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Benign prostatic hyperplasia

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Benign prostatic hyperplasia

  1. 1. - Dr. Anusha . M
  2. 2.  Most Common Benign Tumour in Men. Histologic Diagnosis is characterized by Proliferation of Epithelial and Stromal elements of Prostate.  Incidence is Age Related. 20% among men aged 41-50 years 50% among men aged 51-60 years >90% in men aged more than 80 years.  BPH develops in Transition zone of Prostate.
  3. 3.  Normal weight of prostate ranges from 20-25 grams  According to Mc Neal, gland is divided into 3 zones.
  4. 4. Peripheral Zone Central zone Transition Zone 70% of gland; 25% of gland; 5% of gland Situated posteriorly -More prone to carcinomatous change Situated posteior to urethral lumen and above the ejaculatory ducts Periurethral zone of prostate
  5. 5. CAPSULES OF PROSTATE • True Capsule: formed by condensation of peripheral part of gland. Fibromuscular and is continous with stroma of gland. • False Capsule: lies outside the true capsule; derived from endopelvic fascia. Prostatic venous plexus is embeded in between two capsules.
  6. 6. The arterial supply to the prostate is primarily from the inferior vesical artery, which originates from the anterior division of the internal iliac artery. The inferior vesical artery then branches into 2 main arterial branches to feed the prostate. The inferior vesical artery supplies the base of the bladder, the distal ureters, and the prostate. • The first arterial branch is the urethral artery , the main arterial supply for the adenomas in benign prostatic hyperplasia • The capsular artery is the second main branch of the prostate.This artery enters the prostate at right angles to supply the glandular tissue.
  7. 7. Venous Drainage  The veins form a rich plexus around the sides and the base of the prostate.The plexus communicates with the vesical plexus and with the internal pudendal vein which drains into vesical and internal iliac veins.  Valveless communications exist between the prostatic and vertbral venous plexuses through which prostatic carcinoma spreads to vertebral column and skull.
  8. 8. Gland enlargement occurs due to epithelial and stromal proliferation or impaired pre- programmed cell death i.e.., Apoptosis or both. Prostatic enlargement depends on potent androgen Dihydrotestosterone (DHT). In prostate, type 2 5α Reductase metabolises circulating TST to DHT, which acts locally. DHT binds to androgen receptors of cell nuclei.
  9. 9.  There observed a positive correlation between levels of free TST, estrogen and volume of Prostate which suggests that the association between aging and BPH might result from increased estrogen levels causing induction of androgen receptor, which there by sensitizes the prostate to free TST.  In men younger than 60 years, may be a heritable form of disease. In such cases it is of autosomal dominant pattern of inheritance.  In First degree male relatives, relative risk is of approximately fourfold.
  10. 10. Pathology:  BPH virtually always occurs in the inner, transitional zone of the prostate. The affected prostate is enlarged, typically weighing between 60 and 100 g, and contains many well circumscribed nodules that bulge from the cut surface.  As BPH nodules in the transition zone enlarge, they compress the outer zones of the prostate, resulting in the formation of a so-called surgical capsule. This boundary separates the transition zone from the peripheral zone and serves as a cleavage plane for open enucleation of the prostate during open simple prostatectomies performed for BPH.
  11. 11. The nodules may appear solid or contain cystic spaces. The urethra is usually compressed by the hyperplastic nodules, often to a narrow slit. In some cases, hyperplastic glandular and stromal elements lying just under the epithelium of the proximal prostatic urethra may project into the bladder lumen as a pedunculated mass, producing a ball-valve type of urethral obstruction. Well-defined nodules compress the urethra into slit like lumen
  12. 12. Microscopically The hyperplastic nodules are composed of variable proportions of proliferating glandular elements and fibromuscular stroma. The hyperplastic glands are lined by tall, columnar epithelial cells and a peripheral layer of flattened basal cells.  Low-power photomicrograph demonstrates a well-demarcated nodule.  Higher-power photomicrograph showing morphology of the hyperplastic glands, which are large, with papillary infolding.
