WEBVTT 1 00:00:15.800 --> 00:00:20.400 So if I'm going to start talking about benign prostatic hypertrophy, the 2 00:00:20.400 --> 00:00:23.100 first things first and we need to know a little about the 3 00:00:23.100 --> 00:00:27.100 anatomy of what is the prostate gland, where is it present and 4 00:00:27.100 --> 00:00:32.300 what are the anatomical relations that it has and what are the 5 00:00:32.300 --> 00:00:36.800 applied points of anatomy. So when we look at the prostate, it 6 00:00:36.800 --> 00:00:41.800 is a walnut sized gland which is part of the male reproductive 7 00:00:41.800 --> 00:00:46.600 system. It is situated anterior to the rectum and is part of 8 00:00:46.600 --> 00:00:51.700 the bladder outflow. Now what is the function of this prostate? 9 00:00:51.700 --> 00:00:56.900 The prostate is responsible for secreting an alkaline fluid that 10 00:00:56.900 --> 00:01:02.200 is contributing about 70% of the seminal fluid that comes 11 00:01:02.200 --> 00:01:07.300 into the body. And you find that it is also responsible for 12 00:01:07.300 --> 00:01:12.500 all of the reproductive functions that part of the reproductive functions that 13 00:01:12.500 --> 00:01:16.900 a male possesses. So when we look at the anatomy of the 14 00:01:16.900 --> 00:01:20.400 prostate, you find that we have an anterior lobe, we have a 15 00:01:20.400 --> 00:01:24.900 posterior lobe, there's a median lobe and two lateral lobes. But when 16 00:01:24.900 --> 00:01:29.400 we're looking at the zones, we find that there is what we 17 00:01:29.400 --> 00:01:34.400 call as the zones which are the periurethral. You have 18 00:01:34.400 --> 00:01:38.600 the peripheral zone and we have the transition zone and you find 19 00:01:38.600 --> 00:01:43.900 that these are responsible for either the prostatic hyperplasia or 20 00:01:43.900 --> 00:01:49.000 when we have prostatic malignancies. So when you look at this picture, 21 00:01:49.000 --> 00:01:54.300 you realize that unlike other organs, when there is an expansion, you 22 00:01:54.300 --> 00:01:58.400 find that the capsule of the prostate does not allow it to 23 00:01:58.400 --> 00:02:03.400 expand laterally. Instead, it expands medially 24 00:02:03.600 --> 00:02:06.800 and as a result of which you can see in this picture 25 00:02:07.000 --> 00:02:12.900 that the urethra is the part that ends up getting compressed. Now 26 00:02:12.900 --> 00:02:17.400 you find that when I'm talking about the prostate, you find that 27 00:02:17.400 --> 00:02:21.600 it is a structure that develops at about the 12th week of 28 00:02:21.600 --> 00:02:26.700 intrauterine life and you find that as I mentioned before, the inner 29 00:02:26.700 --> 00:02:31.800 adenomatus or the transitional area is what is associated with 30 00:02:31.800 --> 00:02:36.800 prostatic hypertrophy and the outer non adenomatus or what we refer 31 00:02:36.800 --> 00:02:42.100 to as the peripheral zone is the area where malignancy or carcinoma 32 00:02:42.200 --> 00:02:46.400 is often seen. Now I'd request you to take a minute to 33 00:02:46.400 --> 00:02:49.800 take a look at this picture and you will see that around 34 00:02:49.800 --> 00:02:54.000 the the opening of the urethra is where the prostate is present 35 00:02:54.200 --> 00:02:59.400 and you have the urogenital diaphragm, you have the prostatic venous plexus 36 00:02:59.600 --> 00:03:03.000 and then in this picture here you are able to see the 37 00:03:03.000 --> 00:03:08.100 ejaculatory duct opening into that portion, what we refer to 38 00:03:08.100 --> 00:03:13.300 as the prostatic urethra. All right, these are points of applied 39 00:03:13.300 --> 00:03:17.500 anatomy and you can see the ejaculatory duct opening over there and 40 00:03:17.500 --> 00:03:22.800 then you can see the prostatic venous plexus and these are responsible 41 00:03:22.900 --> 00:03:27.500 for the torrential bleeding that can happen or the retrograde ejaculation that 42 00:03:27.500 --> 00:03:32.600 will happen after a patient undergoes transurethral resection 43 00:03:32.600 --> 00:03:36.600 of the prostate. So the applied anatomy point is that it is 44 00:03:36.600 --> 00:03:41.600 surrounding the bladder neck and this results in what we call as 45 00:03:42.100 --> 00:03:47.500 outflow obstruction and as a result of which there is a proximal 46 00:03:47.500 --> 00:03:51.300 build up of pressure and I will allude to this in my 47 00:03:51.300 --> 00:03:55.600 subsequent slides. But this is a good slide to remember for the 48 00:03:55.600 --> 00:04:00.800 points of applied anatomy. Now when we look 49 00:04:00.800 --> 00:04:06.100 at the structural anatomy, it is made up of fibro-adenomatus glands. Now 50 00:04:06.100 --> 00:04:10.700 when I say fibro-adenomatus, it has an implication that when there is 51 00:04:10.700 --> 00:04:16.200 an enlargement, not only is there a glandular enlargement, there is also 52 00:04:16.200 --> 00:04:21.500 stromal hypertrophy. So both epithelial as well as stromal elements 53 00:04:21.800 --> 00:04:27.500 contribute to this process of the benign prostatic hyperplasia 54 00:04:27.600 --> 00:04:32.900 or hypertrophy as we colloquially refer to it. Now 55 00:04:32.900 --> 00:04:37.400 between the anatomic capsule and the pelvic peritoneum, as I showed you 56 00:04:37.400 --> 00:04:42.600 in the previous slide, is the prostatic venous plexus and this is 57 00:04:42.600 --> 00:04:46.700 what is responsible for the hematuria that happens in patients with an 58 00:04:46.700 --> 00:04:51.700 enlargement and for the torrential bleed that happens during dissection. 59 00:04:53.000 --> 00:04:58.700 So when I'm looking at what is responsible for this enlargement 60 00:04:58.700 --> 00:05:02.100 of the gland, we need to look a little at the epidemiology. 