外科学教学课件：Benign Prostatic Hyperplasia

BenignProstaticHyperplasia

BenignProstaticHyperplasiaGeneraliseddiseaseoftheprostateduetohormonalderangementwhichleadstoenlargementofthegland(increaseinthenumberofepithelialcellsandstromaltissue)tocausecompressionoftheurethraleadingtosymptomsBPH

ProposedEtiologiesCausenotcompletelyunderstoodReawakeningoftheurogenitalsinustoproliferateChangeinhormonalmilieuwithalterationsinthetestosterone/estrogenbalanceInductionofprostaticgrowthfactorsIncreasedstemcells/decreasedstromalcelldeathAccumulationofdihydroxytestosterone,stimulationbyestrogenandprostaticgrowthhormoneactionsBPHfactsOccursin50%ofmenover50andin80%ofmenover80haveBPHBPHprogressesdifferentlyineveryindividualManymenwithBPHmayhavemildsymptomsandmayneverneedtreatmentBPHdoesnotpredisposetothedevelopmentofprostatecancer

BenignProstaticHyperplasiaBPHPathophysiologyNormalBPHHypertrophieddetrusormuscleObstructedurinaryflowPROSTATEBLADDERURETHRAKirbyRSetal.Benignprostatichyperplasia.HealthPress,1995.BPH

PathophysiologySlowandinsidiouschangesovertimeComplexinteractionsbetweenprostaticurethralresistance,intravesicalpressure,detrussorfunctionality,neurologicintegrity,andgeneralphysicalhealth.InitialhypertrophydetrussordecompensationpoortonediverticulaformationincreasingurinevolumehydronephrosisuppertractdysfunctionComplicationsUrinaryretentionUTISepsissecondarytoUTIResidualurineCalculiRenalfailureHematuriaHernias,hemorroids,bowelhabitchangeClinicalmanifestationsVoidingsymptomsdecreaseintheurinarystreamStrainingDribblingattheendofurinationIntermittencyHesitancyPainorburningduringurinationFeelingofincompletebladderemptying

ClinicalmanifestationsIrritativesymptoms urinaryfrequency urgency dysuria bladderpain nocturia incontinence symptomsassociatedwithinfectionBenignProstaticHyperplasiaLeadingto“symptombother”andworsenedQOLOtherRelevantHistoryGUHistory(STD,trauma,surgery)Otherdisorders(eg.neurologic,diabetes)Medications(anti-cholinergics)FunctionalStatusDiagnosticTestsHistory&ExaminationAbdominal/GUexamFocusedneuroexamDigitalrectalexam(DRE)Validatedsymptomquestionnaire.UrinalysisUrinecultureBUN,CrProstatespecificantigen(PSA)Transrectalultrasound–biopsyUroflometryPostvoidresidualAUASymptomScoreSheetInternationalprostatesymptomscore(IPSS)

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NotatallLessthan1timein5LessthanhalfthetimeAbouthalfthetimeMorethanhalfthetimeAlmostalwaysYourscoreIncompleteemptying

Overthepastmonth,howoftenhaveyouhadasensationofnotemptyingyourbladdercompletelyafteryoufinishurinating?012345

FrequencyOverthepastmonth,howoftenhaveyouhadtourinateagainlessthantwohoursafteryoufinishedurinating?012345

IntermittencyOverthepastmonth,howoftenhaveyoufoundyoustoppedandstartedagainseveraltimeswhenyouurinated?012345

UrgencyOverthelastmonth,howdifficulthaveyoufoundittopostponeurination?012345

WeakstreamOverthepastmonth,howoftenhaveyouhadaweakurinarystream?012345

StrainingOverthepastmonth,howoftenhaveyouhadtopushorstraintobeginurination?012345

None1time2times3times4times5timesormoreYourscoreNocturia

Overthepastmonth,manytimesdidyoumosttypicallygetuptourinatefromthetimeyouwenttobeduntilthetimeyougotupinthemorning?012345

Totalscore:0-7Mildlysymptomatic;8-19moderatelysymptomatic;20-35severelysymptomatic.Qualityoflifeduetourinarysymptoms