  13. 13. Pathophysiology • The symptoms of BPH are related to 1) The obstructive component of the prostate 2) Secondary response of the bladder to the outlet resistance. Obstructive: Mechanical or Dynamic  Mechanical: As the prostate enlarges, the surrounding capsule prevents it from radially expanding, potentially resulting in urethral compression. Obstruction-induced bladder dysfunction contributes significantly to LUTS.  Dynamic component of prostatic obstruction is explained as follows: The prostatic stroma, composed of smooth muscle and collagen, is rich in adrenergic nerve supply. The level of autonomic stimulation sets a tone to the prostatic urethra. Use of α-blocker therapy decreases this tone, resulting in a decrease in outlet resistance.
  14. 14. The secondary response of the bladder to the increased outlet resistance : • Bladder outlet obstruction leads to detrusor muscle hypertrophy and hyperplasia as well as collagen deposition. • This leads to a decrease in bladder compliance, detrusor instability is also a factor. • On gross inspection, thickened detrusor muscle bundles are seen as trabeculation on cystoscopic examination. • If left unchecked, mucosal herniation between detrusor muscle bundles ensues, causing diverticula formation.
  15. 15. Obstructive  Hesitancy  Decreased force and caliber of stream  Sensation of incomplete bladder emptying  Double voiding  Straining to urinate  Postvoid dribbling Irritative  Urgency  Frequency  Nocturia The symptoms of BPH can be divided into obstructive and irritative complaints.
  16. 16.  Special attention to the following features is essential in making the correct diagnosis and recommending treatment choices:  Onset and duration of symptoms  General health issues (including sexual history)  Fitness for any possible surgical interventions  Severity of symptoms and how they are affecting quality of life  Medications  Previously attempted treatments
  17. 17. GRADING: • The American Urological Association (AUA) developed a self administered questionnaire which is reliable in identifying the need to treat patients and in monitoring their response to therapy. • The AUA Symptom Score Questionnaire has been extensively validated and it is now more commonly called the International Prostate Symptom Score • This assessment focuses on seven items that will be asked to patients to quantify the severity of their obstructive or irritative complaints on a scale of 0–5. • The score can range from 0 to 35. IPSS Grade 0-7 Mild 8-19 Moderate 20-35 Severe
  18. 18.  A physical examination, Digital rectal examinaton are performed on all patients.  The size and consistency of the prostate is noted, even though prostate size, as determined by DRE, does not correlate with severity of symptoms or degree of obstruction.  BPH usually results in a smooth, firm, elastic enlargement of the prostate.
  19. 19. Normal prostate – Grade I (approximately 20g): Flat or slightly rounded surface, median sulcus usually unnoticed; with approximately one fingertip length anteroposteriorly, and one fingertip mediolaterally; Grade I/ II prostate (approximately 30g): Surface of the prostate between Grade I, and Grade II
  20. 20. Grade II (approximately 40g): Bilobar rounded surface, well-delimitated median sulcus; with approximately two fingertips of length anteroposteriorly, and one/one and a half fingertip mediolaterally or one fingertip length anteroposteriorly, and two fingertips mediolaterally.
  21. 21. Grade II/III (approximately 50g): Rounded surface, partial obliteration of the median sulcus; with approximately the same length of a Grade II prostate , or an asymmetric surface with one lobe Grade II, and the other lobe Grade III.
  22. 22. Grade III (approximately 60g): Rounded surface, complete obliteration of the median sulcus; with two fingertips anteroposteriorly, and two fingertips mediolaterally Grade IV (approximately 80g or greater): Rounded surface, complete obliteration of the median sulcus;with no accessibility of the upper limits of the prostate to the tip of the examining finger.
  23. 23.  The American Urological Association (AUA) has issued a guideline on the management of benign prostatic hyperplasia.  Investigations can be grouped into 3 categories: --Laboratory tests --Imaging --Function assessment
  24. 24. Urinalysis and Urine Culture Urine Examination using dipstick methods or via centrifuged sediment evaluation to assess for the presence of blood, leukocytes, bacteria, protein, or glucose. If the initial urinalysis findings indicate an abnormality, a urine culture may be useful to exclude infectious causes of irritative voiding. Electrolytes, BUN, and Creatinine These evaluations are useful screening tools for chronic renal insufficiency in patients who have high post-void residual (PVR) urine volumes.
