SURGERY

1. BENIGN PROSTATE HYPERPLASIA
(BPH)
PRESENTER: KUWABOMWENDABAI
DATE: 23/02/18
KABWE GENERALHOSPITAL
BPH16-Apr-19

2. CONTENT
1. DEFINATION OF THE PROSTATE
2. GROS ANATOMY
3. BLOOD SUPPLY
4. BPH DEFINATION
5. PATHOPYSIOLOGY
6. AETIOLOGY
7. CLINICAL PRESENTATION
8. COMPLICATIONS
9. INVESTIGATIONS
10.MANAGEMENT
BPH
2
6-Apr-19

3. THE PROSTATE
This is is a male reproductive organ whose main function is to
secret prostate fluid,one of the components of semen.it is found
in front of the rectum and just below the bladder
BPH 36-Apr-19

4. • A normal prostate gland is approximately 15g-20g in
weight. 3cm in length, 4cm wide, and 2cm in depth.
However, when men get older, the prostate variable
in size secondary to BPH
• The gland is located posterior to the pubic
symphysis, superior to the perineal membrane,
inferior to the bladder, and anterior to the rectum.
GROSS ANATOMY OF THE PROSTATE
BPH 46-Apr-19

5. Microscopic anatomy
The prostate is historically divided in to
three zones [MCNEAL]
1. the transition zone
 it surrounds the urethra
 it is small in young adult, grows through out
life
 responsible for about 20% BPH cases.
1. central zone
 area surrounding the ejaculatory duct
 only a very small percentage of cancer begins
from here[<5%]
1. peripheral zone
 contain the majority of prostatic glandular
tissue, it is felt on DRE.
 About 70-80% cancers begin from this zone
BPH 56-Apr-19

6. anatomy….cont’d
BPH 66-Apr-19

7. BLOOD SUPPLY OF THE PROSTATE
ARTERIAL SUPPLY
Branches of internal iliac artery
• Branches from inferior vesicle artery.
• Branches from middle rectal artery.
• Branches from internal pudendal
artery.
There are two types of branches
• Capsular and Urethral
• Urethral branches mainly supply the
median lobe
Capsular artery supply the glandular
tissue.
VENOUS DRAINAGE
• Veins from the prostatic plexus drain
into the internal iliac vein.BPH 76-Apr-19

8. BENIGN
PROSTATE
HYPERPLASIA
BPH 86-Apr-19

9. DEFINITION
• BPH is the enlargement of the prostate. The prostate often
enlarges to a point where urination becomes difficult. BPH is
more prone to adults above the age of 50,usually betwen 60
and 70 years(SRB manual of surgery)
• benign prostatic hyperplasia is non cancerous growth of the
prostate gland.
BPH 96-Apr-19

10. PATHOPHYSIOLOGY
 Although the cause of BPH is not completely
understood, it is thought BPH results from
endocrine changes associated with the aging
process. Prostate causes may include excessive
accumulation of hormones like estrogen.
 Typically BPH develops in the inner part of the
prostate. This enlargement gradually compresses
the urethra eventually leading to partial or
complete obstruction.
10BPH 6-Apr-19

11. Patho cont....
 It is the compression of the urethra that ultimately
leads to development of clinical symptoms. There
is no direct relationship between the size of the
prostate and the degree of obstruction. It is the
allocation of the enlargement that is significant in
the development obstructive symptoms. For
example, it is possible for mild hyperplasia to
cause severe obstruction; likewise it is possible
for extreme hyperplasia to cause to few
obstructive symptoms.
11BPH 6-Apr-19

12. AETIOLOGY
• There is no known cause (Idiopathic)+
Predisposing factors
 Age : over 50 years as part of natural aging process(increase in
androgen receptors)
 Hormone imbalance between testosterone and estrogen
 Chronic prostitis : common affects men over 50 years.
 Obesity :(increase in abdominal girth)-especially if they are
inactive(physical activities exerts protection against prostatic
enlargement)
 family history : involving first degree relatives
BPH 126-Apr-19

13. CLINICAL PRESENTATION
(LUTS/Prostatism)
IRRITATIVE SYMPTOMS
• Frequency
• Nocturia
• Urgency
• Urge incontinence
OBSTRUCTIVE SYMPTOMS
• Hesitancy
• Dysuria
• Intermittency
• Poor stream
• Residual volume
• Post-micturitional dribblingBPH 136-Apr-19

14. BLADDER OUTFLOW OBSTRUCTION
(BOO)
This can also be caused by BPH. Its symptoms are:
• Abdominal pain
• Continuous filling of a full bladder
• Frequent urination
• Acute Urinary Retention
• Dysuria
• Urinary Hesitancy
• Slow urine flow
• Intermittence
• Nocturia
BPH 146-Apr-19

