Prostate BPH- evaluation & management

2. Moderators: Professors: • Prof. Dr. G. Sivasankar, M.S., M.Ch., • Prof. Dr. A. Senthilvel, M.S., M.Ch., Asst Professors: • Dr. J. Sivabalan, M.S., M.Ch., • Dr. R. Bhargavi, M.S., M.Ch., • Dr. S. Raju, M.S., M.Ch., • Dr. K. Muthurathinam, M.S., M.Ch., • Dr. D. Tamilselvan, M.S., M.Ch., • Dr. K. Senthilkumar, M.S., M.Ch. Dept of Urology, GRH and KMC, Chennai. 2

3. Male urinary tract - PROSTATE Gland Location base of bladder and surrounds the urethra PROSTATE 3 Dept of Urology, GRH and KMC, Chennai.

4. PROSTATE Gland • At birth- pea size • Gradually increase until puberty • Reaching normal adult size - walnut - third decade of life • Size remains same until the age of 40-45 • Increase in the size on or after 45 yrs. 4 Dept of Urology, GRH and KMC, Chennai.

5. PROSTATE Gland Prostate cancer commonly occurs in peripheral zone while BPH occurs in transition zone. Transitional Zone Anterior Zone Central Zone Peripheral Zone 5 Dept of Urology, GRH and KMC, Chennai.

6. Benign Prostatic Hyperplasia 6 Dept of Urology, GRH and KMC, Chennai.

7. Definition & terminology • Microscopic BPH • Macroscopic BPH • Clinical BPH LUTS ( Paul Abrams) Detrusor instability BPH related complications 7 Dept of Urology, GRH and KMC, Chennai.

8. LUTS BOO BPE 8 Dept of Urology, GRH and KMC, Chennai.

9. 9 Dept of Urology, GRH and KMC, Chennai.

10. Initial evaluation • Medical history • Physical exam Gen Exam DRE & Focused neurologic examination • Urinalysis • Sr PSA 10 Dept of Urology, GRH and KMC, Chennai.

11. Normal gland 20 gms Chestnut Minimally perceptible on DRE 1+ 25 gms Plum <1/4 of the Rectal Lumen 2+ 50 gms Lemon <1/2 of the Rectal Lumen 3+ 75 gms Orange 3/4 of the Rectal Lumen 4+ 100 gms Small grapefruit Fills the Rectal Lumen 11 Dept of Urology, GRH and KMC, Chennai.

12. Normal gland Encroaches 0-1 cm into Rectal Lumen 1 Encroaches 1-2 cm into Rectal Lumen 2 Encroaches 2-3 cm into Rectal Lumen 3 Encroaches 3-4 cm into Rectal Lumen 4 Encroaches >4 cm into Rectal Lumen 12 Dept of Urology, GRH and KMC, Chennai.

13. Benign Prostatic Hyperplasia Patho - physiology of Bladder Outlet Obstruction • Mechanical component • Dynamic component • Detrusor response 13 Dept of Urology, GRH and KMC, Chennai.

14. Symptomatology Symptoms of BPH Obstructive symptoms Irritative symptoms • Hesitancy • Impairment of size and force of urinary stream • Interruption of stream • Terminal dribbling • Nocturia • Daytime frequency urgency • Dysuria • Sensation of incomplete emptying of the bladder/ Sense of incomplete void Lower urinary tract symptoms 14 Dept of Urology, GRH and KMC, Chennai.

15. Symptom assessment • Non validated scoring system Boyarsky symptom index Madsen-Iverson symptom index • Validated scoring system AUA • Disease specific QOL scoring system IPS-S BPI 15 Dept of Urology, GRH and KMC, Chennai.

16. AUA (1992) 16 Dept of Urology, GRH and KMC, Chennai.

17. If you were to spend the rest of your life with your urinary condition the way it is now, how would you feel about that? (Please tick which best describes how you would feel.) 0. Delighted 1. Pleased 2. Mostly satisfied 3. Mixed - about equally satisfied and dissatisfied 4. Mostly dissatisfied 5. Unhappy 6. Terrible IPSS • 2nd International consultation on BPH & WHO (1994) 17 Dept of Urology, GRH and KMC, Chennai.