  25. 25. Prostate-Specific Antigen • Although BPH does not cause prostate cancer, men at risk for BPH are also at risk for prostate cancer and should be screened accordingly. • The current American Cancer Society (ACS) guideline for early detection of prostate cancer stresses the importance of involving men in the decision whether to test for prostate cancer. • If the patient wishes to proceed with screening ,the ACS recommends that screening to start at the following ages:  Age 50 years in men at average risk for prostate cancer who are expected to live at least 10 more years  Age 45 years in men at high risk for prostate cancer (African Americans and men with a first-degree relative diagnosed with prostate cancer before age 65)  Age 40 years in men at very high risk (those with more than one first-degree relative who had prostate cancer at an early age).
  26. 26. Ultrasonography  Ultrasonography (abdominal, renal, transrectal) are useful for helping determine bladder and prostate size and the degree of hydronephrosis in patients with urinary retention or signs of renal insufficiency.  Transrectal ultrasonography (TRUS) of the prostate is recommended in selected patients, to determine the dimensions and volume of the prostate gland.  In patients with elevated PSA levels, TRUS- guided biopsy may be indicated to assess for prostate cancer.
  27. 27. Transectal ultrasound showing the volume of prostate Transrectal ultrasound probe with biopsy needle
  28. 28.  Imaging of the upper tracts is indicated in patients who present with any of the following:  Concomitant hematuria  A history of urolithiasis  An elevated creatinine level  High PVR volume  History of upper urinary tract infection Other imaging studies, such as CT scanning and MRI, have no role in the evaluation and treatment of uncomplicated BPH.
  29. 29. Cystoscopy  Cystoscopy is not routinely recommended to determine the need for treatment.  It may assist in choosing the surgical approach in patients opting for invasive therapy.  When marked obstructive symptoms exist in the setting of relative minimal prostate enlargement, cystoscopy may be useful to identify a high bladder neck, urethral stricture, or other pathology.  If BPH is associated with hematuria, then cystoscopy is mandatory to rule out other bladder pathology.
  30. 30. Normal appearance Moderate benign prostatic hyperplasia with urethral obstruction.
  31. 31.  Measurement of flow rate, determination of post-void residual urine, and pressure-flow studies are considered optional.  Cystometrograms and urodynamic profiles are reserved for patients with suspected neurologic disease or those who have failed prostate surgery
  32. 32.  Options include: ----Watchful waiting ----Medical Therapy ----Minimally Invasive therapy ----Surgery
  33. 33. Watchful Waiting or “Self-Help” • Watchful waiting is the appropriate management of men with mild symptom scores (0–7). Men with moderate or severe symptoms can also be managed in this fashion if they choose. • A significant proportion of men with LUTS will not choose medical or surgical intervention because the symptoms are not bothersome, the complications of treatment are perceived to be greater than the inconvenience of the symptoms, and there is a reluctance to take a daily pill owing to side effects and/or the cost of treatment. • Self-management could be considered as first-line treatment for men with LUTS. • Main Components of Self-Management Program: - Education and Reassurance -Fluid Management -Caffeine and Alcohol avoidance -Concurrent Medication
  34. 34. Education and Reassurance • The causes of LUTS, including normal prostate and bladder function; natural history of BPH and LUTS,expected future symptoms are to be discussed with patient. • Reassure that no evidence of a detectable prostate cancer has been found. Fluid Management • Advise a daily fluid intake of 1500 to 2000 mL. • Avoid inadequate or excessive intake on the basis of a frequency volume chart. • Advise fluid restriction when symptoms are most inconvenient i.e.., during long journeys or when out in public. • Advise evening fluid restriction for nocturia (no fluid for 2 hours before retiring).
