Download MBBS Surgery Presentations 34 Luts, Bph, Carcinoma Prostate Lecture Notes

Download MBBS (Bachelor of Medicine, Bachelor of Surgery) 1st Year, 2nd Year, 3rd Year and Final year Surgery 34 Luts, Bph, Carcinoma Prostate PPT-Powerpoint Presentations and lecture notes


LUTS, BPH, Carcinoma Prostate

Dept. of Surgery

LUTS: definition

? Storage (irritative) symptoms:

? Urgency
? Urinary frequency
? Nocturia
? Urinary incontinence

? Voiding (obstructive) symptoms

? Hesitancy, poor stream, terminal dribbling
Causes of LUTS

? Obstructive

? BPH
? Prostate/bladder/rectal cancer
? Bladder neck/urethral strictures
? Antimuscarinic drugs
? Autonomic neuropathy/neurogenic bladder

Causes of LUTS

? Irritative

? BPH
? Bladder/prostate cancer
? Infection
? Bladder stones
? Neurological

? Dementia
? Diabetes
? Stroke
Assessment

? History ? type of LUTS, duration of Sx, how

bothersome are they?

? Examination ? abdomen (distended bladder),

external genitalia, DRE

? International Prostate Symptom Score:

? Used to assess severity of symptoms
? Score of 0-5 for seven symptoms (total 35):

? 0-7 ? mildly symptomatic
? 8-19 ? moderately symptomatic
? 20-35 ? severely symptomatic

Management

? Urine dip +/- culture

? U&E

? Chronic retention

? Recurrent UTI

? Hx of renal stones

? PSA

? Urinary frequency-volume chart

? Ask patient to note down when they drink fluid/pass water

and to comment on type of fluid

? Allows to differentiate between frequency of urine,

polyuria and nocturia
? Obstructive symptoms

? Lifestyle changes.
? Alpha blocker: e.g tamsulosin
? 5 ? reductase inhibitors

? Irritative symptoms

? Exclude/manage treatable causes
? Urine containment devices
? Supervised bladder retraining
? Anticholinergics e.g oxybutinin


Benign Prostatic Hyperplasia


? Generalised disease of the

prostate due to hormonal

derangement which leads to

enlargement of the gland

(increase in the number of

epithelial cells and stromal

tissue)to cause compression

of the urethra leading to

symptoms

3/24/2022

9

Etiology

? Cause not completely understood
? Reawakening of the urogenital sinus to proliferate
? Change in hormonal milieu with alterations in the

testosterone/estrogen balance

? Induction of prostatic growth factors
? Increased stem cells/decreased stromal cell death
? Accumulation of dihydroxytestosterone, stimulation by estrogen

and prostatic growth hormone actions


BPH facts

? Occurs in 50% of men over 50 and in 80% of men

over 80 have BPH

? BPH progresses differently in every individual
? Many men with BPH may have mild symptoms and

may never need treatment

? BPH does not predispose to the development of

prostate cancer

11

Benign Prostatic Hyperplasia

12






BPH Pathophysiology

Normal

BPH

BLADDER

Hypertrophied

detrusor muscle

PROSTATE

URETHRA

Obstructed

urinary flow

Pathophysiology

? Slow and insidious changes over time
? Complex interactions between prostatic urethral resistance,

intravesical pressure, detrussor functionality, neurologic
integrity, and general physical health.

? Initial hypertrophydetrussor decompensation poor

tonediverticula formationincreasing urine
volumehydronephrosisupper tract dysfunction
Complications

? Urinary retention
? UTI
? Sepsis secondary to UTI
? Residual urine
? Calculi
? Renal failure
? Hematuria
? Hernias, hemorroids, bowel habit change

3/24/2022

15

Clinical manifestations

? Voiding symptoms

? decrease in the urinary stream

? Straining

? Dribbling at the end of urination

? Intermittency

? Hesitancy

? Pain or burning during urination

? Feeling of incomplete bladder emptying




3/24/2022

16
Clinical manifestations

? Irritative symptoms

urinary frequency
urgency
dysuria
bladder pain
nocturia
incontinence
symptoms associated with infection

3/24/2022

17

Benign Prostatic Hyperplasia

? Leading to "symptom bother" and

worsened QOL
Other Relevant History

? GU History (STD, trauma, surgery)
? Other disorders (eg. neurologic, diabetes)
? Medications (anti-cholinergics)
? Functional Status

Diagnostic Tests

? Prostate specific antigen

? History & Examination

(PSA)

? Abdominal/GU exam
?

