Lutom Lower Urinary Tract Obstruction Management

MANAGEMENT of LOWER URINARY TRACT OBSTRUCTION MOHD BADRUL HISYAM B.HASHIM

Benign Prostate Hyperplasia Prostate Carcinoma Bladder Carcinoma

Assessment Evaluated using International Prostate Symptom Score (IPSS) questionnaire. It gives information regarding severity of symptoms. LURT • mild 0-7 • Moderate 8-19 • Severe 20-35 Uroflowmetry • Noninvasive test to detect lower urinary tract obstruction. • Qmax<10ml/sec=BOO • Qmax>15mls/sec=no BOO • Low flow rate suggests BOO.

Post void Residual Volume (PVR) PVR is a safety parameter Men with a significant PVR should be monitored

more closely if they elect non-surgical therapy. It can be measured accurately non- invasively with trans abdominal US Elevated residual volume-stasis of urine can increse the risk of UTI and bladder stones.

TREATMENT  WATCHFULL WAITING and conjuntion with fluid restricton and reduced caffiene

intake. -Indicate for men with mild and not bothersome symptoms. Flow rate > 15ml/s and residual volume < 100ml. • Drug Therapy. α-Blockers • Relax smooth muscles in the prostate fibromuscular stroma. • Achieve a dose dependent improvement in maximum urinary flow rate and symptom score Examlpes- terazosin(hytrin),doxazocin(cardura),tamsulosin(floma x/contoflo),alfuzosin(xatral/uroxatral) 5α-reductase inhibitors- finasteride (proscar) inhibits type II 5α- reductase. Detasteride (Avodart) inhibits type I and type II 5α-reductase . The enzyme that converts testosterone to DHT Low DHT leads to: -↑max urinary flow rate by approximately 10% - Improves symptom -↓ the risk BPH progression -↓total PSA by 50% after 6 month of treatment . Combination therapy is better than either agent alone

Surgery Indication Failed a preliminary trial of medical therapy Present of BOO. Haematuria. Combination of severity of symptoms and low flow

rate. Complication of BPH such as bladder diverticuli, hydroureter, UTI and stone.

TURP – Gold standard Open surgery

TURP  Use of a resection loop to remove “chips”of prostate

tissue. Complications. including impotence and incontinence & retrograde ejaculation Fluids used during TURP build up, water intoxication can develop, which can be serious. This condition is referred to as the transurethral resection (TUR) syndrome and includes abdominal cramps, nausea, vomiting, lethargy, and dizziness.

Open Prostatectomy The enlarged prostate is removed through an open

incision in the abdomen using standard surgical techniques. Open prostatectomy is used only for severe cases, about 2 - 3% of BPH patients, when the prostate is severely enlarged Ideal for patients with bladder stones or require diverticulum repaire.

Minimally Invasive Procedures Use some form of heat to destroy excess prostate tissue. The heat may be delivered by: * Radio frequency: Transurethral needle ablation (TUNA) * Microwave: Transurethral microwave thermotherapy (TUMT) * Electrical current: Transurethral electrovaporization (TUVP) * Laser: Interstitial laser coagulation (ILC) and holmium laser enucleation of the prostate (HoLEP)

PROSTATE CARCINOMA

TNM Staging

Treatment  Treatment option for prostate cancer depend on stage of disease,

life expectancy and patient preference.  Conservative treatment:  Localized T1a - T1b disease for men in their 70s.  Radical prostatectomy:  In younger fitter men ( < 70 years) with T1 –T2 form of the disease.  T1 and T2 also can be treated by radical radiotherapy. Eg External Beam Radiotherapy and Brachytherapy.  Locally advanced T3 and T4. These patients are at significant risk

of disease to progress. Androgen ablation coupled with radiotherapy is standard treatment.  Metastaic disease – Immediate androgen ablation which include: - LHRH agonist plus antiandrogen - Orchiectomy

Prostate Cancer

Other Therapies

Cryosurgery of the Prostate

Prostate Cancer Chemotherapy Using Agents: Doxorubicin Cisplatin cyclophosphamide

Bladder Carcinoma

TNM Staging T - Tumor

N - Regional Lymph Node

M - Distant Metastasis

TX - Primary tumor cannot be evaluated T0 - No primary tumor TIS - Carcinoma in situ ("flat tumor") Superficial Tumor. Ta – Tumor confined to the urothelium T1 - Tumor invades connective tissue under the epithelium (involvement of lamina propria) Invasive Tumor. T2 - Tumor invades muscle T2a - Superficial muscle affected (inner half) T2b - Deep muscle affected (outer half) T3 - Tumor invades perivesical (around the bladder) fatty tissue T3a – microscopically T3b - macroscopically (e.g., visible tumor mass on the outer bladder tissue) Fixation Tumor. T4 - Tumor invades any of the following: prostate, uterus, vagina, pelvic wall, abdominal wall and fixation to pelvic wall.

NX - Regional lymph nodes cannot be evaluated N0 - No regional lymph node metastasis N1 - Metastasis in a single lymph node < 2 cm in size N2 - Metastasis in a single lymph node > 2 cm, but < 5 cm in size, or Multiple lymph nodes < 5 cm in size N3 - Metastasis in a lymph node > 5 cm in size

MX - Distant metastasis cannot be evaluated M0 - No distant metastasis M1 - Distant metastasis

Treatment  Non-muscle invasive (Superficial) tumors :  a) Ta (G1 or G2 ) :

Transurethral Resection (TUR).  b) Ta G3 (high risk of recurrence): TUR + 6 weekly intravesical instillation of BCG started 3-4 weeks after TUR.  c) Tis (precursor for invasiveness): TUR + intravesical instillation of BCG once weekly for 6 weeks. T1 ( G1 or G2, solitary , not associated with Tis ) : Same as Ta (G1 or G2). T1 (G3, multifocal, associated with Tis, vascular invasion or recurrent after BCG): TUR + intravesical instillation of BCG, OR radical cystectomy and bilateral pelvic lymphadenectomy. 

Muscle invasive tumors (T2, T3 and T4a)

Radical cystectomy (cystoprostatovesiculectomy with bilateral pelvic nodal dissection up to the bifurcation of the common iliac LN) together with urinary diversion. External beam radiotherapy – option for unfit patient @ declined cystectomy. Neoadjuvant cisplatin – base chemotherapy to improve survival rate. Downstages the tumor by radiotherapy @ chemotherapy to enable cytectomy.

Follow-up

* Every 2 months in the first year, every 3 months in the 2nd & every 6 months thereafter. * CXR and CT abdomen & pelvis are performed every year. * Bone scan to be performed whenever necessary.

Follow up: - At every follow up visit the physician should be able to evaluate: Tumor response: No evidence of disease, site & size of recurrence; local, bone, chest, liver, …etc.

REFERENCES Bailey & Love's Short Practice of Surgery http://emedicine.medscape.com/ http://www.umm.edu/

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