Discuss treatment option in bph and their basis

DISCUSS TREATMENT OPTIONS
IN BPH AND THEIR BASIS
DR BASHIR YUNUS
Surgical resident
AKTH18-Apr-15 BBINYUNUS2002@GMAIL.COM 1

OUTLINE
18-Apr-15 BBINYUNUS2002@GMAIL.COM 2

INTRODUCTION
• fibromuscular and
glandular organ, around
the prostatic urethra.
• Average weight 20g
• Made up 4 zones
– Transitional zone
– Central zone
– Peripheral
– Preprostatic zone

physiology
• Stimulation of adrenergic
nerves of the smooth
muscle clearly results in
dynamic increase in
prostatic urethral
resistance.
• The bulk of the gland
mediates the static
obstruction mediated by
androgens
Distribution of α1 adrenergic
receptor

• Arteries;
– Inferior vesical
• Urethral- prostatovesical junction 1- to 5 and 7-to 11 o’
clock
• Capsular
• Vein
– Preprostatic plexus

INTRODUCTION
• BPH is the proliferation of the epithelial and stromal
element of the prostate evidenced by enlargement of the
gland as detected by DRE/ TRUS.
• It occurs after the age of 50years, usually between 60-
70years

INTRODUCTION
• Aetiological risk factors :
• Age
• Androgens (a permissive role only)
• Race
• Diet
• Genetics (role again unclear) – 50% of men undergoing
prostatectomy before 60 could be attributed to have some
genetic factors
• Growth factors (basic fibroblastic GF, insulin-like GF, etc)

INTRODUCTION
• Diagnosis
– History;
• irritative and obstructive lower urinary tract symptoms
that waxs and wane,
• History of complication; haematuria, recurrent UTI,
urine retention, co-morbidity
• IPSS
– Baseline of symptom severity
– Response to therapy
– Symptoms progression in watchful waiting.

• Sum up all score
– Mild score < 7
– Moderate 8-19
– Severe 20-35

• EXAMINATION
– GPE
– SYSTEMIC
– DRE
• Smooth, elastic(rubbery), preserved median and lateral
sulci, symmetrical.

• Investigation
– Abd pelvic USS
– PSA
– Urinalysis, Urine mcs, U/Ecr, clotting profile, ECG
– Urodynamics

TREATMENT OPTIONS
• WATCHFUL WAITING
– Indication
• Symptoms not bothersome
• IPSS < or =8
• Complication of treatment out weighs the symptoms
– Bases;
• Base on fact that the course is unpredictable; 25% improve
spontaneously;50% have static symptoms, 25% deteriorate and require
specific treatment
• Size does not necessarily correlate with the symptoms
– Regular(3monthly) assessment by IPSS, DRE, USS, PSA, PFR, PVR,
TRUS-guided biopsy when indicated
– Lifestyle advices; decrease fluid intake at bedtime, moderate
cosumption of alcohol and coffeine, timed voiding shedule.

• WATCHFUL WAITING
– Replaced by medical or surgical therapy when
condition change or when indicated
– Contra-indicated in the presence of complication
• Urine retention
• Vescical calculi
• Diverticulli
• Hematuririal

MEDICAL TREATMENT
• Indications
– Patients with LUTS in whom cancer of the prostate
has been excluded
– Patients with IPSS <19
– Patients who are much bothered about their
symptoms
– Patient who do not have complications
(indications for surgery)

MEDICAL TREATMENT
• Bases
– Obstruction is caused by contraction of the a-
adrenergic smooth muscles of the bladder neck
and prostate (dynamic)
– Bulk of the prostate is a function of DHT

• A – ADRENERGIC BLOCKER
– Relaxes the bladder neck and the prostate smooth
muscle thereby increasing urine flow(relieves
dynamic obstruction)
– They include:
• Long acting alpha-1-adrenergic blockers eg
terrazosin, alfuzocin, doxazosin
• Selective alpha-1A-adrenergic blocker , Tamsulosin

• Side effects;
– orthostatic hypotension, dizziness, asthenia, flu-
like symptoms, nasal congestion, weakness
– Tamsulosin (Flomax) and alfuzosin (UroXatral) do
not affect blood pressure, as do the other alpha
blockers; abnormal ejaculation has been reported
in about 10% of men on tamsulosin

• Selective alpha blockers
– Tamsulosin (Flomax) 0.4 mg PO daily
• Initially 0.4 mg qd; can be increased to 0.8 mg qd after 2
weeks if response is inadequate
• Dizziness, orthostatic hypotension, rhinitis/nasal congestion,
abnormal ejaculation, decreased libido, insomnia
• Use cautiously with cimetidine and warfarin. Titration should
proceed on the basis of response to therapy and side effects
– Alfuzosin (UroXatral) 10 mg PO daily after a meal
• Postural hypotension, chest pain, priapism, dizziness,
headache

• ANDROGEN SUPPRESSION
– Reduces the level of DHT and thereby shrink the
prostate volume so as to relieve the static
obstruction
• e.g
– 5-alpha reductase inhibitors; finesteride,
episteride
– Androgen receptor antagonists; zanoterone,
Flutamide

