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Anatomi prostat

Apa itu kelenjar prostat?


Kelenjar prostat adalah organ yang berukuran seperti almond yang terletak tepat di bawah kandung kemih dan terdiri dari dua daerah ter tutup oleh lapisan luar dari jaringan. Iniadalah salah satu komponen utama dari sistem reproduksi lakilaki dan memainkanperan penting da lam pengembangan organ seks pria.

Apa fungsi dr kelenjar prostat?


Fungsi utama kelenjar prostat adalah untuk menambahkan cairan penting ke dalam semen untuk membantu menghasilkan sper ma saat ejakulasi. Ini melindungi semen terhadap asam alami yang dihasilkan oleh vagina. Mengeluarkan semen yang membawa sperm a. Selama orgasme, otot prostat kontrak dan me ndorong ejakulasi keluar dari penis

Understanding the prostate


Mengeluarkan semen ya ng membawa sperma. Selama orgasme, otot pr ostat kontrak dan mendo rong ejakulasi keluar dari penis.

Dimana letak kelenjar prostat?


Kelenjar prostat terletak t epat di bawah bagian bawah kandung kemih dan di atasrektum. Pada gambar menunjukkan, kel enjar prostat mengelilingi urethra pada titikdi mana uretra terhubung ke kandung kemih.

I. Introduction/General Information A. Attached inferiorly to urinary bladder by ligaments B. Posterior to pubic symphysis C. Surrounds superior portion of urethra D. Anterior to rectum (palpation, ultrasound) E. Conical shape

Introduction, Prostate Gland, continued

F. Walnut sized
1. 4 cm trans x 2 cm A/P x 3 cm Sup/Inf

G. Lightly encapsulated
1. Fibrous connective tissue 2. Smooth muscle 3. Capsule extends into lobes

Anatomy of the Male Pelvis

II. Prostate Gland: Detailed Anatomy


A. Largest male accessory gland B. Located in subperitoneal compartment
(between pelvic diaphragm & peritoneum)
Prostate Gland, Mid-sagittal Section

Prostate Gland: Detailed Anatomy

C. Enclosed in fascial sheath


prostatic sheath)

(aka:

1. Inferiorly, sheath is continuous with superior fascia of urogenital diaphragm 2. Posteriorly, sheath forms part of retrovesical septum

Prostate Gland: Detailed Anatomy

D. Double Capsule 1. Fibrous portion contacts gland 2. External capsule formed by pelvic fascia 3. Venous plexus lies between

Male Reproductive System, Posterior View

Detailed Anatomy, contined

E. Conical shape with base (sup), apex (inf), four surfaces 1. Surfaces: posterior, anterior, right &
left inferolateral

2. Base (aka: vesicular surface): superior


a. Attached to neck of urinary bladder b. Prostatic urethra enters middle of base close to anterior surface

Prostate Anatomy

Prostatic Urethra

Detailed Anatomy, contined

3. Apex: inferior
a. Rests on superior fascia of urogenital diaphragm muscle
b. Associated with sphincter urethrae

c. Contacts medial margins of levator ani muscles

Detailed Anatomy, contined

4. Posterior surface: triangular, flat 5. Anterior surface: narrow, convex 6. Inferiorolateral surfaces
a. Meet with anterior surface b. Rest on levator ani fascia above urogenital diaphragm

Detailed Anatomy, contined

F. Lobes of the Prostate


1. Divisions are arbitrary, indistinct

2. Usually divided into


a. two lateral lobes

b. one median lobe


c. anterior and posterior lobes

Lobes of the Prostate, continued

3. Median lobe
a. Lies posterior and superior to prostatic utricle and ejaculatory ducts b. May project into urinary bladder c. Utricle lies within lobe
1. Vestigial remains of uterine homolog 2. Sometimes called uterus masculinis

Lobes of the Prostate, continued

4. Lateral lobes
a. Comprise the greatest mass of the gland b. Contain most secretory tissue

c. Are continuous posteriorly

5. Glandular tissue with varying amounts of fibrous tissue

Lobes of the Prostate, continued

Prostate Gland in situ

Detailed Anatomy, continued

G. Blood & lymph


1. Arteries derived from:
a. Internal pudendal artery
b. Inferior vesical artery c. Middle rectal artery

Blood & Lymph, continued

2. Veins
a. Form venous plexus b. Drain into internal iliac veins c. Communicate with vesical & vertebral venous plexuses

Blood & Lymph, continued

3. Lymphatics
a. Most terminate in internal iliac & sacral nodes (unable to palpate) b. From posterior: to external iliac nodes (unable to palpate)

Detailed Anatomy, contined

H. Glandular tissue

1. 30 - 50 different glandular elements


a. Serous glands

b. 20 - 30 ducts empty into prostatic urethra

2. Most are posterior & lateral to urethra

Blood & Lymph, continued

3. Prostatic secretions a. Thin, milky, alkaline (looks like


skim milk)

b. Discharged at ejaculation

c. Make up ~ 1/3 of semen

Detailed Anatomy, continued

I. Prostate size changes


1. 2. 3. 4. 5. Small at birth Enlarges at puberty Maximum at about 13 Progressive enlargement after 40 Sometimes: undergoes atrophy

What is PSA?
PSA or prostate specific antigen is an enzyme produced by the prostate cells. PSA levels can be used as an indicator of prostaterelated diseases, especially prostate cancer. As part of a general prostate health program, your doctor may recommend that you have a PSA blood test perform periodically.

