and the prostate
  contracts to corresponding agonists. The
  contractile properties of the prostate and
  bladder neck are mediated primarily by the
  subtype a1a receptors
• Alpha blockade improves both objective and
  subjective symptoms and signs of BPH in some
  patients
• Alpha blockers can be classified according to
  their receptor selectivity as well as their
  half-life

• Alpha Blockers Oral Dosage
• Alpha-1 short-acting
• Prazosin 2mg
  BID
• Alpha-1, long-acting
• Terazosin 5 or 10 OD
• Doxazosin 4 or 8 OD
• Alpha-1a selective
• Tamsulosin 0.4 or 0.8 OD
  
  

44
12.3. Medical Treatment, Alpha
blockers (contd)

• Short Acting Prazosin
• Long-acting Alfuzosin, Doxazosin mesylate,
  Tamsulosin, Terazosin
• Side Effects dizziness, postural hypotension,
  fatigue, retrograde ejaculation, rhinitis, and
  headaches. May potentiate other antihypertensive
  medications
• Studies have shown that all of them have
  comparable effectiveness and the future research
  is focussed on improving convenience and
  tolerability
• Terazosin and doxazosin may decrease the total
  cholesterol as well as LDL fraction. Both may
  cause first-dose syncope so titration is required
• Alfuzosin and tamsulosin -have alpha 1A
  selectivity and dose titration is not required

45
12.3. Medical Treatment, Alpha
blockers (contd)

• A study performed at the University of Maryland,
  Baltimore, USA, published in Jan. 2007, TitleA
  review of the clinical efficacy and safety of
  5alpha-reductase inhibitors for the enlarged
  prostate
• Conclusion alpha-blockers in men with enlarged
  prostate have reported improvements in total
  symptom scores of 10 to 20 compared with
  placebo
• Do not reduce the risk of long-term complications
  nor disease progression

46
12.3. Medical Treatment 5a-Reductase
inhibitors

• Finasteride is a 5a-reductase inhibitor that
  blocks the conversion of testosterone to
  dihydrotestosterone. It affects the epithelial
  component of the prostate, resulting in a
  reduction in the size of the gland and
  improvement in symptoms
• Six months of therapy are required to see the
  maximum effects on prostate size (20 reduction)
  and symptomatic improvement
• Several randomized, double-blind,
  placebo-controlled trials have compared
  finasteride with placebo. Efficacy, safety, and
  durability are well established
• Symptomatic improvement is seen only in men with
  enlarged prostates (gt 40 mL)
• Side effects include decreased libido, decreased
  ejaculate volume, and impotence. Serum PSA is
  reduced by approximately 50 in patients being
  treated with finasteride, but individual values
  may vary, thus complicating cancer detection
• Cost 73 for 30 day supp.

47
12.3. Medical Treatment 5a-Reductase
inhibitors (contd)

• Dutasteride not enough data! In 3 double-blind
  trials it reduced acute urinary retention (1.8
  versus 4.2- placebo) and need for surgery (2.2
  vs 4.1) but increased impotence ( 7.3 vs 4.0),
  ejaculation disorder, and gynecomastia and
  lowered libido
• Cost 84 for 30 day supp.

48
12.3. Medical Treatment 5a-Reductase
inhibitors (contd)

• Summary
• Significantly reduced the relative risk for acute
  urinary retention(AUR) and enlarged
  prostate-related surgery, slowed the disease
  progression, and showed greater relief of
  symptoms compared to placebo
• Dutasteride, improved symptom scores greater
  after 4 years of therapy compared with 2 years
  (-6.4 vs -4.3 points, respectively) and flow
  rates were better (2.6 vs 2.3 mL/sec).
• Finasteride showed maintenance of the decreased
  risk for AUR and enlarged prostate-related
  surgery over 4 year period
• Generally well tolerated, with sexual dysfunction
  the most frequently reported adverse effect
  (1-8)

49
12.3. Medical Treatment Combination
therapy

• Short term
• Veterans Affairs Cooperative Study, 1229 men with
  BPH randomly assigned to placebo, finasteride,
  terazosin or both for one year. Results as
  follow
• Terazosin lowered the symptom score and increased
  the peak urinary flow rate when compared with
  placebo
• Finasteride alone was no better than placebo
• The combination of finasteride and terazosin was
  no better than terazosin alone

50
12.3. Medical Treatment Combination
therapy (contd)

