FK UNLAM

BPH
(BENIGN PROSTATIC HYPERPLASIA)
dr Eka Yudha Rahman,M.Kes,SpU
 ANATOMY
• Vaskularisasi : a. vesikalis inferior
• a. hemorrhoidalis media
• a. pudenda interna
• Aliran vena dari prostat  plexus periprostatika
• Aliran limfe dari prostat  obturator dan iliaka interna
• Persarafan dari plexus pelvicus
 ANATOMY
• Mc Neal ( 1988 ) :
• Zona transisional, Zona central,Zona peripher ,Zona anterior
fibromuskuler stroma.
 Prevalence of BPH

• The Most Frequent Benign Tumor in Men

•20 % of men 41 - 50 years.
• 50 % of men 51 - 60 years.
• 65 % of men 61 - 70 years
•80 % of men 71 - 80 years.
• 90 % of men 81 - 90 years
(autopsy study)

• Indonesia : The Second after Stone

 Prevalence of BPH

USA
• Above 85 yrs : 90% (Isaac, 1990)
• 80 years : 1 out of 4 male (Barry, 1990, 1995)
• 300.000 TUR yearly (Holtgreve, Mebust, Daud, 1989)
• Expenditure 2 billion Dollar/ year
 Patient profile: Age of the patients

Hospital/Author Mean Age

Cipto Mangunkusumo* 65.2  8.0 years

Sumber Waras* 65.2  9.9 years

Kojima et al ** 69.1  6.6 years

*Rahadjo D., Birowo P. MKI 2000 Vol 50 no. 2 :

81-5
* *Kojima et al J.Urol.1997; 157 : 2060 - 2065
Hospital Incidence In Jakarta 1995 - 1997

HOSPITAL n

Cipto Mangunkusumo 462

Sumber Waras 602

Rahadjo D., Birowo P. MKI 2000 Vol 50 no. 2 81-5

ETIOLOGY
 Theories for the cause of BPH
Theory Cause Effect
Dihydrotestosteron  5- reductase and Epithelial and stromal
hypothesis androgen receptors hyperplasia

Oestrogen-testosteron  Oestrogens Stromal hyperplasia

imbalance  Testosteron

Stromal-epithelial  Epidermal growth Epithelial and stromal

interactions factor/fibroblast hyperplasia
growth factor
 Transforming growth
factor 

Reduced cell death  Oestrogens  Longevity of stroma

and epithelium

Stem cell theory Stem cells Proliferation of transit

Cells
Inflammation infection Epithelial and stromal
Hyperplasia ? 9
 DHT theory
Testosteron

DHT

Inskripsi RNA

Sintesis Protein

Hiperplasia epitel & stroma

prostat
 Diagnosis I

• Anamnesis
Cardinal symptoms:
Weak Stream
Frequency
Nocturia

Storage symptoms, Voiding Symptoms

Scoring System : M.I, IPSS

 Symptoms

Storage Voiding Post Voiding

• Frequency • Weak Stream • Incomplete
• Urgency • Hesitancy emptying
• Nocturia • Intermittency • Terminal
• Disuria • Straining dribbling
Symptom Score (symptom profile)
I-PSS Score:
- Mild :0–7
- Moderate : 8 – 19
- Severe : 20 - 35
 DIAGNOSIS II
Physical examination:
• flanks : kidneys bimanual
palpation ballotement
• Supra sympisis: bladderpalpation
bladder distention  urine
`retention
• Genitalia : urethra, testis, epidydimis
 Diagnosis II

Physical examination: Prostate:

DRE 1. Size
2. Nodule
3. Consistency
TMSA 4. Tenderness
BCR 5. Symetrical/asymetri
cal enlargement
 Diagnosis II

Uroflowmetry Qmax
Voided volume

Residual urine TAUS

Catheter
 UROFLOWMETRY CHART

Male 70 years old with LUTS

 Lab test
• Blood Count
• Serum Electrolyte
• Serum Creatinine
• Serum PSA (TPSA)
• Urine :
Proteinuria
Sediment
Culture
 IMAGING
• TRUS
• TAUS
• With Indication :
IVP
Cystography
TRUS

Hypoechoic lession
TAUS
IVU
CYSTOGRAM
 Prostate Volume
Hospital/Author Mean Prostate Vol (ml)
Cipto Mangunkusumo 57.0  26.5
Sumber Waras 44.3  22.4
Girman et al 26.4 cc ( median ) *
Kojima 30.3  9.8 **
Collins et al 32 ***
Oesterling et al 29 ****
* J Urol. 1995 ; 153 (50 : 1550 –5
** J urol. 1997 ; 157 : 2160 – 5
*** Br J. Urol 1993 ; 71 ; 445 – 50
**** JAMA 1993 ; 220 (7) ; 860 - 4
 Indication for Biopsy
Accepted Standard Proposed standard for
Jakarta

 4 ng No. biopsy  8 ng

4- 10 ng/ml 8-30 ng/ml

Biopsy
PSA D > 0.15 PSA D > 0.20

>10 ng/ml Biopsy > 30 ng/ml

Hard Nodule Hard Nodule
Biopsy
Hypo/hiperchoic lession Hypo/hyperechoic lession
Rahardjo D, ST Kamil Gardian, Med J Indones 9(1);35-42
 Differensial Diagnosis
• Urethral stricture
• Bladder neck contracture
• Bladder stone
• Prostate cancer
• Prostatitis
• CIS bladder
FMUI

Treatment I : Non Surgical

• Watchful Waiting (IPSS 0-7)

• Medical Treatment (IPSS 8 – 19)
- 5  reduktase inhibitor
- alpha adrenergic Blockers
1 blocker : Doxazosin
Terazosin
1a blocker: Tamsulosin
- Phytotherapy
 Indication for non surgical treatment

• IPSS score < 20

• Residual Urine < 100 ml
• PSA < 4 ng/ml
• No Hard Nodule
• No complication
 Indication for surgery
(Complication of BPH)

• Chronic retention
• recurrent UTI
• Decreased Renal Function/Hydronefrosis
• Haematuria
• With bladder stone
• with bladder divertikel
 Surgical Treatment
• TUR-P
• TUI-P
• Open Prostatectomy
• Laser Ablation
• Laser Resection
• Thermo Therapy
• Hyperthermia
• TUNA
TUR-P

Foto :
Universitatsklinikum
Tubingen, prof. Bichler,
Abt.urologie
33
LASER ND-YAG
SIDE FIRING

www.endoscopy.com
Personal Jakarta Experience Morbidity Associated with Surgery

Open TUIP TURP VILAP

Complication of Surgery surg.
(n=30) (n=24) (n=100) (n=100)
Bleeding 4 (11%) 0 (0%) 8 (8%) 2 (2%)
Incontinence 1 (3%) 0 (0%) 1 (1%) 0 (0%)
Bladder neck contracture 0 (0%) 0 (0%) 2 (2%) 0 (0%)
Stricture 1 (3%) 1 (4%) 3 (3%) 0 (0%)
Retrograde ejac. 21 (70%) 0 (0%) 62 (62%) 2 (2%)
Impotence ? ? 4 (4%) 1 (1%)
 Alternative Treatment

• Balloon Dilatation
• Stenting
FMUI
FMUI