7 prostate lecture

BENIGN PROSTATIC HYPERPLASIABENIGN PROSTATIC HYPERPLASIABPHBPH

Ahmad A. Elabbady, MDAhmad A. Elabbady, MD

Professor, Urology Department, Professor, Urology Department,

University of AlexandriaUniversity of Alexandria

BENIGN PROSTATIC HYPERPLASIABENIGN PROSTATIC HYPERPLASIABPHBPH

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.

BENIGN PROSTATIC HYPERPLASIABENIGN PROSTATIC HYPERPLASIA Incidence Incidence

- 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

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.

BENIGN PROSTATIC HYPERPLASIABENIGN PROSTATIC HYPERPLASIA PathologyPathology

I- MicroscopyHyperplasia 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 capsulewith a plane of cleavage in between

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


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).


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).


• 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).


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


IV- Cystourethroscopy ( prior to surgery)

Degree of middle &/or lateral lobe enlargement Hematuria

Bladder stone

Associated pathology

Urethral stricture


Differential DiagnosisDifferential Diagnosis

Meatal stenosisUrethral strictureProstatic cancerBladder neck fibrosisDrugs ( parasympatholytic and sympathomimetics)Neurologic lesions

BENIGN PROSTATIC HYPERPLASIABENIGN PROSTATIC HYPERPLASIATreatmentTreatment

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.


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.

III- Less invasive methods (Still inferior to TURP):

- Laser,

- hyperthermia,

- Incisions,

- Balloon dilatation.

BENIGN PROSTATIC HYPERPLASIABENIGN PROSTATIC HYPERPLASIAIndications 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.

Complications of prostatectomyComplications of prostatectomyA- 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


- 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.

Prostate CancerProstate Cancer

Ahmad A. Elabbady, MD

Professor, Urology Department,

University of Alexandria

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


• 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

Prostate cancerProstate cancer Risk FactorsRisk Factors

- Age

- Family history

- Race

- Dietary fats

- Hormones

- Geography

- Genetics


• It is a Heterogeneous, wide spectrum disease.

• Often, It is a slowly progressive disease.


• 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.

PROSTATIC PROSTATIC 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

PROSTATIC PROSTATIC 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 painGeneral symptoms

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).

Diagnosis of prostate CancerDiagnosis of prostate Cancer Early diagnosisEarly diagnosis

- DRE Asymmetry, hard nodules - Serum PSA 0-4 ng/ml

- TRUS-directed prostatic Bx.

Early detection of prostate CancerEarly detection of prostate Cancer PSAPSA

PSA is organ-specific

but not cancer specific

Early detection of prostate CancerEarly detection of prostate Cancer PSAPSA

PSA elevations

-Prostate disease (BPH, prostatitis, P Ca)

-prostate manipulation (massage, Bx).

Diagnosis of prostate CancerDiagnosis of prostate CancerAdvanced 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)

Diagnosis of P CaDiagnosis of P CaTRUS-BxTRUS-Bx

The major role of TRUS is to ensure accurate wide-area sampling of prostate tissue.

Prostate cancerProstate cancerPathologyPathology

• Commonly: adenocarcinoma . 95%• Other types: 5% e.g. TCC

- Sarcoma

• 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

TNM staging for Ca PTNM staging for Ca P

Prostate cancerProstate cancergradinggrading

• Gleason grading system

Depends on architectural pattern

Grades 1-5 for the primary and secondary pattern

Gleason sum: primary + secondary grades

Prostate cancerProstate cancer

• Pattern of spread• Direct• Inward > outward• Lymphatic • Obturator• Hypogastric• Distant• 90% to bones• Lung,liver

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)

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•

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

Thank you

7 prostate lecture

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