• Short term
• PREDICT trial in which 1095 men were randomly
  assigned to doxazosin, finasterid or both for one
  year. Resluts as follow
• Doxazosin more effective than finasteride or
  placebo for urinary symptoms and flow rate
• Combination no more effective than doxazosine
  alone
• Conclusion Combination treatment with an
  alpha-blocker and a 5ARI is beneficial for
  immediate relief of symptoms ( with
  discontinuation of the alpha-blocker after
  several months of therapy)

51
12.3. Medical Treatment Combination
therapy (contd)

• Long term
• Medical Therapy of Prostatic Symptoms (MTOPS)
  trial-3047 men with BPH randomly assign. to
  doxazosin, finasteride, combination therapy or
  placebo were evaluated for symptomatic
  improvement and overall clinical progression of
  the BPH. Follow up 4.5 years. Results as follow
• Risk of overall progression- reduced to a similar
  degree by doxazosin and finasteride (39 and 34
  when compared to placebo)
• Combination therapy reduced the risk of clinical
  progression by 66
• Symptom scores improved with all therapies, but
  to a greater degree with combined therapy

52
Combination Therapy for BPH ( MTOPS Study )
53
12.3. Medical Treatment Combination
therapy(contd)

• Combination therapy or finasteride alone (but not
  doxazosin alone), reduced the risk of acute
  urinary retention and the need for invasive
  therapy
• NNT( needed to treat) to prevent one instance of
  overall clinical progression was 8.4 for
  combination therapy, 13.7 for doxazosin, and 15.0
  for finasteride
• AE -similar with combination therapy and
  monotherapy, with the exception of abnormal
  ejaculation, peripheral edema, and dyspnea, which
  were more common with combination therapy
• Conclusion long-term combination therapy lowered
  the risk of overall clinical progression of BPH
  significantly more than treatment with either
  drug alone. In addition, combination therapy or
  finasteride alone (but not doxazosin alone),
  reduced the risk of acute urinary retention and
  the need for invasive therapy

54
12.4. Phytotherapy

• Saw Palmetto Extracts
• Beta-sitosterol plant extract
• Rye Grass Pollen Extract
• Pygeum Africanum

55
12.5. Surgical Treatment Conventional
Surgical Treatment

• For patient who do not experience response to
  medical treatment in 12-24 months for those
  whose symptoms progress
• TURP (transurethral resection of the prostate)-
  Gold standard
• A resectoscope loaded with diathermy loop is
  introduced to the bladder and strips of prostatic
  adenoma are resected and dropped into the
  bladder. The prostate chips are extracted from
  the bladder and hemostasis is achieved with
  electrocautery
• Under general anesthesia or with a regional
  block 60-90 min. Procedure.Requires 24-48 hours
  observation in hospital

56
12.5. Surgical Treatment Conventional
Surgical Treatment
57
12.5. Surgical Treatment Conventional
Surgical Treatment

• Efficacy- decrease in symptom scores and increase
  in maximal urinary flow rates
• Complications bleeding, urethral
  stricture/bladder neck contracture,
  hyper/hypovolemia, retrograde ejaculation (75),
  nausea, vomiting, confusion, hypertension,
  bradycardia, and visual disturbances
• Treatment of complications diuresis and
  hypertonic saline administration for severe cases

58
12.5. Surgical Treatment Conventional
Surgical Treatment

• TUIP (Transurethral incision of the prostate)
• For moderate to severe symptoms and small
  prostate
• Patients had posterior commisure hyperplasia or
  an elevated bladder neck a muscle resection is
  performed
• Short-term improvement in BPH symptoms is about
  the same for TUIP as for TURP
• Lower rate of retrograde ejaculation (25)

59
12.5. Surgical Treatment Conventional
Surgical Treatment

• Open Prostatectomy
• Not done routinely
• When prostate too large for TURP
  (gt100mL)
• Concomitant conditions - bladder diverticulum or
  bladder stone present,recurrent or persistent
  urinary tract infections,acute urinary
  distention,bladder outlet obstructions,recurrent
  gross hematuria of prostate origin,pathological
  changes in the bladder, ureters, or kidneys due
  to prostate obstruction

60
12.5. Minimally Invasive Surgical
treatment

• TUMT-transurethral microwave therapy
• TUNA- transurethral needle ablation
• Urinary Stents
• Laser Prostatectomy