DelightedPleasedMostlysatisfiedMixed–aboutequallysatisfiedanddissatisfiedMostlydissatisfiedUnhappyTerribleIfyouweretospendtherestofyourlifewithyoururinaryconditionthewayitisnow,howwouldyoufeelaboutthat?0123456

Totalscore:0-7Mildlysymptomatic;8-19moderatelysymptomatic;20-35severelysymptomatic.DREBPH

DangerSignsonDREFirmtohardnodulesIrregularities,unequallobesIndurationStonyhardprostateAnypalpablenodularabnormalitysuggestscancerandwarrantsinvestigationOptionalEvaluationsandDiagnosticTestsUrinecytologyinpatientswith:Predominanceofirritativevoidingsymptoms.SmokinghistoryFlowrateandpost-voidresidualNotnecessarybeforemedicaltherapybutshouldbeconsideredinthoseundergoinginvasivetherapyorthosewithneurologicconditionsUppertractevaluationifhematuria,increasedcreatinineCystoscopyPSAElevatedlevelsofPSA0–4ng/mlProstaticpathologyCorrelateswithtumormassSomemenwithprostatecancerhavenormalPSAlevelsBPHSYMPTOMS

DifferentialDiagnosisUrethralstrictureBladderneckcontractureCarcinomaoftheprostateCarcinomaofthebladderBladdercalculiUrinarytractinfectionandprostatitisNeurogenicbladderBPHTREATMENT

INDICATIONS

AbsolutevsRelative

SevereobstructionUrinaryretentionSignsofuppertractdilatationandrenalinsufficiencyModeratesymptomsofprostatismRecurrentUTI’sHematuriaQualityoflifeissuesTreatmentOptionsMildtoseveresymptomswithlittle“bother”Managewithwatchfulwaiting.RiskoftherapyoutweighsthebenefitofmedicalorsurgicaltreatmentModeratetoseveresymptomswithbotherManagementoptionsincludewatchfulwaiting,medicalmanagementandsurgicaltreatment.TherapyWatchfulwaitingandbehavioralmodificationMedicalManagementAlphablockers5-alphareductaseinhibitorsCombinationtherapySurgicalManagementOfficebasedtherapyORbasedtherapyUrethralstentsWatchfulWaitingandBehavioralModification“isthepreferredmanagementtechniqueinpatientswithmildsymptomsandminimalbother”AUAscore<7,1/3improveonown.WatchfulWaitingandBehavioralModificationDecreasecaffeine,alcohol)diureticeffect(AvoidtakinglargeamountsoffluidoverashortperiodoftimeVoidwhenevertheurgeispresent,every2-3hoursMaintainnormalfluidintake,donotrestrictfluidAvoidbladderirritantstoincludedairyproducts,artificialsweeteners,carbonatedbeveragesLimitnighttimefluidconsumptionBPHsymptomscanbevariable,intermittentMedicalManagementNutritionalsupplementsSawPalmettoAlphablockersDoxazosin(Cardura),Terazosin(Hytrin),Tamsulosin(Flomax),Alfuzosin(Uroxatral)5-alphareductaseinhibitorsFinasteride(Proscar),Dutasteride(Avodart)CombinationtherapyAlphablockerand5-alphareductaseinhibitorBenefitsConvenientNolossofworktimeMinimalriskDisadvantagesExpensiveDrugInteractionsMustbetakeneverydayManagestheprobleminsteadoffixingitmedicationnnnnnnnMedicalManagementAlphaadrenergicreceptorblockers

promotesmoothmusclerelaxationintheprostateRelaxationofthemusclesfacilitatesurinaryflowDoxazosin(Cardura),Terazosin(Hytrin),Tamsulosin(Flomax),Alfuzosin(Uroxatral)Sideeffects:posturalhypotension,dizziness,fatigue,OtherproblemscanoccurwhenptisalsotakingcardiacorotherhypertensivedrugsAlpha-AdrenergicBlockersEqualclinicaleffectivenessSlightdifferencesinadverseeventprofileOrthostasis(lowerintamsulosin)Ejaculatorydysfunction(higherintamsulosin)DecreasedenergylevelsNasalcongestionIncreaseinCHFriskwithdoxazosinMusttitratedoxazosinandterazosintoeffectivelevelsMedicalManagement5alphareductaseinhibitor)finasteride:

