Benign prostatic hyperplasia lecture.ppt

Benign prostatic hyperplasia lecture.ppt

1. Prostate Gland AdenomaProstate Gland Adenoma
((Benign prostatic hyperplasiaBenign prostatic hyperplasia))
Kazan state medical university
Urology department

2. 
Prostate gland Prostate gland
adenoma adenoma ( (benign benign
prostatic hyperplasiaprostatic hyperplasia) ) is is
age depended age depended
involutional disease. Its involutional disease. Its
clinical manifestation is clinical manifestation is
caused by arising and caused by arising and
enlarging of the enlarging of the
adenomatoid nodesadenomatoid nodes and and
as a result by as a result by
obstructive urination obstructive urination
symptoms developmentsymptoms development

3. ActualityActuality
Prostate gland adenoma is rather Prostate gland adenoma is rather
common diseasecommon disease in elderly menin elderly men. . It is fixed It is fixed
inin 20% 20% among men between among men between 40 40--50 50 years years
oldold, , in age group between in age group between 51-60 51-60 yearsyears in in
50%50% andand  in the age of in the age of в 80 в 80 yearsyears inin 90%  90%
of menof men

4. The most frequent diseases
of the prostate glandof the prostate gland
BPH

Prostate cancer
Prostatitis
80%
2%
18%
Kirby R. et al., 1995

5. BPH developing risk factors
Smoking
Obesity
Alcohol
Sexual activity
Hereditary
predisposition
Androgens

6. PathogenesisPathogenesis

7. PathogenesisPathogenesis

Prostate is the central target-organ for the Prostate is the central target-organ for the
testosteronetestosterone. . Free testosterone enters the cell by Free testosterone enters the cell by
diffusiondiffusion. . It is subjected to an active metabolismIt is subjected to an active metabolism
(inside the cell)(inside the cell), the main phase of which is the , the main phase of which is the
transformation of testosterone to 5α-Dtransformation of testosterone to 5α-DHHT under T under
the action of the 5α-reductase enzyme (5α-R). The the action of the 5α-reductase enzyme (5α-R). The
reaction is irreversible and proceeds on the outer reaction is irreversible and proceeds on the outer
membrane or the endoplasmic reticulum of cells membrane or the endoplasmic reticulum of cells
in the prostate epithelium and stroma. in the prostate epithelium and stroma.

8. PathogenesisPathogenesis

DDHHT-AR complex binds T-AR complex binds withwith these elements as these elements as
a dimer and initiates transcription. Going back a dimer and initiates transcription. Going back
to the cell cytoplasm, the complex controls the to the cell cytoplasm, the complex controls the
biosynthesis of proteins - the latest instance of biosynthesis of proteins - the latest instance of
hormonal information. With aging, the hormonal information. With aging, the
development of development of BPHBPH was explained by was explained by
«accelerat«acceleratinging»» of of this physiological process this physiological process ..

9. PathogenesisPathogenesis
Т Т
5α-R
DHT

10. ClassificationClassification
I stage residual urine up to 50 ml
II stage over 50 ml
III stage – paradoxical ischuria

11. Development of BPH : Early

12. Development of BPH : Intermediate
Slide 2 of 3

13. Development of BPH : Late
Slide 3 of 3

14. SymptomatologySymptomatology

15. Clinical picture of the
adenoma is stipulated
by the urethral
obstruction in prostatic
part and compensatory
changes in urinary
bladder which are
results of urethral
compression by
adenomatoid nodes.
Obstructive symptomsObstructive symptoms

16. Obstructive symptomsObstructive symptoms
WeakWeak stream of urine stream of urine
Trouble urinatiTrouble urinationon
The need to stretch the abdominal wall with The need to stretch the abdominal wall with
urination urination
Increased time Increased time of of urination urination
Uneven urination Uneven urination
DDroproppingping urine at the end of urination urine at the end of urination
Incomplete emptying of the bladder Incomplete emptying of the bladder
Paradoxical isParadoxical iscchuriahuria

17. 
FrequentFrequent urinationurination
with small portionswith small portions

ImperativeImperative urgesurges for for
urination urination


Imperative urine Imperative urine
incontinenceincontinence

NocturiaNocturia
Irritative symptomsIrritative symptoms

18. DiagnosticsDiagnostics

19. DiagnosticsDiagnostics

AnamnesisAnamnesis

IPSSIPSS

PSAPSA

Rectal examRectal exam

TRUITRUI

RoentgenographyRoentgenography

Descending cystographyDescending cystography

Ascending cystographyAscending cystography

MRI,MRI, CTCT

UroflowmetryUroflowmetry

Cystoscopy Cystoscopy

20. International Prostate
Symptom Score (I-PSS)

21. International Prostate
Symptom Score (I-PSS)

22. I-PSS score
Mild (symptom score less than of equal to
7)
Moderate (symptom score range 8-19)
Severe (symptom score range 20-35)