61 00:05:02.700 --> 00:05:05.900 Now you find at the age of 60, about 50% of the 62 00:05:05.900 --> 00:05:10.800 males have prostatic hypertrophy. When we're looking at them at 85 years 63 00:05:10.800 --> 00:05:15.400 of age, about 90% of them have prostatic hypertrophy. Now there was 64 00:05:15.400 --> 00:05:20.800 this concept that all of this was responsible because of the circulating 65 00:05:20.800 --> 00:05:25.900 levels of what we refer to as the dihydrotestosterone. Now when we 66 00:05:25.900 --> 00:05:30.400 look at the dihydrotestosterone, which is nothing but a byproduct of testosterone 67 00:05:30.400 --> 00:05:35.400 itself, you realize that as a person grows older, there's going 68 00:05:35.400 --> 00:05:39.400 to be a decrease in the level of testosterone. So this prompted 69 00:05:39.500 --> 00:05:44.600 a look at what other factors would be responsible and factors 70 00:05:44.600 --> 00:05:49.700 like hyperinsulinemia, metabolic syndrome, you find that the role 71 00:05:49.700 --> 00:05:55.200 of insulin like growth factors, nor epinephrine, you find the angiotensin 72 00:05:55.200 --> 00:06:00.300 two are all factors which are implicated in the process 73 00:06:00.300 --> 00:06:05.500 of causing proliferation of all elements, fibrous elements, muscular 74 00:06:05.500 --> 00:06:10.500 elements as well as glandular elements. Now this 5 HT, 75 00:06:10.800 --> 00:06:15.900 five dihydrotestosterone, which is the linked as the crucial 76 00:06:15.900 --> 00:06:21.200 factor, bears remembering because this will again have implications 77 00:06:21.400 --> 00:06:26.100 when we are talking about medical management of looking at the DHT. 78 00:06:26.600 --> 00:06:32.200 Now this DHT is converted from testosterone by the action of five 79 00:06:32.300 --> 00:06:36.000 alpha reductase. All right, so again I reiterate for the benefit of 80 00:06:36.000 --> 00:06:41.000 students, testosterone gets converted to dihydrotestosterone by 81 00:06:41.000 --> 00:06:46.000 the action of five alpha reductase and increase levels of DHT 82 00:06:46.800 --> 00:06:52.100 is the largest contributor for the development of prostatic hypertrophy. 83 00:06:52.400 --> 00:06:57.200 So you find that a large number of alpha one receptors are 84 00:06:57.200 --> 00:07:01.900 also situated in the smooth muscle fibers in and around the bladder 85 00:07:01.900 --> 00:07:06.600 neck as well as in the prostate. Stimulation of these alpha one 86 00:07:06.600 --> 00:07:12.400 receptors results in increased muscle tone and this is what aggravates 87 00:07:12.400 --> 00:07:17.200 or worsens the symptoms that we have in patients who have prostatic 88 00:07:17.200 --> 00:07:22.300 hypertrophy. So microscopically, when we're looking at the process, it is 89 00:07:22.300 --> 00:07:27.400 actually a hyperplasia. Even though we say benign prostatic hypertrophy, 90 00:07:27.500 --> 00:07:32.300 it is actually a hyperplasia because there is a proliferation and you 91 00:07:32.300 --> 00:07:36.000 find that as a result of which there is a restriction of 92 00:07:36.000 --> 00:07:39.200 the flow of urine from the bladder and as a result of 93 00:07:39.200 --> 00:07:43.000 which there are all of the clinical manifestations that we have. All 94 00:07:43.000 --> 00:07:45.800 right, so the takeaway of a point from this slide is the 95 00:07:45.800 --> 00:07:50.800 role of testosterone, dihydrotestosterone and the role 96 00:07:50.800 --> 00:07:55.900 of five alpha reductase. So what do we find out and 97 00:07:55.900 --> 00:08:00.000 who are the people who are at risk? We already agreed that 98 00:08:00.000 --> 00:08:05.000 as they grow older, they are at a higher risk. Now people 99 00:08:05.000 --> 00:08:09.900 who have higher levels of testosterone, as has been documented among African 100 00:08:09.900 --> 00:08:15.100 Americans, you find are at higher risk. As I mentioned before, metabolic 101 00:08:15.100 --> 00:08:20.200 syndrome, diabetes etc. and obesity are associated with a higher 102 00:08:20.200 --> 00:08:24.700 risk and you find that this is the way in which you 103 00:08:24.700 --> 00:08:29.800 see a proliferation of both the glandular elements as well as the 104 00:08:29.800 --> 00:08:35.200 fibro muscular stroma and as a result of which the gland enlarges 105 00:08:35.200 --> 00:08:40.400 in size and because the capsule restricts the enlargement in a radial 106 00:08:40.600 --> 00:08:46.400 or a lateral fashion, it moves medially and it results in compression 107 00:08:46.700 --> 00:08:51.600 of the urethra, the prostatic urethra and that is what causes the 108 00:08:51.700 --> 00:08:56.700 symptoms. So the secondary effects of the prostatic hypertrophy are going 109 00:08:56.700 --> 00:09:00.500 to be seen on the urethra, on the bladder, on the urethra 110 00:09:00.700 --> 00:09:05.700 and also on the kidney itself. Now what is the way 111 00:09:05.700 --> 00:09:10.000 in which this happens? So this is a beautiful schematic representation to 112 00:09:10.000 --> 00:09:15.000 show you what happens when there is a prostate prostatic hypertrophy. So 113 00:09:15.000 --> 00:09:18.800 you can see that there is going to be an enlargement of 114 00:09:18.800 --> 00:09:22.900 the gland. You are seeing over here the urethra is getting compressed 115 00:09:23.300 --> 00:09:29.100 and as a result there are symptoms like the bladder wall becoming 116 00:09:29.100 --> 00:09:34.200 larger. There is a hypertrophy, there are trabeculations happening 117 00:09:34.200 --> 00:09:38.600 on the bladder wall as it increases the force of contraction in 118 00:09:38.700 --> 00:09:43.600 order to overcome what we refer to as a bladder neck obstruction. 119 00:09:44.100 --> 00:09:48.300 Now you find that the urethra is now become narrowed and as 120 00:09:48.300 --> 00:09:52.800 a result of which there is a poor stream. There is also 121 00:09:52.900 --> 00:09:57.200 stasis of urine happening over here as a result of which the 122 00:09:57.200 --> 00:10:02.800 patient is now much more susceptible for urinary tract infections. 123 00:10:03.100 --> 00:10:08.400 You find that this results in development of calculi which are present 124 00:10:08.400 --> 00:10:12.100 as a result of stasis and as a result of the infection. 