7 prostate lecture

BENIGN PROSTATIC HYPERPLASIABENIGN PROSTATIC HYPERPLASIA
BPHBPH
Ahmad A. Elabbady, MDAhmad A. Elabbady, MD
Professor, Urology Department,Professor, Urology Department,
University of AlexandriaUniversity of Alexandria

BPHBPH
Definition
• I- Microscopic (BPH) refers to histological proliferation.
• II- Macroscopic: senile prostatic enlargement (SPE)
refers to organ enlargement due to cellular proliferation.
• III-Clinical: refers to the lower urinary tract symptoms
thought to be due to BP obstruction.

IncidenceIncidence
- BPH is a disease of the elderly men
- The most common benign neoplasm in the aging male
- Usually > 60 years Rarely < 40years
- Normal prostate is about 18-25 gm

• BPH arises from the peri-urethral glands in the
transition zone
• BPH occurs in almost all men who have normal serum
testosterone level and who lived long enough
• Testosterone (T) ---under the effect of 5-alpha reductase
enzyme in the stromal cells is converted to
Dihydrotestosterone (DHT) which leads to glandular
epithelial proliferation.

PathologyPathology
I- Microscopy
Hyperplasia and hypertrophy of the glands + smooth muscles +
fibrous tissue stroma
• Mainly glandular------- (soft)
• Mainly fibrous stroma------ (firm)
II- Gross
Pattern:
* Monolobar = Middle lobe
*Bilobar = 2 lateral lobes
*Trilobar = Middle + 2 Lateral lobes
The hyperplastic lobes outwardly compress the surrounding zones Surgical capsule
with a plane of cleavage in between

Pathophysiology of obstruction:Pathophysiology of obstruction:
I- Static component
- Bulk of the gland elongation, compression and
angulations of the prostatic urethra
- Middle lobe obstruction of the bladder neck (ball-valve )
II- Dynamic component
- Prostatic smooth muscle are innervated by alpha-
adrenergic fibers
- Atony of the detrusor muscle by long standing
obstruction resulting in chronic retention

SymptomsSymptoms
I- Lower urinary tract symptoms ( LUTs)
A. Obstructive symptoms
- Hesitancy
- Weak urinary stream
- Straining during urination.
- Sense of incomplete emptying
- Terminal dribbling
B. Irritative symptoms
- Frequency
- Urgency
- Urge incontinence
II- Hematuria
III- Complications
Retention
Infection
Bladder stone.
Symptoms of renal failure (in patients with chronic retention).

SignsSigns
- Elderly Male
- DRE: Size- Shape- Consistency- symmetry
- Suprapubic Area (urine retention)
- Renal mass ( hydronephrosis)
- Hernia orfices (straining)
- Neurological examination (S2,3,4)
- Signs of renal failure (late).

• Investigations:
• I- Uroflowmetry
• - Simple and non-invasive.
• - Normal maximum flow rate (Q-Max) >18 ml/second
• -Maximum Flow Rate < 10ml/Sec is indicative of
obstruction &/or weak detrusor muscle
• II- Laboratory Investigations
• - Urinalysis
• - Serum creatinine
• - Serum PSA ( prostatic specific antigen, <4ng/ml).

III- Diagnostic Imaging
A. U/S Abdominal
- Gives an idea about kidneys, post voiding residual, size of the
prostate and other pathology ,e.g. bladder stone, diverticulum
B. Plain KUB and IVU
Stones
Upper tract affection
Smooth basal filling defect
Fish hook of the lower ureters
Bladder trabeculations, cellules, and diverticula
Post-voiding film

IV- Cystourethroscopy ( prior to surgery)
Degree of middle &/or lateral lobe enlargement Hematuria
Bladder stone
Associated pathology
Urethral stricture

Differential DiagnosisDifferential Diagnosis
Meatal stenosis
Urethral stricture
Prostatic cancer
Bladder neck fibrosis
Drugs ( parasympatholytic and sympathomimetics)
Neurologic lesions

TreatmentTreatment
I- Medical Treatment
Watchful waiting
Phytotherapy e.g. pumpkin seed oil
Alpha-blockers e. g. doxazosin, Terazocin, Tamsolucin
5-alpha reductase inhibitors e. g. finastride, Dutasteride.

II- Surgical treatment
A. Transurethral resection of the prostate
(TURP):
This is the gold standard option.
B. Open prostatectomy:
Retropubic, transvesical and perineal routes
N.B. Histopathological examination.

III- Less invasive methods (Still inferior to TURP):
- Laser,
- hyperthermia,
- Incisions,
- Balloon dilatation.

Indications of surgeryIndications of surgery
1. Repeated attacks of acute urine retention
2. Chronic retention, hydronephrosis
3. Hematuria (repeated significant)
4. Recurrent UTI
5. Bladder stone
6. Severe obstructive symptoms
7. Poor response to medical therapy
8. Side effects of medical treatment.

Complications of prostatectomyComplications of prostatectomy
A- Complications of anesthesia
B- intra-operative
- Bleeding
- TUR syndrome
- Trauma (urethra, B.N., bladder)
C- Immediate post-operative
- Bleeding primary, reaction
- Problems with catheters
- Re-retention
D- Delayed post-operative
- Bleeding secondary
- Infection UTI, Wound
- Urine leak
- Urine incontinence
- Urethral stricture

- 20% of post-adenectomy biopsies have prostate cancer.
- The peripheral zone (surgical capsule) may still at risk of
developing cancer after TURP or Open prostatectomy;
Follow up is essential by PSA & clinical evaluation.

