Urosurgery 23 Prostate

  1. Outline the various investigations for lower urinary tract symptoms (LUTS). [TU 2057,59]
    Investigations recommended for men presenting with the features of LUTS

    • 1. Urinalysis and urine microscopy
    • To exclude urinary tract infection and haematuria

    • 2. Blood tests
    • Blood glucose level to screen for diabetes mellitus
    • Creatinine level to exclude renal impairment
    • Prostate-specific antigen level to support differential diagnosis (ie, to exclude advanced prostate cancer among older men with bladder overflow obstruction) and treatment decisions, and to monitor response to therapy (watchful waiting or 5-α-reductase inhibitor use)

    • 3. Voiding chart
    • Involves the recording of date, time of day and night, volume voided and fluid intake over at least 3 days
    • Helps exclude polyuria, which may be misinterpreted as increased frequency, and conditions associated with nocturnal diuresis (eg, heart failure)

    • 4. Imaging
    • Postvoid residual (PVR) ultrasound
    • PVR volume > 50 mL has been associated with a higher risk of disease progression in controlled clinical trials; however, PVR may be influenced by voided volume and test conditions. For practical purposes, urology referral should be considered for patients with PVR > 250 mL. 

    • 5. Optional
    • Urinary tract ultrasound
    • Uroflowmetry
    • Pressure flow urodynamic study
    • Cystoscopy
  2. Lobes of prostate?
    Four lobes: anterior, posterior, lateral, and median.

    The anterior lobe, or isthmus, lies anterior to the urethra. It is mainly fibromuscular and contains very little glandular tissue. Roughly corresponds to part of transitional zone. 

    The posterior lobe lies posterior to the urethra and inferior to the ejaculatory ducts. This is the lobe palpated during the digital rectal examination.  Roughly corresponds to peripheral zone

    The lateral lobes lie on either side of the urethra and are a large portion of the prostate. Spans all zones. 

    The median, or middle, lobe lies between the urethra and the ejaculatory ducts. Roughly corresponds to part of central zone. 

    • The prostate may not be felt enlarged if only the median lobe is enlarged. 
    • The two lateral lobes of the gland can be felt to bulge into the rectum divided by the central sulcus which is well defined. It is obliterated in carcinoma. 

    • Enlargement of median lobe gives rise to mainly irritative symptoms e.g nocturia, frequency and urgency. 
    • Enlargement of lateral lobes mainly gives rise to obstructive symptoms e.g slow stream, terminal dribbling and hesitancy. 

    Image Upload 1
  3. McNeal concept of zonal anatomy of the prostate?
    • Three distinct zones-
    • Peripheral zone - 70%,
    • Central zone - 25%
    • Transition zone - 5%

    These anatomic zones have distinct ductal systems but, more important,are differentially afflicted with neoplastic processes. Sixty to seventy percent of carcinomas of the prostate (CaP) originate in the peripheral zone, 10–20% in the transition zone, and 5–10% in the central zone. 

    Benign prostatic hyperplasia (BPH) uniformly originates in the transition zone

    Image Upload 2
  4. Why do carcinoma prostate reach advanced stage early?
    Carcinoma of prostate begins in the outer part of the gland, so it spreads easily into the floor of the pelvis.
  5. Etiology of BEP?
    • The association between aging and BPH might result from the increased estrogen levels of aging causing induction of the androgen receptor, which thereby sensitizes the prostate to free testosterone.
    • Genetic or environmental factors that influence 5α-reductase appear to be important in the development of BPH as well
  6. Pathology of BEP?
    • Microscopic evaluation reveals a nodular growth pattern that is composed of varying amounts of stroma and epithelium. Stroma is composed of varying amounts of collagen and smooth muscle.
    • Significant component of smooth muscle - α-blocker therapy is effective
    • Predominantly composed of epithelium - 5α-reductase Inhibitors is more effective.
    • Significant components of collagen in the stroma - may not respond to either form of medical therapy
    • As BPH nodules in the transition zone enlarge, they compress the outer zones of the prostate, resulting in the formation of a so-called surgical capsule. This boundary separates the transition zone from the peripheral zone and serves as a cleavage plane for open enucleation of the prostate during open simple prostatectomies performed for BPH.

