power point presentation

1. MANAGEMENT OF
BPH
PRESENTER
DR.MUHAMMAD UJUDUD MUSA
SURGERY DEPT.
A.K.T.H. KANO
10th MARCH, 2009.

2. OUTLINE
INTRODUCTION
SURGICAL ANATOMY
PATHOLOGY
HISTORY
EXAMINATION
DIFFERENTIALS
INVESTIGATIONS
RESUSCITATION
TREATMENT OPTIONS
WATCHFUL WAITING
MEDICAL THERAPY
MINIMALLY INVASIVE RX
SURGERY
FOLLOW UP
CONCLUSION
REFERENCES

3. INTRODUCTION
When the hair becomes grey & scanty,
when the specks of earthly matter begin
to be deposited in the tunics of the artery
& when a white zone is formed @ the
margin of the cornea, @ this same
period the prostate gland usually- one
might perhaps say invariably- becomes
increased in size. (Sir Benjamin C.B
1783-1862).
Riolan recognized urinary obstruction
due to BPH in 17th Century, the
pathology credited to Virchow in 19th
Century.

4. INTRO CONTD.
BPH a fibromyoadenoma is the commonest dx
of the prostate-80%.
Not seen <20yrs 8% - < 40yrs 50%-57 to
60yrs & 90% - 80yrs.
Afflicted about 14M in the USA & 30M world
wide.
Presence of testis, androgen, oestrogen
imbalance, familial, genetic, nutritional &
metabolic factors incriminated
Stem cell & neoplastic theories, the DHT,
embryonic reawakening & non androgenic
testis secretory factor hypothesis offer some
explanations.
Microscopic, macroscopic & clinical divisions
of BPH.

5. SURGICAL ANATOMY

6. SURGICAL ANATOMY
The Prostate gland arises from the primitive
urethra as a series of epithelial buds @
12weeks of embryonic life.
It lies behind the pubis symphysis separated by
pubo-prostatic ligaments, fibro-fatty & blood
vessels.
A cone shaped gland extends from the bladder
neck to the urogenital diaphragm surrounds the
prostatic urethra measures 3.5 * 2.5cm &
weight 18-26g.
Mc Neal classified prostate into 4 zones:
peripheral, central, transitional & pre-prostatic
zones

7. SURGICAL ANAT. CONT.

8. ZONES OF PROSTATE

9. ANATOMY CONT.
Blood supply: middle & inferior rectal
arteries. Venous drainage to the prostatic
plexus to internal iliac vein.
venous plexus connect with valve less
vertebral veins through which ca may
spread.
Lymphatic drainage to internal iliac
vessels connect to sacral spinal vessels
Nerve supply: sympathetic &
parasympathetic

10. HISTOLOGY OF PROSTATE

11. PATHOLOGY
Nodular hyperplasia with a variegated gross
appearance mainly in the peripheral zone separated by
a distant smooth cleavage plane from the pathological
capsule
Randall observed 8 gross configurations
{1} Simple bilateral lobe hypertrophy
{2} Posterior commissural
{3} Subcervical (Abarran’s lobe)
{4} Anterior commissural
{5} Subtrigonal (lobe of Home)
{6} Median
{7} Lateral & median
{8} Lateral & Subcervical
# The epithelial cells may be tall columnar, cuboidal or
flattened low cuboidal
May be arrange peripherally, show papillary infolding or
assume a cribriform pattern
# Both ductal & acinar epithelium appear to be involved in

12. PATHOLOGY CONT.
Franks identified types of nodules histologicaly:
stromal (fibrovascular), fibromuscular, muscular,
fibroadenoma & fibromyoadenoma.
Histological variants :postatrophy, basal
cribriform & atypical adenomatous hyperplasia,
sclerosing adenomas & stromal hyperplasia with
giant cells.
The capsule transmits the pressure to the
urethra which causes prostatism, Collin's knife is
used to incise the capsule to improves outflow
obstruction.
The hyperplastic nodes compress the periphery
to form the false capsule from which BPH can be
enucleated or resected.

13. BPH

14. BPH

15. EFFECTS ON BLADDER
•
• Bladder wall hypertrophy
Bladder wall hypertrophy
-
-trabeculations
trabeculations,
, sacculations
sacculations,
,
diverticulations
diverticulations
-
-Hydroureteronephrosis
Hydroureteronephrosis –
– CRF
CRF -
-
Haematuria
Haematuria
•
• Urine stasis
Urine stasis –
– UTI
UTI
-
- Calculi formation
Calculi formation

16. PRINCIPLES OF MANAGEMENT
Patient selection the mode of therapy &
education about the disease
To identify the patient’s LUTS both symptomatic
& physiologic.
To establish the etiologic role of BPH to LUTS
To evaluate the necessity for & probability of
success & risks of various therapeutic approach
to these problems.
To present the results of these assessments to
the patient for an informed consent about mgt
recommendations & available alternatives
The clinical evaluation centres on an evaluation
of symptoms, signs, lab results, selected images
& endoscopic studies
The insidious symptoms are recognized by yes
answer to any of : Do you wake up to micturate,
slow urine flow or bothersome bladder

