Dr. Kaveh Mehravaran
Urologist, Fellowship of Endourology & Laparoscopy
Hasheminejad Hospital
BENIGN PROSTATIC HYPERPLASIA
 Incidence & Epidemiology
 BPH is the most common benign tumor in men, and its
incidence is age related.
 The prevalence of histologic BPH in autopsy studies rises
from approximately 20% in men aged 41–50, to 50% in men
aged 51–60, and to >90% in men older than 80.
 Etiology
 The etiology of BPH is not completely understood, but
it seems to be multifactorial and endocrine controlled.
 The prostate is composed of both stromal and
epithelial elements, and each, either alone or in
combination, can give rise to hyperplastic nodules and
the symptoms associated with BPH.
 Pathophysiology
 One can relate the symptoms of BPH to either the
obstructive component of the prostate or the secondary
response of the bladder to the outlet resistance.
Clinical Findings
 SYMPTOMS
 The symptoms of BPH can be divided into obstructive and
irritative complaints.
 Obstructive symptoms include hesitancy, decreased force
and caliber of stream, sensation of incomplete bladder
emptying, double voiding (urinating a second time within
2 hours of the previous void), straining to urinate, and
post-void dribbling.
 Irritative symptoms include urgency, frequency, and
nocturia.
 SIGNS
 A physical examination, DRE, and focused neurologic
examination are performed on all patients.
 LABORATORY FINDINGS
 A urinalysis to exclude infection or hematuria and serum
creatinine measurement to assess renal function are
required.
 Serum PSA is considered optional, but most physicians will
include it in the initial evaluation.
IMAGING
 Upper-tract imaging (intravenous pyelogram or renal
ultrasound) is recommended only in the presence of
concomitant urinary tract disease or complications from
BPH (eg, hematuria, urinary tract infection, renal
insufficiency, history of stone disease).
Differential Diagnosis
 Other obstructive conditions of the lower urinary tract,
such as urethral stricture, bladder neck contracture,
bladder stone, or CaP, must be entertained when
evaluating men with presumptive BPH.
 A urinary tract infection, which can mimic the irritative
symptoms of BPH
 Although irritative voiding complaints are also associated
with carcinoma of the bladder, especially carcinoma in situ,
the urinalysis usually shows evidence of hematuria.
 Likewise, patients with neurogenic bladder disorders may
have many of the signs and symptoms of BPH, but a history
of neurologic disease, stroke, diabetes mellitus, or back
Treatment
 WATCHFUL WAITING
 watchful waiting is the appropriate management of men
with mild symptom scores
 Men with moderate or severe symptoms can also be
managed in this fashion if they so choose.
Alpha-blockers
5-Alpha-reductase inhibitors
Phytotherapy
 Several plant extracts have been popularized, including the
saw palmetto berry, (Serenoa repens) the bark of Pygeum
africanum, the roots of Echinacea purpurea
CONVENTIONAL SURGICAL
THERAPY
 Transurethral resection of the prostate(TURP)
 Transurethral incision of the prostate
 Open simple prostatectomy
 Laser therapy
 Transurethral electrovaporization of the prostate
 Hyperthermia
 Transurethral needle ablation of the prostate
 High-intensity focused ultrasound
 Intraurethral stents
CARCINOMA OF THE PROSTATE
 Incidence & Epidemiology
 Prostate cancer is the most common cancer detected in
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American men.
The lifetime risk of a 50-year-old man for latent CaP
(detected as an incidental finding at autopsy, not related to
the cause of death) is 40%; for clinically apparent CaP,
9.5%; and for death from CaP, 2.9%.
Several risk factors for prostate cancer have been identified.
increasing age heightens the risk for CaP.
African Americans are at a higher risk for CaP than whites.
A positive family history of CaP also increases the relative
risk for CaP.
 Epidemiologic studies have shown that the incidence of
clinically significant prostate cancer is much lower in parts
of the world where people eat a predominantly low fat,
plant-based diet.
Pathology
 Over 95% of the cancers of the prostate are
adenocarcinomas.
 Of the other 5%, 90% are transitional cell carcinomas, and
the remaining cancers are neuroendocrine (“small cell”)
carcinomas or sarcomas.
 Approximately, 60–70% of cases of CaP originate in the
peripheral zone, while 10–20% originate in the transition
zone, and 5–10% in the central zone.
Grading & Staging
 The Gleason score or Gleason sum is obtained by
adding the primary and secondary grades together.
 As Gleason grades range from 1 to 5, Gleason scores or
sums
 thus range from 2 to 10.
 Well-differentiated tumors have a Gleason sum of 2–4,
moderately differentiated tumors have a Gleason sum of 5–
6, and poorly differentiated tumors have a Gleason sum of
8–10.
Patterns of Progression
 The likelihood of local extension outside the prostate
(extracapsular extension) or seminal vesicle invasion and
distant metastases increases with increasing tumor volume
and more poorly differentiated cancers.
 Lymphatic metastases are most often identified in the
obturator lymph node chain.
 The axial skeleton is the most usual site of distant
metastases, with the lumbar spine being most frequently
Implicated
 Visceral metastases most commonly involve the lung, liver,
and adrenal gland.
Clinical Findings
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SYMPTOMS
Most patients with early-stage CaP are asymptomatic.
The presence of symptoms often suggests locally advanced or
metastatic disease.
Obstructive or irritative voiding complaints can result from local
growth of the tumor into the urethra or bladder neck or from its
direct extension into the trigone of the bladder.
 Metastatic disease to the bones may cause bone pain.
 Metastatic disease to the vertebral column with impingement on
the spinal cord may be associated with symptoms of cord
compression, including paresthesias and weakness of the lower
extremities and urinary or fecal incontinence.
 A physical examination, including a DRE, is needed.
 Induration, if detected, must alert the physician to the
possibility of cancer and the need for further evaluation
 Locally advanced disease with bulky regional
lymphadenopathy may lead to lymphedema of the lower
extremities.
 Specific signs of cord compression relate to the level of the
compression and may include weakness or spasticity of the
lower extremities and a hyperreflexic bulbocavernosus
reflex.
 LABORATORY FINDINGS
 Azotemia can result from bilateral ureteral obstruction
either from direct extension into the trigone or from
retroperitoneal adenopathy.
 Anemia may be present in metastatic disease.
 Alkaline phosphatase may be elevated in the presence of
bone metastases.
 TUMOR MARKERS—PROSTATE-SPECIFIC ANTIGEN
 PSA is a serine protease produced by benign and malignant
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prostate tissues.
It circulates in the serum as uncomplexed (free or unbound) or
complexed (bound) forms.
Normal PSA values are those ≤4 ng/mL.
Current detection strategies include the efficient use of the
combination of DRE, serum PSA, and TRUS with systematic
biopsy.
Unfortunately, PSA is not specific for CaP, as other factors such
as BPH, urethral instrumentation, and infection can cause
elevations of serum PSA.
 PSA velocity
 PSA density
 Age-adjusted reference ranges for PSA
 Molecular forms of PSA
 PROSTATE BIOPSY
 Prostate biopsy is best performed under TRUS guidance
using a spring-loaded biopsy device coupled to the imaging
probe.
 IMAGING
 TRUS
 Endorectal magnetic resonance imaging (MRI)
 Axial imaging (CT, MRI)
 Bone scan
 Antibody imaging
Treatment
 LOCALIZED DISEASE
 Watchful waiting and active surveillance
 Radical prostatectomy
 Radiation therapy (Brachytherapy- external beam
therapy)
 Cryosurgery and high-intensity focused ultrasound
(HIFU)
 METASTATIC DISEASE
 Initial endocrine therapy