Dr. Saba KhanHouse Officer

Dept. of General Surgery & UrologyB & B Hospital

CASE 80 years old presented with the c/o frequency, urgency,

hesitancy, poor flow of urine, feeling of incomplete voiding, dribbling of urine.

No h/o fever, burning micturition, dysuria, or hematuria, or abdominal pain.

K/C/O HTN and BPH. Drug history- on Cardace, Isosorbide, Verapamil, Aspirin.

O/E:

General Examination Findings:

GC fair, Dehydration (+), Jaundice (-), Anaemia (-), Oedema (-), Vitals WNL

Chest/CVS- NAD

PA- soft, non tender, non distended

Investigations:

CBC, URINE RME, LFT, KFT- WNL ( except Na- 129)

Imp: Benign Prostate Hyperplasia

Plan- TURP

Pre-op: due to hyponatremia, operation was withheld for 2 days. Aspirin was kept on hold.

Relevant OT findings: ~100 gms of prostate was resected

Intra-operative period: uneventful

Post-op period:

Pt developed retention of urine after few hrs of surgery. Bladder was washed out and clots were removed.

On 4th post op day pt again developed retention. Bladder was washed out and clots removed.

After 7th post-op day pt’s Foley was removed and he developed urinary incontinence. Retention on 8th post op day.

Foley catheter was placed and removed again on 10th

postop day .

Patient was discharged on 13th post-op day with indwelling catheter.

Pt was readmitted after 1 week with indwelling catheter for observation for 1 day.

Pt was passing adequate urine, so Foley was removed and pt was discharged with oral antibiotics and anti-spasmodic.

The Prostate Gland

Clip

Fibromusculoglandularorgan

Pear-shaped,wt7-18gm

~ 3cm long, sorroundsprostatic urethra.

Resembles the size and shape of a chestnut.

Helps control urine flow

Produces fluid component of semen

Secretes Prostate Specific Antigen (PSA)

Four Areas of the Prostate

Transition Zone

Peripheral Zone

Anterior Zone

Central Zone

Prostatic capsules Normally two but, pathologically three.

The True Capsule: a thin fibrous sheath that sorrounds the prostate

The False Capsule: lies outside the true capsule, formed by the condensation of pelvic fascia. It continues with the fascia of Denonvilliers posteriorly and into the fascia sorrounding the bladder.

Between true and false capsule lies the prostatic venous plexus.

The Pathological Capsule: when BPH takes place the, the normal peripheral parts of the gland becomes compressed into a capsule around this enlarging mass. Also called the Surgical Capsule of the prostate

Blood supplyArterial:

Mainly from the inferior vesical and middle rectal branches of the internal iliac artery.

Venous :

To the prostatic venous plexus which, drains into the internal iliac vein.

Some venous blood from prostate passes directly to the valveless prevertebral venous plexus.

What is Benign Prostatic Hyperplasia?A condition in which the prostate gland becomes

enlarged.

Epidemiology:

Occurs in men over 50 years of age; by the age of 60 years, 50% of men have histological evidence of BPH.

Peripheral zone

Transition zone

Urethra

EtiologyMultifactorial & endocrine controlled:

Stromal and epithelial elements of the prostate can give rise to hyperplastic nodules and the symptoms a/w BPH.

The association between aging and BPH might result from the increased estrogen levels with advancing age, causing induction of the androgen receptor, which thereby sensitizes the prostate to free testosterone.

PathologyDevelops in the TZ, forming a nodular enlargement which, compresses the PZ glands into a false capsule giving the appearance of typical ‘lateral’ lobes.

When BPH affects the subcervical CZ glands, the ‘middle’ lobe develops that projects up into the bladder within the internal sphincter.

Clinical features

Initially outlet obstruction:

Weak stream, hesitancy, intermittency, dribbling, straining to void, acute urinary retention.

Subsequent detrusor instability:

Frequency, urgency, nocturia, dysuria, urge incontinence.

Finally detrusor failure and chronic retention:

Palpable (or percussible) bladder, overflow incontinence.