125 00:10:12.600 --> 00:10:18.000 There is a back flow effect and the dilatation of the ureter 126 00:10:18.000 --> 00:10:23.000 can happen and this can also result in a hydroureter 127 00:10:23.100 --> 00:10:28.100 and a hydroureteronephrosis. So this again is a 128 00:10:28.100 --> 00:10:32.800 schematic representation of exactly what I had described in the process of 129 00:10:32.800 --> 00:10:37.800 pathogenesis just before. So you can see over here when the prostate 130 00:10:37.800 --> 00:10:43.100 enlarges, it interferes with the outflow. The bladder now 131 00:10:43.200 --> 00:10:48.400 hypertrophies, there is muscular hypertrophy, there is trabeculations 132 00:10:48.700 --> 00:10:53.600 and sometimes you can also have a diverticular form as a result 133 00:10:53.700 --> 00:10:59.200 of this bladder straining against the obstruction and 134 00:10:59.200 --> 00:11:04.200 there is an association of very often pseudo or sometimes even true 135 00:11:04.200 --> 00:11:09.500 diverticular that can happen. The back flow now causes the ureter to 136 00:11:09.500 --> 00:11:14.600 become larger and then you find that you have a bilateral hydroureter 137 00:11:14.900 --> 00:11:19.600 and then this spills over into the renal pelvis and as the 138 00:11:19.600 --> 00:11:24.400 pelvis enlarges in size, there is a decrease in the amount of 139 00:11:24.400 --> 00:11:28.400 renal parenchyma which is present and when there is a decrease in 140 00:11:28.400 --> 00:11:33.200 the amount of renal parenchyma, the end product is likely to become 141 00:11:33.300 --> 00:11:38.100 renal shutdown or you find in the earlier phases we can actually 142 00:11:38.100 --> 00:11:43.100 see the presence of uremia and serum creatinine can start to 143 00:11:43.100 --> 00:11:47.800 elevate. So you find that these are what we refer to as 144 00:11:47.800 --> 00:11:53.000 the BPH complications. So I am speaking about the complications 145 00:11:53.200 --> 00:11:58.200 just so that you understand the entire sequence of how the 146 00:11:58.300 --> 00:12:03.800 simple act of an enlargement of the prostate not only interferes 147 00:12:03.800 --> 00:12:08.500 with the urinary flow, it also produces what we refer to as 148 00:12:08.500 --> 00:12:12.900 a back flow symptoms and results in all of this. Now the 149 00:12:12.900 --> 00:12:16.300 moment you're going to have a diverticular, there is going to be 150 00:12:16.400 --> 00:12:21.400 urinary stasis as there's going to be stasis inside the urinary bladder 151 00:12:21.500 --> 00:12:25.000 itself and as a result of which there's going to be proliferation 152 00:12:25.100 --> 00:12:28.700 of organisms inside. And all as all of you very well know, 153 00:12:28.900 --> 00:12:32.900 E. coli is a common contaminant and you find the moment there 154 00:12:32.900 --> 00:12:38.300 is stasis, it is able to adhere to the mucosa and 155 00:12:38.300 --> 00:12:43.800 you find that infections are pretty recalcitrant to treat in this particular 156 00:12:43.800 --> 00:12:49.000 setting. Now this is what we refer to as the triad 157 00:12:49.000 --> 00:12:54.000 of the benign prostatic hyperplasia. There is frequency, there is 158 00:12:54.000 --> 00:12:59.300 urgency and there is hesitancy. Now when we talk about frequency, 159 00:12:59.300 --> 00:13:04.600 the patient has an urge to micturate several times 160 00:13:04.600 --> 00:13:08.900 during the day and also get up several times in the night. 161 00:13:09.200 --> 00:13:12.200 But even though he gets up and has a sensation of a 162 00:13:12.200 --> 00:13:16.800 full bladder, he is able to void only small amounts of urine 163 00:13:16.800 --> 00:13:20.700 at every particular time. When we talk about urgency, there is a 164 00:13:20.700 --> 00:13:25.700 sudden urgent need to micturate and there's also the sense of imminent 165 00:13:25.700 --> 00:13:30.500 loss of control and you find several of these patients also have 166 00:13:30.600 --> 00:13:35.800 incontinence. There is hesitancy because the bladder is now having 167 00:13:35.800 --> 00:13:40.300 to exert a larger amount of force in order to initiate the 168 00:13:40.300 --> 00:13:45.300 urinary stream. Not only is there difficulty in initiation, there is 169 00:13:45.300 --> 00:13:50.400 also an interrupted or a very very weak stream. Now all 170 00:13:50.400 --> 00:13:55.400 of this now contributes to an incomplete bladder emptying. So there 171 00:13:55.400 --> 00:14:00.300 is a sense of a persistent residual urine present and you find 172 00:14:00.300 --> 00:14:04.900 even though the patient is actually micturating a number of times, there 173 00:14:04.900 --> 00:14:09.100 is residual urine and this residual urine, as I alluded to you 174 00:14:09.100 --> 00:14:14.100 earlier, is responsible for the urinary tract infection and possible calculi 175 00:14:14.200 --> 00:14:19.200 formation. The patient also expresses a sense of straining and 176 00:14:19.200 --> 00:14:24.200 very often has to employ a Valsalva maneuver or consciously 177 00:14:24.200 --> 00:14:29.100 contract abdominal musculature in order to generate enough force to be able 178 00:14:29.100 --> 00:14:34.600 to overcome this sense of the bladder outflow obstruction. There 179 00:14:34.600 --> 00:14:38.300 is also a decreased flow of stream and you find at the 180 00:14:38.300 --> 00:14:42.100 end of micturition the patient can also end up having a small 181 00:14:42.100 --> 00:14:47.400 quantity of dribbling because there is a poor very very poor urinary 182 00:14:47.400 --> 00:14:52.100 stream. It is also important to find out about the sense of 183 00:14:52.100 --> 00:14:57.300 the sexual history because several of them can also have associated 184 00:14:57.600 --> 00:15:02.600 erectile dysfunction. So this is the same symptoms which now 185 00:15:02.800 --> 00:15:07.500 I have classified into what we call as the obstructive symptoms and 186 00:15:07.500 --> 00:15:11.700 the irritative symptoms. So the obstructive symptoms are as a result, as 187 00:15:11.700 --> 00:15:16.400 I told you before, about how this compresses on the urethra. There's 