18. Additional diagnostic testing • Optional: Following the initial evaluation of the patient, urinary flow-rate recording and measurement of post void residual urine (PVR) may be appropriate. • Indications: – Moderate to severe LUTS – Bothersome LUTS – Prior to invasive therapy – Initial evaluation point to a non prostatic cause – Patients with complex medical history 18 Dept of Urology, GRH and KMC, Chennai.

19. Uroflowmetry • Electronic recording of urinary flow rate through out the course of micturition • Simple / non invasive / reproducible 19 Dept of Urology, GRH and KMC, Chennai.

20. Contd… • Q max - Maximal flow rate • Q ave - Average flow rate • TQ max - Time lapsed from onset to maximal flow • Flow time - Time over which measurable flow actually occurs • Voided Vol - Total volume of urine actually voided 20 Dept of Urology, GRH and KMC, Chennai.

21. Contd… Gender Age (Yr) Flow rate (ml/sec) Males <40 >22 40 - 60 >18 >60 >13 Females <50 >25 >50 >18 Flow rate (ml/sec) Interpretation > 15 unlikely to be obstructed 10 - 15 Equivocal < 10 Either obstructed or weak bladder contractility 21 Dept of Urology, GRH and KMC, Chennai.

23. Guidelines • Qmax is more specific than Qave • Qmax decreases with advancing age & decreasing voided volume • Qmax of > 15 ml/sec – Poor outcome after surgery • Qmax of < 15 ml/sec – does not differentiate between obstruction and poor bladder contractility • Uroflow is not needed in patients who elect watchful waiting therapy 23 Dept of Urology, GRH and KMC, Chennai.

24. PVR • Volume of urine remaining in the bladder immediately after the completion of urination • Normal range 0.09 to 2.24 ml • Mean 0.53 ml • 78% of normal men - < 5 ml • 100% of normal men - < 12 ml • Measurement – USG – Catheterization 24 Dept of Urology, GRH and KMC, Chennai.

25. UDE • Pressure flow studies (PFS) – Is the only test directly measures the relative contributions of bladder, outlet and prostate to lower urinary tract function, dysfunction or symptoms – Differentiate between pts with low Qmax due to obstruction or nerogenic dysfunction • Indications – Uroflow is equivocal – Bothersome LUTS with high Qmax – Evaluation of men with LUTS who have failed prior invasive therapy – Pts with history / examination suggestive of concomitant neurologic diseases (CVA,Parkinsons,Neuropathy) 25 Dept of Urology, GRH and KMC, Chennai.

26. Urethrocystoscopy • H/O microscopic or gross hematuria • H/O stricture disease • H/O bladder cancer • H/O prior lower urinary tract surgery • To select specific technique in pts choosing invasive therapy 26 Dept of Urology, GRH and KMC, Chennai.

27. Size Intraurethral lateral Intraurethral middle or dorsal portions of lateral Intravesical middle or dorsal portion of lateral Normal Concave lateral prostatic urethral walls 1-2 cm between veru and prostatic border Does not cover trigone Gr I Lobes bulge inwards but do not touch in midline 2-3 cm between veru and prostatic border Covers upto ½ of trigone Gr II Lobes touch in the midline 3-4 cm between veru and prostatic border Covers from ½ to all trigone Gr III Lobes touch in the midline for 2-3 cm 4-5 cm between veru and prostatic border Covers more than trigone Gr IV Lobes touch in the midline for > 3 cms >5 cm between veru and prostatic border Extends up into fundus 27 Dept of Urology, GRH and KMC, Chennai.

28. Management Options • Watchful waiting. • Medical Management. • Surgical Management. 28 Dept of Urology, GRH and KMC, Chennai.

29. Watchful waiting • 85% of men will be stable on WW at 1 year. • 65% of men will be stable on WW at 5 years. • Reason why some men deteriorate and others do not is not understood. • Education ,reassurance ,and periodic monitoring is a must. EAU Update 2004 29 Dept of Urology, GRH and KMC, Chennai.

30. • Patients with mild symptoms and patients with moderate to severe symptoms without bother should be managed using watchful waiting • Patients with bothersome moderate to severe symptoms include medical, minimally invasive, or surgical therapies 30 Dept of Urology, GRH and KMC, Chennai.

31. Surgery in BPH Absolute Indications  Refractory retention of urine  Persistent hematuria  Persistent UTI with BPH  Vesical calculi with BPH  Bladder diverticulae with BPH  Renal failure in BPH  Severe symptoms 31 Dept of Urology, GRH and KMC, Chennai.