    Image Upload 3
  7. Pathophysiology of BEP?
    • 1. Obstructive component of the prostate - Mechanical and dynamic obstruction
    • Mechanical obstruction - result from intrusion into the urethral lumen or bladder neck, leading to a higher bladder outlet resistance.
    • Dynamic obstruction - The prostatic stroma, composed of smooth muscle and collagen, is rich in adrenergic nerve supply. The level of autonomic stimulation thus sets a tone to the prostatic urethra. Use of α-blocker therapy decreases this tone, resulting in a decrease in outlet resistance

    2. Secondary response of the bladder to the outlet resistance - Bladder outlet obstruction leads to detrusor muscle hypertrophy and hyperplasia as well as collagen deposition. The irritative voiding complaints (see later) of BPH result from the secondary response of the bladder to the increased outlet resistance.
  8. Why do prostatic size correlate poorly with symptoms of BEP?
    Prostatic size on digital rectal examination (DRE) correlates poorly with symptoms, in part, because the median lobe is not readily palpable.
  9. Symptoms of BEP?
    • Obstructive symptoms – Weak Urinary stream, Intermittent flow, Straining, incomplete Emptying
    • Irritative symptoms – Frequency, urgency, and nocturia. [@ WISE FUN]
  10. What is IPSS?
    The International Prostate Symptom Score (IPSS) is an 8 question (7 symptom questions + 1 quality of life question) written screening tool used to screen for, rapidly diagnose, track the symptoms of, and suggest management of the symptoms of the disease benign prostatic hyperplasia

    • This assessment focuses on seven items that ask patients to quantify the severity of their obstructive or irritative complaints on a scale of 0–5. Thus, the score can range from 0 to 35.
    • An IPSS of 0–7 is considered mild, 8–19 is considered moderate, and 20–35 is considered severe. 

    Components of IPSS – WISE FUN

    The 8th question of quality of life is assigned a score of 1 to 6.
  11. DRE finding in BEP?
    • BPH usually results in a smooth, firm, elastic enlargement of the prostate.
    • Induration, if detected, must alert the physician to the possibility of cancer and the need for further evaluation (ie, prostate-specific antigen [PSA], transrectal ultrasound [TRUS], and biopsy)
  12. Estimation of prostate size by DRE?
    • Upper pole reached easily - 20-40gm 
    • Upper pole reached with difficulty - 40-60gm 
    • Upper pole cannot be reached - >60gm
  13. USG in BEP
    Size of prostate - 20-25 gms is normal

