Benign Prostatic Hyperplasia (BPH)

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Questions and Answers

What are the two main factors contributing to the etiology of Benign Prostatic Hyperplasia (BPH)?

Increasing age and exposure to testosterone.

Define BPH, highlighting its key characteristics.

BPH is a nonmalignant enlargement of the prostate gland caused by cellular hyperplasia of both glandular and stromal elements, leading to troublesome lower urinary tract symptoms (LUTS) in some men.

How does BPH impact a patient's quality of life, and can you provide two specific examples?

BPH can significantly erode a patient's quality of life by causing various limitations, such as limiting fluids before travel, limiting fluids before bedtime.

Name the five terminologies related to the aging prostate.

<p>Benign Prostatic Hypertrophy (BPH), Benign Prostatic Hyperplasia (BPH), Benign Prostatic Enlargement (BPE), Benign Prostatic Obstruction (BPO), and Lower Urinary Tract Symptoms (LUTS).</p>
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List three storage Lower Urinary Tract Symptoms (LUTS) associated with BPH.

<p>Frequency, Nocturia, Urgency, Urge incontinence</p>
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List three voiding Lower Urinary Tract Symptoms (LUTS) associated with BPH.

<p>Hesitancy, weak stream, intermittency, sense of incomplete emptying.</p>
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What are three potential causes of storage LUTS (irritative) besides BPH?

<p>Urinary outflow obstruction, locally irritating pathology, and neuro-vesical dysfunction.</p>
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Name three potential complications or adverse effects of BPH if left unmanaged.

<p>Urinary retention, recurrent hematuria, bladder stones, compromised renal function</p>
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What are the 8 components of the evaluation of patients with BPH?

<p>History, General &amp; Abdominal Exam, Digital rectal examination, Urinalysis, Urine Cytology, Prostate Specific Antigen (PSA), Urine Flowmetry, U/S KUB &amp; post void residue estimation.</p>
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According to the IPSS scoring system, what score range indicates mild BPH symptoms?

<p>0-7</p>
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According to the IPSS scoring system, what score range indicates moderate BPH symptoms?

<p>8-19</p>
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According to the IPSS scoring system, what score range indicates severe BPH symptoms?

<p>20-35</p>
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Name five conditions included in the differential diagnosis of BPH.

<p>Urethral stricture, bladder neck contracture, bladder tumors, neurogenic bladder, bladder calculi, urinary tract infections, prostatitis, prostate cancer</p>
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List the three main categories of management options for patients with BPH.

<p>Medical therapy, instrumental therapy, surgical therapy</p>
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What are the two main types of medications used in the medical therapy for BPH?

<p>5 alpha-reductase inhibitors and Alpha-blockers</p>
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What is the mechanism of action of alpha-blockers in treating BPH, and where do they exert their effects?

<p>Alpha-blockers act on alpha-receptors in the bladder neck and prostatic capsule to promote relaxation.</p>
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What are two potential adverse effects associated with alpha-blockers?

<p>Postural hypotension and retrograde ejaculation.</p>
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What is the mechanism of action of 5-alpha reductase inhibitors in treating BPH?

<p>They prevents conversion of testosterone to leul</p>
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Name two potential adverse effects associated with Finasteride (Proscar).

<p>Erectile dysfunction and Retrograde ejaculation.</p>
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State 6 Minimally Invasive Therapies for BPO

<p>TUIP (Incision), Prostate balloon dilatation, Urethral (prostatic) stents, Hyperthermia, Cryosurgery, TUNA and Laser devices.</p>
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What are two main indications for considering surgical therapy for BPH?

<p>Failed medical treatment and complications.</p>
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Give 3 examples of surgical therapy for BPO

<p>Open prostatectomy Transurethral prostatectomy, TURP (Resection), TUVP (Vaporization), TUVRP (Vaporization-Resection)</p>
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What surgical procedure is considered the 'Gold Standard' in the treatment of men with BPH?