Enlarged smooth prostate on digital rectal examination.

What’s LUTS?Voiding: Hesitancy

Intermittent stream

Poor flow (unimproved by straining)

Dribbling (including after micturition)

Sensation of poor bladder emptying

Episodes of near retention

Storage: Urgency

Frequency

Nocturia

Urge incontinence Nocturnal incontinence

(enuresis)

LUTS is not specific to BPH – not everyone with LUTS has

BPH and not everyone with BPH has LUTS

Assessment of patients with LUTS– International Prostate Symptom Score (IPSS) is based on a survey and

questionnaire developed by the American Urological Association (AUA).

– It contains:• seven questions about the severity of symptoms• Completion gives total score of 35

1 – 7 mild 8 – 19 moderate 20 – 35 severe

– Ask 7 questions. Answers on scale 0 – 5 depending on severity of symptoms– For first 6 questions scores are

• Not at all = 0• < 1 in 5 = 1• < half the time = 2• About half the time = 3• > half the time = 4• Almost always = 5

– Q7 • Never = 0, once = 1, 2x = 2, 3x = 3, 4x = 4, 5x = 5

Questions

In past month how often have you1. Had sensation of not emptying bladder completely?2. Had urge to urinate in < 2 hours after previous micturition?3. Found you stopped and started again several times4. Found it difficult to postpone urination?5. Had a weak stream (compared to when aged 30)?6. Had to strain to begin urination?7. How many times do you get out of bed per night to urinate?

Quality of life• If you were to spend the rest of your life with your urinary condition just the way it

is now, how would you feel about that?– Delighted 0– Pleased 1– Mostly satisfied 2– Mixed feelings 3– Mostly dissatisfied 4– Unhappy 5– Terrible 6

Investigations

Further investigations Voiding diary.

Ultrasonography of kidneys and bladder: structural abnormalities.

Transrectal ultrasound: to determine prostate size.

IVU: structural abnormalities.

Cystoscopy.

Uroflowmetry and residual volume measurement (normal<100 ml): evidence of obstruction.

Basic investigations•Urinalysis and urine culture for evidence of infection or haematuria.•FBC: infection.•U+E and serum creatinine: renal function.•PSA: suspicion of underlying malignancy.

Treatment

Mild symptom score (0-7): Watchful waiting with fluid restriction and reduction in caffeine intake.

Strong indications for treatment (usually prostatectomy ) include:

Acute retention in fit men with no other cause for retention

Chronic retention or renal impairment- residual urine of 200 ml or more, increased BUN, hydroureter or hydronephrosis.

Complications of BOO- stone, infection and diverticulum formation.

Hemorrhage – occasionally, from ruptured vein overlying the prostate.

Elective prostatectomy for severe symptoms- a low maximum flow rate (<10 ml/sec) and increased residual volume (100-250 ml)

Medicalα-Adrenergic blockers

Relax the muscle of the prostate and bladder neck, which allows urine to flow more easily.

There are at least five medications in this category: terazosin, doxazosin, tamsulosin, alfuzosin, and silodosin.

usually recommended as a first-line treatment for men with mild to moderate symptoms.

Side effects — The most important side effects of alpha blockers are dizziness and low blood pressure after sitting or standing up. Terazosin and doxazosin are usually taken at bedtime (to reduce lightheadedness). The dose can be increased over time if needed

5 α- Reductase Inhibitor:

inhibit the conversion of testosterone to DHT (most active form of androgen).

These drugs, when taken for 1 year, result in a 25%shrinkage of prostate (20% improvement in symptom score)

Finasteride and dutasteride

Side effects — A small percentage of men who take alpha-reductase inhibitors have decreased sex drive or difficulty with erection or ejaculation. This side effect is reversed when the drug is stopped

SurgicalConventional: Transurethral resection of prostate (TURP)–

improves max flow rates from 9 – 18 ml/sec and 75% improvement in the symptom scores.

Transurethral incision of prostate (TUIP)- men with moderate to severe symptoms and a small prostate often have posterior commissure hypreplasia( elevated bladder neck. Such pt. benefit from TUIP.