    Post voidal residual urine (PVRU) - <50cc  is normal

    Intravesical protrusion of prostate (IVPP) - IPP exceeding 5.5 mm is significantly associated with BOO.
  14. Indication of cystoscopy in BEP?
    • When marked obstructive symptoms exist in the setting of relative minimal prostate enlargement, cystoscopy may be useful to identify a high bladder neck, urethral stricture, or other pathology.
    • If BPH is associated with hematuria, then cystoscopy is mandatory to rule out other bladder pathology.
  15. Cause of hematuria in BEP?
    Dilatation of Submucosal venous plexus of urinary bladder
  16. Differential diagnosis of BEP?
    • Urethral stricture - history of previous urethral instrumentation, urethritis, or trauma
    • Bladder neck contracture
    • Bladder stone – Hematuria associated with pain
    • Carcinoma Prostate - abnormalities on the DRE or an elevated PSA
    • UTI – do urinalysis and culture
    • Neurogenic bladder - history of neurologic disease, stroke, diabetes mellitus, or back injury, examination may show diminished perineal or lower extremity sensation or alterations in rectal sphincter tone or the bulbocavernosus reflex.
  17. Discuss the non-operative management of symptomatic benign enlargement of prostate. Describe their limitations. [TU 2055] 
    Discuss the principle of management of BPH. [TU 2062/1]
    Discuss the non-operative mgmt. Of symptomatic benign enlargement of prostate. Describe their limitations. [TU 2055]
    • Watchful observation - men with mild symptom scores (0–7)
    • Medical Therapy - alpha-Blockers, 5-α-reductase inhibitors (dutasteride and finasteride), combination therapy
    • Phytotherapy - Pumpkin seeds, african plum tree, pollen extracts
    • Surgical
  18. Behavioural and dietary modifications in BEP?
    • Education (about the patient’s condition);
    • • reassurance (that cancer is not a cause of the urinary symptoms);
    • • periodic monitoring;
    • • lifestyle advice such as:- reduction of fluid intake at specific times aimed at reducing urinary frequency when most inconvenient (e.g. at night or when going out in public); avoidance/moderation of intake of caffeine or alcohol
  19. MOA of Alpha blockers?
    • α1-blockers aim to inhibit the effect of endogenously released noradrenaline on smooth muscle cells in the prostate and thereby reduce prostate tone and BOO.
    • α1-blockers can reduce both storage and voiding LUTS.
    • α1-blockers neither reduce prostate size nor prevent AUR in long-term studies
    • Near maximal improvement in urinary flow rate occur within 8 hours of first dose of alpha-1a blockers.
  20. Alpha blockers Names?
    • Nonselective – Phenoxybenzamine
    • α1, short acting – Prazosin
    • α1, long acting – Terazosin, Doxazosin
    • α1a-Selective – Tamsulosin, Alfuzosin
  21. Adverse events of α1-blockers?
    • Asthenia, dizziness and Orthostatic hypotension.
    • Retrograde ejaculation
    • Nasal congestion 
    • Adverse ocular event termed intra-operative floppy iris syndrome (IFIS)
  22. Mechanism of 5α-reductase inhibitors?
    • Androgen effects on the prostate are mediated by dihydrotestosterone (DHT), which is converted from testosterone by the enzyme 5α-reductase
    • Inducing apoptosis of prostate epithelial cells leading to prostate size reduction of about 18-28% and a decrease in circulating PSA levels of about 50% after 6-12 months of treatment.
    • 5-ARIs, but not α1-blockers, reduce the long-term (> 1 year) risk of AUR or need for surgery.
    • Finasteride might reduce blood loss during transurethral prostate surgery, probably due to its effects on prostatic vascularisation. 
    • Six month therapy to see maximum effect on prostate size (20% reduction) and symptomatic improvement
  23. Muscarinic receptor antagonists in BEP?
    • Muscarinic receptor antagonists may be used in men with moderate-to-severe LUTS who mainly have bladder storage symptoms
    • Caution is advised in men with a PVR volume greater than 150 mL
    • E.g - oxybutynin, propiverine
  24. Indication of combined therapy in BEP?
    Offer combination treatment with an α1-blocker and a 5α-reductase inhibitor to men with moderate-to-severe LUTS and risk of disease progression (e.g. prostate volume > 40 mL).

    Use combination treatment of an α1-blocker with a muscarinic receptor antagonist in patients with moderate-to-severe LUTS if relief of storage symptoms has been insufficient with monotherapy with either drug. Prescribe combination treatment with caution in men with a PVR volume > 150 mL.
  25. Side effects of 5α-reductase inhibitors?
    • Reduced libido
    • Impotence
    • Decreased volume of ejaculation 
    • Gynecomastia
  26. Choice for medical drugs in BEP?
    No bothersome symptoms - Watchful waiting

    If size <40ml - alpha-1-blocker, if residual storage symptoms are present, add muscarinic receptor antagonist/Beta -3 agonist

    If size >40ml - 5α-reductase inhibitor ± α-1-blocker/PDE5I

    Low postvoid residual urine volumes and storage/irritative symptoms - anticholinergics 

