urology

BLADDER OUTLET OBSTRUCTION(B.O.O.)

BOO
It’s urodynamic concept of low flow rates and high intravesical pressures.Causes:*BPH.*CAP.*bladder neck stenosis.*urethral stricture.*neuropathic conditions.

Pathophysiology

Boo over time will result in.. increase in the intravesical voiding pressure (>80 cm H2O), bladder muscle hypertrophy (trabiculation, sacculation and diverticulum formation). High pressure may transmit to the upper tract causing hydroureter, hydronephrosis and renal insufficiency. Boo results in incomplete bladder evacuation (residual urine) which predisposes to UTI and stone formation. Decrease uro flow rate under 10 ml /sec

Symptomatology (LUTS

Obstructive: Hesitancy Straining Weak stream Intermittency. Post voiding dribbling. Retention of urine. Irritative: Frequency.,nocturia Urgency & urge incontinence.

IPSS [international prostatic symptom score]

Benign prostatic hyperplasiaBPH
Third most common urological pathology. Starts at late 30s & appear clinically at 60s.

Theories:

Hormonal: DHT, growth factor. Neoplastic: fibromyoadenoma. Typically affects submucosal glands at transitional zone.


Symptomatology
Boo (irritative and obstructive). Symptoms are slowly progressive over years, worsening at winter time. Renal failure. Hematuria. Pain is not afeature of BPH the presence of which may indicate acute retention,vesical stone,infection,CAprostate

Precipitating causes for retention

Severe pain. MI, joint pain. Psychological upset. Cold exposure. Constipation. Drugs Anticholenergic & diuretic ,decongestant,antihistamin Ignoring first desire for urination.

Clinically

Usually normal. Distended bladder.in acute or chronic retention PR ex: enlarged prostate, smooth, regular, firm, maintained median sulcus and mobile rectal mucosa Normal anal sphencter tone. Normal bulbocovernosus reflex

Investigations:

GUE: normal or UTI RFT: normal unless there is renal failure U/S:TRUS: BPH, vesical stone, residual urine and hydronephrosis. IVU:

Benign prostatic hyperplasia

Vesical stone


PSA: (prostate specific Ag)<10 ng/ml. Cystoscopy: enlarged prostate, trabiculation & stones. Size of the prostate has no relation with the severity of the symptom but the degree of urethral compression.

Treatment

Conservative: Avoid ppt factors.Treat pains.Treat UTI.Αlfa blocker: prazocin 1 mg, terrazocin 2mg, doxazocin 2mg.tamsulusin,alfuzosin At nightS/E hypotension, 1st dose syncope.


*
5 α reductase inhibitors: fenasteride, prosteride 5 mg/day > 6 months.S/E impotence.Usually used in large gland

Semi surgical: TUMT (trans urethral microwave thermotherapy) HIFU ( high intensity focused u/s) TUIP (Trans urethral incision of prostate) TUNA (Trans urethral needle ablation) Prostatic stents TU baloon dilatation

TUMT STENT

TUNA

Surgical treatment

Endoscopic: TURP Laser Open surgery: Trans vesical prostatectomy. Rertopubic prostatectomy

INDICATION OF SURGERY IN BPH

SEVERE SYMTOMS FAILURE OF MEDICAL TREATMENT COMPLICATIONS LIKE ACUTE URINARY RETENTION CHRONIC RETENTION REPEATED HEMATURIA REPEATED UTI VESICAL STONE RENAL IMPERMENT DUE TO CHRONIC RETENTION

TURP

Transvesical retropubic

BEFORE TURP AFTER TURP

Complications
Early: Bleeding and clot retention. TUR syndrom (water intoxication) due to. dilutional hyponatremia. Infection. Wond infection[in open prostatectomy]

*
Late: Urethral stricture Bladder neck contracture Retrograde ejaculation. Incontinence. Impotence. Recurrence of BPH. After 5-10 years.

Carcinoma of the prostate CAP

One of the most common malignant tumor affecting males over the age of 65 in western countries.

Pathology

95% of the tumor are adenocarcinoma and derived from acinar epithelium75% of CAP arise from peripheral zone.grading: Gleason’s grade based on the degree of glandular differentiation and growth pattern.

Spread

Direct invasion: to nearby structures.Denonvvilliar’s fascia act as barrier.Lymphatic: internal, external & common iliacBlood: to the lower lumber vertebrae & pelvic bones due to reverse blood flow from vesicoprostatic plexus to the emissary veins of the bones during coughing & sneezing (OSTEOBLASTIC)


Osteoblastic lesion of secondary CAP

Presentation

Accidental during histopathological ex after prostatectomy. During PR ex High PSA BOO. Metastatic: back ache, sciatica, paraplegia or pathological fractures..

*
CAP
BPH
older
Younger age
Rapid progression
Symptoms slowly progressive
More back ache & neurological symptoms
Usually no back or bone pain
Hard irregular prostate with obliterated sulcus
Smooth rubbery prostate with sulcus


*
Rectal examination: Stony hard irregular prostatic nodule, obliterated median sulcus, difficulty in moving the rectal mucosa over it and fixity. Normal PR ex does not exclude CAP.


prostatic cancer
*

Investigations

PSA: prostatic tumor marker for diagnosis and follow up, it may also increase in prostatitis and BPH. 10 ng/ml normal, 10-15 suspicious. >15 is diagnostic. Acid phosphatase: prostatic fraction. Alkaline phosphatase: in bone metastasis.

Radiological investigations

Plain X ray: osteoblastic lesion. Bone scan: hot areas (active). CT scan. TRUS & biopsy (sixtant biopsy).

prostatic cancer

*

Differential Diagnosis

Not all patients with an elevated PSA concentration have CaP.(BPH, urethral instrumentation, infection, prostatic infarction, or vigorous prostate massage) Not all patients with an Induration of the prostate have CaP.(chronic granulomatous prostatitis, previous TURP or needle biopsy, or prostatic calculi). Not all patients with sclerotic bony lesion and elevated alk. phosphatase have CaP.(Paget disease)

prostatic cancer

*

Treatment

Watchful waiting: Radical prostatectomy: Enblock surgical removal of the entire prostate, seminal vesicles and pelvic lymph nodes. The bladder anastomosed to the urethra. Indicated for early disease and healthy fit pt.


2. Radical prostatectomy
prostatic cancer
*

ROBOTIC RADICQL PROSTQTECTOMY

prostatic cancer
*

Radiotherapyexternal beam & brachytherapy

Indication: 1- Locally advanced disease. 2- Unfit patient for surgery. 3-Symptomatic metastases to relieve pain.

3. Radiation therapy 

external beam therapy
brachytherapy
prostatic cancer
*

Hormonal therapy

Its trearment of choice for metastatic tumor Cap is hormonal dependant (androgen), and about one third of tumors are hormone-insensitive. Androgen ablation may change the course of the disease.

Methods of androgen ablation

surgical Bilateral orchiectomy: complete or subcapsular. medical LHRH agonist: (Zoladex)/28 days SC. Anti androgen: (Nilutemide) 250 mg/6h. .


prostatic cancer
*

Thank you