15. INVESTIGATION
• FBC
• Ultrasound,Intravenous Venourogram (IVU),trasrectal
US
• Biopsy
• Urine M/C/S or urinalysis
• U & Es
• Cystoscopy
• Post voiding residual urine: Normal < 100mls
• Flow Rates: Normal = 15mls/sec , Abnormal(Low):
<10mls/sec
• Prostate Specific Antigen (PSA) -rule out cancer
• Acid phosphotase
BPH 156-Apr-19

16. Examination
1.Digital rectal examinations:
 reveals smooth, firm, elastic and enlarged
prostate.
2.0n abdomen palpation:
 enlarged bladder, kidney and constipation
BPH 166-Apr-19

17. WHEN SHOULD BPH BE TREATED?
BPH needs to be treated only if:
 The symptoms are severe enough to bother patient
and affect the quality of life.
 Renal insufficiency
 Frequent urinary tract infection.
NOTE: if the above are not a
problem....management is ''watctful waiting''
BPH 176-Apr-19

18. MANAGEMENT
MEDICATION
*two major types:
Alpha-1-blocker- relax the prostate and provide a larger
urethral opening
 prazosin
 terazosin
5-alpha reductase inhibitor-shrink the prostate gland
 finasteride (proscar)
Antibiotics (if suspected UTIs)
Conservative therapy (catheterisation)
BPH 186-Apr-19

19. Possible side effects of medication
 Impotence
 Dizziness
 Headache
 Fatigue
 Loss of sexual drive
BPH 196-Apr-19

20. Management cont.……
Management of BPH is based on patient’s complaints and clinical assessment
IPSS (International Prostate Score System)
 7 symptoms each with a score of 5 = 35 in total
1. feelling of incomplete bladder emptying,
2. frequecy,
3. intermitency,
4. urgency,
5. weak stream,
6. straining and
7. nocturia
score (points) symptoms management
0-7 mild conservative
8-19 moderate medical treatment
20-35 severe surgical
BPH 206-Apr-19

21. MANAGEMENT….cont’d
• Failure of Medical Tx
• Hematuria
• Acute retention of urine
• Complications (stone formation,hydronephrosis,recurent
infections)
• When IPSS > 20
• Pt’s choice
• Bladder diverticulum
• Post voiding residual urine: more than 100mls
INDICATIONS FOR SURGERY
BPH 216-Apr-19

22. • “Gold Standard” of care for BPH
• Uses an electrical “knife” to surgically cut and remove
excess prostate tissue
• Effective in relieving symptoms and restoring urine flow
Transurethral Resection of the
Prostate(TURP)
BPH 226-Apr-19

23. Surgical treatment
Complications of TURP
 hemorrhage
 TURP syndrome
 hypothermia
 septicemia
 NOTE:
 TURP syndrome is caused by hyponatremia due to constant flushing
during surgery (nausea, vomiting, fatigue, disorientation, seizures or
brain edema )
BPH 236-Apr-19

24. Other Procedures
Transurethral Resection of the prostate
 This is the surgical procedure involving the removal of the prostate
tissue using a resectoscope inserted through the urethra. This has
been considered the gold standard surgical treatment for
obstructing BPH. No external surgical incision is made.
Transurethral incision of the prostate
 The procedure can even be done under local anesthesia.
No surgical incision is required.
Suprapubic prostatectomy
 This operation may be chosen when the prostate is
large and when bladder surgery is indicated as well
Retropubic prostatectomy
 This is a useful approach if the prostate is too large or
cancer is suspected. An abdominal incision is made
above the bladder
24BPH 6-Apr-19

25. Differentials
stricture urethra
bladder tumor
bladder carcinoma
neurogenic causes (Diabetes)
idiopathic detrusor activity
bladder neck stenosis
BPH 256-Apr-19

26. COMPLICATIONS
Hemorrhage-Due to sippage of a ligature
during surgery
Infection- On the incision due to lack of
aseptic techniques during wound cleaning
Shock- Due to bleeding
Acute urine retention-Due to poor irrigation
Urethral stricture-Due to damage during
surgery like in transurethral prostatectomy
8/20/2013 26

27. COMPLICATIONS
Acute or chronic renal failure-Due to
hydronephrosis
Hydronephrosis-Due to incomplete bladder
irrigation
UTI –Due to urine stasis
Pyelonephritis-Due to delayed treatment of acute
urine retention
Detrusor muscle hypertrophy- Due to urine
stasis. 8/20/2013 27

28. Thank you
BPH 286-Apr-19

29. REFERENCES
• SHORT PRACTICE of SURGERY 25th Edition, N
Williams, et al, Hodder Arnold Publishers, 2008
• Medscape.com
• Revised Magic Notes (Surgery)
• SRB manual for surgery
• wwww.Uptodate
BPH 296-Apr-19