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Benign Prostatic Hyperplasia

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Benign Prostatic Hyperplasia Hann-Chorng Kuo Department of Urology Buddhist Tzu Chi General Hospital Bladder Outlet obstruction Bladder neck dysfunction Prostatic ... – PowerPoint PPT presentation

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Title: Benign Prostatic Hyperplasia


1
Benign Prostatic Hyperplasia
  • Hann-Chorng Kuo
  • Department of Urology
  • Buddhist Tzu Chi General Hospital

2
Bladder Outlet obstruction
  • Bladder neck dysfunction
  • Prostatic enlargement
  • Urethral stricture
  • External sphincter dyssynergia
  • Urethral meatal stenosis
  • BOO is a condition of progressive degree

3
Lower urinary tract symptomsIPSS AUA symptom
score
  • Frequency
  • Urgency
  • Nocturia
  • Small caliber of urine
  • Dysuria
  • Intermittency
  • Residual urine sensation

4
LUTS and BOO
  • 1/3 of men with LUTS do not have BOO
  • 5 - 35 of patients with BPH LUTS do not
    improve symptoms after TURP
  • LUTS have a poor diagnostic specificity for BOO
  • Prostate size and uroflowmetry have better
    correlation with urodynamic study than symptoms
    alone

5
Pathogenesis of Bladder outlet obstruction
  • Progressive increased urethral resistance
  • High voiding pressure and low flow
  • Bladder compensation in energy
  • Increased residual urine volume
  • Elevated intravesical pressure at end-filling
  • Bladder stone, diverticulum, UTI
  • Hydroureter, hydronephrosis, azotemia

6
Reduction in AChE-positive nerve fibers after BOO
7
Differential diagnosis of male BOO and LUTS
  • Benign prostatic enlargement
  • Bladder neck dysfunction
  • Spastic urethral sphincter
  • Poor relaxation of urethral sphincter
  • Urethral stricture
  • Low detrusor contractility
  • Pseudodyssynergia due to neuropathy

8
Relation of prostate and urethra
9
Benign prostatic hyperplasia
  • Prostatic enlargement benign or malignant, a
    sign
  • Prostatic hyperplasia histological term
  • Prostatic obstruction a clinical diagnosis
  • Bladder outlet obstruction an urodynamic term
  • Lower urinary tract symptoms symptom

10
Anatomy of Prostate gland
11
Anatomy of Prostate gland
12
Prostatic glandular anatomy
13
Cystoscopic Prostatic obstruction
14
Benign Prostatic Hyperplasia
  • BPH requires testicular androgen during prostatic
    development
  • Basic fibroblast growth factor, epidermal growth
    factor, keratinocyte growth factor, transforming
    growth factor-beta play some part in prostate
    growth
  • Decreased endogenous apoptosis in prostate cause
    abnormal tissue growth in prostate

15
Histology of Benign prostatic hyperplasia
16
Clinical BPH
  • LUTS ( storage or empty symptoms) due to
    histological benign prostatic hyperplasia and
    urodynamical bladder outlet obstruction which has
    been proven by urodynamic pressure flow study as
    prostatic obstruction
  • Treatment for LUTS and restoration of normal
    storage and empty function by reducing prostatic
    enlargement either medically or surgically

17
Pathophysiology of BPH and LUTS
  • Nodular proliferation of prostate gland
  • Increased stroma to epithelial ratio to 21 to
    51 in benign prosatic hyperplasia
  • Increased smooth muscle component
  • Detrusor compensatory change and bladder
    dysfunction, detrusor overactivity
  • LUTS may related to BPH or detrusor
    dysfunction,or combination

18
Symptom scores of BPH as treatment guideline
  • 1970 Boyarsky and Madsen-Iverson
  • 1992 AUA symptom index
  • International prostatic symptom score adds
    quality of life index
  • Bothersomeness and health related quality of life
    (HRQOL)
  • Symptom problem index
  • BPH impact index (BII)

19
Clinical evaluation of BPH
  • Digital rectal examination of prostate
  • -- Prostate size, consistency, surface
    nodularity, tenderness
  • Bladder palpation residual urine volume
  • Cystography, Intravenous pyelography
  • Transrectal sonography of prostate
  • Cystourethroscopy

20
Cystography of Bladder base elevation indicating
BPH
21
Sonography of BPH
22
Clinical evaluation of BPH
  • Uroflowmetry, prstatic volume
  • Postvoid residual urine volume
  • Prostatic specific antigen (PSA)
  • Pressure flow study improves in diagnosis and aid
    in selection for specific invasive treatment
  • Videourodynamic study is helpful in determining
    complicated case

23
Uroflowmetry in BPH without or with obstruction
24
Pressure flow study in BPH with Obstruction
25
Videourodynamic study in BPH with Obstruction
26
Causes of non-obstructive Men with LUTS
  • Normal bladder and urethra 25
  • Bladder hypersensitivity 17
  • Detrusor instability 6
  • Detrusor underactivity 3
  • Poor relaxed urethral sphincter 61

27
Videourodynamic study in Man with normal bladder
and urethra
28
Videourodynamic study in Man with low detrusor
contractility
29
Videourodynamic study in Man with Poor relaxation
of sphincter
30
Subjective improvement rate in patients after
prostatectomy
31
Improvement in Qmax after Prostatectomy
32
Causes of 185 Men with LUTS after prostatectomy
  • Normalbladder and urethra 17
  • Detrusor instability 18
  • Low detrusor contractility 35
  • Poor relaxation of urethral sphincter 36
  • Detrusor instability and low contractility 27
  • Bladder outlet obstruction 52