188 00:15:16.400 --> 00:15:21.400 poor flow, there's decreased flow, caliber, there's hesitancy, there's straining, 189 00:15:21.400 --> 00:15:27.300 there's terminal dribbling, there's intermittency of stream, a sense of incomplete evacuation 190 00:15:27.500 --> 00:15:30.900 and sometimes patients have to practice what they call as a double 191 00:15:30.900 --> 00:15:35.200 void. They feel that they have passed urine but then afterwards they 192 00:15:35.200 --> 00:15:38.900 realize that if they attempt to pass urine again, they are still 193 00:15:38.900 --> 00:15:43.200 able to overcome that little residue that was sitting in the area 194 00:15:43.500 --> 00:15:48.600 beneath or behind the median lobe. And then you find sometimes 195 00:15:48.600 --> 00:15:53.300 patients can present with what we call as retention, either an acute 196 00:15:53.300 --> 00:15:58.500 retention or a chronic retention. The irritative symptoms on the other hand 197 00:15:58.500 --> 00:16:02.600 happen as a result of the stretching of the bladder wall and 198 00:16:02.600 --> 00:16:05.600 when there is a stretching of the bladder wall, there's also a 199 00:16:05.600 --> 00:16:10.400 stretching of the detrusor muscle and this is responsible for the increased 200 00:16:10.400 --> 00:16:15.900 frequency and the urgency that the patient experiences. So 201 00:16:15.900 --> 00:16:21.400 this is what is called as the the American Neurological Association score 202 00:16:21.500 --> 00:16:26.900 or the International Prostate Symptom Score. So this basically takes into account 203 00:16:27.500 --> 00:16:31.300 the criteria like not at all, less than one, less than half 204 00:16:31.300 --> 00:16:35.400 the time, about half the time, more than half, almost always. And 205 00:16:35.400 --> 00:16:41.200 you find that we use this score to grade the symptoms severity. 206 00:16:41.600 --> 00:16:44.800 So if a person is going to be having a score of 207 00:16:44.800 --> 00:16:49.300 zero to seven, we will refer to it as mild. Anything up 208 00:16:49.300 --> 00:16:54.100 to 19 is considered moderate and anything more than that is considered 209 00:16:54.100 --> 00:16:59.600 severe. Now this is an reasonable guide to determine 210 00:16:59.700 --> 00:17:04.000 the treatment plan that we have for all of these patients. So 211 00:17:04.000 --> 00:17:06.800 look at the questions. It says, do you have a sensation of 212 00:17:06.800 --> 00:17:10.400 not having emptied your bladder? Have you had to urinate less than 213 00:17:10.400 --> 00:17:14.500 two hours? Have you had to stop and start again when you 214 00:17:14.700 --> 00:17:20.000 micturate? How often have you had difficulty in postponing micturition? 215 00:17:20.900 --> 00:17:24.700 What is the nature of the urinary stream? And do you find 216 00:17:24.700 --> 00:17:28.600 how often have you had to push or strain? And how many 217 00:17:28.600 --> 00:17:33.800 times did you actually have to get up to micturate during 218 00:17:33.900 --> 00:17:37.400 the night? So this is in this is the way in which 219 00:17:37.500 --> 00:17:42.800 we will calculate what I call as the IPSS 220 00:17:42.800 --> 00:17:46.900 score. So this is what I told you before where it basically 221 00:17:46.900 --> 00:17:50.700 takes into account all of these features. In addition, a few other 222 00:17:50.700 --> 00:17:55.900 variables are included and and that is the difference between the American 223 00:17:55.900 --> 00:18:01.000 neurological score and the IPSS. Now how do we make a clinical 224 00:18:01.000 --> 00:18:06.400 diagnosis? As always, there is no substitute for a clinical examination 225 00:18:06.600 --> 00:18:11.300 and based upon the symptoms that we think, based upon very often 226 00:18:11.300 --> 00:18:14.700 the age of the patient, we do what we call as the 227 00:18:14.700 --> 00:18:19.900 direct rectal examination. There's what's called as the Roger Bond's 228 00:18:20.000 --> 00:18:25.100 grading and today we have moved away from a rectal examination 229 00:18:25.100 --> 00:18:30.200 based on grading to more of an ultrasound guided grading. Basically, you 230 00:18:30.200 --> 00:18:35.600 find that one width of the finger is considered as accommodating. A 231 00:18:35.600 --> 00:18:40.600 normal prostate will accommodate two finger breadths. So that is considered normal. 232 00:18:40.900 --> 00:18:44.800 One finger breadth is a rough guide of 15 grams. All right, 233 00:18:44.900 --> 00:18:49.600 so this is just an arbitrary grade but basically we are able 234 00:18:49.600 --> 00:18:54.800 to assess that when we do a rectal examination, whether the prostate 235 00:18:54.900 --> 00:18:59.600 is actually bulging into the lumen of the rectum that we are 236 00:18:59.600 --> 00:19:04.600 able to feel through the muscular wall. Now what are 237 00:19:04.600 --> 00:19:09.200 some of the investigations that we will do? You find that before 238 00:19:09.200 --> 00:19:12.500 we start the investigation, we are looking to see what is the 239 00:19:12.500 --> 00:19:17.100 prostate size? Are we seeing any contour? Are we able to assess 240 00:19:17.100 --> 00:19:22.600 any areas of nodularity and am I able to assess any particular 241 00:19:22.800 --> 00:19:27.800 focal areas of hardness which could be a harbinger of malignancy? 