医学精品课件：14.3&15.1 BPHnephrosis.ppt

1、LOGO 何卫阳何卫阳重庆医科大学附属第一医院泌重庆医科大学附属第一医院泌尿外科尿外科Urinary Obstruction&Benign Prostatic Hyperplasia(BPH)IntroductionEtiologyClinical ManifestationDignosisTreatmentBenign prostatic hyperplasia(BPH)Anatomy and physiologyThe prostate is a part of the male reproductive system Function is to store and secrete a

2、clear fluid(Prostatic fluid)that constitutes 10-30%of the volume of the seminal fluidPass way of urine located below the bladder In front of the rectum surrounding the urethraAnatomy and physiologyDefinition BPH is a nonmalignant enlargement of the prostate gland caused by cellular hyperplasia of bo

3、th glandular and stromal elements that leads to troublesome lower urinary tract symptoms(LUTS)in some men It is the most common benign tumor in men and is not a precancerous condition Zonal Anatomy(McNeal-1972)Peripheral Zone 70%of the young adult(60-70%of CaP)Central Zone 25%(5-10%CaP)Transition Zo

4、ne 5%(10-20%CaP)BPHEtiology of BPH Androgens Ageing Lifestyle Hereditary(genetic)/RaceAndrogen(Functional testicle):the prostate is an androgen dependent organ,thus the hyperplasia of prostate rely on functional testicle.The eunuch Ageing:Male elder than 50 are more liable to BPH,and the incidence i

5、ncreases as the age increases.Life Style&Race Men who lead a western lifestyle have a much higher incidence of symptomatic BPH than men who lead a traditional or rural lifestyle Animal protein,Green tea,tomato,bean American blackswhitesAfrica blacksAsians(prostata cancer)Adapted from Nordling J et a

6、l.In Benign Prostatic Hyperplasia.Plymouth,United Kingdom:Health Publication,2001:107-166.Pathophysiology of Clinical BPH:Overlapping but Independent FeaturesSlide I.2LUTSEnlargedprostateBOOLUTS:lower urianry track syptomBOO:bladder outlet obstructionLower Urinary Tract Symtoms-LUTSVoiding/Obstructi

7、ve symptoms:Hesitancy Intermittency Incomplete voiding Weak urinary stream Straining to pass urine Prolonged micturition Terminal dribblingLower Urinary Tract Symtoms-LUTSStorage/Irritative symptoms:Frequency of urination Nocturia Urgency(compelling need to void that can not be deferred)Urge inconti

8、nence Clinical Manifestation Irritation symptoms:nocturia frequency urgency urgent incontinence The effective volume of the bladder decreaseLow bladder compliance for longtime obstructionObstruction symptoms:Hesitancy Intermittency Incomplete voiding Weak urinary stream Straining to pass urine Prolo

9、nged micturition Terminal dribbling Complications:Infection Cystic calculus Hematuria Hydronephrosis Chronic renal failure Inguinal hernia&Anal prolapseDiagnosis History:(LUTS).Use IPSS Physical Examination:digital rectal exam prostatitis:tenderness,soft,bogginess;prostate cancer:harder;Abdomianl ex

10、am-distended bladder Urinalysis-by dipstick and routine microscopy,urine culture and sensitivity to infections and hematuria Serum PSA-optional to Prostate CancerDiagnosisu Upper tract imaging(IVP,CT,U/S)only in presence of concomitant urinary tract disease or complications-hematuria,UTI,renal insuf

11、ficiency,stone diseaseu Cystometrograms and urodynamic profile-for patients with suspected neurologic disease or those who failed prostate surgeryu Flow rate,post-void residual urine determination and pressure flow IPSSu Mild(score 0-7)u Moderate(score 8-19)u Severe(score 20-35)Differential Diagnosi

12、s Pre-prostatic Urethral stricture Bladder neck contracture Bladder tumors Neurogenic bladder Bladder calculi Urinary tract infectionsProstatic Prostatitis Prostate CancerManagement of BPH Goal-rapid and sustained relief of symptoms:Decrease bladder outlet obstruction Improve bladder emptying Revers

13、e renal insufficiency Prevent future episodes of gross hematuria,UTI and urinary retention Quality of life and sexuality Management depends on severity Treatment of BPH Lifestyle modification Watchful Waiting Medical Therapy Phytotherapy(alternative)Surgical Treatment:Conventional Surgical or Minima

14、lly Invasive TreatmentLifestyle Changes Enriched diet with ample amounts of fresh fish,fruits and vegetables Reduce stress regular Exercise Weight within normal limits Limit fluid intake,decrease bladder irritants-caffeine,alcohol;avoid anticholinergic drugs,narcotics and skeletal muscle relaxants S

15、ee your doctor if you develop nocturia Be aware of interaction of botanical and medical treatmentWatchful Waiting The risk of progression or complications is uncertain In men with symptomatic BPH,progression is not inevitable and some men undergo spontaneous improvement or resolution of their sympto