Using PSA to evaluate prostate health


Elevated PSA is often associated with prostate cancer, however there are other conditions that cause an increased PSA. Benign prostatic hyperplasia (BPH or enlarged prostate), prostate cancer, and prostatitis are the most common reasons for an elevated PSA. While an elevated PSA does not always indicate prostate cancer, ruling out prostate cancer should continue to be the first priority. A PSA score of greater than 4.0 is generally referred to follow-up to rule out prostate cancer, and PSA scores are normally evaluated over time in order to track any unusual or sudden change in levels.

Understanding prostate problems


After age 40, most men begin to experience some degree of symptoms of prostate disorders, and the likelihood of symptoms arising may continue to increase over time. There are 3 major diseases associated with the prostate. They are prostatitis, benign prostatic hyperplasia (BPH), and prostate cancer. It is very important that you understand the symptoms and the warning signs of prostate disease and tell your doctor about any that you experience. Even in the absence of urinary symptoms your doctor may perform periodic prostate exams and regularly monitor your prostate specific antigen (PSA) level.

Prostatitis

Urinary Tract Infection


Upper urinary tract Infections:
Pyelonephritis

Lower urinary tract infections


Cystitis (traditional UTI) Urethritis (often sexually-transmitted) Prostatitis

Prostatitis
Symptoms:
Pain in the perineum, lower abdomen, testicles, penis, and with ejaculation, bladder irritation, bladder outlet obstruction, and sometimes blood in the semen

Diagnosis:
Typical clinical history (fevers, chills, dysuria, malaise, myalgias, pelvic/perineal pain, cloudy urine) The finding of an edematous and tender prostate on physical examination Will have an increased PSA Urinalysis, urine culture

Treatment:
Trimethoprim/sulfamethoxazole, fluroquinolone or other broad spectrum antibiotic 4-6 weeks of treatment

Risk Factors:
Trauma Sexual abstinence Dehydration

Prostatitis
Prostatitis is an inflammation of the prostate that can affect men of all ages. Some of the signs and symptoms include fever and chills, lower pelvic pressure and pain in the pubic area, pain during urination, and painful or uncomfortable feeling before or during ejaculation. Prostatitis is generally treated with antibiotics.

Prostatitis Classification
Class Definition
Acute Bacterial
Chronic Bacterial Inflammatory CPPS Non-Inflam. CPPS

Comment
Dysuria, systemic symptoms
> 3 months of symptoms, + post-massage urine culture > 3 months of symptoms, UCx, + leukouria > 3 months of symptoms, UCx, - leukouria

I
II IIIa IIIb

IV

Asymptom. Inflammatory

Incidental finding, - UCx

Prostatitis
Lifetime prevalence: 1 in 6 men Most common urologic complaint in men under 50 90% of cases are chronic abacterial (Classes IIIa and IIIb) Most cases of bacterial prostatitis are chronic as well (Class II)

Acute Prostatitis
Rare ( < 1% of cases) Often fulminant presentation Moderate to marked elevation of PSA High risk of bacteremia Avoid prostatic massage Tx: ABX Parenteral Oral Alpha blockers Bladder drainage may be indicated

Physiology
+Gz
dependent venous pooling

AGSM
Venous return Intrabdominal pressure Intravesicular pressure

Pelvic Venous Plexus

Treatment Acute Prostatitis


ABX (Quinolones and/or TMP-SMX)
Probably should not wait for cultures significant chance of false negative

-blockers
Effective, with rapid onset Improve pain and urinary symptoms

NSAIDs Diazepam

Treatment Chronic Prostatitis


-blockers 5-reductase inhibitors
Slower onset than -blockers Better side effect profile

Lifestyle modifications

Herbal Therapy
Probably Effective
-Sitosterols Saw Palmetto

No evidence of effectiveness
Cernilton Pygeum africanum

Guidelines
ICAO
Acute infections -- disqualifying Clinically recovered but on suppressive therapy case by case based on medication effects

Guidelines
USN
Ground during acute episode Waiver possible for patients with chronic prostatitis if asymptomatic even on chronic suppressive medication

