PROSTATE GLAND

PROSTATE GLAND
The prostate is a walnut-sized gland located between the bladder and the penis. The prostate is just in front of the rectum. The urethra runs through the center of the prostate, from the bladder to the penis, letting urine flow out of the body. The prostate secretes fluid that nourishes and protects sperm. During ejaculation, the prostate squeezes this fluid into the urethra, and its expelled with sperm as semen.

ZONES

Transition zone constitutes 5% of prostate gland . The transition zone surrounds the proximal urethra 10-20% prostate cancer originate in this zone Peripheral zone constitutes 70 % of prostate gland. The sub-capsular portion of the prostate gland that surrounds the distal urethra. About 70-80% prostate cancer originate in this zone Central zone constitutes 25 % of prostate gland. This zone surrounds the ejaculatory ducts 2.5% prostate cancer originate in this zone

LOBES
Anterior lobe (or isthmus) roughly corresponds to part of transitional zone Posterior lobe roughly corresponds to peripheral zone Lateral lobes spans all zones Median lobe (or middle lobe) roughly corresponds to part of central zone

DISORDERS OF PROSTATE GLAND

Prostatitis Benign prostatic hyperplasia Prostate Cancer

BPH

Normal Prostate

Enlarged Prostate

SYMPTOMS

Storage
Frequency Urgency nocturia

Voiding
Hesitancy Intermittency Straining to void

DIAGNOSIS OF BPH
Symptom assessment the International Prostate Symptom Score (IPSS) is recommended as it is used worldwide IPSS is based on a survey and questionnaire developed by the American Urological Association (AUA). It contains: seven questions about the severity of symptoms; total score 07 (mild), 819 (moderate), 2035 (severe) eighth standalone question on QoL

DIAGNOSIS OF BPH
Digital rectal examination(DRE)

inaccurate for size but can detect shape and consistency

PV determination- ultrasonography Measurement of prostate-specific antigen (PSA) Men with larger prostates have higher PSA level As PSA values tend to increase with increasing PV and increasing age, PSA may be used for predicting BPH

MANAGEMENT OF BPH
Watchful waiting Medication Surgical approaches

WATCHFUL WAITING
For mild symptoms. follow up1 to 2 times yearly

Offer suggestions that help reduce symptoms

Avoid caffeine and alcohol
Avoid decongestants and antihistamines

MEDICAL MANAGEMENT -adrenergic 5-reductase Combination

blockers
inhibitors therapy

ALPHA BLOCKERS
Relax smooth muscle in bladder neck and prostate Improve urinary flow

Agents indicated for symptomatic BPH include 1: Alfuzosin Doxazosin Silodosin Tamsulosin Terazosin

5-reductase inhibitors
Testosterone is converted to dihydrotestosterone (DHT) within the prostatic stromal & basal cells facilitated by 5-reductase enzyme 5-reductase inhibitor: deprive the prostate of its testosterone support Agents suchas finasteride and dutasteride

SURGICAL MANAGEMENT
Standard Surgical options TURP TUIP Open prostatectomy

Minimally Invasive Procedures

LASER PROSTATECTOMY TUMT Transurethral electrovaporization, etc.,

TURP
The surgeon inserts an instrument called a resectoscope through the tip of the penis into the urethra. The resectoscope contains a light, valves for controlling irrigating fluid and an electrical loop that cuts tissue and seals blood vessels. The removed tissue pieces are carried by the irrigating fluid into the bladder and then flushed out and sent to a pathologist for examination under a microscope. At the end of the procedure, a catheter is placed in the bladder through the penis.

The bladder is continuously irrigated with fluid through the catheter in order to monitor bleeding and prevent blood from clotting and obstructing the catheter.

TUIP
Instead of cutting and removing tissue to relieve the obstructed bladder, this procedure widens the urethra by making several small cuts in the bladder neck where the urethra joins the bladder and in the prostate itself.

This reduces the pressure of the prostate on the urethra and makes urination easier. Patients normally stay in the hospital one to three days. A catheter is left in the bladder for one to three days after surgery.

OPEN PROSTATECTOMY
Open prostatectomy is performed for those patients with very large prostates (greater than 80 grams) in whom transurethral surgery would be difficult to perform safely. In this procedure, an w is made from the navel to the pubic bone. The bladder is opened; and prostatic tissue is removed through the bladder.

A urethral catheter remains for approximately 7 days and patients stay in the hospital 5-7 days.

It is a more invasive procedure and complications include bleeding and infection.

LASER PROSTATECTOMY
Laser prostatectomy is performed with the use of a laser with various types and wavelengths have the advantages of lack or decreased risk of complications such as intraoperative bleeding and fluid absorption, retrograde ejaculation, impotence, and incontinence. Patients undergoing this procedure tend to require shorter hospital stays and can be admitted on an outpatient basis. Four general techniques include:

Non-contact visual laser ablation of the prostate (VLAP)

Interstitial laser coagulation of the prostate (ILC) Transurethral laser enucleation prostatectomy

Transurethral laser vaporation of the prostate

Transurethral laser photoselective vaporation of the prostate (PVP)

TUMT
Transurethral thermotherapy (microwave hyperthermia) uses microwave energy with frequencies between 915 and 2450 MHz to heat tissues through radiant heat transfer. Using a probe transurethrally (also transrectally), microwave heat delivery is maximized to the prostatic tissue (to a temperature of 42 ? to 45 ? C) while the surrounding tissue is cooled by a special catheter in certain devices. This procedure can be performed as an outpatient procedure with local anesthesia.

TRANSURETHRAL ELECTROVAPORIZATION
Transurethral electrovaporization simultaneously vaporizes and coagulates prostatic tissue so no bleeding or fluid absorption occurs. First introduced into the urologic community in 1995, there have been many studies demonstrating similar efficacy, increased safety, and decreased side effects compared to the standard TURP. Studies with long-term follow-up over 7 years have demonstrated this to be a durable procedure. It is now utilized by about 40% of the urologic community.

Catheters remain for 1 day and patients spend 1 day in the hospital. Though complications similar to TURP can occur, the risk of significant complications such bleeding, salt imbalances from fluid absorption, impotence and incontinence are low.