  35. 35. Caffeine and Alcohol • Avoid caffeine by replacing with alternatives. • Avoid alcohol in the evening if nocturia is bothersome. • Replace large-volume alcoholic drinks with small-volume alcoholic drinks . Concurrent Medication • Adjust the time when medication with an effect on the urinary system is taken, to improve LUTS at times of greatest inconvenience. • Replace antihypertensive diuretics with suitable alternatives with fewer urinary effects. Types of Toileting and Bladder Retraining • Advise men to double-void. • Advise urethral milking for men with postmicturition dribble. • Advise bladder retraining. Using distraction techniques, aim to increase the minimum time between voids to 3 hours (daytime) or the minimum voided volume to between 200 and 400 mL (daytime). The urge to void should be suppressed for 1 minute, then 5 minutes, then 10 minutes, and so on, increasing on a weekly basis. Use frequency-volume charts to monitor progress. Miscellaneous • Avoid constipation in men with LUTS
  36. 36. MEDICAL THERAPY: • Medical therapies extensively investigated for LUTS and BPH include α-adrenergic blockers, 5α-reductase inhibitors and numerous plant extracts. Selecting Candidates for Medical Therapy: The ideal candidate for medical therapy should have symptoms that are bothersome and negatively affect quality of life so that the patient is willing to make a long-term commitment to medical therapy, providing the drug is effective and adverse experiences are minimal. • Patients with absolute indications for intervention should be discouraged from selecting medical therapy. • If informed patients are willing to accept potential risks, medical therapy may be offered with a provision for careful follow-up and future prostatectomy if medical therapy proves ineffective.
  37. 37. Alpha Blockers  The rationale for α-adrenergic blockers in the treatment of LUTS is based on the hypothesis that the pathophysiology of LUTS is in part caused by BOO, which is mediated by α1 adrenoceptors associated with prostatic smooth muscle.  The human prostate and bladder base contains α1 adrenoreceptors, and the prostate shows a contractile response to corresponding agonists.  The contractile properties of the prostate and bladder neck seem to be mediated primarily by the subtype α1a-receptors. α-Blockade has been shown to result in both objective and subjective degrees of improvement in the symptoms and signs of BPH in some patients.
  38. 38.  Phenoxybenzamine and prazosin are the prototypical nonselective and selective α- blockers, but today, they are not recommended.  Long-acting α1-blockers make once-a-day dosing possible, but dose titration is still necessary.  Terazosin is initiated at 1 mg daily for 3 days and increased to 2 mg daily for 11 days and then to 5 mg/d. Dosage can be escalated to 10 mg daily if necessary.
  39. 39. Doxazosin: • The half-life of doxazosin is longer than that of terazosin (22 vs. 12 hours). • Therapy with doxazosin is started at 1 mg daily for 7 days and increased to 2 mg daily for 7 days, and then to 4 mg daily. Dosage can be escalated to 8 mg daily if necessary. • Possible side effects of long acting alpha 1 blockers include orthostatic hypotension, dizziness, tiredness, retrograde ejaculation, rhinitis, and headache.  Selective blockade of the α1a-receptors, which are localized in the prostate and bladder neck, results in fewer systemic (particularly cardiovascular) side effects, thus obviating the need for dose titration with these agents (tamsulosin, alfuzosin, and silodosin).  Other side effects such as retrograde ejaculation still can occur.
  40. 40. Tamsulosin is currently the most widely used α1 antagonist investigated for LUTS and BPH . • One of the features of tamsulosin is that it exhibits some degree of specificity for the α1A adrenoceptors. • Dose to be started at 0.4 mg and can be increased to 0.8 mg per day.  Adverse events include mild and included dizziness, rhinitis, and abnormal ejaculation which increase in dose dependent manner.
  41. 41. Alfuzosin was safe and effective for the treatment of LUTS and BPH. • The primary limitation of alfuzosin was a requirement for multiple daily doses (2.5 mg three times a day or 5 mg twice a day). • ER or SR alfuzosin is a new formulation that allows for a once-daily dosing regimen without dose titration. • Because of the lack of adverse effects and blood pressure changes, alfuzosin has been described as a uroselective drug
  42. 42. Silodosin, a selective α1-adrenergic receptor antagonist, is the LUTS-BPH market leader. • Silodosin was shown to increase urine flow in 2 to 6 hours after the initial dose. • Improvement of symptoms was realized in 3 to 4 days, with the majority of patients, including men on concomitant cardiovascular medications, achieving at least a three-point improvement in IPSS score, regardless of age or severity of symptoms. • It was associated with a low incidence of orthostatic hypotension and syncope, fainting, and dizziness. • The most common drug-related side effect was retrograde ejaculation.The second most commonly reported adverse event was dizziness.
