1. BLADDER OUTLET OBSTRUCTION (B.O.O.)

2. BOO It’s urodynamic concept of low flow rates and high intravesical pressures. Causes: *BPH. *CAP. *bladder neck stenosis. *urethral stricture. *neuropathic conditions.

3. Pathophysiology Boo over time will result in.. increase in the intravesical voiding pressure (>80 cm H 2 O), bladder muscle hypertrophy (trabiculation, sacculation and diverticulum formation). High pressure may transmit to the upper tract causing hydroureter, hydronephrosis and renal insufficiency. Boo results in incomplete bladder evacuation (residual urine) which predisposes to UTI and stone formation. Decrease uro flow rate under 10 ml /sec

4. Symptomatology (LUTS Obstructive: Hesitancy Straining Weak stream Intermittency. Post voiding dribbling. Retention of urine. Irritative: Frequency.,nocturia Urgency & urge incontinence.

5. IPSS [international prostatic symptom score ]

6. Benign prostatic hyperplasia BPH Third most common urological pathology. Starts at late 30s & appear clinically at 60s.

8. Theories: Hormonal: DHT, growth factor. Neoplastic: fibromyoadenoma. Typically affects submucosal glands at transitional zone.

10. Symptomatology Boo (irritative and obstructive). Symptoms are slowly progressive over years, worsening at winter time. Renal failure. Hematuria. Pain is not afeature of BPH the presence of which may indicate acute retention,vesical stone,infection,CAprostate

11. Precipitating causes for retention Severe pain. MI, joint pain. Psychological upset. Cold exposure. Constipation. Drugs Anticholenergic & diuretic,decongestant,antihistamin Ignoring first desire for urination.

12. Clinically Usually normal. Distended bladder.in acute or chronic retention PR ex: enlarged prostate, smooth, regular, firm, maintained median sulcus and mobile rectal mucosa Normal anal sphencter tone. Normal bulbocovernosus reflex

14. Investigations: GUE: normal or UTI RFT: normal unless there is renal failure U/S:TRUS: BPH, vesical stone, residual urine and hydronephrosis. IVU:

15. Benign prostatic hyperplasia

16. Vesical stone

17. PSA: (prostate specific Ag)<10 ng/ml. Cystoscopy: enlarged prostate, trabiculation & stones. Size of the prostate has no relation with the severity of the symptom but the degree of urethral compression.

18. Treatment Conservative: Avoid ppt factors. Treat pains. Treat UTI. Αlfa blocker: prazocin 1 mg, terrazocin 2mg, doxazocin 2mg.tamsulusin,alfuzosin At night S/E hypotension, 1 st dose syncope.

19. * 5 α reductase inhibitors: fenasteride, prosteride 5 mg/day > 6 months. S/E impotence. Usually used in large gland

20. Semi surgical: TUMT (trans urethral microwave thermotherapy) HIFU ( high intensity focused u/s) TUIP (Trans urethral incision of prostate) TUNA (Trans urethral needle ablation) Prostatic stents TU baloon dilatation

21. TUMT STENT

22. TUNA

23. Surgical treatment Endoscopic: TURP Laser Open surgery: Trans vesical prostatectomy. Rertopubic prostatectomy

24. INDICATION OF SURGERY IN BPH SEVERE SYMTOMS FAILURE OF MEDICAL TREATMENT COMPLICATIONS LIKE ACUTE URINARY RETENTION CHRONIC RETENTION REPEATED HEMATURIA REPEATED UTI VESICAL STONE RENAL IMPERMENT DUE TO CHRONIC RETENTION

25. TURP

26. Transvesical retropubic

27. BEFORE TURP AFTER TURP

28. Complications Early: Bleeding and clot retention. TUR syndrom (water intoxication) due to. dilutional hyponatremia. Infection. Wond infection[in open prostatectomy]

29. * Late: Urethral stricture Bladder neck contracture Retrograde ejaculation. Incontinence. Impotence. Recurrence of BPH. After 5-10 years.

30. Carcinoma of the prostate CAP

31. One of the most common malignant tumor affecting males over the age of 65 in western countries.

32. Pathology 95% of the tumor are adenocarcinoma and derived from acinar epithelium 75% of CAP arise from peripheral zone. grading: Gleason’s grade based on the degree of glandular differentiation and growth pattern.

33. Spread Direct invasion: to nearby structures. Denonvvilliar’s fascia act as barrier. Lymphatic: internal, external & common iliac Blood: to the lower lumber vertebrae & pelvic bones due to reverse blood flow from vesicoprostatic plexus to the emissary veins of the bones during coughing & sneezing (OSTEOBLASTIC)

34. Osteoblastic lesion of secondary CAP

35. Presentation Accidental during histopathological ex after prostatectomy. During PR ex High PSA BOO. Metastatic: back ache, sciatica, paraplegia or pathological fractures..

36. * CAPBPH olderYounger age Rapid progression Symptoms slowly progressive More back ache & neurological symptoms Usually no back or bone pain Hard irregular prostate with obliterated sulcus Smooth rubbery prostate with sulcus

37. * Rectal examination: Stony hard irregular prostatic nodule, obliterated median sulcus, difficulty in moving the rectal mucosa over it and fixity. Normal PR ex does not exclude CAP.

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39. Investigations PSA: prostatic tumor marker for diagnosis and follow up, it may also increase in prostatitis and BPH. 10 ng/ml normal, 10-15 suspicious. >15 is diagnostic. Acid phosphatase: prostatic fraction. Alkaline phosphatase: in bone metastasis.

40. Radiological investigations Plain X ray: osteoblastic lesion. Bone scan: hot areas (active). CT scan. TRUS & biopsy (sixtant biopsy).

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42. Differential Diagnosis Not all patients with an elevated PSA concentration have CaP.(BPH, urethral instrumentation, infection, prostatic infarction, or vigorous prostate massage) Not all patients with an elevated PSA concentration have CaP.(BPH, urethral instrumentation, infection, prostatic infarction, or vigorous prostate massage) Not all patients with an Induration of the prostate have CaP.(chronic granulomatous prostatitis, previous TURP or needle biopsy, or prostatic calculi). Not all patients with an Induration of the prostate have CaP.(chronic granulomatous prostatitis, previous TURP or needle biopsy, or prostatic calculi). Not all patients with sclerotic bony lesion and elevated alk. phosphatase have CaP.(Paget disease) Not all patients with sclerotic bony lesion and elevated alk. phosphatase have CaP.(Paget disease) prostatic cancer 42

43. Treatment Watchful waiting: Radical prostatectomy: Enblock surgical removal of the entire prostate, seminal vesicles and pelvic lymph nodes. The bladder anastomosed to the urethra. Indicated for early disease and healthy fit pt.

44. 2. Radical prostatectomy prostatic cancer 44

45. ROBOTIC RADICQL PROSTQTECTOMY prostatic cancer 45

46. Radiotherapy external beam & brachytherapy Indication: 1- Locally advanced disease. 2- Unfit patient for surgery. 3-Symptomatic metastases to relieve pain.

47. 3. Radiation therapy external beam therapy brachytherapy prostatic cancer 47

48. Hormonal therapy Its trearment of choice for metastatic tumor Cap is hormonal dependant (androgen), and about one third of tumors are hormone- insensitive. Androgen ablation may change the course of the disease.

49. Methods of androgen ablation surgical Bilateral orchiectomy: complete or subcapsular. medical LHRH agonist: (Zoladex)/28 days SC. Anti androgen: (Nilutemide) 250 mg/6h..

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51. Thank you