<p>Transurethral Resection of the Prostate (TURP).</p>
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What are two potential morbidities associated with TURP?

<p>Bleeding and TUR syndrome (Low serum sodium)</p>
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What are the 3 components of TUVRP?

<p>Thick Loop (Resection), Augmented Electocutting energy (Electrovaporization), TURP + TUVP</p>
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How does TUVRP improve the safety of transurethral prostatectomy compared to standard TURP?

<p>TUVRP improves safety by reducing bleeding and electrolyte disturbances.</p>
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What is an identified benefit of TUVRP related to post-operative recovery?

<p>Shorter post operative catheterization time</p>
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Name 2 conclusions related to BPH.

<p>Symptomatic BPH affects men over 40 years of age and erodes their quality of life, Patients that fail medical treatment or develop complications related to BPH should be referred to the Urologist for further work-up and interventional managmen.</p>
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Why is pre-treatment evaluation of patients with suspected BPH necessary?

<p>To rule out other pathology that needs a different therapeutic approach.</p>
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What type of medication is typically recommended as the first line of treatment for patients presenting with BPH?

<p>Alpha- blockers</p>
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What traits should be considered when choosing a type of Alpha-blocker medication?

<p>efficacious, once daily dose (with no titration), No sexual adverse effects and cost effective</p>
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For patients that have failed medical treatment, what specialist are they likely to be referred to?

<p>Urologist</p>
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How does BPH typically manifest in terms of urinary symptoms?

<p>It leads to lower urinary tract symptoms (LUTS) such as frequent urination, urgency, weak stream, and nocturia.</p>
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In the context of BPH evaluation, what is the significance of performing a digital rectal examination (DRE)?

<p>To assess and evaluate the size and consistency of the prostate.</p>
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What is the role of a Prostate-Specific Antigen (PSA) test in evaluating patients with BPH?

<p>To screen for and rule out prostate cancer.</p>
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Which of the following is considered the most significant risk factor for prostate cancer?

<p>Age (C)</p>
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Men of which race are more likely to be diagnosed with prostate cancer at an advanced stage and have twice the mortality rate from the disease, compared to non-Hispanic whites?

<p>African-American (C)</p>
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According to the information, which of the following factors has the least impact on the risk of prostate cancer?

<p>Obesity, diet, exercise, prostatitis, STDs, vasectomy. (C)</p>
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Finasteride chemoprevention reduces the incidence of prostate cancer, but what is a significant limitation regarding its use?

<p>It has not been shown to reduce mortality from prostate cancer. (B)</p>
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What was the conclusion of the Selenium and Vitamin E Cancer Prevention Trial (SELECT) regarding prostate cancer?

<p>The trial failed to demonstrate these drugs reduce prostate cancer in relatively healthy men. (B)</p>
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Why is transrectal ultrasound not recommended for prostate cancer screening?

<p>It is only useful for guiding biopsies, not for initial detection. (B)</p>
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What is the significance of a prostate-specific antigen (PSA) level between 4 and 10 ng/mL in the context of prostate cancer risk?

<p>It falls within the borderline range, indicating approximately a 1 in 4 chance of having prostate cancer. (C)</p>
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Which of the following factors can cause an increase in PSA levels, potentially confounding prostate cancer screening?

<p>Ejaculation (D)</p>
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In evaluating potential prostate cancer, what does a lower ratio of free PSA to total PSA suggest?

<p>A higher likelihood of prostate cancer (B)</p>
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Why is screening for prostate cancer generally not recommended for men over the age of 70?

<p>The risk of side effects from treatment outweighs potential benefits. (C)</p>
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Which of the following factors is most directly related to prostate cancer survival rates?

<p>The stage and grade of the cancer, and the extent of the tumor at diagnosis (D)</p>
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Which diagnostic procedure is essential for confirming a diagnosis of prostate cancer?

