Benign Prostatic Hyperplasia

Prostate anatomy and BPH

1. MANAGEMENT OF BPH Moderator : Dr M Talukdar Associate Professor Presenter : Dr Monitosh Paul 2 nd yr PGT

2. Anatomy of Prostate It is an accessory gland of male reproductive system Average weight 20gms Capsules: True capsule- condensation of peripheral part of gland & False Capsule- derived from pelvic fascia Lobes: 5 lobes; 1anterior, posterior, 2 lateral lobes and 1 median lobe

3. Zonal Anatomy of Prostate (McNeal Classification) Transition Zone  median lobe Central Zone │ Peripheral Zone│  posterior & lateral lobes Anterior fibromuscular stroma  anterior lobe

4. Blood Supply of Prostate Arterial Supply From Inferior vesical artery prostatic artery divides into two main branches: Urethral artery- supply urethra, periurethral glands, transition zone Capsular artery Venous drainage to periprostatic plexus(Santorini’s plexus )  Internal iliac vein

5. Benign Hyperplasia of Prostate (BPH) BPH is benign enlargement of prostate which involves increase in number of cells in both glandular epithelium and connective tissue stroma It commonly develops from periurethral transition zone Theories: Hormonal(disturbance in androgen and estrogen ratio), neoplastic theory ( fibromyoadenoma )

6. Pathology: BPH involves median and lateral lobes or one of them Median lobe enlarges into bladder Lateral lobe enlargement causes narrowing of urethra causing obstruction Initially there is trabeculations and sacculation formation in bladder and later diverticula formation Enlarged prostate compresses prostatic venous plexus causing congestion , vesical piles leading to haematuria Backpressure hydroureter and hydronephrosis Chronic pyelonephritis Obstructive uropathy with renal failure

7. Lower Urinary Tract Symptoms (LUTS): Storage Symptoms(Irritative Symptoms) : frequency (m/c), urgency, incontinence, nocturia, pain Voiding Symptoms( Obstructive Symptoms) : weak stream, hesitancy, urinary retention Post mictural LUTS: incomplete emptying and post void dribbling Bladder Outlet Obstruction: Voiding symptoms along with postmictural LUTS

8. Management of BPH Diagnosis: Medical History: History of hematuria, uti , urinary retention History of diabetes, nervous system disease, urethral stricture disease Medications like: anticholinergics and α sympathomimetic drugs Signs and Symptoms: Two scoring systems are: American Urological Association Symptom Scoring Index( AUA SS Score) 0-7 = mild 8-19 = moderate 20-35 = severe 2. International Prostate Symptom Score (IPSS)

9. Examination: Physical Examination -Abdominal Examination- Supra pubic bulge with tenderness - Examination of external Genitalia(abnormality, discharge) - Digital Rectal Examination Urinalysis: routine, microscopy, culture Kidney Function tests Serum Prostate Specific Antigen Ultrasonography KUB

10. Additional Diagnostic investigations: Urethrocystogram Urodynamic and Pressure/flow study flowmetry bladder pressure >15-20ml/sec- normal >80 cm H2O - high 10-15ml/sec –equivocal 60-80 cm H2O - equivocal <10ml/sec – BOO <60cm H2O - normal Urethro-cystoscopy TRUS & biopsy (if elevated PSA or suspicious DRE)

11. Treatment : Watchful Waiting Pharmacological treatment Surgical treatment

12. Watchful waiting • In patients with mild symptoms Regular follow ups • Patients with moderate symptoms who are not bothered by their symptoms

13. Medical Management • Non selective alpha 1 antagonists a) short acting: Prazosin, Alfuzosin b) long acting: Terazosin, Doxazosin • Selective alpha 1 A antagonists Tamsulosin, Silodosin • 5- alpha reductase inhibitors Finasteride, Dutasteride • Miscellaneous PDE 5 inhibitor – Tadalafil GnRH agonists – Naferelin acetate, Leuprolide