Guidelines
USAF
Ground during acute episode Waiver available only if asymptomatic, even on suppressive meds Rigors of flying (vibration, heat, prolonged sitting) may markedly exacerbate mild symptoms

Guidelines
FAA
No specific guidance Flight Safety Journal (1993): No perceived risk to flight safety identified

USA
No specific mention of condition

Aeromedical Disposition
Acute prostatitis Grounding Chronic asymptomatic prostatitis CD, waiverable

Aeromedical Disposition
-blockers CD, No waiver 5-reductase inhibitors CD, waiverable Ciprofloxacin NCD Nitrofurantoin CD, waiver possible (concern with pneumonitis, peripheral neuropathy) TMP/SMX CD, waiver possible

Aeromedical Disposition
Herbal Therapy
Saw Palmetto Class B Supplement -Sitosterols Class C Supplement (not included in Waiver Guide) Cernilton, P. Africanum not effective and Class C Supplement

Synopsis
Some risk involved in delaying treatment of acute prostatitis Rigors of aviation medicine may predispose individuals to acute episodes Acute episodes are grounding Chronic well controlled prostatitis may be compatible with flight Therapy must be tailored to aviation environment

BPH

III. Pathology
A. Benign prostatic hypertrophy (BPH):
1. Affects ~90% of men >50

BPH, continued

2. Common cause of urethral obstruction: causes a. Nocturia b. Dysuria c. Urgency d. Back-pressure effects e. Complete obstruction can occur

Benign Prostatic Hyperplasia


Benign prostatic hyperplasia (BP H), sering disebut sebagai pemb esaran prostat,merupakan pem besaran nonkanker dari prostat yang dapat menyebabkan terganggunya gejalakencing da n memiliki dampak yang signifikan terhadap kualitas hiduppenderit a. Gejala urin meliputi peningka tan frekuensi, urgensi, dan kesul itan buang air kecil.

Enlargement of the prostate gland and PSA levels


Pembesaran prostat adalah salah satu penyebab tersering yg menimbulkan masalah berkemih.PSA lebih besar dari 1,5 dapat menunjukka n pembesaran prostatlanjutan da n peningkatan risiko buruknya gejala urin, reten si urin akut, dan akhirnya membutuhkan intervensi bedah seiring waktu.

BPH

Ukuran prostat membesar secara mikroskopik sejak usia 40 tahun. Sebagian laki2 dewasa diatas usia 60 tahun dapat menyebabkan pembesaran prostat.. By the time men reach their 70s and 80s, 80% will experience urinary symptoms
But only 25% of men aged 80 will be receiving BPH treatment

What is Benign Prostatic Hyperplasia?

Peripheral zone Transition zone Urethra

Peripheral zone Transition zone Urethra

What causes BPH?


n

BPH is part of the natural aging process, like getting gray hair or wearing glasses BPH cannot be prevented BPH can be treated

Whats LUTS?
Voiding (obstructive) symptoms Hesitancy Weak stream Straining to pass urine Prolonged micturition Feeling of incomplete bladder emptying Urinary retention Storage (irritative or filling) symptoms Urgency Frequency Nocturia Urge incontinence

LUTS is not specific to BPH not everyone with LUTS has BPH and not everyone with BPH has LUTS
Blaivas JG. Urol Clin North Am 1985;12:21524

Symptom assessment

Diagnosis of BPH

the International Prostate Symptom Score (IPSS) is recommended as it is used worldwide IPSS is based on a survey and questionnaire developed by the American Urological Association (AUA). It contains:
seven questions about the severity of symptoms; total score 07 (mild), 819 (moderate), 2035 (severe) eighth standalone question on QoL

Digital rectal examination(DRE)


inaccurate for size but can detect shape and consistency

PV determination- ultrasonography Urodynamic analysis


Qmax >15mL/second is usual in asymptomatic men from 25 to more than 60 years of age

Measurement of prostate-specific antigen (PSA)


high correlation between PSA and PV, specifically TZV men with larger prostates have higher PSA levels PSA is a predictor of disease progression and screening tool for CaP as PSA values tend to increase with increasing PV and increasing age, PSA may be used as a prognostic marker for BPH
1

Interfere with sexual life


9 8 7 6 5 4 3 2 1 0 4.9 8.5 7.6

Sexual Activity Decreases with n=12,815 Age and LUTS: MSAM-7 Survey
IPSS = 0 IPSS 17 5.7 5.7 4.6 3.7 4.0 3.5 2.6 1.7 IPSS 819 IPSS 2035

6.6

5059 years

6069 years

7079 years

Rosen et al. Eur Urol 2003 n=12815

When should BPH be treated?