242 00:19:28.200 --> 00:19:30.800 Remember at the beginning of the class, I did tell you that 243 00:19:30.800 --> 00:19:35.600 the transition zone is responsible for hyperplasia and the peripheral zone is 244 00:19:35.600 --> 00:19:40.200 responsible for malignancy. So you find that the peripheral zone is more 245 00:19:40.200 --> 00:19:45.700 often appreciated on a DRE and you find a nodularity there. Could 246 00:19:45.700 --> 00:19:50.300 be a harbinger of malignancy though I'm not actually getting into a 247 00:19:50.300 --> 00:19:54.600 discussion of that today. You find that what we can do is 248 00:19:54.600 --> 00:19:58.800 the blood urea and creatinine. You remember I said that as a 249 00:19:58.800 --> 00:20:02.800 result of the outflow obstruction, you find that there is a back 250 00:20:02.800 --> 00:20:07.200 pressure effect and as a result of this back pressure effect, it 251 00:20:07.200 --> 00:20:12.800 goes and it compresses on the the outflow, the ureter 252 00:20:12.800 --> 00:20:18.200 dilates, hydroureter, hydroureteronephrosis and when there is a compromise 253 00:20:18.200 --> 00:20:21.800 of the renal function, there will be an elevation of both the 254 00:20:21.800 --> 00:20:27.000 blood urea nitrogen as well as the creatinine. We also look 255 00:20:27.000 --> 00:20:31.400 at the uroflowmetry. We're looking to see we have the uroflow machines 256 00:20:31.400 --> 00:20:34.200 and we look to see how much time the patient takes to 257 00:20:34.200 --> 00:20:39.300 be able to enter completely void and this uroflowmetry is 258 00:20:39.300 --> 00:20:44.100 also used as a measure of the prostatic hypertrophy. But the gold 259 00:20:44.100 --> 00:20:48.300 standard that we use often in all of this is the ultrasonogram. 260 00:20:48.500 --> 00:20:53.300 The ultrasonogram will be able to tell you either a regular transabdominal 261 00:20:53.300 --> 00:20:58.600 ultrasound or often a transrectal ultrasound will tell you 262 00:20:58.700 --> 00:21:02.800 the size of the prostate and it will tell you whether which 263 00:21:02.800 --> 00:21:07.000 of the lobes are enlarged. It will also tell you what is 264 00:21:07.000 --> 00:21:12.100 the approximate volume of enlargement and this is often a good 265 00:21:12.100 --> 00:21:17.100 guide for us to plan any kind of definitive procedures. Now 266 00:21:17.100 --> 00:21:22.300 you find that the complications like urinary retention, renal insufficiency, urinary 267 00:21:22.300 --> 00:21:27.500 tract infections, hematuria, bladder calculi or 268 00:21:27.500 --> 00:21:32.500 uremia can sometimes also be the presenting features. So it's important 269 00:21:32.500 --> 00:21:37.200 for us to have that as a differential BPH as a differential 270 00:21:37.200 --> 00:21:42.400 when patients present with the symptoms of retention or even insufficiency, 271 00:21:42.400 --> 00:21:47.300 recurrent urinary tract infections and you find the presence of bladder calculi 272 00:21:47.500 --> 00:21:52.700 or renal failure. Now when we're looking at who are the people 273 00:21:52.700 --> 00:21:57.000 who are going to require treatment, you find that we have to 274 00:21:57.000 --> 00:22:00.600 first of all start off by telling these patients that it is 275 00:22:00.600 --> 00:22:05.700 important to have some moderation or an alteration in 276 00:22:05.700 --> 00:22:10.700 the way in which they are going about their activities of daily 277 00:22:10.700 --> 00:22:15.400 living. You find that we would encourage them to consume large drink 278 00:22:15.400 --> 00:22:19.900 large quantities of fluid because you find that it will help. We 279 00:22:19.900 --> 00:22:24.500 will also instruct them to ensure to prevent the urinary tract infections 280 00:22:24.700 --> 00:22:29.800 even though it sounds counter intuitive. You want to ask them to 281 00:22:29.800 --> 00:22:35.200 consciously go and empty their bladder every few hours thereby 282 00:22:35.200 --> 00:22:40.300 preventing the possibility of urine retaining, possibility of urinary 283 00:22:40.300 --> 00:22:45.500 tract infection and the possibility of the bladder hypertrophy and 284 00:22:45.500 --> 00:22:50.200 trabeculations happening. You find that we would also ask them to avoid 285 00:22:50.200 --> 00:22:55.500 agents which would cause the alpha one receptors to go into 286 00:22:55.500 --> 00:23:00.800 hyperactivity. So products like caffeine are to be avoided. You 287 00:23:00.800 --> 00:23:05.900 find that all these would also be instructions that would help 288 00:23:05.900 --> 00:23:09.400 these patients. You find that in all of these patients we would 289 00:23:09.400 --> 00:23:13.000 also like to do a urine analysis because we want to make 290 00:23:13.000 --> 00:23:18.100 sure that there is no urinary tract infection. The PSA, which 291 00:23:18.100 --> 00:23:22.900 has been spoken about, it can be increased in cases with a 292 00:23:22.900 --> 00:23:27.400 prostatic hypertrophy and you find that we are not using PSA as 293 00:23:27.400 --> 00:23:32.400 a landmark or as a guide for determining treatment plans. It is 294 00:23:32.400 --> 00:23:37.600 more often used as an indicator for prostatic malignancy. Now 295 00:23:37.600 --> 00:23:42.600 here is the paradox. An elevated PSA can identify a 296 00:23:42.600 --> 00:23:48.600 coexisting prostatic carcinoma that would not have been flagged in 297 00:23:48.600 --> 00:23:53.600 the routine course and therefore we included because we want to make 298 00:23:53.600 --> 00:23:58.800 sure that we are not missing an associated prostatic 299 00:23:58.900 --> 00:24:03.900 malignancy. So you find that the screening for prostatic and for 300 00:24:03.900 --> 00:24:08.000 prostatic carcinoma, it it is not within the purview of this topic 301 00:24:08.100 --> 00:24:11.700 but you find that if you are looking at men more than 302 00:24:11.700 --> 00:24:15.800 50 who are expected to live for more than another more 10 303 00:24:15.800 --> 00:24:18.800 years, then they would be the patients that you're going to add 304 00:24:18.800 --> 00:24:21.500 a PSA. You find that if you're looking at a patient who's 305 00:24:21.500 --> 00:24:26.600 45 years who have a first degree relative already identified, that would 306 00:24:26.600 --> 00:24:29.700 be a case where you would look at a PSA. You find 307 00:24:29.700 --> 00:24:32.800 that you would do a PSA in a man who's 40 years 308 00:24:32.900 --> 00:24:37.900 because he's already had one prostate cancer in the family. 