BLOCK 15:

NEPHROLOGY, UROLOGY, AND BODY FLUIDS

FAKULTAS KEDOKTERAN UNIVERSITAS TADULAKO MAY 3RD 2012

SURGICAL
TREATMENT OF BPH

dr. Untung Tranggono, MS, SpB, SpU, PA(K)

Sub Bagian Urologi Bagian Ilmu Bedah FK UGM
/ SMF Urologi RS Sardjito
Yogyakarta
The organs and diseases

 Kidney  Congenitale
 Ureter  Trauma
 Bladder  Inflamation-
 Urethra infection
 Prostate  Neoplasia
 Testicular  Idiopathic
 Adrenal  Aging
 Metabolic
 imunologic
Background

 Men
 Testes
 Adult age
 Proliferation of
stromal & epithelial
 BPH
 BPE
 BPO
 LUTS
Prostatic zone (Mc Neal)
Anatomy
 Inverse pyramide
 Circumscribe surrounded urethra
 Strangulate potential
 About 15-20 cc
 5 lobes (Lowsley, 1912)
 Heterogenic composed (Gil Vernet, 1953)
 Anteriorly fibromusculare (Rifkin)
 3-zones (McNeal, 1968)
 Central, transitional, peripheral
Physiology

 Urine production: 0,5 – 1 cc/kg/hr

 Every 15 – 20 minutes flew from kidney
 Bladder act as reservoir and pump
 200 – 250 cc give sensation to void
 Send to brain to coordinate among detrussor,
sphincters, and supporting muscles
Pathology

 Congenital
 Trauma
 Inflamation / Infection
 Neoplasm
 Idiopahic
 Immunologic
 Metabolic
 Aging
 Others
Voiding disturbances
 Time
 Frequency
 Intermitency
 Nocturia
 Ammount
 Polyuria
 Oligouria
 Anuria
 Urinary retention
 Sensation
 Satisfy (fully satisfied)
 Not emptied (rest urine)
 Pain, burn
 Colors
 Yellowish clear, cloudy, redish, milky
 Contains
Voiding disturbances (2)

 Time
 Ammount
 Sensation
 Colors
 Yellowish clear, cloudy, redish, milky
 Contains (macroscopic, microscopic, chemic, microbiologic,
cytologic)
 Fresh blood, Blood clott
 Pus (pyuria, Air (pneumaturia)
 Bacteria (bacteriuria), cancer cells
 Keton bodies, crystals, etc.
Voiding disturbances (3)

 Time
 Ammount
 Sensation
 Colors
 Contains
 Stream
 Enough (without straining)
 Lack (straining)
 Incontinence
Assessment of men with BPH

 > 50 yr & non BPH related LUTS

 < 50 yr, neurologic disease, LUT disease –

surgery,  intensive work up

 diagnostic test divided into 3 categories:

 Recommended
 Optional
 Not recommended
A. Recommended diagnostic
1. Medical history: identify cause of LUTS other than BPH
2. Symptom scores: to allocating treatment and monitoring
response IPSS
3. Physical examination
a. Digital rectal examination (DRE)
b. Basic neurological examination
4. Prostate Spesific Antigen (PSA)
a. Prostate cancer
b. Prostate volume
c. The risk of AUR
d. The risk of surgery

5. Creatinine measurement
A. Recommended diagnostic

5. Creatinine measurement
a. UUT dilatation
b. Renal failure
c. USG (alt)
6. Urine analysis
causes of LUTS other than BPH: cancer, infection, stone
7. Uroflowmetry
a. two or more flows > 150 ml
b. abnormal voiding
8. Post void residual urine (PVR)
indicate bladder dysfunction
B. Optional diagnostic

1. Pressure flow study

a. VV < 150 ml
b. Qmax > 15 ml/s
c. > 80 yr
d. PVR > 300 ml
e. Neurogenic bladder dysfunction
f. After radical pelvic surgery
g. After unsuccessful treatment of BPH
Optional diagnostic

1. (Pressure flow study)

2. Endoscopy
a. Shape and size of the prostate
b. Other pathologies of LUTS
3. Urinary tract imaging
a. TAUS and TRUS
b. Selection of surgery
4. Voiding charts, 24 hr voiding diary
C. Not recommended

No evidence to support the use of the tests:

1. Excretory urography
2. Filling cystometry
3. Retrograde urethography
4. Computed tomography
5. Magnetic resoneance imaging (MRI)
 Staging of BPH (WHO, 1993)

Parameter Measurement Symbol Score

Symptom Questionere IPSS 0 -35
Quality of life Questionare Qol 0–6
Flow rate Uroflowmetry Qmax ml/sec
PVR urine TAUS RU ml/g
Obstruction Pressure flow study PQ Pdet on Qmax
EAU recommendaton (2004)
1. Watchfull waiting
a. IPSS 0-7
b. QOL 0-2
2. 5-alpha reductase inhibitor
a. LUTS – BPH : > 40 g
b. no absolute indications
3. Alpha blockers
a. LUTS – BPH & no absolute indications
4. Surgical treatment (TURP, TUIP,
OpenP)
a. treatment of choice
b. BPH with absolute indication
Absolute indications

1. Recurrent urinary retention

2. Gross hematuria due to BPH
3. Renal failure due to BPH
4. Bladder stone due to BPH
5. Recurrent urinary tract infection
due to BPH
6. Large bladder diverticle due to BPH
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