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7 prostate lecture

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Benign Prostatic Hyperplasia
Benign Prostatic Hyperplasia
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7 prostate lecture

  1. 1. BENIGN PROSTATIC HYPERPLASIABENIGN PROSTATIC HYPERPLASIA BPHBPH Ahmad A. Elabbady, MDAhmad A. Elabbady, MD Professor, Urology Department,Professor, Urology Department, University of AlexandriaUniversity of Alexandria
  2. 2. BENIGN PROSTATIC HYPERPLASIABENIGN PROSTATIC HYPERPLASIA 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.
  3. 3. BENIGN PROSTATIC HYPERPLASIABENIGN PROSTATIC HYPERPLASIA 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
  4. 4. BENIGN PROSTATIC HYPERPLASIABENIGN PROSTATIC HYPERPLASIA • 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.
  5. 5. BENIGN PROSTATIC HYPERPLASIABENIGN PROSTATIC HYPERPLASIA 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
  6. 6. BENIGN PROSTATIC HYPERPLASIABENIGN PROSTATIC HYPERPLASIA 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
  7. 7. BENIGN PROSTATIC HYPERPLASIABENIGN PROSTATIC HYPERPLASIA 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).
  8. 8. BENIGN PROSTATIC HYPERPLASIABENIGN PROSTATIC HYPERPLASIA 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).
  9. 9. BENIGN PROSTATIC HYPERPLASIABENIGN PROSTATIC HYPERPLASIA • 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).
  10. 10. BENIGN PROSTATIC HYPERPLASIABENIGN PROSTATIC HYPERPLASIA 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
  11. 11. BENIGN PROSTATIC HYPERPLASIABENIGN PROSTATIC HYPERPLASIA
  12. 12. BENIGN PROSTATIC HYPERPLASIABENIGN PROSTATIC HYPERPLASIA IV- Cystourethroscopy ( prior to surgery) Degree of middle &/or lateral lobe enlargement Hematuria Bladder stone Associated pathology Urethral stricture
  13. 13. BENIGN PROSTATIC HYPERPLASIABENIGN PROSTATIC HYPERPLASIA Differential DiagnosisDifferential Diagnosis Meatal stenosis Urethral stricture Prostatic cancer Bladder neck fibrosis Drugs ( parasympatholytic and sympathomimetics) Neurologic lesions
  14. 14. BENIGN PROSTATIC HYPERPLASIABENIGN PROSTATIC HYPERPLASIA 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.
  15. 15. BENIGN PROSTATIC HYPERPLASIABENIGN PROSTATIC HYPERPLASIA 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.
  16. 16. III- Less invasive methods (Still inferior to TURP): - Laser, - hyperthermia, - Incisions, - Balloon dilatation.
  17. 17. BENIGN PROSTATIC HYPERPLASIABENIGN PROSTATIC HYPERPLASIA 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.
  18. 18. 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
  19. 19. BENIGN PROSTATIC HYPERPLASIABENIGN PROSTATIC HYPERPLASIA - 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.
  20. 20. Prostate CancerProstate Cancer Ahmad A. Elabbady, MD Professor, Urology Department, University of Alexandria
  21. 21. 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
  22. 22. Prostate CancerProstate Cancer • 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
  23. 23. Prostate cancerProstate cancer Risk FactorsRisk Factors - Age - Family history - Race - Dietary fats - Hormones - Geography - Genetics
  24. 24. Prostate CancerProstate Cancer • It is a Heterogeneous, wide spectrum disease. • Often, It is a slowly progressive disease.
  25. 25. Prostate CancerProstate Cancer • 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.
  26. 26. 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
  27. 27. 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
  28. 28. 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).
  29. 29. Diagnosis of prostate CancerDiagnosis of prostate Cancer Early diagnosisEarly diagnosis - DRE Asymmetry, hard nodules - Serum PSA 0-4 ng/ml - TRUS-directed prostatic Bx.
  30. 30. Early detection of prostate CancerEarly detection of prostate Cancer PSAPSA PSA is organ-specific but not cancer specific
  31. 31. Early detection of prostate CancerEarly detection of prostate Cancer PSAPSA PSA elevations -Prostate disease (BPH, prostatitis, P Ca) -prostate manipulation (massage, Bx).
  32. 32. 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)
  33. 33. 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.
  34. 34. Prostate cancerProstate cancer PathologyPathology • Commonly: adenocarcinoma . 95% • Other types: 5% e.g. TCC - Sarcoma
  35. 35. • 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
  36. 36. TNM staging for Ca PTNM staging for Ca P
  37. 37. Prostate cancerProstate cancer gradinggrading • Gleason grading system Depends on architectural pattern Grades 1-5 for the primary and secondary pattern Gleason sum: primary + secondary grades
  38. 38. Prostate cancerProstate cancer • Pattern of spread • Direct • Inward > outward • Lymphatic • Obturator • Hypogastric • Distant • 90% to bones • Lung,liver
  39. 39. Prostate cancerProstate cancer 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)
  40. 40. BENIGN PROSTATIC HYPERPLASIABENIGN PROSTATIC HYPERPLASIA
  41. 41. Prostate cancerProstate cancer 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 •
  42. 42. Prostate cancerProstate cancer 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
  43. 43. Thank you

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