? Transrectal ultrasound ?

Focused neuro exam

? Digital rectal exam (DRE)

biopsy

? Validated symptom

? Uroflometry

questionnaire.

? Postvoid residual

? Urinalysis
? Urine culture
? BUN, Cr

3/24/2022

20


Optional E DRE

valuations3/24/2022

21

and
? Urine cytology in patients with:

D

? Predominance of irritative voiding symptoms.
? Smoking history

i ? Flow rate and post-void residual

a

? Not necessary before medical therapy but should be

g

considered in those undergoing invasive therapy or those

with neurologic conditions

n ? Upper tract evaluation if hematuria, increased creatinine

o ? Cystoscopy

stic Te
st
s
Differential Diagnosis

? Urethral stricture
? Bladder neck contracture
? Carcinoma of the prostate
? Carcinoma of the bladder
? Bladder calculi
? Urinary tract infection and prostatitis
? Neurogenic bladder

Treatment Indications

Absolute vs Relative

? Severe obstruction

? Moderate symptoms

? Urinary retention

of prostatism

? Signs of upper tract

? Recurrent UTI's

dilatation and renal

? Hematuria

insufficiency

? Quality of life issues
Therapy

? Watchful waiting and behavioral modification

? Medical Management

? Alpha blockers

? 5-alpha reductase inhibitors

? Combination therapy

? Surgical Management

? Office based therapy

? OR based therapy

? Urethral stents


Carcinoma Prostate
Epidemiology
? Risk factors

? Increasing age

? Family history

? African-American

? Dietary factors.

? Nutritional factors have protective effect against prostate cancer

? Reduced fat intake

? Soy protein

? Lycopene

? Vitamin E

? Selenium

? Race

? Incidence doubled in African Americans compared to white Americans.

? Genetics

? Common among relatives with early-onset prostate cancer

? Susceptibility locus (early onset prostate cancer)

? Chromosome 1, band Q24

? An abnormality at this locus occurs in less than 10% of prostate cancer

patients.

Pathophysiology

? Adenocarcinoma

? 95% of prostate cancers

? Developing in the acini of prostatic ducts

? Rare histopathologic types of prostate carcinoma

? Occur in approximately 5% of patients

? Include

? Smal cel carcinoma

? Mucinous carcinoma

? Endometrioid cancer (prostatic ductal carcinoma)

? Transitional cel cancer

? Squamous cel carcinoma

? Basal cel carcinoma

? Adenoid cystic carcinoma (basaloid)

? Signet-ring cel carcinoma

? Neuroendocrine cancer


Pathophysiology

? Peripheral zone (PZ)

? 70% of cancers

? Transitional zone (TZ)

? 20%
? Some claim

? TZ prostate cancers are relatively nonaggressive
? PZ cancers are more aggressive

? Tend to invade the periprostatic tissues.

Clinical Manifestations

? Early state (organ confined)

? Asymptomatic

? Locally advanced

? Obstructive voiding symptoms

? Hesitancy

? Intermittent urinary stream

? Decreased force of stream

? May have growth into the urethra or bladder neck

? Hematuria

? Hematospermia

? Advanced (spread to the regional pelvic lymph nodes)

? Edema of the lower extremities

? Pelvic and perineal discomfort
Clinical Manifestations

? Metastasis

? Most commonly to bone (frequently asymptomatic)

? Can cause severe and unremitting pain

? Bone metastasis

? Can result in pathologic fractures or
? Spinal cord compression

? Visceral metastases (rare)
? Can develop pulmonary, hepatic, pleural, peritoneal, and

central nervous system metastases late in the natural

history or after hormonal therapies fail.

Detection and Diagnosis

? PSA level

? Helpful in asymptomatic patients

? > 60% of patients with prostate cancer are asymptomatic
? Diagnosis is made solely because of an elevated screening PSA level

? A palpable nodule on digital rectal examination

? Next most common clinical presentation
? Prompts biopsy

? Much less commonly, patients are symptomatic

? Advanced disease

? Obstructive voiding symptoms
? Pelvic or perineal discomfort
? Lower extremity edema
? Symptomatic bone lesions.
Detection and Diagnosis

? Digital rectal examination

? Low sensitivity and specificity for diagnosis
? Biopsy of a nodule or area of induration

? Reveals cancer 50% of the time
? Suggests

? Prostate biopsy

? Should be undertaken in all men with palpable nodules.