<p>U/S-guided biopsy (B)</p>
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What is the purpose of utilizing the Gleason score when diagnosing prostate cancer?

<p>To assess the aggressiveness and differentiation of the cancer cells under microscopic examination (D)</p>
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In the context of prostate cancer staging, what does stage IV indicate?

<p>The cancer has invaded adjacent structures or has metastasized to distant sites. (D)</p>
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What is the primary goal of 'watchful waiting' as a treatment strategy for prostate cancer?

<p>To monitor the cancer's progression and intervene only if it progresses. (A)</p>
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What is the key advantage of the 'nerve-sparing' technique during a radical retropubic prostatectomy (RRP)?

<p>Potential preservation of the nerves that control erectile function (B)</p>
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What is the primary purpose of external beam radiation therapy (EBRT) in the treatment of prostate cancer?

<p>To damage the DNA and kill prostate cancer cells with high-powered X-rays (C)</p>
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Which of the following is a potential complication specific to brachytherapy for prostate cancer?

<p>Prostate inflammation and swelling, sometime with severe urinary symptoms. (C)</p>
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Which of the following hormonal therapies is often used as an initial treatment for locally advanced or metastatic prostate cancer?

<p>LHRH analogs (+/- anti-androgens) (D)</p>
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Why are estrogens no longer commonly used in the treatment of prostate cancer?

<p>They had unbearable side effects. (A)</p>
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What is the primary action of LHRH analogs in the treatment of prostate cancer?

<p>They reduce testosterone production (B)</p>
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What is a common side effect of androgen removal therapies for prostate cancer?

<p>Hot flashes (A)</p>
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How is hormone-refractory prostate cancer (HRPC) defined?

<p>Prostate cancer that initially responds to hormonal therapy but later progresses despite continued treatment. (D)</p>
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Which of the following is a typical treatment approach for symptomatic, hormone-refractory metastatic prostate cancer?

<p>Cytotoxic chemotherapy (A)</p>
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What is often used in selected circumstances to evaluate response to prostate cancer treatment?

<p>PSA and Acid Phosphatase (A)</p>
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What side effect is highly associated with all hormone therapy treatment types?

<p>Sexual dysfunction (D)</p>
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Which of the following statements best summarizes the conclusions regarding prostate cancer from content provided?

<p>Risk factors are age, family history, race, possibly diet, and overall survival is excellent, but early detection benefits are uncertain. (A)</p>
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Which of the following statements is most correct regarding the overall survival in the conclusions about prostate cancer?

<p>Excellent (many years) (C)</p>
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Hormonal therapy utilizes which of the following mechanisms to treat metastatic prostate cancer?

<p>Inhibit the growth of cancer cells by blocking the effects of androgens (B)</p>
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Why are bone scans considered 'difficult' in the evaluation of treatment response?

<p>They can be difficult because an increase in the scan can mean healing or worsening. (C)</p>
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In the management of prostate cancer bone metastases, which of the following medications are used?

<p>Bisphosphonates (A)</p>
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What is the correct dose administration timeframe for Docetaxel that is used in cytotoxic chemotherapy?

<p>Every 3 weeks (A)</p>
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Which of the following is an effect of early diagnosis?

<p>Mortality rates are similar (A)</p>
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Following a diagnosis of early-stage prostate cancer, what management approach would be suitable for a patient demonstrating a low-grade T1-T2 tumor?

<p>Constant observation; regular re-evaluation (A)</p>
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Following a diagnosis of prostate cancer, what can PSA and DER do?

<p>Detect prostate cancer at a very early stage (B)</p>
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What is the intent of External Beam Radiation?

<p>Maximize the damage to the prostate, minimize to tissues. (D)</p>
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What is the average timeline of a prostate tumor's doubling time?

<p>2-4 Years (A)</p>
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What do all hormonal therapies CAN cause?

