Surgery Marrow Pg 367-376 (Speciality Surgery)

Benign Prostatic Hyperplasia (BPH) & Prostate Cancer

• Both BPH and prostate cancer present with lower urinary tract symptoms (LUTS).
• LUTS can be categorized as voiding (obstructive) and storage (irritative) symptoms.
• Voiding symptoms include hesitancy, poor flow, intermittent stream, dribbling, sensation of poor bladder emptying and episodes of near retention.
• Storage symptoms include frequency, nocturia, urgency, urge incontinence, and nocturnal incontinence.
• In BPH, post-micturition LUTS like dribbling and incomplete emptying are not corrected even after transurethral resection of the prostate (TURP).

Work Up to Confirm Diagnosis

• Digital rectal examination:
  • BPH: Rubbery, mobile mucosa
  • Cancer: Hard, fixed mucosa
• Urine examination:
  • Urine routine & microscopy
  • Urine glucose
  • Urine culture & sensitivity
• A 3-tube test involves collecting urine from the first void (VB1), urine after prostate massage (VD2), and prostate secretions after massage (EPS).

Urachal Abnormalities

• The urachus is a tube connecting the bladder to the umbilicus during fetal development.
• Patent urachus:
  • Urine leakage from umbilicus when straining or crying.
  • Management: Excision.
  • Complications: Risk of adenocarcinoma.
• Urachal cyst:
  • Fluid-filled sac within the urachus.
  • Management: Excision.
  • Complications: Infection.
• Urachal sinus:
  • Open connection between the umbilicus and bladder.
  • Discharge from the umbilicus.
  • Management: Excision.
  • Complications: Prone to infections.
• Urachal diverticulum:
  • Outpouching from the bladder into the urachus.
  • Management: Excision.

Urology - Surgery

• Partial cystectomy:
  • Indications: Small tumors, Carcinoma on the dome of bladder, Carcinoma away from ureteric orifice
  • Structures removed: Bladder
• Radical cystectomy:
  • Structures removed: Bladder, Prostate (male), Urethra + Uterus (female), Ilia + Obturator Lymph Nodes (LN)
• Urinary diversion:
  • Divert ureter post cystectomy
  • Types:
    • Non-continent urinary diversion:
      • Uretersigmoid anastomosis (obsolete)
      • Ileal conduit (most common)
        • Complications: Hyperchloremic, hypokalemic metabolic acidosis, Stenosis, Stricture, Recurrence.
    • Continent urinary diversion:
      • Neobladder using ileum
• Important Prognostic Factor: Depth of invasion (T-stage).

Prostate: Part 1

• Capsule of Prostate:
  • Prostatic venous plexus: Can bleed during TURP if the capsule is invaded
  • Carries metastases to bones and the vertebral column.
• Corpora amylacea:
  • Precursor lesion for prostatic stones.
• Prostatic stones:
  • Endogenous (20%): Formed in the prostate, common composition: CaPO₄, Incidental diagnosis, No further treatment needed
  • Exogenous: Formed elsewhere (e.g., kidney), No further treatment needed.

Diseases of the Prostate

• Acute Prostatitis vs Chronic Prostatitis:
  • Etiology:
    • Acute: E.coli (most common organism), Secondary to UTI
    • Chronic: Multiple episodes of acute prostatitis
  • Clinical features:
    • Acute: Fever, Pain
    • Chronic: Dull perineal pain (Prostatodynia)
  • Digital rectal examination:
    • Acute: Tender, boggy prostate
    • Chronic: Tender prostate
  • Ix:
    • Acute: Urine microscopy: Threads & neutrophils
    • Chronic: 3 tube test
  • Rx:
    • Acute: Antibiotics for 2-3 weeks
    • Chronic: Antibiotics for 4-6 weeks

Neurogenic Bladder vs. Obstruction in Bladder

• Bladder Outlet Obstruction:
  • Bladder pressure: ↑
  • Flow rate: ↓
• Marion disease: Due to hypertrophy of the internal sphincter, causing LUTS but no BPH or cancer.

BPH: Benign Prostatic Hyperplasia

• Occurs in the 5th decade.
• Affects the transitional zone of the prostate.
• Obstruction leads to increased pressure in the bladder and increased residual urine.
• Narrowing of the prostatic urethral lumen increases the curve, making catheterization difficult and leading to diverticulae and trabeculae.

International Prostate Symptom Score (IPSS)

• 0-7: Mild severity
• 8-19: Moderate severity
• 20-35: Severe severity: Requires medical or surgical intervention.

Components of BPH

• Normal prostate structure
• Hyperplastic prostate: Increased prostate bulk with static and dynamic components.
• Dynamic components are mediated by adrenergic receptors.

Work Up for BPH

• Ultrasound (USG) KUB:
  • Prostatic size
  • Prostatic volume
  • Residual urine
• Prostate-specific antigen (PSA):
  • Free PSA better than protein bound PSA
  • PSA velocity: > 0.75 ng/ml/year
  • BPSA (Nicked) & IPSA (Intact): Raised in benign prostatic conditions
  • Pro PSA: Raised in cancer
• Evaluation:
  • At 50 to 69 years
  • PSA levels:
    • 0-3 ng/ml: Normal. Rule out prostatitis.
    • 0-3 ng/ml: BPH or Prostatitis. Manage prostatitis if present with antibiotics.

    • 3-4 ng/ml: BPH, Cancer, or Prostatitis. Start BPH management. Biopsy. Repeat PSA after 6 weeks. If PSA is normal, rule out cancer.

• Prostate biopsy:
  • Minimum 12 cores to be taken.
    • Transperineal biopsy: Anterior lobe, Under general anesthesia (GA), Reduced risk of infection. Performed if PSA elevated but transrectal ultrasound (TRUS) biopsy is negative.
    • Transrectal biopsy: Posterior lobe, Under local anesthesia (LA), Increased risk of infection.
• Uroflowmetry (urine flow rate):

  • 15 ml/sec: Normal

  • 10-15 ml/sec: Equivocal
  • < 10 ml/sec: Low
• Bladder pressure:
  • < 60 cm of H₂O: Normal
  • 60-80 cm of H₂O: Equivocal

  • 80 cm of H₂O: High