17. HISTORY
Age
Irritative (overactive) Symptoms
Obstructive (underactive) symptoms
Jepsen & Bruskewitz review of LUTS: Nucturia >
Urgency
Heamaturia
Urine retention
Recurrent UTI
Ureamia
IPSS
Boyarsky Symptom Index
Madsen Inversen Index
Maine Medical Assessment Index

19. ACUTE URINE RETENTION

20. CHRONIC URINE RETENSION

21. DIFFERENTIALS
IRRITATIVE SYMPTOMS
UTI & Cystitis
Bladder calculus
Carcinoma of the prostate
Carcinoma of the bladder
Vesical Schistosomiasis
Brain Tumour
Internal hydrocephalus
Diabetes mellitus
CVA
Parkinsonism
Multiple sclerosis
OBSTRUCTIVE SYMPTOMS
Urethral stricture
Carcinoma of the prostate
Carcinoma of the bladder
Vesical calculus
Phimosis
Neurogenic bladder

22. EXAMINATION
General physical examination: Anaemia,
dehydration, ureamic frost oedema e.t.c
Chest
CVS
Abdomen: swelling, tenderness, palpable kidney,
bladder & other masses, hernial orifices, genitalia
for evidence of stricture DRE: after
micturation/catherisation, tenderness, size,
surface, consistency median sulcus & rectal
mucosa.
Expressed prostatic secretions
Post void residual urine estimation

23. INVESTIGATIONS
TRUS
TRUS guided biopsy
PSA
EPS
Colour doppler imaging of the prostate
Urethrocystoscopy
IVU
U&E
Urinalysis & MCS
FBC
Plain Abdominal X-ray

24. IVU

25. BIOPSY NEEDLES

26. CYTOSCOPIC VIEW OF BPH

27. COMPLICATIONS OF BPH
Retention of urine
Recurrent UTI
Diverticuli
Hydroureter & hydronephrosis
Vesical calculus
Heamaturia
Progressive renal failure
Effects of quality of life: sleep, recreation e.t.c

28. TREATMENT
Resuscitation
Relieve of urine retention
Watchful waiting
Medical Rx
Minimally invasive Rx
Surgery

29. RESUSCITATION
IVFs
Antibiotics
Blood transfusion
Dialysis

30. WATCHFUL WAITING
IPSS < 8
Patients adequately assessed & Ca.
prostate R/o
DRE, Serum PSA, TRUS guided prostatic
biopsy.
Regular: IPSS, PFR, PSA, PVR, Abd USS
& DRE @ follow up.
Abandon when patient’s condition is
deteriorating

31. MEDICAL THERAPY FOR BPH
Ideal for those with IPSS < 19
ALPHA ADRENERGIC BLOCKERS: e.g.
Terrazosin & doxasoxin (long acting)
Tamulzosin & Alfuzosin
ANDROGEN SUPPRESION: e.g. Finesteride &
Episteride ( 5ARI) Zanoterone ( receptor
antagonist)
AROMATASE INHIBITORS : e.g. Atamestame
PHOSPHODIESTERASE INHIBITORS: e.g.
Tadalif
COMBINATION THERAPY: e.g. Sildenafil &
Alfuzosin

35. MINIMALLY INVASIVE RX
The mgt of BPH is of timely importance to patients,
their spouses & relatives hence the development of
these techniques.
INDICATIONS: IPSS 8-19 & Pts with severe
symptoms but unfit for surgery.
CONTRAINDICATIONS:
{1} Recurrent heamaturia
{2} Refractory acute or chronic retension
{3} Bladder stone due to BPH
{4} Hydroureters & hydronephrosis
{5} Large diverticuli
{6} Renal insufficiency
{7} Recurrent UTI

36. AVAILABLE MI TECHNIQUES
High intensity focus ultrasound HIFU
Transurethral laser therapy TULIP: {a}Intestitial
laser coagulation of the prostate
{b}Holmium laser ablation of the prostate HoLAP
{c}Holmium laser resection of the prostate HoLRP
{d}Photoselective vaporisation of the prostate PVP
{e}Thulium laser resection of the prostateTmLRP
Hyperthermia & thermotherapy
Intraurethral stents
Transurethral needle ablation of prostate TUNA
Transurethral balloon dilatation
Laparoscopic simple prostatectomy
Transperineal botulium toxin injection

37. MIT CONTD.
Transurethral vaporisation of the prostate: is
done with a grooved roller ball electrode to
vaporises the prostate by T > 100^C
HoLRP: uses the resectoscope to push the
adenoma into the bladder & remove using tissue
morcellator.
HIFU: involves tissue ablation by inducing high T
90-100^C using a sonoblate probe.
Prostatic stents: temporary ( gold plated
prostakin) & permanent ( urolome ).
TUNA: high frequency radio waves are used to
achieve high T 120^C.
PVP: performed with the potassium titanyl
phosphate ( KTP) laser which is selectively
absorbed by hemoglobin resulting in the
vaporisation of intercellular water in the tissue