14. Alpha 1 blockers • Relaxation of both bladder neck and prostatic smooth muscle, thus decreasing pressure in the bladder and urethra improve the urinary flow • Improve the obstructive symptoms than irritative symptoms • Drugs are- Prazosin, Terazosin , Doxazosin , Alfuzosin , Tamsulosin , Silodosin 5 alpha reductase inhibitors • In prostate, testosterone converted to dihydroxy testosterone ( DHT ) by 5 alpha reductase enzyme. • DHT increases the growth in prostate • Drugs: Finasteride, Dutasteride

15. Surgical Management INVASIVE Open prostatectomy Endoscop ic -Transurethral resection of prostate (TURP) -Transurethral incision of prostate (TUIP) MINIMALLY INVASIVE - Transurethral electro vaporizations (TUEV) - Transurethral microwave thermotherapy (TUMT) - Transurethral needle ablation (TUNA) - Laser ablation - High intensity focused ultrasound - Transurethral ethanol ablation - Water induced thermotherapy

16. Indication of Surgical Intervention (1) acute urinary retention; (2) recurrent or persistent UTIs; (3) significant symptoms from bladder outlet obstruction not responsive to medical therapy; (4) recurrent gross hematuria of prostatic origin; (5) pathophysiologic changes of the kidneys, ureters, or bladder secondary to prostatic obstruction; and (6) bladder calculi secondary to obstruction.

17. Open Prostatectomy Indications: Patients with symptomatic bladder outlet obstruction due to BPH and markedly enlarged prostate gland Patients with a concomitant bladder condition, such as bladder diverticulum or large bladder calculi Patient who cannot be placed in the dorsal lithotomy position for TURP

18. Different approaches of Open Prostatectomy: Freyer’s Suprapubic Transvesical Prostatectomy Millin’s Retropubic Prostatectomy Young’s Perineal Prostatectomy

19. Minimally Invasive & Endoscopic management of BPH Transurethral resection of Prostate(TURP) Transurethral Needle Ablation of Prostate(TUNA) Transurethral Microwave Therapy(TUMT) Lasers Transurethral Vaporization of Prostate Transurethral Incision of Prostate(TUIP) Intraprostatic Stents PKVP( TUVis ) (plasma kinetic vaporization) and TURis (transurethral resection in saline)

20. Transurethral Resection of Prostate(TURP) It is Gold standard for surgical management of BPH Resection done from proximal to distal If large middle lobe, then it is done first

21. Stages of TURP 1 st stage: Resect bladder neck(superiorly to inferiorly) 12 to 3 O’clock 2 nd stage: resect lateral & median lobes( superiorly to inferiorly) 3 rd stage: resect apical lobes (inferiorly to superiorly)

22. Complications of TURP Hemorrhage Clot Retention TURP Syndrome Incontinence Retrograde Ejaculation (m/c) Re-operation 5-15% Strictures (m/c bladder neck )

23. TURP Syndrome Occurs within 4-6 hrs of surgery Primarily due to dilutional hyponatremia Features: confusion, disorientation, nausea, vomiting Management: S. Na <120mmol/L → 3% NaCl (not >8-10mEq/L/day) S. Na>120 mmol/L → fluid restriction

24. Transurethral radiofrequency needle ablation of prostate (TUNA) Low-level radiofrequency is transmitted to the prostate via transurethral needle delivery system The resultant heat causes localized necrosis of the prostate.

25. Laser Therapy: Mechanism of action Ablation Resection Vaporization Types of Laser used : Nd:YAG KTP(Potassium Titanyl Phosphate) Ho:YAG laser Diode Laser

26. Novel approaches: • Gene therapy • COX-2/ LOX-5 inhibitors • Vit D3 analogue • Antibody dendrimer conjugates • Oxytocin antagonists • Radio nucleotide therapy • NX-1207 (pro-apoptotic)

27. THANK YOU