  43. 43. 5α-reductase Inhibitors • Finasteride is a competitive inhibitor of the enzyme 5α- reductase Finasteride lowers serum and intraprostatic DHT levels. • Two isozymes (types 1 and 2) of 5α-reductase exist . • Finasteride is a selective inhibitor of the type 2 isozyme. • Finasteride does not reduce DHT levels to castrate levels because circulating testosterone is converted to DHT by type I isozymes that exist in skin and liver.
  44. 44. • Prostate volume regression was maximal at 6 months. The greatest change in symptom scores and PFR occurred within the first 2 months of initiation of active treatment. • Adverse effects include decreased libido, ejaculatory disorder, and impotence. • Because of the variable effect on PSA, men who are candidates for early detection of prostate cancer should have their PSA level determined before beginning finasteride therapy. A biopsy should be considered if the PSA level is elevated or for progressively rising PSA levels after initiation of therapy. The Prostate Cancer Prevention Trial showed that finasteride reduced the incidence of diagnosed prostate cancer . There was an increased incidence of high-grade disease, possibly because of the volume change effect, which was also seen with dutasteride.
  45. 45. Dutasteride Dutasteride is a dual inhibitor of 5α-reductase 1 and 2 and therefore has a greater impact on suppressing serum DHT levels. • The symptom score was improved by 4.5 points. • Long-term treatment with dutasteride results in continuing improvements in both symptoms and urinary flow • Similar to finasteride, the principal side effects were loss of Libido and ED, but these were most frequently seen at the start of therapy and declined over time with treatment.
  46. 46. Combination therapy Combination of alpha blockers and 5-alpha reductase inhibitors:  The risk of overall clinical progression—defined as an increase above baseline of at least four points in the IPSS, acute urinary retention, urinary incontinence, renal insufficiency, or recurrent urinary tract infection—was significantly reduced by doxazosin (39% risk reduction) and finasteride (34% risk reduction), as compared with placebo.  The reduction in risk associated with combination therapy (66% risk reduction) was significantly greater than that associated with doxazosin or finasteride alone.  Patients most likely to benefit from combination therapy are those in whom baseline risk of progression is very high, generally patients with larger glands and higher PSA values.
  47. 47. PHYTOTHERAPY  The pharmacologic use of plants and herbs (phytotherapy) for the treatment of LUTS and BPH is common.  These agents are popular in Europe, particularly in France, Austria, and Germany.  Although α-blocker monotherapy was the most frequently prescribed treatment; phytotherapy was very popular followed by 5α-reductase inhibitor monotherapy.  Phytotherapeutic products are not the actual plant but are extracts derived from the roots, the seeds, the bark, or the fruits of the various plants used.  The composition of plant extracts is very complex. They contain a wide variety of chemical compounds, which include phytosterols, plant oils, fatty acids, and phytoestrogens.
  48. 48. S. repens (also known by its botanical name of S.serrulata), is the most popular phytotherapeutic agent consumed for LUTS and BPH.The extract of the berry of the plant is used.
  49. 49. Suggested Mechanism of Action of Phytotherapeutic Agents:  Inhibition of 5α-reductase  Anti-inflammatory action  Interference with growth factors  Antiandrogenic effects  Estrogenic effects  Inhibition of aromatase  Decrease of sex hormone–binding globulin  Alteration of cholesterol metabolism  Action on α-adrenergic receptors  Free radical scavenging  Alteration of lipid peroxidation  Modulation of prolactin-induced prostatic growth  Protection of bladder and detrusor function  Placebo effect
  50. 50. Surgical Therapy Transurethral resection of the prostate Current indications for transurethral resection of the prostate. Moderate (8–19) to severe (20–35) lower urinary tract symptoms (LUTS) not responding to medical treatment ●● Refractory urinary retention with at least one failed attempt at catheter removal ●● Chronic retention with back pressure changes, leading to: ––Hydronephrosis ––Renal insufficiency ●● Complications of benign prostatic hyperplasia (BPH), including: ––Recurrent urinary tract infection ––Recurrent gross hematuria ––Bladder diverticula ––Bladder stones
  51. 51. • TURP involves an endoscopic approach via the patient’s urethra to surgically remove the inner portion primarily the transition zone of the prostate that encircles the urethra. • An electrified wire loop is used to remove the portion of the prostate between the bladder neck and the verumontanum to a depth of the surgical capsule. • The current is carried from the cutting loop through the tissue to the return electrode in the grounding pad. • This requires the use of a nonionic irrigant (water, glycine, sorbitol) to allow electroresection of the prostate. • The use of an ionic solution (i.e., normal saline) leads to dissipation of the cutting current and poor cutting efficacy. • These nonionic solutions are hypo-osmolar and can be problematic when absorbed through open prostate sinuses into the systemic circulation.