• 5-a-reductase inhibitors
– 3 months of Rx is needed to achieve symptoms relief but effect
persist for many years
– Blocks conversion of testosterone to DHT which is the potent
androgen that causes prostatic growth.
– Decrease in prostate volume; by 12 months, the PSA is reduced
by 50%, then the PSA reduction plateaus at 50% of baseline.
– PSA level should be checked b4 treatment is started or
multiplied
– Reserve 5-a-reductase inhibitors for patients with large
prostates who remain symptomatic while taking 1-blockers.
– Improved symptom scores and urinary flow rates
– About 5% to 10% of men notice decreased libido or ejaculatory
abnormalities over the first year of treatment

• Finasteride (Proscar) 5 mg daily PO
– Erectile disorder, ejaculate dysfunction, decreased
libido
– gynaecomastia, or breast
– Avoid in patients with liver dysfunction.

• COMBINATION CHEMOTHERAPY
– This involves the use of alpha-adrenergic blockers in
combination with anti-androgens
• AROMATASE INHIBITOR
– Atemestame
– Oestrogen causes stromal hyperplasia, therefore,
inhibition of oestrogen levels by an aromatase
inhibitor should lead to diminution of prostate volume

• PHYTOTHERAPY
– Various plant extracts have been used empirically
to treat LUTS due to BPH
– Their clinical value and safety have not been
scientifically proven
– But they have improved IPSS and PFR
– E.g; sow palmetto, Urtica Spp, Hypoxis roopers,
pygeum Africannum e.t.c

• Future strategies for drug devt. for symptomatic
BPH
– Endothelin antagonist- to prevent contractile effect
of endothelin on prostatic smooth muscles which is
not abolish by alpha-adrenergic blockers
– Nitric oxide inhibitors- may relax prostate smooth
muscles which is increased by nitric oxide
– New generation therapeutic strategies for non-
prostatic factors causing LUTS such as ageing,
hormonal status, non-urological disorders and
neurological factors need to be identified

MINIMALLY INVASIVE TREATMENT
• Indications
– Patients with moderate symptoms score (IPSS 8-19)
– Patients with severe symptoms but handicapped
– Patients with severe symptoms but unfit for major surgery eg
HF, MI, liver disease, pulmonary disease, neurologic conditions
• Contra-indications
– Recurrent episodes of hematuria
– Recurrent urine retention
– Bladder stone due to bph
– Upper tract dilatation
– Large diverticulum
– Renal insufficiency
– Recurrent uti

• Minimally invasive techniques;
– High intensity focused ultrasound (HIFU)
– Transurethral vaporization of the prostate
– Transurethral laser therapy (TULIP)
– Intra-urethral stents
– Transurethral needle ablation of prostate (TUNA)
– Transurethral balloon dilatation

SURGERY
• Indications
– Acute urinary retention
– Chronic urinary retention
– Haematuria
– Recurrent UTI
– Vesical calculi
– Large bladder diverticula
– Upper urinary tract dilatation
– Renal impairment/ ureamia

• Other indications for surgery include
– Patients with symptoms score which are moderate to
severe (IPSS 19-35)
– Bothersome symptoms that interfere with patients
QOL not relieved by medical treatment or minimally
invasive surgery
• Contra-indications (not absolute)-
– frail elderly,
– severe co-morbidity eg HF, MI, pulmonary dx,
– bleeding tendency or patient on anticoagulants

• Options;
– Transurethral incision of the prostate (TUIP)
– Transurethral resection of the prostate (TURP)
– Open prostatectomy
• Transvesical prostatectomy
• Retropubic prostatectomy

• Transurethral incision of prostate (TUIP)
– Suitable for small prostate with tight bladder neck and
no middle lobe enlargement
– An incision is made using Collin’s knife, just below the
ureteric orifice on one or bothsides
– Excellent results with good PFR >18ml/sec post-
operatively
– Low incidence of complications
– Less occurrence of retrograde ejaculation <10%
– About 10% will relapse and require TURP

• Transurethral resection of prostate (TURP)
– It is now the gold standard treatment for BPH
– Removes tissues of the transitional zone in all obstructing
prostate <60g
– Strips of tissue are cut from the bladder neck down to the
level of verumontanum
– Cutting is performed by high frequency diathermy current,
which is applied across a loop mounted on the hand-held
trigger of the resectoscope
– Coagulation of bleeding points can be accurately achieved
– After the procedure, a 3-way catheter is inserted for
continuous irrigation (usually removed after 48hrs)

• TURP is safer in that:
– There is less pain
– Early mobilization and short hospital stay
– Few post-op complications
– Low mortality <1.5%
– Little risk of DVT, embolism
• Morbidity is increased with
– Prolonged resection time >90mins
– Large gland >60g
– Age over 80yrs
• Outcome
– 88% of patients improve with reduction of IPSS
– 85%, improvement of PFR 8-18ml/sec
– Likelihood of re-operation in 5yrs is 3.4%

• Complications of TURP
– TURP syndrome
– Primary haemorrhage
– Clot retention
– Secondary haemorrhage
– Priapism
– Urinary incontinence
– Retrograde ejaculation
– Erectile dysfunction
– Urethral stricture