BPH needs to be treated ONLY IF:
n

Symptoms are severe enough to bother the patient and affect his quality of life Complications related to BPH

Choosing the right treatment


n

Consider risks, benefits and effectiveness of each treatment


Consider the outcome and lifestyle needs

Treatment options
n

Watchful waiting

Medication Surgical approaches


Minimal invasive nTURP nInvasive open procedures
n

watchful
n

waiting

For mild symptoms. follow up1 to 2 times yearly

Offer suggestions that help reduce symptoms


n

Avoid caffeine and alcohol n Avoid decongestants and antihistamines

Medication
n

First line of defense against bothersome urinary symptoms Two major types:

n n

blockers - relax the smooth muscle of prostate and provide a larger urethral opening (Hytrin,Doxaben,
Harnalidge)

n 5 reductase inhibitor - Shrink

the

prostate gland (Proscar,


Avodart)

Medication
Benefits
n n

Disadvantages
n

Convenient No loss of work time

Drug Interactions

n
n

Must be taken every day


Manages the problem instead of fixing it

Minimal risk

Possible side effects of


n Impotence n Dizziness n Headaches n Fatigue n Loss of sexual drive

medication

-Adrenergic Blockers: Rationale


Prostate smooth muscle tone is mediated via 1-adrenergic receptor Blockage of the receptor leads to improvement of flow rate and LUTS1 Central -receptors and the effect of agents on these receptors likely play an additional role Density of adrenergic receptors changes with prostate size and age

Three 1-adrenergic receptor subtypes have been identified (A, B, D)


Schwinn DA. BJU Int. 2000;86(suppl 2):11-22.

Distribution of 1-Adrenergic Receptors

Localization of 1-Adrenergic Receptors (1-ARs)

-Blockers
Nonselective
Phenoxybenzamine

Short-acting selective 1-blocker


Prazosin, Alfuzosin

Long-acting selective 1-blockers


Terazosin Doxazosin

Long-acting selective 1A-subtype


Tamsulosin Alfuzosin-SR

1-Adrenergic Blockers: Summary


All currently available 1-blockers induce fast improvement in LUTS and flow rate parameters with similar efficacy They are all well tolerated; however, the adverse event spectrum differs between the agents
Terazosin and doxazosin induce more dizziness, fatigue, and asthenia Tamsulosin induces more ejaculatory disturbances

None of the 1-blockers alter urodynamic parameters, prostate volume or serum PSA None have been shown to alter the natural history of the disease or prevent AUR / Surgery

5-Reductase Inhibitor: Rationale


Prostatic differentiation & growth depend on androgenic stimulation Testosterone is converted to dihydrotestosterone (DHT) within the prostatic stromal & basal cells facilitated by 5-reductase enzyme 5-reductase inhibitor: deprive the prostate of its testosterone support 5-reductase enzyme: Type I: skin & liver Type II: stromal & basal cells of prostate, seminal vesicle, epididymis
Kirby RS et al. Br J Urol. 1992;70:65-72 Tammela TLJ et al. J Urol. 1993;149:342-344

Regulation of cell growth in the prostate in BPH


Serum testosterone (T) Serum Dihydrotestosterone (DHT)

T
5AR (1 and 2)
DHT Growth factors

Prostate cell

DHT-androgen receptor complex


Cell death

Increased Cell growth

Unbalanced

5-reductase inhibition
Mode of action
OH
OH

5 -reductase type 1 and 2

O NADPH Testosterone NADP

H Dihydrotestosterone

Avodart (dutasteride) - Dual (type 1&2) 5ARI Proscar(finasteride) - Only type 2 5ARI

Combination therapy with 5aRIs and a1 blockers

Rationale for Combination Therapy


Alpha blockers relax the smooth muscle of bladder neck and prostatic capsule/adenoma, thereby improving symptoms and flow rates, relieving obstruction 5 ARIs reduce the action of androgens in the prostate, inducing apoptosis, atrophy, and, by shrinking the prostate improve symptoms, relieve obstruction and prevent AUR & prostate surgery

5ARIs

1-adrenergic

blockers

Arrest disease progression

Rapidly relieve symptoms

Medical Therapy of Prostatic Symptoms (MTOPS)

Change in AUA Symptom Score at Year 4


Placebo
4.0

Doxazosin

6.0

(p<0.001)

Finasteride

5.0

(p<0.047)

Combination
4 6

7.0 2

(p<0.001) 10

Median point decrease from baseline


Median baseline AUA SS = 17.0

Change in Qmax at Year 4


Placebo
1.4

Doxazosin

2.5 (p<0.001)

Finasteride

2.2 (p<0.047)

Combination

3.7 (p<0.001)

Median point decrease from baseline


Median baseline Qmax = 10.6

Conclusions
Single arm therapy with alpha blocker
Improve symptoms and prevent symptom progression Does not alter natural history or cross over to invasive therapy

Single arm therapy with 5 ARI


Treats symptoms only when LUTS associated with BPH (ie enlargement or high PSA) Alters natural history in pts at risk (large gland, high PSA)