  52. 52. • Irrigation fluid must be non-conductive that the diathermy current is concentrated at the cutting point. • Irrigation fluid has to be non-haemolytic so that haemolysis does not occur if it enters the circulation. • Irrigation fluid must have neutral visual density so that the surgeon‘s view is not distorted. • Most commonly used irrigants are glycine1.5% in water ( 230 mOsm/L) or Cytal a mixture of 2.7% sorbitol and 0.54% mannitol ( 195 mOsm/L). • During a TURP - procedure 20 ml/min irrigant solution is normally absorbed .This is a total of 1 - 1.5 litres for the average case.
  53. 53. Procedure: Anaesthesia: General / spinal/ regional • Regional anesthesia is a desirable choice in patients undergoing transurethral prostatic surgery. Excellent skeletal and smooth-muscle relaxation allows easy filling of the bladder and reduces bladder spasms. • Once adequate anesthesia has been initiated,the patient is placed in the modified lithotomy position. • Care is taken to avoid overextension at the hip joint, and adequate padding is used for bony prominences. • Cystourethroscopy is done as the first step to assess the distal urethra, position of verumontanum, size and configuration of the prostate, bladder neck, urinary bladder, and both ureteric orifices.
  54. 54. • Fluid level may be raised during the procedure if visualization becomes obscured because of bleeding. • The opening of the procedure should start with resection of any impediment to movement of the irrigating fluid. • A 24 or 26 Fr size resectoscope, the continuous irrigation variety is the most commonly employed equipment. • The presence of a middle lobe should lead the surgeon to start the resection there. • Once a median lobe has been removed, the lateral lobes of the prostate may then be tackled. • Irrigating fluid should be maintained at body temperature and placed at the lowest height relative to the patient to provide adequate visualization.
  55. 55. • Some surgeons use a modification of the Nesbit“encirclement” approach . • In the Nesbit approach, resection is initiated at the 11 o’clock to 9 o’clock and the 1 o’clock to 3 o’clock positions. • The resection exposes but does not resect the bladder neck fibers and carries the resection proximally to the base of the verumontanum,avoiding any injury to the external sphincter.
  56. 56. • Surgeons starting with the prostatic floor usually start by resecting a “channel” at either the 5 or 7 o’clock position and resecting down to the surgical capsule of the prostate. • By finding the surgical capsule early in the procedure, the depth of the resection is set. • The channel is then widened (usually laterally) and then carried up the lateral walls toward the anterior aspect of the prostate, following the surgical capsule as the depth of resection.
  57. 57. • The area between the 5 and 7 o’clock positions is then resected at the final stages of the procedure to smooth out the prostatic floor and finish the procedure without undermining the bladder neck during multiple movement of the scope. • The initial stages of the resection should involve long, smooth tissue cuts. The produced prostate chips should be long and canoe-like in appearance, with a length equivalent to the extended resection loop. • Over-resection in any area before the major portion of the adenoma has been removed may expose large venous sinuses. Exposing these sinuses will predispose to bleeding and fluid extravasation and absorption and compromise the resection and patient outcome. • The prostate apex is best resected at the end of the procedure in a bloodless field where resection can be done precisely to avoid injury to the external sphincter.