<p>Sexual dysfunction and decreased libido (D)</p>
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While obesity, diet, exercise, prostatitis, STDs, and vasectomies can influence overall health, how significant is their direct effect on the risk of developing prostate cancer?

<p>Have a minimal direct impact on prostate cancer risk (A)</p>
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Finasteride reduces the incidence of prostate cancer, but what is a key consideration regarding its use as a chemopreventive agent?

<p>The evidence is inadequate to determine mortality reduction. (A)</p>
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What does a lower ratio of free PSA to total PSA often suggest about the likelihood of prostate cancer?

<p>A lower ratio suggests an increased risk of prostate cancer, the free PSA from normal prostate is degraded. (D)</p>
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How might prostate volume influence the interpretation of PSA levels in diagnostic testing?

<p>PSA density normalizes PSA levels to prostate volume for better assessment. (B)</p>
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Which of the following findings from a prostate biopsy is most indicative of a favorable prognosis?

<p>Gleason score of 2-4 (B)</p>
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In External Beam Radiation Therapy (EBRT) for prostate cancer, what is the primary goal concerning the surrounding tissues?

<p>Minimize damage to surrounding tissues like the bladder and rectum. (D)</p>
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What is the rationale behind using anti-androgens when initiating LHRH analog therapy for prostate cancer?

<p>To limit the flare reaction by initially stimulating then desensitizing occurs (D)</p>
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What is the established average time frame for prostate cancer tumors to double in size?

<p>2-4 years (B)</p>
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How does hormone-refractory prostate cancer (HRPC) defy typical treatment strategies?

<p>HRPC cells can grow even in the scarcity of androgens. (C)</p>
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Flashcards

What is Benign Prostatic Hyperplasia (BPH)?

BPH is a nonmalignant enlargement of the prostate gland caused by cellular hyperplasia, leading to lower urinary tract symptoms (LUTS).

What are the two main categories of Lower Urinary Tract Symptoms (LUTS)?

LUTS are divided into Storage (irritative) and Voiding (obstructive) symptoms.

What are Storage LUTS?

Frequency, nocturia, urgency, and urge incontinence.

What are Voiding LUTS?

Hesitancy, weak stream, intermittency, sense of incomplete emptying.

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What are the Causes for Storage LUTS?

Urinary outflow obstruction, locally irritating pathology, and neuro-vesical dysfunction.

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What are the adverse effects of BPH?

Urinary retention, recurrent hematuria, bladder stones, and compromised renal function.

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How to evaluate patients with BPH?

History, general & abdominal exam, digital rectal exam, urinalysis, urine cytology, PSA, urine flowmetry, U/S KUB & post void residue estimation.

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What are the ranges for IPSS scores?

Mild (0-7), moderate (8-19), and severe (20-35).

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What are the differential diagnosis considerations for BPH?

Urethral stricture, bladder neck contracture, bladder tumors, neurogenic bladder, bladder calculi and urinary tract infections.

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Management options for BPH?

Medical therapy, instrumental (minimally invasive) therapy and surgical therapy.

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What is the first line management of patients with symptomatic BPH?

Medical therapies are the first line of management for patients with symptomatic BPH.

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What are common medical therapies for BPH?

5 alpha-reductase inhibitors and alpha-blockers.

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Name 5 alpha-reductase inhibitors

Finasteride (Proscar) and dutasteride (Avodart).

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What are common Alpha-blockers?

Terazosin, doxazosin, alfuzosin, and tamsulosin.

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How do Alpha-blockers work?

Alpha-blockers act on alpha-receptors in the bladder neck & prostatic capsule.

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Adverse effects of Alpha-blockers?

Postural hypotension and retrograde ejaculation.

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What to consider when choosing the best Alpha-blocker?

Efficacy, dosing, minimal side effects, and cost.

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What are the side effects of Finasteride (Proscar)?

Erectile dysfunction and retrograde ejaculation.

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What does TUIP stand for?