Combination (doxazosin+finasteride) therapy is the most effective form of treatment for LUTS and BPH
Improve symptoms and flow rate Prevent AUR and/or surgery Alter the natural history of the disease

Symptom Management After Reducing Therapy: SMART1


SMART1 was designed to examine short-term dutasteride and a1-blocker combination therapy, followed by dutasteride monotherapy
Entry criteria:

IPSS 12
PV 30 cc, estimated by DRE PSA 1.5 10.0 ng/ml
Barkin et al (2002)

SMART-1: study design


DT24 + D12 DT36

Placebo run-in

Combination dutasteride 0.5mg + tamsulosin 0.4mg once daily

dutasteride 0.5mg + placebo (tamsulosin) Combination

Placebo

4 weeks Single blind


Barkin et al (2002)

24 weeks Single blind

12 weeks Double blind


Wk 30

1 week Single blind


Wk 36

SMART-1: primary endpoint question at week 30 by baseline IPSS


100 80 60 40 Severe pts need longer AB treatment 20 0 DT36 DT24 + D12 DT36 DT24 + D12 % patients better/same
Barkin et al (2002) 57.5% 93%

Moderate (baseline IPSS <20) (n=220)


84%

Severe (baseline IPSS 20) (n=82)


86%

5 Reductase Inhibitors
Compared to Baseline Duration (yr) Total Prostate Volume

Finasteride
PROWESS1 PLESS2 MTOPS3 2 -15.3% 4 -18% 4 -19%

Dutasteride*
2yrs4 2 -25.7% 4yrs5,6,7 4 -27.3%

Symptoms Urinary Flow Rate


Risk of AUR Risk of BPH Surgery

-2.1 1.5
-57% -40%

-3.3 1.9
-57% -55%

-5.6 3.2
-68% -64%

-4.5 2.2
-57% -48%

-6.5 2.7
Continue Reduction Continue Reduction

Note: Not from a comparative trial, all result abstracted from treatment group. PROWESS=Proscar Worldwide Efficacy and Safety Study; PLESS=Proscar Long-term Efficacy and Safety Study; MTOPS=Medical Therapy of Prostatic Symptoms *: Avodart Phase III trial2double blind 24open-label study
References: 1. Marberger MJ. Urol.51:677-86,19982. McConnell JD et al. N Engl J Med 338(9):577-63,19983. McConnell JD et al. N Engl J Med 349(25):2387-98,20034. Roehrborn CG et al.Urol.60:434-41,20025. T.Tammela et al. 2004 EAU Abstract 6. F.Debruyne et al. 2004 EAU Abstract7.M.Emberton et al. 2004 EAU Abstract

Conclusions
In MTOPS study, finasteride afforded long-term reduction in risk of AUR on surgery when combined with alpha 1-blocker doxazosin 5ARI alpha blocker,BPH, BPH In SMART-1 study, dutasteride can be used in combination with tamsulosin to achieve fast symptom relief that is maintained with alpha 1- blocker is removed after 6 months BPH,Avodart alpha blocker,6alpha blocker

Medical Therapy Algorithm


Patient

IPSS 7 No or little bother Prostate small PSA low Prostate large PSA high

IPSS >7 Moderate to severe bother

Prostate small PSA low


Adrenergic Blocker

Prostate large PSA high

No Treatment

Preventive therapy 5-Reductase Inhibitor

5-Reductase Inhibitor Combination Rx

IPSS <19 (Moderate) Short term

IPSS >19 (Severe) Long term

Surgical treatment

Treatment Modalities for BPH


Watchful waiting Medical therapy
Phytotherapy -adrenergic blockers 5-reductase inhibitors Combination therapy

Surgicenter/Hospital-based treatment
TURP (gold standard) TUIP Open surgery (prostatectomy) TUVP ILC VLAP Prostatic stents

Office-based treatment
TUMT TUNA WIT

Chatelain C et al. In: Chatelain C et al, eds. Benign Prostatic Hyperplasia. Plymouth, UK: Health Publication Ltd; 2001;519-534. McConnell JD et al. Benign Prostatic Hyperplasia: Diagnosis and Treatment. Clinical Practice Guideline, Number 8.

