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Treatment of Benign Prostate Hypertrophy + Operative Treatment

Investigations

  • Blood tests:-Serum sugar, urea, creatinine, electrolytes and hemoglobin should be measured.
  • Examination of urine:-The urine is examined for glucose and blood; a midstream specimen should be sent for bacteriological examination , and cytological examination may be carried out if carcinoma in situ is thought possible.
  • Pressure-flow urodynamic studies:-
  • They should be performed on the following patients:- Men with suspected neuropathy (Parkinson’s disease, dementia, longstanding diabetes, previous strokes, multiple sclerosis);
  • Men with a dominant history of irritative symptoms and men with lifelong urgency and frequency;
  • Men with a doubtful history and those with flow rates in the near normal range (or>15mls);
  • Men with invalid flow rate measurements (because of low voided volumes).
  • Micturograph help in determining the degree of outflow obstruction.
  • Upper tract imaging:-Ultrasound scan is sufficient.
  • Transrectal ultrasound scanning:-There is no need to carry out this routinely as accurate estimation of prostatic size is possible by means trans-abdominal ultrasound scanning.
  • Cystourethroscopy:- Inspection of the urethra, the prostate and the urothelium of the bladder is ideal prior to prostatectomy.
  • PSA if indication

Treatment

  • This should be based on the patient’s symptoms, signs and investigations.
  • Although medical treatment may alleviate symptoms by curing superadded infection, oedema or congestion, it does not prevent the disease nor alter the basic pathological changes, so treatment is surgical if at all.
  • Conservation treatment:- If relatively mild symptoms, reasonable flow rates (>10ml) and good bladder emptying (residual urine < 100ml) waiting for a period of few months is indicated and then reevaluate.
  • Drugs Two classes of drug are in use. Alpha-adrenergic blocking agents inhibit the contraction of smooth muscle that is found in the prostate. 5 alpha-reductase inhibitors which inhibit the conversion of testosterone to DHT, the most active form of androgen.
  • These drugs, when taken for a years, result in a 25% shrinkage of the prostate gland.
  • Both groups of drugs are effective, however, alpha-blockers work more quickly and, although the 5alpha-reductase inhibitors have fewer side-effects, they need to be taken for at least 6 months, and their effect is greatest in patients with large (>50 g) glands.
  • They may be best targeted at men who have failed an initial trial of watchful waiting and who wish to avoid surgery for a period.

Management of Retention

Acute urinary retention is distressing and painful, it requires temporary decompression with catheter and ultimate prostatectomy.

Chronic urinary retention is painless.

  • If uraemic, catheterization is mandatory to allow renal function to recover and stabilize, then prostatectomy.
  • Haematuria often occurs following catheterization if not slow decompressed in few minutes.
  • Owing to the chronic back pressure on the kidney, there is loss of the ability to reabsorb salts and water, and on sudden release of pressure may result in post-obstructive diuresis.
  • It is for this reason that a careful fluid chart, daily measurements of the patient’s weight and serial estimation of creatinine and electrolytes are essential, if needed  intravenous fluid replacement.
  • These patients are often anemic and may require a blood transfusion.

Management of Benign Prostatic Hyperplasia

  • Indications for prostatectomy are:-
  • Acute retention which do not relieve by temporary passing the catheter and when there is no other cause for retention (drugs, constipation, recent operation, etc).
  • Chronic retention and renal impairment: a residual urine of 200 ml or more, a raised blood urea, hydroureter or hydronephrosis and uraemic manifestations.
  • Complication: stone, infection and diverticulum formation. Haemorrhage:  occasionally, venous bleeding form a ruptured vein overlying the prostate will require prostatectomy.
  • Elective prostatectomy for severe symptoms (prostatism): Increasing difficulty in micturition, with considerable frequency day and night, delay in starting and poor stream etc.
  • Frequency alone is not a strong indication for prostatectomy.