    Mild-to-moderate symptoms of BPH and erectile dysfunction - PDE-5 inhibitors
  27. Surgical appraoch to prostate?
    • (1) transurethrally (TURP),
    • (2) retropubically (RPP),
    • (3) through the bladder (transvesical;TVP)
    • (4) from the perineum
    • Image Upload 4
  28. Transurethral Surgical Modalities for BEP?
    Transurethral resection of the prostate (TURP) - Unipolar Vs Bipolar 

    Transurethral incision of the prostate (TUIP)

    Transurethral microwave therapy (TUMT) 

    Transurethral needle ablation (TUNA)

    • Transurethral laser therapies 
    • - HoLAP (ablation of prostate) 
    • - Holmium laser Enucleation of the prostate (HoLEP)
    • - HoLRP (resection of prostate) [@ lAsER]
  29. Indications of TURP?
    • Absolute indications 
    • Acute urinary retention refractory to medical treatment
    • Recurrent urinary tract infection (UTI) caused by bladder outlet obstruction
    • Recurrent hematuria caused by bladder outlet obstruction
    • Azotemia
    • Bladder stone and bladder diverticuli 

    • Relative indication
    • Symptoms that are moderate to severe, bothersome, and interfere with the patient’s quality of life
  30. Steps of TURP?
    Steps of Nesbit technique - Sequence of resection (proximal to distal) - bladder neck - mid portion - apical tissue

    1. Resect bladder neck in all quadrants starting from 12 o'clock until circular fibers of bladder neck are seen. 

    2. Resect midportion superiorly to inferiorly until fibers of prostatic capsule are seen (right 12-9, then left 12-3, then right 9-6, then left 3-6 o'clock position) 

    3. Resect the apical tissue - begin next to veru towards 12 o'clock position. Do not exceed distal end of verumontanum to preserve sphincter

    4. Catheter in prostatic fossa with application of skin traction to catheter.
  31. Clinical importance of Verumontanum?
    The seminal colliculus  or verumontanum, of the prostatic urethra is a landmark near the entrance of the ejaculatory ducts . 

    Verumontanum is a reference to the distinctive median elevation of urothelium that characterizes the landmark on magnified views.

    The verumontanum is an important anatomic landmark for pathology in a congenital anomaly known as posterior urethral valves.
  32. Complications of TURP? [TU 2062,64/5, 63/12,61/5]
    • Intraoperative complications -
    • Bleeding
    • TUR-syndrome
    • Capsular perforation and extravasation
    • Injury to urethral orifice
    • Injury to external sphincter
    • Mortality 

    • Immediate post-operative complications - 
    • - Bladder tamponade – clot formation that require evacuation
    • - Post TUR Infection
    • - Urinary retention
    • - UTI 
    • - Septicemia 
    • - DVT 
    • - PE 

    • Late complications - 
    • - Incontinence
    • - Urethral stricture
    • - Bladder neck stenosis
    • - Retrograde ejaculation
    • - Erectile dysfunction
    • - Recurrent BEP
  33. Short note on TUR syndrome. [TU 2072]

    Mechanism of clinical manifestations in TUR Syndrome?
    1. Dilutional hyponatremia - Usually, the patients do not become symptomatic until the serum sodium concentration reaches 125 mEq/dL. 

    2. Effects of glycine

    • - Glycine is a inhibitory CNS neurotransmitter at GABA receptors and paradoxically potentiates NMDA receptors. 
    • - Glycine also has cardiodepressant effects
    • - Glycine may have renal toxicity. 
    • - Transient blindness is attributed to glycine toxicity.  
    • - Ammonia is the major byproduct of glycine metabolism. Encephalopathy may ensue if serum ammonia rises sufficiently.