Indication of surgical intervention


Acute urinary retention Gross hematuria Frequent UTI Vesical stone BPH related hydronephrosis or renal function deterioration Obstruction
IPSS8, prostate size, image study, UFR cystoscopic findings, residual urine

Conventional Surgical Therapy


Transurethral resection of the prostate (TURP) Open simple prostatectomy

TURP

(transurethral resection of the prostate)

n n

Gold Standard of care for BPH

Uses an electrical knife to surgically cut and remove excess prostate tissue Effective in relieving symptoms and restoring urine flow

TURP
Gold standard of surgical treatment for BPH 80~90% obstructive symptom improved 30% irritative symptom improved Low mortality rate 0.2%

The gold standard- TURP


Benefits
n
n n

Disadvantages
n

Widely available Effective Long lasting

Greater risk of side effects and complications 1-4 days hospital stay 1-3 days catheter

n n n

4-6 week recovery

Complication of TURP
Immediate complication
bleeding capsular perforation with fluid extravasation TUR syndrome

Late complication
urethral stricture bladder neck contracture (BNC) retrograde ejaculation impotence (5-10%) incontinence (0.1%)

Open Simple Prostatectomy


too large prostate -- >100 gm Combined with bladder diverticulum or vesical stone surgery Suprapubic or retropubic method

Minimally invasive therapy


During the last decade, numerous amounts of minimally invasive therapy modalities have been developed to challenge the traditional surgery of TURP The aim of these therapies is to achieve results similar to TURP but with minimal anesthesia, complication, risk and hospital stay.

Minimally invasive therapy for BPH


transurethral balloon dilatation of the prostate (TUBDP) transurethral incision of the prostate (TUI) intraprostatic stent transurethral microwave thermotherapy (TUMT) transurethral needle ablation of the prostate (TUNA) transurethral electrovaporization of the prostate (TUVP) photoselective vaporization of the prostate (PVP), Cryotherapy Transurethral ethanol ablation of the prostate (TEAP),

Minimally invasive therapy for BPH


transurethral laser-induced prostatectomy (TULIP) visual laser ablation of the prostate (VLAP) contact laser prostatectomy (CLP) interstitial laser coagulation of the prostate (ILC) holmium:YAG laser resection of the prostate (HoLRP) holmium:YAG laser enucleation of the prostate (HoLEP) high-intensity focused ultrasound (HIFU) coagulation botulinum toxin-A injection of the prostate

HoLEP Vs. TURP


IPSS & urodynamic findings: no statistically significant differences Operation time: HoLEP 74 +/- 19.5 vs. TURP 57 +/- 15 mins (p <0.05) Catheterization time: 31 +/- 13 vs 57.78 +/- 17.5 hours (p <0.001) Hospital stay: 59 +/- 19.9 vs 85.8 +/- 18.9 hours (p <0.001) Urge incontinence: more common in the HoLEP group The overall complication rate was comparable in the 2 groups

Journal of Urology. 172(5, Part 1 of 2):1926-1929, November 2004

TURP vs HIGH POWER (80 W) POTASSIUM TITANYL PHOSPHATE


(KTP) LASER VAPORIZATION
Hemostasis: standardized ablation volume of 16 cm3 tissue (23.3 vs 2.1 ml per minute, p <0.0001). Tissue ablation: more rapid in the resection group (100 vs 20 seconds, p <0.001). Histological examinations: larger coagulation zones for the KTP group compared to conventional tissue resection (0.9 vs 0.6 mm, p <0.01). 80 W KTP laser vaporization: bloodless ablative procedure, but more time-consuming

Journal of Urology. 171(6, Part 1 of 2):2502-2504, June 2004

How does PVP work?


n

Uses a very high powered green laser and a thin, flexible fiber

Fiber is inserted into the urethra through a cystoscope

How does PVP work?

n Quickly and precisely vaporizes and removes

the enlarged prostate tissue


n The green laser energy is hemostatic, so there

is almost no bleeding

Enlarged Prostate
n
n

After GreenLight PVP


n n

Urethra is obstructed Urine flow blocked

Urethra is open Normal urine flow is restored

Summary
Minimally invasive therapies for the treatment of BPH has the advantages such as less blood loss, less occurrence of hyponatremia, quicker recovery, and reduced risk of urethral stricture. However, it also has the disadvantages such as long-lasting bladder irritation owing to higher temperature during therapy and possible longer catheterization period due to swelling of the prostate. It is still too early to make a definitive conclusion concerning the future role of these minimally invasive therapies for the treatment of BPH.

Kanker Prostat

Prostate Cancer

What is Prostate Cancer


Prostate cancer is cancer of the prostate gland in which cells grow out of control within the body, invading and destroying tissues and organs in the prostate. This can spread to other parts of the body, including the bladder, colon, rectum, and bone. Routine blood tests and physical exams can help screen for prostate cancer at its earliest stages. Only your physician can diagnose prostate cancer.

Symptoms associated with prostate cancer


Some of the symptoms associated with prostate cancer are dull pain in the lower pelvic area; frequent urination; problems with urination such as the inability to urinate, pain or burning when urinating, weakened urine flow, blood in the urine or semen; painful ejaculation; general pain in the lower back, hips or upper thighs; loss of appetite and/or weight; and persistent bone pain.

How is prostate cancer diagnosed?