Incision of the prostate.

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What does TUNA stand for?

Transurethral needle ablation

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Which surgical therapy is regarded as the 'Gold Standard'?

TURP (Resection).

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What is the morbidity associated with TURP?

Bleeding and TUR syndrome (Low serum sodium).

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What are the two components of TUVRP?

Thick Loop (Resection) and augmented Electrocutting energy (Electrovaporization).

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What are the two morbidities that are associated with standard TURP?

Bleeding and electrolyte disturbances.

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What is an advantage of TUVRP?

The shorter post operative catheterization time that is noted following TUVRP.

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Who does symptomatic BPH affect?

Symptomatic BPH affects men over 40 years of age and erodes their quality of life

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What type of drug should be used as first line of treatment for restoring life quality?

Alpha-blockers should be the first line of treatment in every patient that is presenting with BPH with the aim of restoring quality of life and sexual function.

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The ideal Alha-blocker?

The Alpha-blocker of choice should be efficacious, once daily dose (with no titration), no sexual adverse effects and cost effective.

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What is Carcinoma of the Prostate?

A malignancy originating in the prostate gland.

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What are the main risk factors for prostate cancer?

Age over 65, African-American race, and family history of prostate cancer.

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Which Nationalities are at higher risk of prostate cancer?

Nationality in North America and Northwest Europe.

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What strategy reduces prostate cancer incidence?

Chemoprevention using finasteride.

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What are methods for early prostate cancer detection?

Digital rectal exam (DRE) and PSA testing.

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What does digital rectal exam (DRE) screen for?

Feeling for nodules or irregularities during a physical examination.

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What are the confounding factors for PSA levels?

BPH, age, prostatitis, ejaculation, certain medications, obesity.

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What are the tools that can be used in prostate cancer investigations?

PSA density, PSA velocity, and % free PSA.

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What are the potential presenting symptoms of prostate cancer?

Decreased urinary stream, urinary frequency, and hematuria.

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In which patients does early screening for prostate cancer provide less benefit?

Limited benefit for those over 70 or with less than 10 years life expectancy.

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What factors does prostate cancer survival relate too?

Related to stage, grade, and extent of tumor at diagnosis.

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How is a diagnosis of prostate cancer established?

Stage, grade, and U/S-guided biopsy.

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What are the prognostic factors in prostate cancer?

TNM staging system and Gleason grading.

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How to stage prostate cancer?

Abdominal/pelvic CT scans, chest X-ray, bone scan, LFTs, serum PSA.

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What defines stage I prostate cancer?

T1a, Grade 1.

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What defines a Stage III prostate cancer?

T3 meaning through the prostate capsule.

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What are the treatment options for prostate cancer?

Surgery, radiation and hormone therapy.

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What is watchful waiting?

Observation, diagnosis of early-stage, low-grade tumor and no medical treatment.

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What surgical procedure spares nerve function in the prostate?

Radical retropubic prostatectomy (RRP).

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What are the radiation therapy options for prostate cancer?

External beam radiation therapy (EBRT) and brachytherapy.

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What are some EBRT early/ late complications?

Diarrhea, rectal irritation, fatigue after completion.

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What are some of the complications of brachytherapy?

High initial radiation fades, inflammation, and swelling.

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How to treat symptomatic metastatic prostate cancer?

Removal of source of androgen, estrogens and androgens.

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What is blocked by Anti-androgens?

Binding of DHT to androgen receptors.

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How do androgens relate to prostate function?

Prostate cells depend on androgens for growth.

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What is Adjuvant Hormone Therapy?

Standard treatment for advanced or metastatic prostate cancer.

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What methods are used to remove androgens?

Orchiectomy, LHRH agonists.

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How LHRH analogs work?

Block LH, FSH that make testosterone.

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What are some common Antiandrogens?

Flutamide and Nilutamide.

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What is primary hormonal therapy for prostate cancer?