Proscar(Reducesizeofprostateglandbyupto30%Blockstheenzymeof5alphareductasewhichisnec,fortheconversionoftestosteronetodihydroxytestostersoneRegressionofhyperplasticgrowthDon’tworkimmediatelySmalleffectonsymptomscoreandflowrates

5-AlphaReductaseInhibitorsAgentsareeffectiveandappropriatetreatmentforpatientswithlowerurinarytractsymptomsanddemonstrableenlargementoftheprostate.Averageprostatesizeis30cc’s.Originalstudiesshowedbenefitonlyinmenwithprostatesizesgreaterthan50cc’s.5-AlphaReductaseInhibitorsFinasteride(Proscar)andDutasteride(Avodart)LesseffectiveforreliefofBPHsymptomsthanalphablockersAdverseeventsincludeDecreasedlibidoWorsenedsexualfunction(erectiledysfunction)decreasevolumeofejaculationBreastenlargementandtendernessReducesriskofurinaryretentionby3%/year.PSAmustbedoubledifscreeningforprostatecancerCombinationTherapyConcomitantuseofalphablockersand5-alphareductaseinhibitorsShouldbereservedforpatientswhoareatsignificantriskofprogressionandadverseoutcomePoorsurgicalcandidatePatientwantstoavoidsurgerySignificantcostassociatedwithdualmedicationsMedicalManagementHerbaltherapy–sawpalmettofruit–usetoimproveurinarysymptomsandurinaryflowProblemwithherbaltherapy–longtermeffectivenesssurgicaltreatmentSurgicalManagementOfficebasedtherapies:Transurethralmicrowavetherapy(TUMT)Transurethralneedleablation(TUNA)TherapiesareeffectiveorpartiallyeffectiveforrelievingthesymptomsofBPHSignificantsideeffects/complicationsassociatedwiththesetreatmentshavepromptedaFDAwarningSurgicalManagementORbasedtherapiesOpensimpleprostatectomyTURPTransurethralincisionoftheprostateLaserphotoselectivevaporizationoftheprostate(greenlightlaserPVP)HoLEPSurgicalManagementPatientsmayselectsurgicaltreatmentasinitialtherapyifmoderateorseverebotherispresent.PatientswhohavedevelopedcomplicationsofBPH(i.eurinaryretention,renalinsufficiency,recurrentUTI)arebesttreatedsurgically.NewsurgicaltreatmenthavenotdemonstratedbetteroutcomesthanTURPtodate.BPHTREATMENT

Surgical

IndicatedforAUAscore>16TransurethralProstatectomy(TURP):18%morbiditywith.2%mortality.80-90%improvementat1yearbut60-75%at5yearsand5%requirerepeatTURP.TransurethralIncisionofProstate(TUIP):lessmorbiditywithsimilarefficacyindicatedforsmallerprostates.OpenProstatectomy:indicatedforglands>60gramsorwhenadditionalprocedureneededforsuprapubic/retropubicapproachesTURP

“GoldStandard”ofcareforBPHnthe“goldstandard”-TURPBenefitsWidelyavailableEffectiveLonglastingDisadvantagesGreaterriskofsideeffectsandcomplications1-4dayshospitalstay1-3dayscatheter4-6weekrecoverynnnnnnnpossiblesideeffectsofGreaterthan5%riskof:IrritativevoidingsymptomsBladderneckcontractureUTIRiskofincontinence1%Declineinerectilefunction65%ofretrogradeejaculationTURsyndrome(acutehyponatremiafromfreewaterabsorption)HemorrhageBladderspasmsTURPPreoperativeGoalsRestorationofurinarydrainageTreatmentofanyurinarytractinfectionUnderstandingofprocedure,implicationsforsexualfunctioningandurinarycontrolPreoperativecareAntibioticsAllowpttodiscussconcernsaboutsurgeryonsexualfunctioningProstaticsurgerymayresultinretrogradeejaculationPostoperativeGoalsNocompli