    • The risk of the TUR syndrome increases with resection times >90 minutes and is usually seen in older men.
    • 20 mL/min of fluid is absorbed normally. When the height of the fluid is changed from 60 to 70 cm, fluid absorption is greater than two-fold. 
    • Risk is also increased if resected prostate is > 60g

    [Note - Glycine is available in 1.2%, 1.5%. 2.2%. Osmolarity of 1.5% glycine is 220mmol/l]
  34. Clinical features of TUR Syndrome?
    • Timing
    • It may occur within 15 minutes or be delayed for up to 24 hours post-operatively
    • typically lasts hours, but neurological manifestations may be prolonged if complications arise

    • Early features
    • mild cases may go unrecognised
    • restlessness, headache, and tachypnoea, or a burning sensation in the face and hands

    • Features of greater severity
    • respiratory distress, hypoxia, pulmonary oedema
    • nausea, vomiting
    • visual disturbance (e.g. blindness, fixed pupils)
    • confusion, convulsions, and coma
    • haemolysis
    • acute renal failure
    • reflex bradycardia from fluid absorption

    Symptoms may be masked by general anaesthesia and severe cases may present with dysrhythmias and cardiovascular collapse
  35. Difference between Unipolar and Bipolar TURP?
    • Bipolar TURP (B-TURP) addresses a major limitation of monopolar TURP (M-TURP) by allowing performance in normal saline.
    • Contrary to M-TURP, in B-TURP systems, the energy does not travel through the body to reach a skin pad. Bipolar circuitry is completed locally; energy is confined between an active (resection loop) and a passive pole situated on the resectoscope tip (“true” bipolar systems) or the sheath (“quasi-” bipolar systems).
    • B-TURP requires less energy/voltage because there is a smaller amount of interpolated tissue.
    • Energy from the loop is transmitted to the saline solution, resulting in excitation of sodium ions to form plasma; molecules are then easily cleaved under relatively low voltage enabling resection. During coagulation, heat dissipates within vessel walls, creating a sealing coagulum and collagen shrinkage.
    • B-TURP is preferable due to a more favourable peri-operative safety profile (elimination of TUR-syndrome; lower clot retention/blood transfusion rates; shorter irrigation, catheterisation, and possibly hospitalisation times)
    • Patients who are treated with saline irrigant (as with bipolar electrosurgery) have much less risk for hyponatremia, but can develop heart failure.
  36. Treatment of TURP?
    • - Termination of surgical procedure 
    • - Diuresis
    • - 15% mannitol
    • - Patient may require intubation for pulmonary edema
    • - Start hypertonic saline  in severe cases
    • - Midazolam - for seizure
  37. Choice of Surgery based on prostate size?
    <30 ml= TUIP,  without a middle lobe

    >30-80 mL - TURP

    > 80-100 mL -  Open Prostatectomy, Enucleation of Prostate (EEP) or HOLEP

    Patients with inguinal hernia - Open approach, as hernia can be repaired in the same setting

    Patients of antiplatelet/anticoagulation therapy that cannot be stopped - Laser vaporization, Laser enucleation

    Patients that are unfit for GA - TUMT, TUNA, PU lift, Stent
  38. Approaches of Open Prostatectomy?
    Retropubic approach (Millin) - excellent anatomic exposure and direct visualization however, direct access to bladder cannot be achieved

    • Suprapubic approach (transvesical) - useful for
    • (1) large median lobe protruding into the bladder
    • (2) clinically significant bladder diverticulum
    • (3) large bladder calculi

    Perineal prostatectomy (Young) - This has now been abandoned for the treatment of BPH.
  39. Options for surgically unfit patients?
    • Prostatic stents
    • Prostatic urethral lift -Encroaching lateral lobes are compressed by small permanent suture-based implants delivered under cystoscopic guidance resulting in an opening of the prostatic urethra that leaves a continuous anterior channel through the prostatic fossa ranging from the bladder neck to the verumontanum.
  40. Recent advances in the management of prostate enlargement. [TU 2064/12]
    In the last year, no new medications that specifically act on the prostate have been brought to commercial market.

    Alpha-blockers, which cause relaxation of the smooth muscle fibers within the prostate, continue to be the first-line treatment.

    The only new medications on the market for BPH in the last few years have been the phosphodiesterase type 5 (PDE5) inhibitors, most notably tadalafil. The most common indication for this medication is the treatment of erectile dysfunction, but trials have shown improvement in BPH symptoms without adverse sexual side effects.