Combined therapy with finasteride and bicalutamide.

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What are the results of Androgen Removal?

Impotence, loss of sexual desire, cardiovascular risks.

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What is Hormone refractory Prostate Cancer?

Hormone-resistant prostate cancer.

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What agents are used in cytotoxic chemotherapy?

Docetaxel and Mitoxantrone.

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What radiation therapies are used to treat Symptomatic Metastatic Disease?

External beam radiotherapy and Radioisotopes.

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What substances indicate the success of prostate cancer evaluation?

PSA and Acid Phosphatase

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What are some complications of Systemic Prostate Cancer Therapy?

Sexual dysfunction ,and decreased libido.

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Why manage Prostate Cancer Bone Metastases?

Prevent pain, improve mobility and maintain quality of life.

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Study Notes

  • Prostate cancer’s 5-year relative survival rate is nearly 100%.
  • Prostate cancer’s 10-year relative survival rate is 91%.
  • Prostate cancer’s 15-year relative survival rate is 76%.
  • Age is a risk factor and is most important; rare before 40, with 65% of cases occurring over the age of 65.
  • Race is a risk factor with a greater prevalence in African-American men.
  • African-American men are more likely to be diagnosed at an advanced stage with prostate cancer.
  • African-American men are twice as likely to die from prostate cancer.
  • Prostate cancer is less common in Asian-American and Hispanic-American men than in non-Hispanic white men.
  • Family history is a risk factor and is indicated by those with 1st degree relatives, father, brother, with prostate cancer.
  • Diet may be a risk factor: higher red meat and high fat dairy product consumption can increase risk, while higher fruit, vegetable, and grain consumption may decrease risk.
  • Exercise and maintaining healthy weight may decrease prostate cancer risk.
  • Finasteride is a 5-alpha reductase inhibitor, blocking intracellular conversion of testosterone to dihydrotestosterone.
  • Chemoprevention with finasteride reduces prostate cancer incidence absolute risk reduction is 6%, relative risk reduction is 25%.
  • There is inadequate evidence to determine whether chemoprevention with finasteride reduces mortality from prostate cancer.
  • Finasteride can cause erectile dysfunction, loss of libido, gynecomastia, and higher grade cancers.
  • The Selenium and Vitamin E cancer Prevention Trial (SELECT) was a large randomized placebo-controlled trial of Vitamin E and selenium, alone or in combination, which failed to demonstrate that these drugs reduce prostate cancer in relatively healthy men.
  • Digital rectal exams and PSA tests can be used for early detection and screening.
  • Transrectal ultrasounds are not for screening.
  • When prostate cancer develops, the PSA level climbs above 4.
  • About 15% of men with a PSA below 4 will have prostate cancer on biopsy.
  • Men with a PSA level between 4 and 10 have a 1 in 4 chance of having prostate cancer.
  • If the PSA is more than 10, there's over a 50% chance of having prostate cancer.
  • PSA levels are considered normal when <4, borderline from 4-10
  • BPH, age, prostatitis and ejaculation can increase PSA levels
  • Confounding factors that can decrease PSA levels are finasteride, dutasteride, some herbal mixtures and obesity.
  • PSA density is normalized to prostate volume
  • PSA velocity is measured via the change in PSA over time.
  • A PSA velocity of more than 15% per year is suspicious.
  • A lower free PSA/Total PSA ratio suggests cancer.
  • A free PSA/Total PSA ratio of <10% indicates biopsy.
  • Presenting symptoms of prostate cancer are decreased urinary stream, urinary frequency, hematuria, bone pain, numbness or weakness, and bladder/bowel incontinence.