33
Prostate volume, Qmax, resected prostate weight
in patients with LUTS after prostatectomy
34
Urodynamic parameters in BPH
35
Relationship of Qmax and Age in BPH patients
36
Clinical Prostate Score in BPH
37
Calculation of Clinical Prostate Score for
Diagnosis of BPO
  • Prostate score Qmax TPV voided volume
    residual urine
  • Score ? 3 sensitivity 90.7,
    specificity 33
  • Prostate score Qmax flow pattern voided
    volume residual urine TPV TZI prostatic
    configuration
  • Score ? 3 sensitivity of BPO 87.2,
    specificity 60.8
  • Score ? 4 sensitivity of BPO 90.7,
    specificity 50.5
  • Score ? 5 sensitivity of BPO 97.6,
    specificity 38.2
  • Sensitivity and specificity of BPO diagnosis in
    patients with at least 1 favorable predictive
    factor (n 148)
  • Score ? 3 sensitivity of BPO 91.6,
    specificity 87.27
  • Exclusion of patients with at least 1 favorable
    predictive factor (n176)
  • Score ? 3 sensitivity of BPO 68.9,
    specificity 23.0

38
Prostatic Transition Zone Index
39
A-G Number in Diagnosis of BPO
40
Treatment of BPH
  • Treating an enlarged prostate ?
  • Treating lower urinary tract symptoms?
  • Treating bladder outlet obstruction?
  • Can LUTS disappear after treatment?
  • Can BOO be relieved after treatment?
  • Any complication may occur?
  • Is the treatment cost- effective ?

41
Therapeutic modalities for LUTS ascribed to the
prostate
  • Watchful waiting and fluid restriction, natural
    history of BPO may wax and wan
  • Medical treatment to reduce prostate size or
    decrease intraprostatic resistance
  • Surgical treatment to remove prostatic
    obstruction or reduce urethral resistance
  • Minimally invasive therapies

42
Surgical Treatment for BPH
  • Suprapubic retropubic prostatectomy
  • Transurethral prostatectomy (TUR-Prostate)
  • Laser interstitial prostatectomy
  • Transurethral incision of prostate
  • Intraprostatic stent
  • Balloon dilatation of prostatic urethra
  • Prostatic hyperthermia

43
Prostate Resectoscope and TURP
44
Complications of TUR-Prostate
  • Peri-operative bleeding
  • Urinary tract infection and urosepsis
  • Electrolyte imbalance, hemolysis, acute tubular
    necrosis
  • Acute pulmonary edema
  • Bladder neck or urethral contracture
  • Retrograde ejaculation and erectile dysfunction
  • Urge or stress urinary incontinence

45
Minimally invasive procedure
  • Transurethral vaporization- resection of prostate
    (TUVRP)
  • Ho-YAG laser coagulation of prostate
  • Visual laser ablation of prostate (VLAP)
  • Transurethral needle ablation (TUNA)
  • High intensity focused ultrasound (HIFU)
  • Microwave hyperthermia
  • Minimally invasive minimally effective?
  • A higher re-treatment rate than TURP although
    less complication occurs

46
Intra-Prostatic Stent
47
Interstitial Laser Coagulation
48
Hyperthermia of BPH
49
Transurethral Dilatation of Prostate
50
Medical Therapy for BPH
  • Prostatic smooth muscle tension was mediated by
    alpha 1-adrenoreceptors
  • Smooth muscle contractions contribute 40 of
    outflow obstruction
  • Alpha 1- blockers can rapidly improve Qmax and
    relieve LUTS
  • Phenoxybenzamine, terazosin, doxazosin have side
    effect of dizziness and hypotension

51
Prostatic specific alpha- adrenoreceptor
  • Alpha 1A- AR subtype comprises 70 of all alpha-1
    receptors
  • Alpha 1A-AR agonist tamslosin has 13 x more
    affinity to prostatic smooth muscle than urethral
    muscle , 10 x than vascular smooth muscle
  • Side effects are still reported
  • Long-acting (once daily) dose

52
Hormone based medical therapy
  • 5-alpha-reductase catalyzes conversion of
    testosterone to dihydrotestosterone
  • Inhibition of 5-alpha-reductase can arrest
    prostatic growth and relieve obstruction
  • Finasteride can improve symptom score,Qmax, QOL
    score
  • Effective especially in prostatic weight of gt40
    gm and effective in prostatic hematuria

53
Combination therapy with alpha-blocker and
finasteride
  • Terazosin is effective therapy, finasteride was
    not, combination was no more effective than
    terazosin alone (Lepor, N Engl J Med 1996 335
    533)
  • Combined dibenyline and finasteride has an
    additive effect than dibenyline or finasteride
    alone in improvement of Qmax and prostatic size

54
Consideration in treating BPH
  • Patients are old in symptomatic BPH
  • Too early surgery may lead to undesired sequalae
    such as erectile dysfunction
  • Too late surgery cannot reverse detrusor
    overactivity and leads to urge incontinence
  • Etiology of LUTS (DI? DHIC? BOO?) should be
    clarified to prevent unsuccessful surgical results

55
Therapeutic guideline for BPO
  • Calculation of clinical prostatic score and QOL
    index, medical treatment for BPO
  • Monitoring Qmax, residual urine volume, and
    prostate volume during treatment
  • If obstructive or irritative symptom exacerbate,
    detailed pressure flow study to confirm the BOO
    diagnosis
  • Surgery for patients with poor QOL index
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