Prostate cancer is diagnosed from the results of a biopsy of the prostate gland. If the digital rectal exam of the prostate or the PSA blood test is abnormal, prostate cancer is suspected. A biopsy of the prostate is usually then recommended. The biopsy is done from the rectum (transrectally) and is guided by ultrasound images of the area. A small piece of prostate tissue is withdrawn through a cutting needle. A pathologist then examines the tissue under a microscope for signs of cancer in the cells of the tissue.

Grading of a cancerous tissue: Gleason Scale


When prostate cancer is diagnosed on the biopsy tissue, the pathologist will then grade each of two pieces of the tissue from 1 to 5 on the Gleason scale. The scale is based on certain microscopic characteristics of the cancerous cells and reflects the aggressiveness of the tumor. The two scores are then added together. Sums of 2 to 4 are considered low, indicating a slowly growing tumor. Sums of 5 and 6 are intermediate, representing an intermediate degree of aggressiveness. Sums of 7 to 10 are considered high, signaling a rapidly growing tumor with the worst prognosis (outcome). Gleason scores can be helpful in guiding treatment that is based, at least in part, on the aggressiveness of the tumor.

Staging of prostate cancer:


Tumor, Nodes and Metastasis (TNM) Classification

A system for staging prostate cancer is called the tumor, nodes, and metastasis (TNM) classification. Stage T1 describes a minimal cancer that can neither be palpated (felt) on physical examination nor seen by imaging techniques. Stage T2 refers to a larger cancer that may be palpated, but that still is confined (localized) to the prostate gland. T3 describes cancer that extends just beyond the capsule (coat) of the prostate, and T4 describes cancer that is fixed to the surrounding tissues. Stage N1 signifies a spread to the nearby (pelvic) lymph nodes and M1 is for distant spread (metastasis), for example, to the bones, liver, or lungs.

Type of Treatment
Stages and Treatments of Prostate Cancer Stages T1 or T2 Characteristics Type of Treatment

Localized in the prostate

Surgery, radiation therapy (radiotherapy)

T3 or T4

Locally advanced

Radiation therapy; combination of hormonal therapy and radiation

N+ or M+

Spread to pelvic lymph nodes (N+) or distant organs (M+)

Hormonal therapy, experimental approaches

Making Treatment decisions


Each one of three characteristics, tumor stage, Gleason score and PSA, is important, and a bad reading for any one of them will effect the treatment options and chances of success of treatment. The three factors are combined to form three risk groups which guide your doctor in your management.

Group One: Favourable risk


This group includes those tumors, which are stage T1 or T2a(involving half a lobe or less of the prostate), with a Gleason score of 6 or less, and a PSA reading of 10ng/ml or less. Hormone therapy is seldom indicated because there is a very low risk of these cancers having spread elsewhere. If your prostate size is not too large, brachytherapy is an excellent option. External beam radiotherapy is also a good choice, and may be better for you if you have a large prostate, or if you already have difficulties passing urine(slow stream, getting up a lot at night).

Group Two: Intermediate risk


This group includes tumors, which are slightly larger, T2b, or has a Gleason score of 7, or have a PSA reading between 10 and 20ng/ml. Since these tumors are somewhat more aggressive, there is a greater chance of spread through the capsule of the prostate into the adjacent tissues. Because the dose from brachytherapy is so tightly focused on the prostate and only extends 2-3mm beyond the prostate, it is not generally considered appropriate for tumors in this group, although it may be used as a boost in combination with a short course of external radiotherapy. Newer radiotherapy techniques such as 3 dimensional conformal radiotherapy, and intensity-modulated radiotherapy (IMRT) allow a highly effective dose to be delivered safety(daily for 8 weeks).

Group Three: High Risk


This group includes tumors which are either locally advanced, or have a PSA higher than 20 at the time of diagnosis, or are aggressive looking under the microscope with Gleason scores of 8, 9 or 10. Since these tumors have a tendency to seed elsewhere early on, treatment will often be directed not only at the prostate, but will also include a prolonged period of hormone therapy which will suppress microscopic spread of the cancer to lymph nodes or bone. The radiotherapy may include a wider field radiotherapy than group two to cover pelvic lymph nodes, but it will almost certainly be combined with 2-3 years course of hormone therapy.

Prostate Brachytherapy

History
Started in the 1900s by physicians at New Yorks Sloan Kettering Memorial Cancer Center. Used an incision into the abdomen to expose the prostate gland. Using their hands they guided surgical needles, inserting radioactive seeds one by one into the prostate gland. Because they could not see inside the prostate, seeds were placed unevenly. This led to later abandonment of this procedure.

Along Comes Ultrasound Technology

Ultrasound Technology
In the early 1980s Dr. Hans Holm of Denmark begins applying a new technology of transrectal ultrasound. This coupled with computerized imaging software allows a major step forward in the development of prostate brachytherapy. In 1985, Dr. John Blasko and Dr. Haakon Ragde introduce ultrasound-guided prostate implantation to the United States.