23. DiagnosticsDiagnostics
UrofloUroflowwmetrymetry
1 N1 Normalormal
2 2 BPHBPH
3 3 UUrethrarethrall stricture stricture
44 S Sphincterphincter-detrusor dyssynergia-detrusor dyssynergia

24. DiagnosticsDiagnostics
PSAPSA

Prostate-specific antigen (PSA) is a protein
produced by normal prostate cells. This enzyme
participates in the dissolution of the seminal
fluid coagulum and plays an important role in
fertility. The highest amounts of PSA are found
in the seminal fluid; some PSA escapes the
prostate and can be found in the serum.

25. PSA
PSA levels under 4 ng/mL has traditionally
been used as the cutoff for concern about the
risk of prostate cancer
PSA levels tend to increase with age; this
increase is related to prostate volume. Most
PSA is made in the transition zone of the
prostate, and this region of the prostate
increases in volume in men with BPH.

26. DiagnosDiagnosttiiccss

"H"Hillill" " ssymptomymptom

Multiple Multiple
diverticulumdiverticulums s and and
urinary bladderurinary bladder
stonesstones. Vesico-. Vesico-
ureteral refluxureteral reflux
leftwardleftward..

27. DiagnosDiagnosttiiccss

AA) «) «FFishing hooks» ishing hooks»
symptomsymptom

BB)) Ureterohydronephrosis Ureterohydronephrosis

C) Ascending ureterogramC) Ascending ureterogram

28. DiagnosDiagnosttiiccss

CombinedCombined
growthgrowth..

A) A) TransversalTransversal
scanningscanning

B) Longitudinal B) Longitudinal
scanscanningning

29. DiagnosDiagnosttiiccss
Intravesical growth Intravesical growth ((llongitudinal scanongitudinal scanningning))

30. DiagnosDiagnosttiiccss
A typical picture of A typical picture of
coming out inside the coming out inside the
bladder cavitybladder cavity middle middle
and both side lobes of and both side lobes of
the adenomathe adenoma

31. Differential diagnosisDifferential diagnosis

32. Differential diagnosisDifferential diagnosis

Prostate sclerosisProstate sclerosis

Urethral strictureUrethral stricture

Bladder stonesBladder stones

Prostate cancerProstate cancer

Neurogenic bladderNeurogenic bladder

Chronic prostatitisChronic prostatitis

Nonspecific granulomatous prostatitisNonspecific granulomatous prostatitis

Tuberculous Tuberculous seatseat of the prostate of the prostate

33. Morphogenesis Morphogenesis of the BPHof the BPH

34. Changing Changing of of the anatomic relationships in the the anatomic relationships in the
BPHBPH
developmentdevelopment
Morphogenesis Morphogenesis of the BPHof the BPH

35. 
I I initial initial
proliferative сenterproliferative сenter

II forming II forming
proliferative сenterproliferative сenter

III III developed developed
proliferative proliferative ccenterenter

IV IV developed developed
proliferative proliferative ccenter enter
with signs of with signs of
atrophic changesatrophic changes

VV atrophic atrophic
proliferative proliferative ccenter enter
Morphogenesis Morphogenesis of the BPHof the BPH

36. Clinical courseClinical course

37. Clinical courseClinical course

Intravesical typeIntravesical type

Extravesical typeExtravesical type

38. 
Clinical course of BPHClinical course of BPH
Clinical courseClinical course

39. TreatmentTreatment

40. Indications for concervative
(drug) treatment

The total IPSS score The total IPSS score is moreis more than 8 and less than 19 than 8 and less than 19

QOL is not less than 3 points QOL is not less than 3 points

Maximum urine flow rate (Qmax) less than 15 and not Maximum urine flow rate (Qmax) less than 15 and not
less than 5 mL / sec less than 5 mL / sec

The volume of urination is not less than 100 ml. The volume of urination is not less than 100 ml.

Residual urine volume Residual urine volume is not moreis not more than 150 ml. than 150 ml.

The presence of contraindicationThe presence of contraindication ss to surgical to surgical
treatmenttreatment because because of concomitant diseases of concomitant diseases

Social causes, in particular, the absolute refusSocial causes, in particular, the absolute refusee of the of the
patientpatient from from invasive method of treatment. invasive method of treatment.