61
12.5. Minimally Invasive Surgical
treatment

• TUMT(transurethral microwave therapy)
• Performed as a single outpatient visit under
  local anesthesia and an oral analgesic. Improves
  symptom scores and urinary flow rates
• (TUMT) uses a special catheter with a tip
  containing an antenna to deliver microwave energy
  to the prostate, thus causing high temperatures
  within the prostate without affecting adjacent
  structures. The heat will kill prostate cells, so
  the prostate will effectively become smaller and
  less obstructing to urine flow. Sensors on the
  catheter and on a tube in the rectum enable
  monitoring of the temperatures throughout the
  procedure, and a cooling system circulates water
  within the catheter to protect the urethra
• Disadvantages the prostate may swell up right
  after therapy due to the heat and a catheter is
  placed for a week. The damaged prostate cells
  will be broken by the body and its molecules
  re-used for several months
• Symptoms may start decreasing after 3 weeks

62
12.5. Minimally Invasive Surgical
treatment

• TUNA (transurethral needle ablation)
• An office procedure performed under local
  anesthesia- improves symptom scores and urinary
  flow rates
• It uses specially designed catheter through which
  interstitial radio-frequency needles are
  deployed from the tip of it. They will heat the
  tissue resulting in coagulative necrosis
• The entire procedure lasts 30-60 minutes
• A catheter is left for 1-4 days after the
  procedure

63
12.5. Minimally Invasive Surgical
treatment

• Intraurethral Stent
• Limited long term experience
• Increases urine flow rates but causes secondary
  obstruction by exuberant granulation tissue
  growth through and around the stent
• Difficult to remove it formation of bladder
  calculi in 50 of patients
• Usually for patients with limited life expectancy
  that are not good surgical or anesthetic
  candidates
• Abandoned by most urologists

64
12.5. Minimally Invasive Surgical
treatment

• Laser Therapy- The wave of the future
• Neodymium yttrium-aluminium-garnet (NdYAG)
  -Visual Laser ablation of the Prostate
• The final result is coagulative necrosis of the
  prostatic urethra and adjacent inner prostatic
  tissue. The obstructive tissue starts to slough
  4-8 weeks post-op leading to an open prostatic
  urethra
  ?
• Green light laser -Laser Vaporization of
  Prostate- causes rapid vaporization of the
  superficial tissue, with a minimal rim (2 mm) of
  coagulation
• Advantage immediate TUR-like efect of the
  prostatic urethra, resulting in shorter duration
  of Foley catheterization in the initial post-op
  period ?
• Holmium-YAG- Laser resection- prostatic lobes are
  resected into multiple small prostate chips that
  fall into the bladder, similar to standard
  electrocautery TURP
• Advantageimmediate anatomical patency of the
  prostatic urethra, resulting in shorter duration
  of Foley catheterization and higher peak flow
  rates in the initial post-op period
  ?

65
12.5. Minimally Invasive Surgical
treatment

• Transurethral balloon dilation of the prostate
• Performed with specially designed catheters
• Most effective in small prostate (lt40mL)
• Does not produce retrograde ejaculation
• May be of value in younger patients wishing to
  avoid or delay TURP, but is unlikely to achieve
  wider application because of the transient
  effects
• Very rarely used today

66
In Summary

• BPH (Benign prostatic hyperplasia) becomes
  increasingly common as men age
• Many men with BPH are asymptomatic or have only
  mild symptoms, and may not require therapy
• Men who develop upper or lower tract injury will
  require surgery
• Alpha-adrenergic antagonists provide immediate
  therapeutic benefits and are first line treatment
  for smaller prostates lt40mL and mild symptoms
• 5-alpha-reductase inhibitors require long-term
  treatment for efficacy and are beneficial for
  larger prostates gt40 mL mild to moderate symptoms

67
In Summary

• Combined alpha adrenergic antagonist and
  5-alpha-reductase inhibitor therapy appears to be
  superior to either agent alone for long-term Trx
• The choice of medical treatment may be made on
  the basis of cost and side-effect profile of the
  drug
• TURP is the GOLD STANDARD for men who require an
  invasive procedure and are in good health
• Men that are poor candidates for surgery and
  require an invasive surgical procedure should be
  advised on TUNA
• Other surgical therapies (TUMT, Laser) may be
  reasonable options based on local expertise

68
Thank you

• Questions???