Counseling men undergoing prostatectomy

  • Men undergoing prostatectomy need to be advised about the following:
  1. Retrograde ejaculation. This occurs in about 65% of men after prostatectomy.
  2. Erectile impotence. This occurs in about 5% of men, usually those whose potency is waning.
  3. The success rate.
    On the whole, men with acute and chronic retention do well from the symptomatic point of view.
    90% of men undergoing elective operation for severe symptoms and Urodynamically proven BOO do well in terms of symptoms and flow rates.
    Only about 65% of those with mild symptoms or those with weak bladder contraction as the cause of their symptoms do well.
    Men with unobstructed detrusor instability do not respond well to prostatectomy.
    This is the reason for carefully documenting the severity of symptoms and flow rates (supplemented when necessary by pressure-flow studies) before deciding on treatment.
  4. The risk of reoperation. After TURP, this is about 15% after 8-10 years.
  5. The morbidity rate. Death after prostatectomy is infrequent.

Operative Treatment

  • Through the bladder –transvesical (TVP)
    –It has an improved form (small hole prostatectomy which is better than any other option).
  • Transurethrally (TURP),
  • Retropubically (RPP),
  • From the perineum.
    –Perineal prostatectomy has now been abandoned due to more incontinence.

Transvesical Prostatectomy

  • The bladder is opened, and the prostate enucleated by putting a finger into the urethra, pushing forwards towards the pubes to separate the lateral lobes, and then working the finger between the adenoma and the false capsule.
  • Prostatic arteries are controlled by lateral stitches of the bladder wall.
  • Closed the wound and drained it.
  • Diverticulectomy or the removal of large stones necessitates open operation.
  • Irrigate the bladder with sterile saline by means of a three-way Foley catheter for 24 hours or so.
  • In urinary infection or prolonged catheter in situ or those with chronic retention or those with prosthetic material or heart valves should receive broad-spectrum prophylactic antibiotics (amoxicillin and gentamicine).

Transurethral Resection of the Prostate (TURP)

  • Strips of tissue are cut from the bladder neck down to the level of the veruontanum.
  • Cutting is performed by a high-frequency diathermy current, which is applied across a loop mounted on the hand-held trigger of the resectoscope.
  • Coagulation of bleeding points can be accurately achieved, and damage to the external sphincter is avoided provided one uses the verumontanum as a guide to the most distal point of the resection.
  • The ‘chips’ of prostate are then removed from the bladder using an Ellik evacuator.
  • The risks of hyponatraemia are reduced by using 1.5% isotonic glycine for irrigation, and the recent introduction of continuous-flow resectoscopes makes the procedure swift and safe in experienced hands.
  • At the end of the procedure, careful homeostasis is performed, and a three-way, self-retaining catheter irrigated with isotonic saline is introduced into the bladder to prevent any clot retention.
  • Irrigation is continued until the outflow is pale pink, and the catheter is usually removed on the second or third post-operative day.
  • In men with small prostates or bladder neck dyssynergia or stenosis, it is better to divide the bladder neck and prostate urethra with a diathermy ‘bee-sting’ electrode.

Newer Treatments

  • In general, newer, minimally invasive treatments occupy a position intermediated between TURP and drug treatment.
  • Tissue ablative techniques using hyperthermia and laser energy were associated with minimal morbidity and could often be performed as out-patient procedures.
  • Many of the initial studies reporting treatment success were poorly designed and over a short duration.
  • Longer-term follow-up and randomised controlled trials have failed to confirm significant benefit from these techniques.
  • More recently, the holmium laser, a pulsed solid-state laser, has been used to enucleate the prostate adenoma. This approach involves excision of parts of the prostate using a cutting laser and then morcellating the excised prostate fragments, which fall back into the bladder so that they can be removed. Morbidity with this procedure is low and short-term results favorable; long-term follow-up will be necessary to determine whether this treatment will have a role to play in the management of BOO. The green light laser is now being used to vaporise the prostate tissue, but has not yet been shown to be as durable as holmium  laser treatment or TURP, because the amount of tissue removed is usually less.
  • Intraurethral stents:-These devices are possibly helpful in the management of men with retention who are grossly unfit (classified by the American Society of Anesthesiologists as ASA grade IV).