Prostate CancerProstate Cancer
Ahmad A. Elabbady, MD
Professor, Urology Department,
University of Alexandria

PROSTATE CANCERPROSTATE CANCER
Normal prostate is about 18-25 gm
- Is a disease of the elderly men
- One of the most common neoplasm in the aging male

• P Ca is the most common non-skin cancer among men.
• Common in USA & Europe.
• Men have 1 in 6 life time risk of developing P Ca.
• Pathologic prevalence > clinical incidence
• About 30% of men > 50 years have P Ca at autopsy.
• Specimens from men > 80 years show 80% P Ca

Prostate cancerProstate cancer
Risk FactorsRisk Factors
- Age
- Family history
- Race
- Dietary fats
- Hormones
- Geography
- Genetics

• It is a Heterogeneous, wide spectrum disease.
• Often, It is a slowly progressive disease.

• P Ca rarely causes symptoms early in the
course of the disease.
• The majority of adenocarcinomas arise in the
periphery of the gland distant from the urethra.

PROSTATICPROSTATIC SymptomsSymptoms
I- Lower urinary tract symptoms ( LUTs)
A. Obstructive symptoms
- Hesitancy
- Weak urinary stream
- Straining during urination.
- Sense of incomplete emptying
- Terminal dribbling
B. Irritative symptoms
- Frequency
- Urgency
- Urge incontinence

PROSTATICPROSTATIC SymptomsSymptoms
II- Hematuria More common with BPH
III- Complications
Retention
UT Infection
Bladder stone.
Symptoms of renal failure (in patients with chronic retention).
IV- Symptoms of Mets (with cancer)
Bone pain
General symptoms

PROSTATICPROSTATIC
SignsSigns
- Elderly Male
- DRE: Size- Shape- Consistency- symmetry
- Suprapubic Area (urine retention)
- Renal mass ( hydronephrosis)
- Hernia orfices (straining)
- Neurological examination (S2,3,4)
- Signs of renal failure (late).

Diagnosis of prostate CancerDiagnosis of prostate Cancer
Early diagnosisEarly diagnosis
- DRE Asymmetry, hard nodules
- Serum PSA 0-4 ng/ml
- TRUS-directed prostatic Bx.

Early detection of prostate CancerEarly detection of prostate Cancer
PSAPSA
PSA is organ-specific
but not cancer specific

Early detection of prostate CancerEarly detection of prostate Cancer
PSAPSA
PSA elevations
-Prostate disease (BPH, prostatitis, P Ca)
-prostate manipulation (massage, Bx).

Diagnosis of prostate CancerDiagnosis of prostate Cancer
Advanced diseaseAdvanced disease
• DRE hard irregular prostate
Distortion of local anatomy
Urine retention (acute, chronic)
• PSA very high figures e.g. >100 ng/ml
• Metastasis
L.N.
Bone (pain, neurologic symp., fractures)

Diagnosis of P CaDiagnosis of P Ca
TRUS-BxTRUS-Bx
The major role of TRUS is to ensure
accurate wide-area sampling of prostate
tissue.

PathologyPathology
• Commonly: adenocarcinoma . 95%
• Other types: 5% e.g. TCC
- Sarcoma

• The 2002 TNM staging for Ca P
• TX Primary tumor cannot be assessed
• T0 No evidence of primary tumor
• T1 Clinically inapparent, not palpable or visible by imaging
• T1a incidental histological finding in 5% or less of tissue
• T1b incidental histological finding in > 5% of tissue
• T1c identified by needle biopsy (because of elevated PSA)
• T2 Tumor confined within the prostate
• T2a involves one half of one lobe or less
• T2b involves > half of one lobe, but not both lobes
• T2c Tumor involves both lobes
• T3a tumor penetrate capsule unilateral or bilateral
• T3b tumor involve S.V.
• T4a Tumor invades bladder neck, externalsphincter, and/or rectum
• T4b Tumor invades levator muscle and/or fixed to pelvic wall

TNM staging for Ca PTNM staging for Ca P

gradinggrading
• Gleason grading system
Depends on architectural pattern
Grades 1-5 for the primary and secondary pattern
Gleason sum: primary + secondary grades

• Pattern of spread
• Direct
• Inward > outward
• Lymphatic
• Obturator
• Hypogastric
• Distant
• 90% to bones
• Lung,liver

DiagnosisDiagnosis
• D.R.E : 50% of cases
• Serum marker P.S.A ( Normal: 0-4 ng/ml)
• T.R.U.S : Needle biopsy 6 each lobe
• Bone Scan Tc labeled phosphate
• CT
• MRI
• IVU
• Bilateral pelvic lymphadenctomy (laparoscopic)

Treatment OptionsTreatment Options
• 1- Watchful Waiting Old age- Low grade
•
• 2- Radical prostatectomy
T1,T2, Young patient-
• Retropubic, perineal, laparoscopic
•
• 3- Radiotherapy
• *Curative = Localized cancer
• *Palliative = Metastatic
•
•
• Types:
• - External beam
• - Interstitial irradiation
• I-123, Gold 198
•

Treatment OptionsTreatment Options
• 4- Hormonal Therapy (Metastatic Tumors)
Types:
• Bilateral orchiectomy Best
• Estrogen: DES
• Anti-androgen : Bicultamide, Flutamide
• LHRH agonists: Leupron, Zoladex
Cord compression Laminectomy, Ketoconazole, orchiectomy
Ureteral obstruction: Ureteric catheter, PCN, Ketoconazole
Retention TUR

7 prostate lecture

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7 prostate lecture