Open simple prostatectomy- if large gland (>100 gms); may be a simple suprapubic prostatectomy (transvesically) or, a simple retropubic prostatectomy.

Minimally invasive therapy:

Laser therapy- 2 main energy sources, Nd:YAG and Holmium:YAG

Advantages-

Minimal blood loss

Rare instances of TUR syndrome

Ability to treat pts. on anticoagulants

Disadvantages-

Lack of availability of tissue for pathologic examination

Longer post-op catherization time

High cost

Transurethral electrovaporization of the prostate

Microwave hyperthermia

Transurethral needle ablation of the prostate

High-intensity focused ultrasound

Intraurethral stents

Transurethral dilatation of the prostate

Transurethral Resection of Prostate

Symptom score and flow rate improvement with TURP is superior to that of any minimally invasive therapy.

Risks of TURP include:

Retrograde ejaculation (75%)

Impotence (5-10%)

Incontinence (1%)

Complications of TURP

Intraoperative:

Hemorrhage- Arterial bleeding can be more pronounced in casesof preoperative infection or urinary retention because of a congested gland. Anti-androgen pretreatment with finasteride or flutamide may reduce bleeding. Venous bleeding generally occurs because of capsular perforation and venous sinusoid openings. The amount of intraoperativebleeding may depend on gland size and resection weight.

Perforation of bladder or prostatic capsule

TUR syndrome

Post-operative: Secondary hemorrhage after discharge of pt.(if clot retention

occurs, catheterization and bladder wash needed; might need re-admission).

Bladder tamponade- Recurrent or persistent bleeding sometimes results in clot formations and a bladder tamponade that require evacuation or even reintervention (1.3–5%)

Incontinence- inevitable if external sphincter mechanism is damaged (when resection extends beyond verumonteum).

TUR syndrome Sepsis- in case of prolonged catheterization or chronic retention, Retrograde ejaculation (>75%) and impotence. Urinary retention (3–9%)- is mainly attributed to primary

detrusor failure rather than to incomplete resection Urethral stricture Bladder neck contracture Reoperation (recurrence 15-18% after 8 yrs)

Irrigation fluid

The irrigating fluids used in TURP are Glycine, distilled water, normal saline, mannitol, sorbitol etc.

However, 1.5% isotonic glycine is used for irrigation nowadays, to prevent the risk of hyponatremia.

Post-operatively, irrigation of bladder is done with sterile saline by means of a 3-way Foley catheter for 24 hour or so.

TUR syndrome (water intoxication):Caused by early perforation of capsular veins or sinuses,

with consecutive influx of hypotonic irrigating fluid resulting in hyervolemic, hyponatremic state.

Clinical manifestations- nausea, vomiting, confusion, hypertension, bradycardia, and visual disturbances.

The risk of TUR syndrome increases with resection time over 90 mins.

Diagnosis: immediate serum Na level post-operatively

Treatment- Diuresis, hypertonic saline infusion (if severe hyponatremia)

Untreated, TUR syndrome may have severe

consequences like cerebral or bronchial edema

Urethral stricture Arise either inside the meatus or in the bulbar urethra

May be secondary to prolonged catheterization, use of large catheter, clumsy instrumentation, or the presence of resectoscope in the urethra for too long.

An early stricture can be managed by simple bouginage.

Later, may be necessary to cut the densely fibrotic sticture with the optical urethrotome.

It’s incidence can be reduced by the routine use of Otis urethrotomy prior to TURP.

Bladder neck contracture

A dense fibrotic stenosis of the bladder neck occurs following overaggressive resection of a small prostate.

May be due to the overuse of coagulation diathermy.

Transurethral resection of the scar tissue is necessary.

Associated morbidity and mortality Despite the increasing mean age (55% of patients are

older than 70), the associated morbidity of TURP maintained a similar low level <1% with a mortality rate of 0–0.25% in large series.

This might be mainly attributable to the advances in anesthesia and to the technical improvements of TURP

Conservative management of postoperative incontinence

Acute urinary retention before TURP

Thank You !