  • Bone pain, numbness or weakness, and bladder/bowel incontinence are symptoms of metastasis.
  • The effect of early prostate diagnosis is largely unknown.
  • If life expectancy is less than 10 years, avoid screening for prostate cancer.
  • Do not screen for prostate cancer under age 60, unless strong family history
  • Recognize limitations for the benefits of screening in ages 60-70
  • Prostate cancer survival is related to the stage, grade, and extent of tumor at diagnosis.
  • Local prostate cancer has a median survival of > 5 years.
  • Metastatic prostate cancer has a median survival of 1-3 years, but sometimes individuals survive 10 or more years.
  • To establish a diagnosis of prostate cancer, conduct a DRE, measure PSA/PSA velocity/percent-free PSA, perform a transrectal U/S, and conduct a U/S- guided biopsy.
  • An ultrasound guided needle biopsy involves approximately 6-12 samples.
  • If the biopsy is positive, record the Gleeson score/grade.
  • The range of the Gleeson score is from 2 (1+1) to 10 (5+5); this depends on glandular differentiation.
  • A PSA < 10 rarely yields detectable metastatic disease.
  • When staging prostate cancer, use the TNM staging system.
  • Prognostic factors include Gleason grading, DNA analysis by flow cytometry, PSA level, and predictive models for organ-confined versus non-organ confined disease.
  • Serum PSA, acid phosphatase, abdominal and pelvic CT scans, chest x-rays, bone scans, and LFT's are used to stage prostate cancer.
  • Stage I prostate cancer is T1a and grade 1.
  • Stage II prostate cancer is Tla and Grade 2-4; T1b,c (By biopsy only) or T2 (Confined to Prostate).
  • Stage III prostate cancer is T3, through prostate capsule
  • Stage IV prostate cancer is T4 (Invades adjacent structures), N1-3, M1.
  • Prostate cancer treatments include watchful waiting, hormone therapy, surgery (RRP), radiation and cryotherapy.
  • Watchful waiting can be used when there is low gleason score and for ages 50-60 years.
  • Radiation can be external beam (EBRT) and Brachytherapy.
  • Oral flutamide and Subcutaneous goserline are hormone therapies.
  • Watchful waiting involves observation, diagnosis of an early-stage (T1-T2), low-grade tumor, no medical treatment, and regular follow-up to monitor tumor.
  • The average doubling time of a prostate tumor is quite slow (2-4 years).
  • Immediate radical therapy may constitute over-treatment and can introduce unnecessary urinary and potency risks.
  • Immediate radical therapy may be appropriate if the patient is elderly and/or in poor health, and will live out their life spans without the cancer causing problems.
  • "Nerve Sparing" Radical Retropubic Prostatectomy (RRP) procedure developed by Walsh consisted of modified surgical technique to control blood and enhance visibility within surgical site.
  • RRP Allows for the identification and potential preservation of the nerves that control erectile function (potency).
  • There are two neurovascular bundles on either side of the prostate that control erectile function.
  • Radiation therapy (RT) involves High-Powered X-Rays that damage DNA and kill prostate cancer cells.
  • External Beam Radiation Therapy (EBRT) involves X-rays aimed at the prostate.
  • Brachytherapy: Radioactive seed implants into prostate.
  • During a procedure, the goal is maximize damage to the prostate and minimize damage to surrounding tissues (i.e. bladder and rectum).
  • Most EBRT symptoms occur during treatments and subside after completion.
  • EBRT can cause diarrhea, rectal irritation, fatigue, frequent and painful urination, and blood in the urine.
  • Erectile dysfunction: less common with EBRT than after radical prostatectomy but slower recovery.
  • Brachytherapy has high initial dose of radiation that slowly fades over 1 year.
  • Brachytherapy can cause prostate inflammation and swelling, sometimes with severe urinary symptoms, and other more rare symptoms include persistent urinary and bowel frequency and urgency.
  • With similar rates of erectile dysfunction with Brachytherapy as EBRT.
  • Treatment of Symptomatic Metastatic Disease uses initial Hormonal Therapy.