309 00:24:38.000 --> 00:24:41.800 So that would be. So it's 40, 45 and 50 years of 310 00:24:41.800 --> 00:24:46.900 age when you are looking at the evaluation. So you find that 311 00:24:46.900 --> 00:24:50.900 when we are talking about the ultrasound, you find that in these 312 00:24:50.900 --> 00:24:55.300 patients when you are doing the ultrasound, not only are you documenting 313 00:24:55.300 --> 00:24:59.400 the prostate size, you are also looking at what we call as 314 00:24:59.400 --> 00:25:04.230 the void residue. Now for those of you who've heard lectures on 315 00:25:04.930 --> 00:25:08.030 hernia, very often they tell you that you look at the post 316 00:25:08.030 --> 00:25:13.030 void residue and if the post void residue is elevated, you find 317 00:25:13.030 --> 00:25:17.630 that that you would treat the prostate first before you actually treat 318 00:25:17.630 --> 00:25:22.630 the hernia and this is a clinical pearl worth remembering. It is 319 00:25:22.630 --> 00:25:26.130 also important for us while doing the ultrasound to look for other 320 00:25:26.130 --> 00:25:29.630 things. You don't have to be focused only on the prostate that 321 00:25:29.630 --> 00:25:34.030 you don't look at other symptoms like you would also look at 322 00:25:34.030 --> 00:25:39.530 any other reasons for prostatic for a bladder outflow 323 00:25:39.530 --> 00:25:45.530 obstruction and this is particular in a patient who is having hematuria 324 00:25:45.630 --> 00:25:50.630 when patient has a concomitant history of urolithiasis and you find when 325 00:25:50.630 --> 00:25:55.630 there is a history of upper urinary tract infections. So 326 00:25:55.630 --> 00:25:59.530 you find that when I am looking at what are the tests, 327 00:25:59.830 --> 00:26:03.830 I'm just recapping these tests before we go on to the treatment 328 00:26:03.930 --> 00:26:08.830 just as a form of reinforcement. So one you do a digital 329 00:26:08.830 --> 00:26:13.630 rectal examination to document the prostate size and any kind of contour 330 00:26:13.730 --> 00:26:18.330 abnormalities. You find that you offer PSA when you think that there 331 00:26:18.330 --> 00:26:22.830 is a need. You need to document the symptoms based upon the 332 00:26:22.830 --> 00:26:28.130 international prostate symptoms score or the AUA score and 333 00:26:28.130 --> 00:26:32.530 you find that you also ask about what we call as the 334 00:26:32.530 --> 00:26:37.830 optional test like the uroflow, the uroflowmetry and also 335 00:26:37.830 --> 00:26:42.830 you look at the bladder neck manometry in indicated cases. 336 00:26:43.430 --> 00:26:48.730 We do a cytology and sensitivity of the urine and 337 00:26:48.730 --> 00:26:53.730 you can also include cystoscopy of the urinary 338 00:26:53.730 --> 00:26:58.930 tract. Now the reason we include cystoscopy is that sometimes 339 00:26:59.230 --> 00:27:04.630 there can be an association of a urothelial malignancy coexisting 340 00:27:04.630 --> 00:27:09.230 in these patients. So my professor used to say when in doubt 341 00:27:09.230 --> 00:27:14.230 shine a light. So always include cystoscopy in your 342 00:27:14.230 --> 00:27:19.730 armamentarium especially when hematuria is indicated. You 343 00:27:19.730 --> 00:27:24.530 find that when there is an associated hypertrophy and when there is 344 00:27:24.530 --> 00:27:29.730 a prostatic hypertrophy and there is a suspicious area on an ultrasound 345 00:27:29.830 --> 00:27:34.830 imaging, it is possible for us to combine a biopsy in these 346 00:27:34.930 --> 00:27:40.330 patients. So once we have made a diagnosis of prostatic 347 00:27:40.330 --> 00:27:45.730 hypertrophy and we feel that these are patients who will benefit 348 00:27:45.730 --> 00:27:50.730 by some form of therapy even after the the symptoms are not 349 00:27:50.730 --> 00:27:55.230 relieved by all of the lifestyle modification methods that we had indicated 350 00:27:55.430 --> 00:28:00.430 like asking the patients to you know have frequent micturition. 351 00:28:00.630 --> 00:28:05.630 Then there is a case for using medical line of management. 352 00:28:06.230 --> 00:28:09.330 So at this point I will reiterate some of the points that 353 00:28:09.330 --> 00:28:14.630 I spoke about in the pathophysiology. I told you that the reason, 354 00:28:14.630 --> 00:28:19.830 one of the reasons for an increase in the prostatic volume was 355 00:28:19.830 --> 00:28:24.430 the increase in the DHT levels. So you can use agents to 356 00:28:24.430 --> 00:28:30.430 reduce DHT. What risk what is responsible for the production of DHT? 357 00:28:30.730 --> 00:28:35.930 It was the conversion from testosterone to DHT by the enzyme 5 358 00:28:35.930 --> 00:28:39.730 alpha reductase. So it is possible for me to go ahead and 359 00:28:39.730 --> 00:28:44.730 use an agent to inhibit this 5 alpha reductase. I 360 00:28:44.730 --> 00:28:48.630 also told you that we have alpha blockers which are smooth muscle 361 00:28:49.230 --> 00:28:54.230 contractors which are present in the bladder neck. So you 362 00:28:54.230 --> 00:28:58.630 can go ahead and use alpha blockers. All right. So these are 363 00:28:58.630 --> 00:29:03.830 the commonly used drugs in the medical management and you find 364 00:29:03.830 --> 00:29:08.530 that they use the alpha blockers. Alpha blockers go and block the 365 00:29:08.530 --> 00:29:13.330 alpha receptors which is responsible for the increased tone of the muscles 366 00:29:13.830 --> 00:29:17.030 and you find that we have a whole group of alpha blockers. 