41. The main directions The main directions
of of BPH BPH drug therapydrug therapy

HormonHormonee ttherapy herapy

Alpha-adrenoblockers (silodosin, tamsulosin, Alpha-adrenoblockers (silodosin, tamsulosin,
alfusosin, doxazozin, terazozin)alfusosin, doxazozin, terazozin)

Inhibitors of 5-alpha-reductase Inhibitors of 5-alpha-reductase (finasteride, (finasteride,
dutasteride)dutasteride)

VVegetable origin egetable origin ddrugs (rugs (extracts of Serenoa extracts of Serenoa
repens, repens, Pygeum africanum))

Other groups of drugs Other groups of drugs (antimuscarinic)(antimuscarinic)

42. Indications for surgical treatment
According to the recommendations of the 4 th
meeting of the International Conciliation
Committee on BPH (1997), absolute indications for
surgical treatment are:
- Delay urination (inability to urinate after at least
one catheterization, either by the impossibility
of catheterization);
- 
  
Massive re hematuria, associated with BPH;
- 
   
Renal failure caused by BPH;
- 
  
Bladder stones;
- Re-infection of the urinary tract, due to BPH;
- 
  
A large bladder diverticulum.

43. Radical methods of Radical methods of
surgical treatmentsurgical treatment

44. Currently, the main method of Currently, the main method of BPH BPH treatment treatment
remains remains operativeoperative, among the many ways , among the many ways of of that that
the most effective and popular is the the most effective and popular is the
transurethral resectiontransurethral resection (TUR)(TUR) of prostate of prostate
TTURUR - a kind of - a kind of
eelectrosurgical lectrosurgical
endoscopic operation endoscopic operation
in which tissue removal in which tissue removal
(resection) and (resection) and
coagulation of vessels coagulation of vessels
is carried out by high is carried out by high
frequency electric frequency electric
current using a special current using a special
endoscopic instrument endoscopic instrument
- re- resectoscopesectoscope
conducted by urethraconducted by urethra
lumenlumen..

45. Technique of BPH TUR.Technique of BPH TUR.

46. Technique of BPH TUR.Technique of BPH TUR.

47. Indications for adenomeIndications for adenomectomyctomy

Absolute indicationsAbsolute indications
delay urination (inability to urinate after at least one
catheterization)

Massive re hematuria, associated with BPH

Renal failure caused by BPH

Vesico-ureteral refluxVesico-ureteral reflux

Bladder stones

A large bladder diverticulum

Paradoxical isParadoxical iscchuriahuria

Exacerbation of chronic pyelonephritisExacerbation of chronic pyelonephritis

Ineffective Ineffective concervativeconcervative treatment treatment

48. Urgent adenomectomy indicatedUrgent adenomectomy indicated

In In a case of a case of life-threatening life-threatening
bleedingbleeding

In acute delayIn acute delay of of urination urination and and
generally satisfactory state of the generally satisfactory state of the
patientpatient

49. Surgical approachesSurgical approaches
1)transvesical
2)retropubic
3)perineal
4)ischio-rectal
5)transrectal
6)transperitoneal

50. Perineal methodPerineal method

Access at perineal adenomectomyAccess at perineal adenomectomy

51. Perineal methodPerineal method

Indications for perineal adenomectomyIndications for perineal adenomectomy: :
inability of performinginability of performing transvesical and transvesical and
retropubic adenomectomyretropubic adenomectomy because of because of
rough scar deformation front surface of rough scar deformation front surface of
stomach and pubic bones stomach and pubic bones

52. Retropubic methodRetropubic method

А) А) Exposure Exposure
prostate prostate capsulecapsule

BB) ) Dissection of Dissection of
the capsulethe capsule

CC andand DD)) Husking Husking
adenomaadenoma

53. Transvesical methodTransvesical method

Husking of the Husking of the
adenomatoid nodeadenomatoid node

54. Transvesical methodTransvesical method

237) 237) With the help With the help
of Foley catheterof Foley catheter

238)238) Putting in Putting in
tobacco-pouchtobacco-pouch stitchstitch

239)239) By Harris By Harris

240)240) By Hrinchak By Hrinchak

55. 

HEMOSTASISHEMOSTASIS
(by (by rremovable ligaturesemovable ligatures))
Ситдыков Э.Н., Автореф.дис., к.м.н. Казань 1964

56. Laser therapy in the treatment of
BPH
Visual laser ablation of the prostate
Laser vaporization of the prostate
Laser resection of the prostate
Laser enucleation of the prostate (with tissue morcellation)
Laser incision of the prostate
Interstitial laser coagulation
Many urologists, for simplicity, refer to all types of laser
therapy of the prostate as “laser prostatectomy,” despite
the fact that in many of these therapies no prostate tissue
is physically removed.

Muta M Issa, 2007