32. MEDICAL TREATMENT • Alpha blockers • 5 alpha reductase inhibitors • Combination therapy( alpha blocker and 5 alpha reductase inhibitor) • Phytotherapy 32 Dept of Urology, GRH and KMC, Chennai.

33. LUTS • Dynamic component - managed by alpha blockers • Static component - managed by 5 alpha reductase inhibitors 33 Dept of Urology, GRH and KMC, Chennai.

34. Alpha receptors Alpha 1 • Alpha 1a – prostatic smooth muscle • Alpha 1b – blood vessels • Alpha 1d - detrusor 34 Dept of Urology, GRH and KMC, Chennai.

35. Alpha blockers • Drugs used Non selective Alpha 1 Long acting alpha 1 Alpha 1a , 1d • Phenoxybenzamine • Prazosin • Terazosin ,Doxazosin Alfuzosin SR • Tamsulosin 35 Dept of Urology, GRH and KMC, Chennai.

37. 5ALPHA REDUCTASE INHIBITORS • Foundation therapy for BPH • 5AR enzyme in 2 forms type 1 –in skin,liver type 2 – prostate • Drugs available – Finasteride , Dutasteride • Mech. of action – inhibits 5AR enzyme which converts testosterone to DHT • DHT –active form 37 Dept of Urology, GRH and KMC, Chennai.

38. COMBINATION THERAPY • Indicated when prostate vol >40gm or PSA >1.5ng/ml • The best tested combination is doxazosin and finasteride • Reduces the risk of progression, reduces the risk of surgery, reduces the risk of acute urinary retention • 0.5mg of Dutasteride + 0.4mg of Tamsulosin provides rapid symptomatic relief • Withdrawal of alpha blocker after 6 months maintains symptomatic relief in 77% of patients 38 Dept of Urology, GRH and KMC, Chennai.

39. Assess prostate size Digital rectal exam Ultrasound optional 40g or less >40g Alpha blocker Alpha blocker+/or 5 alpha reductase inhibitors Reassess Reassess Improvement No improvement Improvement No improvement Continue indefinitely Surgery Continue indefinitely Surgery 39 Dept of Urology, GRH and KMC, Chennai.

40. When to switch over ? • Progression in symptoms/ IPSS • No change in the PFR • Progressively increasing PVR • Intolerance / C.Indications to medical treatment 40 Dept of Urology, GRH and KMC, Chennai.

41. Surgical Options • Open prostatectomy • TURP • Newer modalities and minimally invasive techniques 41 Dept of Urology, GRH and KMC, Chennai.

42. TURP • TURP is the gold standard in treating patients with BPH • Surgical therapy(TURP) betters the symptom score compared to other modalities • Only limitation is its morbidity and associated high costs 42 Dept of Urology, GRH and KMC, Chennai.

43. TURP 43 Dept of Urology, GRH and KMC, Chennai.

44. The prostate "chips" seen here are the firm, rubbery fragments obtained from transurethral resection of prostate (TURP) performed for symptomatic nodular hyperplasia 44 Dept of Urology, GRH and KMC, Chennai.

45. BPH – OPEN PROSTATECTOMY • Transvesical • Retropubic • Perineal 45 Dept of Urology, GRH and KMC, Chennai.

46. BPH – MINIMALLY INVASIVE PROCEDURES • Trans Urethral Inscision of Prostate. • Transurethral needle ablation • Laser Ablation • Electrovaporization • Transurethral microwave therapy • Transurethral baloon dilatation • Intra prostatic stents 46 Dept of Urology, GRH and KMC, Chennai.

47. Trans Urethral Incision of Prostate • Small gland ( <30gms) causing obstruction • Associated BNE without middle lobe hyperplasia. • Results comparable with TURP. • Less complications than TURP especially retrograde ejaculation. 47 Dept of Urology, GRH and KMC, Chennai.

48. TUIP 48 Dept of Urology, GRH and KMC, Chennai.

49. Trans Uethral Needle Ablation • RF energy delivered into prostate producing temperature > 60 degree C • Localized necrotic lesion in hyperplastic tissue without damaging urethra. • RF generator attached to TUNA catheter (Pro Vu system). • Lateral lobes <60 gms without median lobe enlargement & bladder neck hypertrophy are best suited. 49 Dept of Urology, GRH and KMC, Chennai.

