BPH

Benign Prostatic Hyperplasia

★ most common location of BPH ?
★ Age related

★ Endocrine controlled
Clinical features

★ Irritative symptoms

★ Obstructive symptoms
Secondary changes in bladder
★ Collagen deposition
★ Detrusor muscle hyperplasia
★ Detrusor muscle hypertrophy
DRE
BPH vs Ca Prostate
Investigations
Uroflowmetry - to document the obstruction

Cystometry - to confirm the diagnosis

Diagnostic criteria for BPH

Qmax < 10 ml/s

Bladder pressure > 80 cm of H2O

Medical Management
In cut section of BPH

If epithelial component is predominant - 5 alpha reductase inhibitors

If stromal component is predominant - Alpha blockers

Alpha blockers
★ Prazosin
★ Terazosin
★ Doxazosin
★ Alfuzosin
★ Silodosin

Alpha 1A selective blocker

★ Tamsulosin ( MC used )
★ silodosin
2nd line agents 5 alpha reductase inhibitors

★ Finasteride
★ Dutasteride
★ Triptorelin Pamoate

Combination treatment ( alpha blockers and 5 alpha RI )

preferred in patients with

★ Large prostate
★ Increased PSA
Indications of surgical intervention
★ No improvement after medical management
★ Recurrent UTI
★ Renal failure
★ Bladder stone
★ Gross hematuria
★ Refractory urinary retention
Surgical treatment
Gold standard - TURP

Trans Urethral Resection of Prostate

Nesbit technique preferred

For irrigation - 1.5 % Glycine is used in monopolar cautery

★ Most important distal landmark in TURP is Verumontanum

★ High risk of injury to internal urinary sphincter by TURP
★ M/C complication of TURP is retrograde ejaculation 75%
Ca prostate
★ MC histological type - adenocarcinoma
★ Seen in high socioeconomic status
★ MC among Afro-Americans
★ Usually seen in 7th to 8th decade
Risk factors
★ Advancing age
★ High fat diet

Protective factors
★ Lycopene
★ Vitamin E
★ Selenium
★ Vitamin A
Pathology
MC site of CA prostate ?

Histological appearance of malignant Glands ?

Clinical features
symptoms in initial stages ?

Symptoms in advanced state/metastasis ?

Lymph Node metastasis ?

Route of spread
MC route of spread ?

MC site of metastasis ?

MC site of visceral metastasis ?

MC malignancy responsible for osteoblastic secondaries in Male ?

MC malignancy responsible for osteolytic secondaries in Males ?

MC site of visceral metastasis ?

Investigations
On DRE ?

IOC for Dx ?

IOC for staging ?

Prostascint

Antibody imaging for CA prostate

Radiolabeled monoclonal antibody against prostate specific membrane antigen

Advantage in biopsy proven CA prostate - soft tissue and lymph node metastasis
can be detected
Prostate specific antigen
Can be raised in benign conditions of prostate also

Not cancer specific

Normal level < 4 ng/ml

Diagnostic of Ca prostate >20 ng/ml

PSA density ?

PSA velocity ?
Conditions that leads to increased PSA Conditions that leads to decreased PSA

CA prostate Castration
BPH Radical prostatectomy
Prostatic Abscess Chemotherapy/Radiotherapy
DRE
Prostatic massage
Catheterization
Sexual intercourse
Prostate Biopsy
NO No regional lymph node metastasis

N1 Metastasis to regional LN ( obturator, internal iliac, external iliac, prescaral)

M0 No metastasis

M1a Distant metastasis in non regional LN

M1b DIstant metastasis to bone

M1c Distant metastasis to other sites

Management of CA prostate
T1a - observation + Follow up ( DRE + PSA )
T1b, T1c and T2
For > 70 years old observation + follow up
For < 70 years old radical prostatectomy or radiotherapy
T3 and T4
Androgen ablation > palliative radiotherapy
Bilateral orchidectomy + flutamide
LHRH agonist ( goserelin, leuprolide ) + flutamide
Goserelin recently FDA approved for advanced and metastatic CA prostate
New drugs for castration resistant metastatic CA prostate
1. Cabazitaxle
2. Sipuleucel T it is a vaccine
Gleason grade
Gleason Grade

1st MC histological type 2nd MC occurring

(1 ° ) grade histological type
(2 °) grade

Gleason Score

1° + 2 ° grade

1-5 + 1-5

Minimum score is 2
Maximum score is 10

Grade 1 - well differentiated

Grade 5 - poorly differentiated