  58. 58. • Strict hemostasis should be maintained througout the procedure. • Before the operation is terminated, all tissue must be removed from the bladder, with careful attention paid to make sure prostatic chips have not fallen into any bladder diverticuli that may exist. • An Ellik or Toomey syringe may help facilitate removal of any tissue. • The prostatic fossa should be examined again as one of the final steps, with control of any arterial bleeding. • A large-bore catheter should be carefully placed into the bladder with the use of a wire catheter guide if required. • The amount of fluid placed in the balloon should be tailored to the volume of resected tissue to avoid the catheter balloon falling into the excavated prostatic fossa. • The use of continuous bladder irrigation (CBI) is not compulsory but can be used if the irrigant is not clear at the end of the procedure.
  59. 59.  Early: Haemorrhage Resection Errors TURSyndrome Obturator Nerve Stimulation Intraoperative Priapism Sepsis
  60. 60.  Late: Bladder Neck Contracture Urethral Stricture Incontinence Impotence
  61. 61. TUR syndrome  This is a complex syndrome of fluid overload, dilutional hyponatremia, and hemolysis due to systemic absorption of large amounts of irrigant, especially in patients with a gland size larger than 45 g and a resection time of more than 90 minutes.  TUR syndrome occurrs in 2% of patients .  The syndrome may occur as quickly as 15 minutes after the resection starts or up to 24 hours postoperatively.  It is characterized by confusion, nausea, vomiting, hypertension, bradycardia, and visual disturbances.  Monitoring the serum sodium concentration is important as the syndrome does not occur until the serum sodium falls below 125 mEq/dl.  Intravenous hypertonic saline, diuretics, and termination of the procedure may be required when this happens.  Limiting the height of the irrigation bottle to 60 cm above the prostate reduced the intravascular fluid absorption.  Leaving a rim of tissue on the capsule until the end of the procedure, where it can be left if signs of TUR syndrome are evident, may reduce the risk of absorption due to opening of prostatic sinuses.
  62. 62. Transurethral incision of the prostate:  Men with moderate to severe symptoms and a small prostate often have posterior commissure hyperplasia . • These patients will often benefit from an incision of the prostate. • This procedure is more rapid and less morbid than TURP. • The technique involves two incisions using the Collins knife at the 5- and 7-o’clock position. The incision is started at the ureteral orifice and carried through the bladder neck up to the verumontanum. This procedure is done bilaterally
  63. 63. Transurethral vaporization of the prostate  This ablative techniques uses photo- or electroevaporation to ablate obstructing prostate tissue.  The two most commonly used devices for these procedures are the neodymium-doped yttrium- aluminum-garnet (Nd:YAG) KTP “GreenLight” laser, which is preferentially absorbed by hemoglobin, and the plasma vaporization “Button” electrode. The latter works with a standard contemporary bipolar generator used for bipolar TURP.  The goal of the procedure in either case is to produce a central prostate defect comparable with traditional TURP, but with less bleeding and lower risk of perforation.
  64. 64. Holmium laser enucleation of the prostate (HoLEP) HoLEP denotes an anatomic dissection in the plane between the central and peripheral zones of the prostate. This approach is felt to provide the largest defect and perhaps the longest durability, but entails a longer learning curve than TURP or TUVP.
  65. 65. Simple (subtotal) prostatectomy Indications: --Glands >100 g --Concomitant bladder diverticulum --large bladder stone --dorsal lithotomy positioning is not possible. Open prostatectomies can be done with either a suprapubic or retropubic approach. • A simple suprapubic prostatectomy is performed transvesically. After the bladder is opened, a semicircular incision is made in the bladder mucosa, distal to the trigone. • The dissection plane is initiated sharply, and then blunt dissection with the finger is performed to remove the adenoma. • The apical dissection should be done sharply to avoid injury to the distal sphincteric mechanism. • After the adenoma is removed, hemostasis is attained with suture ligatures, and both a urethral and a suprapubic catheter are inserted before closure.
  66. 66. • In a simple retropubic prostatectomy, the bladder is not entered. Rather, a transverse incision is made in the surgical capsule of the prostate, and the adenoma is enucleated as described earlier. • Only a urethral catheter is needed at the end of the procedure. Transurethral microwave thermotherapy Microwave hyperthermia is most commonly delivered with a transurethral catheter. Some devices cool the urethral mucosa to decrease the risk of injury. If temperatures are not >45°C, cooling is unnecessary.