367 00:29:17.330 --> 00:29:22.730 We started off with phenoxybenzamine which was a non-selective alpha blocker. Now 368 00:29:22.730 --> 00:29:26.230 today we have an alpha one blocker. Alpha one blockers can be 369 00:29:26.230 --> 00:29:31.130 classified as the short acting as well as the long acting alpha 370 00:29:31.130 --> 00:29:36.430 blockers. So you have prazosin, alfuzosin, indoramin and when we're talking 371 00:29:36.430 --> 00:29:41.430 about a long acting blocker, we have terazosin, doxazosin and 372 00:29:41.530 --> 00:29:46.830 alfuzosin within a sustained release form. Now we also 373 00:29:46.830 --> 00:29:50.430 have a finer division of that when we call about we refer 374 00:29:50.430 --> 00:29:54.930 to it as the alpha one agent and we have the tamsulosin 375 00:29:54.930 --> 00:29:59.930 which is what everybody nowadays uses along with the silodosin and it 376 00:29:59.930 --> 00:30:03.930 is also possible for me to use a combination of a 5 377 00:30:03.930 --> 00:30:09.230 alpha reductase inhibitor along with a combination of an alpha 378 00:30:09.230 --> 00:30:14.330 blocker either with a either with either 379 00:30:14.330 --> 00:30:19.530 you know a selective or a non-selective alpha blocker. So this combination 380 00:30:19.630 --> 00:30:23.530 works very very well. Now you remember at the beginning I said 381 00:30:23.630 --> 00:30:28.230 that there is also another component of the metabolic syndrome which are 382 00:30:28.230 --> 00:30:33.230 kind of is believed to contribute to the hypertrophy. So in 383 00:30:33.230 --> 00:30:36.830 all of these patients it is very very important for you to 384 00:30:36.830 --> 00:30:41.830 control their diabetic status. So if patients are diabetic 385 00:30:42.030 --> 00:30:46.330 and they have a BPH also, they far have found that a 386 00:30:46.330 --> 00:30:51.330 control of the sugar status is responsible with a reduction 387 00:30:51.330 --> 00:30:56.330 in the severity of the symptoms. So today we will definitely try 388 00:30:56.330 --> 00:31:00.830 with the alpha blocker and with the combination. There is often a 389 00:31:00.830 --> 00:31:06.430 4 to 6 degree or 6 point improvement in the score 390 00:31:06.530 --> 00:31:11.630 in all of these patients who have been uh treated with these 391 00:31:11.730 --> 00:31:15.430 drugs. Okay. I am not going into the dosage of all of 392 00:31:15.430 --> 00:31:18.630 it and that will be the learning exercise for you where you 393 00:31:18.630 --> 00:31:22.730 get familiar with what are the brands, what are the doses, which 394 00:31:22.730 --> 00:31:27.830 is remember that the understand the pathophysiology of how you are 395 00:31:27.830 --> 00:31:32.930 going to treat these patients. Now when you have put these patients 396 00:31:32.930 --> 00:31:36.830 on medication and you have followed them for a period of about 397 00:31:37.330 --> 00:31:40.430 6 months and in that case you go ahead and then you 398 00:31:40.430 --> 00:31:45.330 take a decision whether these are patients who are having an improvement 399 00:31:45.330 --> 00:31:49.230 in the symptoms as a result of the medication or there has 400 00:31:49.230 --> 00:31:54.430 been no improvement and whether there is a case for 401 00:31:54.430 --> 00:31:59.730 indication for surgery. The classical indications for surgery are acute 402 00:31:59.730 --> 00:32:04.730 retention, chronic retention and the presence of complications or when 403 00:32:04.730 --> 00:32:09.330 it affects activities of daily living. So what do I mean by 404 00:32:09.330 --> 00:32:14.630 acute retention? Suddenly the patient comes into your emergency with acute 405 00:32:14.630 --> 00:32:19.330 retention and that would be an indication that the prostate is large 406 00:32:19.330 --> 00:32:23.730 enough. So these are the patients who come into the emergency room 407 00:32:23.930 --> 00:32:29.230 require either a specialist to pass in the smallest possible catheter 408 00:32:29.230 --> 00:32:34.230 into the urinary bladder or failing which you can do a 409 00:32:34.630 --> 00:32:39.630 suprapubic puncture in order to prevent an occurrence of a bladder rupture. 410 00:32:39.930 --> 00:32:44.830 So an acute retention is an emergency requires fixing and you find 411 00:32:44.830 --> 00:32:50.030 that this is something that every undergraduate, every medical officer 412 00:32:50.130 --> 00:32:54.330 needs to know how to deal with the acute retention. Now you 413 00:32:54.330 --> 00:32:57.530 find that chronic retention on the other hand is when the symptoms 414 00:32:57.530 --> 00:33:02.730 are such that the patient is actually not seeking attention 415 00:33:02.730 --> 00:33:07.830 or not seeking hospital care or a consultation for the retention per 416 00:33:07.830 --> 00:33:11.530 se. But when you are doing an ultrasound either as a part 417 00:33:11.530 --> 00:33:16.730 of a master health checkup or as a result of a screening 418 00:33:16.730 --> 00:33:20.230 for any other procedure like I mentioned before for a hernia, you're 419 00:33:20.230 --> 00:33:24.730 finding a post void residue. Normally at the end of micturition the 420 00:33:24.730 --> 00:33:28.630 bladder is expected to be empty. But what happens in these patients 421 00:33:28.630 --> 00:33:33.530 is that it bulges into the prostatic urethra and as a result 422 00:33:33.530 --> 00:33:37.530 of which the urine is not able to overcome that little bump 423 00:33:37.530 --> 00:33:40.830 produced and as a result of which there is a retention and 424 00:33:40.830 --> 00:33:45.530 when this post void residue is greater than 200 ml, we say 425 00:33:45.530 --> 00:33:49.330 150 to 200 you find that that would be an indication to 426 00:33:49.330 --> 00:33:52.830 go ahead and fix the prostate. Now you find that any of 427 00:33:52.830 --> 00:33:57.830 the complications that I spoke about earlier, hematuria, presence of calculi, the 428 00:33:57.830 --> 00:34:02.930 presence of trabeculations, you find muscular hypertrophy, you 429 00:34:02.930 --> 00:34:08.030 find a hydroureter, hydronephrosis in all of these cases that 430 00:34:08.030 --> 00:34:13.030 is straight away an indication for surgery. So you find that 431 00:34:13.330 --> 00:34:18.430 when we talk about surgical options, the gold standard is what we 432 00:34:18.430 --> 00:34:24.130 talk as the transurethral rectal resection of the prostate. Now 433 00:34:24.130 --> 00:34:26.930 you find that when we were medical students, you find that they 434 00:34:26.930 --> 00:34:31.530 used to do an open prostatectomy. Today we have moved away from 435 00:34:31.530 --> 00:34:35.830 open prostatectomy and today the gold standard for every patient who has 436 00:34:36.030 --> 00:34:41.230 a prostatic hypertrophy is the transurethral resection 437 00:34:41.430 --> 00:34:46.030 of the prostate itself. Now you find that