Detection and Diagnosis

? Transrectal ultrasound with biopsies

? Indicated when

? The PSA level is elevated

? The percent-free PSA is less than 25%, or

? An abnormality is noted on digital rectal examination

? Type of biopsy

? Sextant biopsies (base, midgland, and apex on each

side)

? Generally obtained

? Seminal vesicles are biopsied in high-risk patients
Detection and Diagnosis

? A bone scan

? Warranted only

? PSA level greater than 10ng/mL

? Computed Tomography or magnetic

resonance imaging

? Abdominal and pelvic CT or MRI is usually

unrevealing in patients with a PSA level less than

20ng/mL. .

Small, E., Cecil Textbook of Medicine, Prostate Cancer, 2004, WB Saunders, an Elsevier imprint

Prostate Cancer

Prognosis
? Prognosis correlates with histologic grade and

extent (stage) of disease

? Adenocarcinoma

? > 95% of prostate cancers

? Multifocality is common

? Grading

? Ranges from 1 to 5

? Gleason score

? Definition

? Sum of the two most common histologic patterns seen on each tissue specimen

? Ranges

? From 2 (1 + 1)

? To 10 (5 + 5)

? Category

? Wel -differentiated (Gleason scores 2, 3, or 4)

? Intermediate differentiation (Gleason scores 5, 6, or 7)

? Poorly differentiated (Gleason scores 8, 9, or 10).

Small, E., Cecil Textbook of Medicine, Prostate Cancer, 2004, WB Saunders, an Elsevier imprint
Prostate Cancer

Staging

?

Stage T1

?

Nodal metastases

? Nonpalpable prostate cancer

? Can be microscopic and can be detected only by

? Detected only on pathologic examination

biopsy or lymphadenectomy, or they can be

?

Incidental y noted after

visible on imaging studies

? Transurethral resection for benign hypertrophy

?

Distant metastases

(T1a and T1b) or

? On biopsy obtained because of an elevated PSA

? Predominantly to bone

(T1c-the most common clinical stage at

? Occasional visceral metastases occur.

diagnosis)

?

Stage T2

? Palpable tumor

? Appears to be confined to the prostatic gland (T2a

if one lobe, T2b if two lobes)

?

Stage T3

? Tumor with extension through the prostatic

capsule (T2a if focal, T2b if seminal vesicles are

involved)

?

Stage T4

? Invasion of adjacent structures

?

Bladder neck

?

External urinary sphincter

?

The rectum

?

The levator muscles

?

The pelvic sidewal

Small, E., Cecil Textbook of Medicine, Prostate Cancer, 2004, WB Saunders, an Elsevier imprint

Treatment

? PRINCIPLES OF THERAPY

? May include

? Watchful waiting
? Androgen deprivation
? External beam radiotherapy
? Retropubic or perineal radical prostatectomy

? with or without postoperative radiotherapy to the prostate margins

and pelvis

? Brachytherapy (either permanent or temporary radioactive seed

implants)

? with or without external beam radiotherapy to the prostate margins

and pelvis.
? Surgery

? Traditional
? Robotic

? Radiation

? Brachytherapy
? External beam

? Cryotherapy
? Androgen Deprivation
? Watchful waiting

Treatment ? Hormone resistant

? HORMONE-RESISTANT PROSTATE CANCER

? Climbing PSA

? First manifestation of resistance to androgen deprivation

? In the setting of anorchid levels of testosterone

? Therapy

? Discontinuation of antiandrogen therapy (flutamide, bicalutamide, nilutamide) while

continuing with LHRH agonists

? Results in a PSA decline

? Can be associated with symptomatic improvement

? Can persist for 4 to 24 months or more

? Secondary hormonal manipulations

? Ketoconazole or

? Estrogens

? Chemotherapeutic regimens

? Mitoxantrone plus corticosteroids or

? Estramustine plus a taxane

? Monitoring

? Serial PSA levels (best)

? A decline of 50% or more is probably clinically significant
? PALLIATIVE CARE

? Bone pain

? Advanced prostate cancer

? Analgesics

? Glucocorticoids

? Anti-inflammatory agents

? Can al eviate bone pain

? Widespread bony metastases not easily controlled with

analgesics or local radiation

? Strontium-89 and samarium-153

? Selectively concentrated in bone metastases

? Al eviate pain in 70% or more of treated patients.

This post was last modified on 08 April 2022