Brachytherapy Today
Today prostate brachytherapy involves the permanent implantation of 90 to 140 tiny radioactive seeds into the prostate, which then, over the subsequent 6 months, deliver an intense focused dose of radiation to the prostate. The seeds remain permanently. After they have completed their job however, they become inert.

Who is Eligible?
The Cancercare Ontario Evidence-based Guideline recommends that this form of treatment be applied only to those men with: T1c/T2a tumors, which either aren't palpable (felt) on rectal exam, or are palpable as small nodules. A Gleason score less than or equal to 6. A presenting PSA less than 10 ng/ml Outside these guidelines, there's considerable risk that prostate cancer cells have spread into tissue surrounding the prostate. Because radioactive seed implants have a very short range, any tumour cells located outside the prostate may not receive a sufficient dose to be eradicated.

Technical Considerations
L prostate size (< 60 cc). Over 500 implants have been performed at the Princess Margaret Hospital of the University Health Network. If the patient has a bigger prostate or has had hormones to shrink his prostate, there is an increased risk of prostate swelling after the implant. The more the swelling, the longer it takes to resolve. no previous TURP ( less tissue to implant) pubic arch configuration( hinders the needles and proper seed placement).

Pubic Arch Interference

Brachytherapy: Advantages
Personal : simple outpatient procedure( Typically, the seed implant takes about two hours and can be done under either general or spinal anesthesia) Avoids lengthy hospitalization rapid return to normal activity comparable 10 year outcome perceived as low morbidity

After Deciding on Brachytherapy


The volume study is the first step. Cross sectional images of the prostate are taken every 5mm and re-assembled on a computer to make a threedimensional model of the prostate. Exact placement of each seed can then be determined. The team (doctor, physicist and dosimetrist) then takes a created map of the prostate into the operating room. This map is followed closely.

Volume Study Geometry

Contouring And Planning

Template Used to Guided Seed Insertion

The Procedure

Urinary Morbidity: PMH


Acute urinary retention :16% Independent of D90, V100, V200 and urethral dose, AUA score Depends on volume: 39.3 cc vs 33.8 p=0.002 Depends on # of seeds: 112 vs 102 p=0.004

Side Effects
Tenderness and bruising which can last 3-7 days in the perineal area, can feel like one is sitting on a golf ball Burning sensation while urinating Blood clots in the first few days following implant, urine is strained for 3 days following implant Frequency and urgency In extreme cases--urinary retention requiring catheterization Rarely are there complications to the bowel and rectum

Medications
Flomax-starts 7 days before implant and must continue for at least 3 months post implant, improves urinary stream and bladder emptying by relaxing the smooth muscle around the bladder neck Cipro- an antibiotic, is taken for 1 week starting the day of the implant Pyridium-taken 3 times a day for the first 2 weeks following implant, this medication lessens the burning sensation and feeling of urgency Mobicox- reduces inflammation from the implant, taken for at least one week to one month Tylenol-Extra Strength or with Codeine--relieves pain from implant, use only as needed

Management of Acute Urinary Retention


In-dwelling Foley x 3 - 5 days Dont stop the Flomax Trial of voiding (measure PVR ! ) Teach ISC Supra pubic if cant do ISC Wait 8- 12 months before TURP (minimal)

Management of Acute Urinary Morbidity


Patience!!! Irritative/obstructive symptoms (high IPS score): blockers (Flomax, dose response) NSAIDs, cox-2 inhibitors better short course steroids

Follow Up
Done at 1 month Every 2-3 months for first year 3-4 Months in second year Every 6 months thereafter DRE,PSA and bladder function at 6 months Biopsy at 2 year mark suggested

Potency
@ 6 Years: 92% (Merrick, 2002, n=209 incl Viagra) @ 5 Years: 85% (Sharkey, 2000, n=1048) @ 3.5 Years: 90% ( Scherr, 1998, n=692) @ 2 Years:78% (Stone, 2000, n=419) Combined with NHT @ 2 years : 50% (additional 25% partial) (Sanchez-Ortiz, 2000, n=171)

Brachytherapy Results for Favourable Risk Patients


Negative biopsy @ 2 years: 87-95% Negative biopsy @ 5 yrs: 86-93% Negative biopsy @ 10 yrs: 71-87%

Summary
Prostate brachytherapy is a highly effective form of treating early stage prostate cancer and involves the permanent implantation of 90 to 140 tiny radioactive seeds into the prostate. It offers men an alternative to radical surgery and can be performed as an outpatient procedure with considerably less impact on urinary and sexual function. Fifteen years experience with brachytherapy and results for 1000s of men have indicated that it has similar efficacy to surgery. The favorable side effect profile however makes it an attractive and highly sought-after form of treatment. In 2003, it surpassed radical surgery as the treatment of choice for newly diagnosed localized prostate cancer in the United States.