TURP SYNDROME
• Occurs as a result of absorption of resection fluid
when the venous sinusoids are open with
resultant dilutional hyponatremia. Symptoms
results from water intoxication, circulatory
overload and toxicity from solute in the irrigation
fluid.
• Manifest as restlessness, headache, tachypnea,
dyspnea, vomiting, mental confusion, visual
disturbance, bradycardia and hypertension

• Risk factors for TURP syndrome;
– Irrigation fluid > 60cm: increase hydrostatic
pressure.
– Hypotension/hypovolemia: decrease venous
pressure more fluid is absorbed
– Duration of surgery > 60min, large prostate > 60g
with resection of 1g /min
– Large blood loss implies more amt of veins are
opened
– Bridge of prostatic capsule

• Treatment of TURP syndrome
– Stop iv fluid
– Terminate surgery; stop bleeding points
– Iv frusemide
– O2 support
– Hypertonic saline
– Fluid restriction
– anticonvulsants

OPEN PROSTATECTOMY
• Definition;
– open simple prostatectomy is removal of the
transitional zone of the prostate
• Indications ;
– Prostate >60g
– Bladder diverticulum
– Haematuria
– Larger hard calculi
– Marked ankylosis of the hip
– Large inguinal hernia requiring repair

• Types ;
– Retropubic (millin’s)
• Direct visualizaton
• Better hemostesis
• No trauma to the bladder
• Accurate incision on the urethra which would minimize
incontinence
– Transvesical/suprapubic (freyer’s)
• Concomitant bladder pathology
• Obese patient
• Visualization of tumour and hemostasis may be difficult.

• Pre-op preparation
– Correct dehydration
– Treat infections
– correct azothmia, co-morbidities
– GXM, clotting profile
– Informed consent
– cystoscopy

Suprapubic
• Anaesthesia ; spinal
• Position;
– lithotomy
– Surgeon, assistant scrub, gown, skin cleaned and
draped. Surgeon on the left side assistant on the right
– Urethral catheter is passed, urine taken for mcs and
bladder distended and catheter clamped
• Incision; pfannenstial
• Exposure and procedure; rectus opened with
electrocautery and the space of retzius and
detrusor exposed. Millins retractor placed.

• Stay sutures placed at 3 and 9 o clock
• The bladder opened with a knife and fluid
aspirated.
• Figure of 8, 2-0 absorbable suture is applied
on the caudal end of the bladder to prevent
tear during manipulation of the bladder.
• Vaginal pack prepared by scrub nurse and
anesthetist comfortable with fluid
resuscitation before enucleation

• Prostate enucleation
– Incision of the bladder neck mucosa from the 5-7 O’
clock position
– Advance the index finger into the bladder down
through the bladder neck and into the prostatic
urethra down the apex of the prostate.
– Fracture the anterior commissure of the prostate, by
firmly sweeping finger anteriorly
– The entire hand of the surgeon should be rotated
clock or anticlockwise with firm index finger
effectively separating the adenoma from the surgical
capsule.

– Pinch the adenoma then separate from the bladder
neck by sharp dissection to prevent tear or injury to
the trigone
– Inspect fossa with finger to determine completion of
enucleation
• Hemostasis
– Fossa packed with vagina packing and held with
sponge stick for 10-15min the removed
– Harris stitch; at 5 and 7 O’clock at the neck
– Use electrocautery
– Maliament stitch;

• Closure
– Position large urethral catheter 22-28Fr
– SPC can be left
– Bladder closed in 2 layers
– Drain placed in the space of Retzius opened through a
separate wound
– Close fascia, skin.
– Urine bag attached to urethral catheter, drainage via
SPC
– For additional hemostasis, the urethral catheter
balloon is distended with 30-60ml of sterile water and
gentle traction and secure to the anterior thigh.

RETROPUBIC
• No need to distend bladder
• After exposure as above, Fat on the surface of the prostate is
removed with electrocautery, achieve hemostasis of blood vessels
overlying the anterior surface of the prostatic capsule.
• A horizontal incision is made between the stay sutures with a knife
blade or cautery through the prostatic capsule (as shown below),
and the index finger is inserted through this incision and the
adenoma enucleated with a sweeping and pinching motion.
• Vaginal packing as above
• Hemostesis under direct vision
• Catheter guided into the bladder, inflated and gentle tractioned
• Prostatic fossa closed with running suture water tight.
• Wound closed over drain from separate opening

POST- OP
• Urethral catheter removed in 7-10 days and
voiding trail performed
• FBC,U/ECr,
• Strict fluid monitering; post op diuresis,
• Antibiotics
• Those on anticoagulant recommence after
catheter is removed

Post op complications
• Haemorrhage
• Clot retention
• UTI
• Epididymo-orchitis
• Persistent vesico-cuteneous fistulae
• Wound infection
• Urine incontinence
• Impotence 4-19%
• Retrograde ejaculation 20-75%
• Infetility
• Urethral stricture
• Bladder neck stenosis
• Damage to the ureters
• Osteitis pubis
• Non-urologic ; DVT,PE,MI,CVA

References

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