  • Hormonal Therapy includes: Orchiectomy, Estrogens, LHRH analogs (+/- anti-androgens) and Antiandrogens.
  • Hormone Therapy involves oral flutamide and Subcutaneous goserline.
  • Prostate cells and prostate cancer cells are dependant upon androgens (male sex hormones) for survival and growth.
  • Removal of androgens kills a majority of prostate cancer cells.
  • Adjuvant Hormone Therapy (androgen ablation) is a standard method of treating advanced and metastatic prostate cancer.
  • For advanced cancers, androgen ablation may be performed prior to prostatectomy or radiation in order to shrink the tumor.
  • Orchiectomy: surgical removal of the testicles.
  • Anti-androgens block the effects of testosterone.
  • Removing androgens can use:
    • Oral drug which blocks testosterone production. Include LHRH agonists and (oral estrogens).
    • 5-a reductase inhibitor (enhances intracellular androgen blockade)
    • Combination therapies.
  • Goserelin (Zolodex) and Leuprolide (Lupron) are LHRH Analogs.
  • LHRH Analogs are available as every 1, 3, or 4 month injections.
  • LHRH Analogs can castrate levels of testosterone attainable in a few weeks
  • Flutamide, Bicalutamide and Nilutamide are Antiandrogens.
  • Combined androgen blockade is not superior to LHRH therapy alone
  • When starting LHRH, antiandrogens are of primarily value in limiting the flare reaction
  • With finasteride and bicalutamide as primary hormonal therapy in advanced adenocarcinoma of the prostate, duration of control is comparable to castration, with preserved sexual function in some patients but with recurrence, some patients can still respond to LHRH agonists
  • Results of Androgen Removal include: Impotence, Loss of sexual desire (libido), Hot flashes, Weight gain, Fatigue, Reduced brain function, Loss of muscle and bone mass, and Some cardiovascular risks
  • Hormone-Refractory Prostate Cancer (HRPC) has an initial response rates of 80-90%, and occurs when most men with advanced prostate cancer develop hormone-resistant prostate cancer after 18-36 months when cells can grow in the absence of androgens, it is a widely different behavior between patients.
  • Treatment of Symptomatic, Hormone Refractory Metastatic Disease:
  1. Cytotoxic chemotherapy
    • Docetaxel (every three weeks) and prednisone improves pain and reduces need for analgesic agents
    • Mitoxantrone
    • Other agents have had limited effectiveness
    • Continue hormone therapy to prevent flare with rising testosterone levels.
  2. Bisphosphonates reduces skeletal complications
  3. Radiation therapy
    • External beam radiotherapy
    • Radioisotopes, such as Strontium 89
  • Evaluation of Response requires PSA and Acid Phosphatase tests in selected circumstances
  • Evaluation of Response requires Bone scans, but are difficult because of increased healing.
  • Complications of Systemic Prostate Cancer Therapy:
    • All hormonal therapies can cause sexual dysfunction and decreased libido; less with finasteride and anti-androgen
    • Orchiectomy - rarely local infection or hematoma
    • Anti-androgen - diarrhea, hepatic dysfunction
    • Estrogen - thromboembolic disease, fluid retention, cardiac disease
    • Chemotherapy - nausea, vomiting, mucositis, marrow suppression, and alopecia
  • Management of Prostate Cancer Bone Metastases has the goals to: prevent pain, improve mobility, prevent complications such as fractures or compression
  • Maintain acceptable quality of life.
  • Methods: bis-phosphonates, radiation of detected metastatic lesions, surgery.
  • Conclusions:
    • Risk factors are age, family history, race, and possibly diet and exercise
    • Overall survival excellent (many years)
    • Early detection can find localized cancer, but survival benefits still uncertain
    • Treatment depends on grade, extent and location of disease
    • Surgery and radiation are equivalent therapeutic tools for localized prostate cancer
    • Hormonal therapy is effective for metastatic prostate cancer
    • Hormone refractory prostate cancer responds to chemotherapy, with occasional long term improvement.

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