38. SURGERY
INDICATIONS
Retension
Heamaturia
Vesical Calculus
UTI
Bladder Diverticulum
Ureamia
IPSS 19 – 35
Failure of MT & MIT

39. SURGERY CONTD.
CONTRAINDICTIONS
Frail elderly
Severe co morbidity
Severe bleeding diesthesia

40. PRE OP PREP.
Correct Dehydration
Correct Anaemia
Correct Dyselectrolytemia
Catheterization
GXM
Urethroscopy
DRE, IPSS & Flow rate
Consent
IVFs for irrigation

41. SURGICAL OPTIONS
Transurethral incision of the prostate
TUIP
Transurethral resection of the prostate
TURP
Open prostatectomy
AIM: to relieve the outflow obstruction by
removal of the adenoma from the outer
shell of the compressed capsule
Cystoscopy is done

42. TRANSURETHRAL INCISION OF
THE PROSTATE (TUIP)
Small prostate with a tight bladder neck &
no middle lobe enlargement.
Post op PFR of > 18mls/sec
< 10% will develop retrograde ejaculation
10% relapse & require TURP.

43. TRANSURETHRAL RESECTION
OF THE PROSTATE (TURP)
Done with a curved wired electrode rigid
resectoscope.
It carve a passageway from the bladder after
which a 3-way Foley's catheter is inserted &
irrigation commenced.
Pt is discharged on 4DPO but may have
haemorrhage on the 10DPO.
Mortality is 1.5% & morbidity increase with
resection time > 90min.
Improve IPSS in 88% & PFR of 8- 18mls/sec in
85%.3.4% 5yrs failure rate

44. COMPLICATIONS OF TURP
Primary haemorrhage (5-15%)
Secondary haemorrhage
Urinary incontinence (0.8)
Urethral stricture (6%)
Sexual dysfunction (70%)

45. TURP ENDOSCOPIC VIEW

46. OPEN PROSTATECTOMY
INDICATIONS
Prostate > 50-70g
Large bladder diverticulum
Large hard calcium stones
Marked ankylosis of the hip or other hip
conditions preventing lithotomy position
Large inguinal hernia requiring concomitant
repair

47. OP CONTD.
CONTRAINDICATIONS
Small prostate
Severe co-morbidity
Difficulty access to the prostate from
scarring due to previous suprapubic surgery
TYPES
Retro pubic (millin’s) prostatectomy
Transversical prostatectomy

48. RETROPUBIC PROSTATECTOMY
Through a midline or transverse suprapubic
incision the prostatic capsule is open from
front behind the pubis.
Hyperplastic part removed & readily visible
vessels ligated.
Foley’s catheter inserted & the capsule
closed by sutures.

49. TRANSVESICAL PROSTATECTOMY
The bladder is open extraperitoneally & the adenoma
enucleated with finger.
Calculus or bladder diverticuli can be seen &
addressed.
Haemorrhage is controlled by tamponade & sutures @
5 & 7 o clock positions.
Foley’s or malecot catheter is inserted & balloon
inflated to it the prostatic fossa & bladder closed
around the catheter.
Post op irrigation with N/S, 2.5% Dextrose or glycine.
PFR > 20mls/sec, 0.4% failure rate, 21.7%
complications rate & < 2% mortality.

50. C0MPLICATIONS OF OP.
Haemorrhage
Clot retension
UTI
Epididymo-orchitis
Persistent vesico cutaneous fistula
Wound infection
Incontinence of urine
Impotence
Retrograde ejaculation
Infertility
Urethral stricture
Damage to the ureters

51. CONPLICATIONS CONTD.
Bladder neck stenosis
Osteitis pubis
DVT.

52. FOLLOW UP
IPSS
PFR
PSA

53. CONCLUSION
The Management of BPH have gone
to supersonic super high way of
advancement in medical technical
know how, which involves the
urologist, pathologist, radiologist & the
urodynamicist However whatever the
enigma is yet to be fully addressed.

54. REFERENCES
1.E.A Badoe, E. Archampong & J.T Rocha A. principles
& practice of surgery including pathology in the tropics
3rd edition, 2000.P 850- 867.
2. Charles V. Mann, R.C.G Russell, et al Bailey &
Love’s short practice of surgery, 22nd edition Chapman
& Hall Medical. 1997,P 970-978.
3.Sani A. Aji, Benign prostatic hyperplasia P 6,11 & 14.
4.Patric Walsh et al. Walsh- Cambell’s Urology, 8th
edition Elsever 2002 P 381, 391- 392.
5. Jack McAninch, Emil Tanagho, Smith’s General
Urology, 6th edition McGraw-Hill/Appleton & Lange
2003,P4,267.
6.Sam G. Graham et al, Glen’s Urologic Surgery,5th
edition Lippincott Williams & Wilkins publishers, 1998
P37.

55. THANKS