16、ms Appropriate management of men with mild symptom scores(0-7)Medical TreatmentAlpha blockers Alpha-blockers are a class of drugs considered to be first-line treatment for BPH.Alpha-blockers work by blocking the alpha-1a receptor in the prostate and the bladder.Alpha-blockers relax the muscles of th

17、e bladder neck and prostate.Alpha-blockers are very effective in the treatment of BPH;roughly 50 percent of men see an improvement in symptoms within the first 48 hours to one week after therapy initiation.However,patients may only retain symptom relief for up to 4 years,and alpha-blockers do not sh

18、rink the prostate or slow down BPH progression.Alpha-blockers are also used to treat high blood pressure.Examples of alpha-blockers used in the treatment of BPH include:Examples of alpha-blockers used in the treatment of BPH include:uTerazosin(Hytrin)uDoxazosin(Cardura,Cardura XL)uAlfuzosin(Uroxatra

19、l)uTamsulosin(Flomax)uSilodosin(Rapaflo)Company Logo 5-Reductase inhibitors Combination TherapyCompany Logo Surgical Treatment For patient who do not experience response to medical treatment in 12-24 months;for those whose symptoms progress TURP(transurethral resection of the prostate)-Gold standard

20、Surgical TreatmentSurgical Treatment Open Prostatectomy Not done routinely When prostate too large for TURP (100mL)Minimally Invasive Surgical treatment TUMT-transurethral microwave therapy TUNA-transurethral needle ablation Urinary Stents Laser Prostatectomy-Holep holmium laser enucleation of the p

21、rostateMinimally Invasive Surgical treatmentu TUMT(transurethral microwave therapy)u Performed as a single outpatient visit under local anesthesia and an oral analgesic.Improves symptom scores and urinary flow ratesMinimally Invasive Surgical treatmentuTUNA(transurethral needle ablation)uAn office p

22、rocedure performed under local anesthesia-improves symptom scores and urinary flow ratesuIt uses specially designed catheter through which interstitial radio-frequency needles are deployed from the tip of it.They will heat the tissue resulting in coagulative necrosisuThe entire procedure lasts 30-60

23、 minutes uA catheter is left for 1-4 days after the procedureMinimally Invasive Surgical treatmentuIntraurethral StentuLimited long term experienceuIncreases urine flow rates but causes secondary obstruction by exuberant granulation tissue growth through and around the stentuDifficult to remove it;f

24、ormation of bladder calculi in 50%of patientsuUsually for patients with limited life expectancy that are not good surgical or anesthetic candidatesuAbandoned by most urologistsMinimally Invasive Surgical treatmentuLaser Therapy-“The wave of the future”uNeodymium:yttrium-aluminium-garnet(Nd:YAG)-Visu

25、al Laser ablation of the ProstateuThe final result is coagulative necrosis of the prostatic urethra and adjacent inner prostatic tissue.The obstructive tissue starts to slough 4-8 weeks post-op leading to an open prostatic urethra uGreen light laser -Laser Vaporization of Prostate-causes rapid vapor

26、ization of the superficial tissue,with a minimal rim(2 mm)of coagulationuAdvantage:immediate TUR-like efect of the prostatic urethra,resulting in shorter duration of Foley catheterization in the initial post-op period uHolmium-YAG-Laser resection-prostatic lobes are resected into multiple small pros

27、tate chips that fall into the bladder,similar to standard electrocautery TURP uAdvantage:immediate anatomical patency of the prostatic urethra,resulting in shorter duration of Foley catheterization and higher peak flow rates in the initial post-op period In SummaryBPH(Benign prostatic hyperplasia)be

28、comes increasingly common as men ageMany men with BPH are asymptomatic or have only mild symptoms,and may not require therapyMen who develop upper or lower tract injury will require surgeryAlpha-adrenergic antagonists provide immediate therapeutic benefits and are first line treatment for smaller pr

29、ostates 40 mL mild to moderate symptomsIn SummaryCombined alpha adrenergic antagonist and 5-alpha-reductase inhibitor therapy appears to be superior to either agent alone for long-term TrxThe choice of medical treatment may be made on the basis of cost and side-effect profile of the drugTURP is the

30、GOLD STANDARD for men who require an invasive procedure and are in good healthUrinary ObstructionUrinary Tract AnatomyReason of Urinary ObstructionHydronephrosisUrinary Tract AnatomyReason of Urinary ObstructionHydronephrosis Hydronephrosis is a dilation of the inside,or collecting part,of the kidney Caused by obstruction Hydronephrosis may also be due to abnormal backwash or reflux of urine into the bladderDegrees of HydronephrosisKidney function:Minimally affected compensation damage If you have any questions,please dont hesitate to contact me E-mail：Cell phone：18602382599