    Apart from traditional oral medication, attempts have been made to inject Botox directly into the prostate. Initial trials in intraprostatic injection have been promising. However, the only long-term randomised controlled trial of intraprostatic Botox did not show significant benefit.

    The most promising new technique has been the prostatic urethral lift. This is a novel mechanical implant placed into the prostate that pulls the encroaching lobes of the prostate out of the way to improve men’s flow.

    A more controversial new technique with only relatively recent published data is prostatic artery embolisation. This is postulated to cause shrinkage of the prostate and an improvement in urinary function.

    TURP has long been the standard of care for the surgery of BPH unless the prostate was very large and in that case an open operation was performed.

    • LASER surgery
    • 1. coagulative laser (Nd:YAG, Diode laser)
    • 2. Cutting laser – HOLMIUM:YAG laser, Thulium:YAG
    • 3. Vapouring laser – Nd:YAG, Ho:YAG, Diode, KTP (Potassium Titanyl Phosphate) and Lithium Triborate

    Laparoscopic surgery 

    Robotic surgery
  41. Short note on Urodynamic study?
    Definition - Urodynamic  testing or urodynamics is a study that assesses how the bladder and urethra are performing their job of storing and releasing urine. Procedure done along with x-ray films is called as video urodynamic study. 

    • Indications 
    • - Suspected bladder outflow obstruction 
    • - Urinary incontinence 
    • - Frequency and Urgency symptoms 
    • - Neurogenic dysfunction 

    Components of UDS -

    1. Non invasive uroflow study - it measures rate, volume, duration and pattern of urine flow. We can also measure the residual volume by USG scan or passing small catheter. 

    2. Multi-channel study - Catheter is placed bladder. Transducer is placed in bladder and rectum. Electrode sticker placed on each side of rectum between legs near anus. Its components are

    a) Filling cystometry - the method by which the pressure volume relation of bladder is examined. It also tells about bladder sensation, capacity, compliance and overactivity. 

    b) Abdominal leak point pressure - patient is asked to cough to bring on urine leakage. Bladder pressure is recorded when leak occurs. 

    c) Urethral pressure profile - measurement of strength of pelvic floor and ability of urethra to close and prevent leakage. 

    d) Voiding cystometry with synchronous pressure flow - Patient is asked to void after removal of catheter and transducer in situ. This measures pressure flow relation of bladder during the voiding phase. The parameters measured are outlet opening pressure, maximum voiding pressure, detrusor pressure at maximum flow and  maximum flow rate.  Voiding cystometry is generally used to assess bladder outlet obstruction, detrusor contractility and overall voiding deficiency.

    e) EMG 

    f) Post-voidal urine - calculated by subtracting the inflow volume and the urine output.
  42. Short note on Foley's catheter.
    Lenght - 45cm
  43. Foleys catheter size - color coding?
    • White - 12F 
    • Green - 14F 
    • Orange - 16F 
    • Red - 18F
    • Yellow - 20F 

    [@ White GORY (गोरी)]
  44. What is the meaning of French?
    The French size is three times the diameter in millimeters. A round catheter of 1 French has an external diameter of  1⁄3 mm, and therefore the diameter of a round catheter in millimetres can be determined by dividing the French size by 3.

    An increasing French size corresponds to a larger external diameter. This is contrary to needle-gauge size, where an increasing gauge corresponds to a smaller diameter needle.
  45. What is Hematuria catheter?
    • The shaft of the catheter is reinforced with a wound nylon/metal coil that offers significant resistance to collapse under the vacuum of irrigation.
    • The additional strength of the coils assures users that any blockage can be cleared by irrigation.
    • In addition, the coils add resistance to any collapse under the balloon from the pressure of inflation.
  46. Coude tip catheter?
    Coude-tip catheters have a slight curve or bend in the insertion tip. 

    Used in BEP.
  47. What can be done if we cannot pass foleys catheter?
    • DRE, elevate prostate and attempt insertion. 
    • Use foleys introducer. 
    • Cystoscopy guided.
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Urosurgery 23 Prostate