50. TUNA 50 Dept of Urology, GRH and KMC, Chennai.

51. TRANSURETHRA NEEDLE ABLATION (TUNA) 51 Dept of Urology, GRH and KMC, Chennai.

52. Trans Urethral Microwave Therapy • Urethral microwave device to heat prostatic tissue > 45 degrees. • Damage to urethra prevented by conductive cooling system. • Commonly used systems – Prostatron & Targis. • Mechanism – Tissue necrosis, induction of apoptosis & damage to intraprostatic nerve endings and alpha receptors. 52 Dept of Urology, GRH and KMC, Chennai.

53. TUMT 53 Dept of Urology, GRH and KMC, Chennai.

54. TUMT Catheter • Catheter tip and balloon (A). • Thermosensing unit and microwave antennae (B) are located just proximal to the balloon. • Coolant-circulating ports (C). • Thermosensor port(D). • Drainage port (E) • Microwave ports (F and G) 54 Dept of Urology, GRH and KMC, Chennai.

55. TUMT 55 Dept of Urology, GRH and KMC, Chennai.

56. Patient undergoing TUMT 56 Dept of Urology, GRH and KMC, Chennai.

57. Trans Urethral Vaporization of prostate • Combination of 2 electrosurgical effects – vaporization & desiccation. • Grooved roller ball electrode made of nickel-silver & insulated with Teflon. • Vaporization occurs at leading edge & desiccation occurs at trailing edge. • Trans urethral vaporization-resection of protate (TURVP) using vaporizing loops. 57 Dept of Urology, GRH and KMC, Chennai.

58. TUVP – ROLLER BALL 58 Dept of Urology, GRH and KMC, Chennai.

59. TUVP – ENDOSCOPIC VIEW 59 Dept of Urology, GRH and KMC, Chennai.

60. Lasers in BPH • Types of Lasers Nd:YAG Laser. KTP Laser. Holmium:YAG Laser. • Mechanism – Desication, coagulation,carbonization&vaporization of prostatic tissue. 60 Dept of Urology, GRH and KMC, Chennai.

61. Methods of Delivery • End firing Laser. • Side firing Laser. • Interstitial Laser. 61 Dept of Urology, GRH and KMC, Chennai.

62. Side firing Laser probe 62 Dept of Urology, GRH and KMC, Chennai.

63. Interstitial Laser Therapy 63 Dept of Urology, GRH and KMC, Chennai.

64. KTP Laser • Wavelength 532 nm. • High absorption in hemoglobin limits penetration of the KTP laser beam to a depth of 0.8mm. • Vaporization occurs from within the tissue where vapor bubbles form and burst the collagen. • Highly hemostatic. • Treatment of patients on anti-coagulants is feasible due to the hemostatic properties of the KTP laser. • Known as Green light PVP or Photoselective Vaporization of the Prostate. 64 Dept of Urology, GRH and KMC, Chennai.

65. Holmium:YAG Laser • Wavelength 2100 nm. • Depth of penetration is only 0.4 mm. • The tissue volume heated by the laser is very small, which limits vaporization speed, coagulation depth and hemostasis. • Energy emitted in a series of rapid pulses. • Permitts actual tissue resection. • HoLAP for glands <40gms & HoLEP for >40 gms. 65 Dept of Urology, GRH and KMC, Chennai.

67. LASER PROSTATECTOMY 67 Dept of Urology, GRH and KMC, Chennai.

68. Post op Results 68 Dept of Urology, GRH and KMC, Chennai.

69. Protatic Stents • Restricted to patients unsuitable for surgical procedures. • First generation stents – Prosto Kath. • Second generation – Memokath,Prostocoil • Polyurethane Stents. • Biodegradable Stents • Permanent Stents – Urolume,Memotherm. 69 Dept of Urology, GRH and KMC, Chennai.

70. TEMPORARY STENTS 70 Dept of Urology, GRH and KMC, Chennai.

71. MEMOKATH STENT 71 Dept of Urology, GRH and KMC, Chennai.

72. TRANSURETHRAL BALLOON DILATATION 72 Dept of Urology, GRH and KMC, Chennai.

73. Conclusion • BPH is one of the most common diseases of aging men. • TURP is the gold standard for BPH. • Newer modalities – short term efficacy comparable with TURP. • Less morbidity & minimal complications. • Long term efficacy under evaluation. 73 Dept of Urology, GRH and KMC, Chennai.

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