there are multiple other 438 00:34:46.030 --> 00:34:50.730 options that you have, but you find that the gold standard as 439 00:34:50.730 --> 00:34:55.430 I mentioned is the transurethral resection of prostate. So how do we 440 00:34:55.430 --> 00:35:00.730 do this transurethral resection of prostate? You find that we use either 441 00:35:00.730 --> 00:35:05.830 a general or a spinal regional anesthesia. It's certainly more 442 00:35:05.830 --> 00:35:09.630 comfortable to go ahead with a general anesthesia and then we use 443 00:35:09.630 --> 00:35:13.430 a cystoscope or a working sheet and in that working sheet you 444 00:35:13.430 --> 00:35:18.730 have a side sheet through which you using a handheld device. It 445 00:35:18.730 --> 00:35:23.230 has an attached wire loop and you find we're using a high 446 00:35:23.230 --> 00:35:28.630 energy electrical cutting current. All right. So we have this uh through 447 00:35:28.630 --> 00:35:33.730 the urethra. We introduce this cystoscope and 448 00:35:33.730 --> 00:35:38.930 through that cystoscope side channel we use an electrical current and we 449 00:35:38.930 --> 00:35:44.030 end up shaving off prostatic tissue. Now as we shave off 450 00:35:44.030 --> 00:35:49.030 the prostatic tissue, we have to be constantly aware of the prostatic 451 00:35:49.130 --> 00:35:54.230 venous plexus. The whole process is now connected to an eyepiece. You 452 00:35:54.230 --> 00:35:56.830 have a video through which we would be able to see it 453 00:35:56.930 --> 00:36:01.230 and today we are even able to connect it to a screen 454 00:36:01.430 --> 00:36:05.130 so that the others are also able to see the procedure as 455 00:36:05.130 --> 00:36:09.530 the surgeon shaves away. It's it's like peeling a carrot for lack 456 00:36:09.530 --> 00:36:13.730 of a big better example. So layer by layer you are taking 457 00:36:13.730 --> 00:36:18.830 off shavings of the prostate and thereby you are reducing 458 00:36:18.830 --> 00:36:24.230 the amount of the prostate that is present and very often whatever 459 00:36:24.230 --> 00:36:28.930 has been shaved off is collected and measured and often they will 460 00:36:28.930 --> 00:36:33.830 say so much grams of prostate removed and you find that this 461 00:36:33.830 --> 00:36:38.830 is the way in which a transurethral resection of prostate is 462 00:36:38.830 --> 00:36:42.030 done. Now remember that as you are shaving there's going to be 463 00:36:42.130 --> 00:36:46.230 bleeding and this bleeding can obscure your field. So therefore you also 464 00:36:46.230 --> 00:36:50.130 have a side channel where we use an irrigating fluid and this 465 00:36:50.130 --> 00:36:54.630 irrigating fluid helps to clear away the uh shavings as we call 466 00:36:54.630 --> 00:36:58.630 it and it also helps to tell you whether there is bleeding 467 00:36:58.630 --> 00:37:02.730 present and it kind of helps to clear this particular field. Now 468 00:37:02.730 --> 00:37:06.930 this electrical current is crucial to the process and we can use 469 00:37:06.930 --> 00:37:10.930 it to fulgurate even the bleeding spots and at the end of 470 00:37:10.930 --> 00:37:15.830 the procedure we leave a catheter in place. Now you find that 471 00:37:15.830 --> 00:37:20.730 this catheter serves as uh serves two functions. One, it has a 472 00:37:20.730 --> 00:37:25.830 tamponade effect that it prevents minor little oozes that have happened 473 00:37:25.930 --> 00:37:30.730 as a result of the disruption of the plexuses. It also ensures 474 00:37:30.930 --> 00:37:34.430 that their patient does not have to get up and has some 475 00:37:34.430 --> 00:37:39.230 amount of comfort in the immediate post operative period. All right. So 476 00:37:39.230 --> 00:37:43.730 the points to remember it is a transurethral process. We are using 477 00:37:43.730 --> 00:37:48.430 a cystoscope. It is a high energy source. We are using an 478 00:37:48.430 --> 00:37:53.330 electrical cutting device. We have a side channel for irrigation. We can 479 00:37:53.330 --> 00:37:58.730 have another side channel for the process of having uh a video 480 00:37:58.830 --> 00:38:02.530 or or a monitor and you find we leave a urinary catheter 481 00:38:02.630 --> 00:38:07.630 in place until the bleeding has almost cleared. So this is the 482 00:38:07.630 --> 00:38:12.330 way in which we go ahead with the process of doing the 483 00:38:12.830 --> 00:38:17.930 uh transurethral resection of prostate. Now when I'm going to be 484 00:38:17.930 --> 00:38:23.230 talking about the complications that are associated, I want you to recall 485 00:38:23.230 --> 00:38:27.230 in your mind's eye the anatomy of what I was talking about. 486 00:38:27.430 --> 00:38:31.130 So you know that when you were looking at the picture of 487 00:38:31.130 --> 00:38:35.830 the prostate, it was very very close to the sphincter. All right. 488 00:38:35.930 --> 00:38:39.030 So we were talking about the perineum. We were talking about the 489 00:38:39.030 --> 00:38:44.330 perineal musculature. So when you are shaving away bits of tissue, 490 00:38:44.530 --> 00:38:49.530 it can be associated with some amount of incontinence and 491 00:38:49.530 --> 00:38:54.630 that occasionally occurs and is less than 1%. Now you 492 00:38:54.630 --> 00:38:58.930 remember the opening of the ejaculatory duct and you find that one 493 00:38:58.930 --> 00:39:02.030 of the functions of the prostate is that that at the time 494 00:39:02.030 --> 00:39:06.330 of ejaculation you find a kind of bulges in and prevents the 495 00:39:06.330 --> 00:39:11.330 ejaculate from going back into the bladder and it kind 496 00:39:11.330 --> 00:39:15.930 of forces it out through the prostatic urethra. So you find the 497 00:39:15.930 --> 00:39:20.330 moment the prostate is removed or removed in a little too much 498 00:39:20.330 --> 00:39:25.330 fashion, you find that patients can have retrograde ejaculation 499 00:39:25.430 --> 00:39:29.730 in as high as 15%. 5 to 10% of the time they 500 00:39:29.730 --> 00:39:34.730 can be associated with impotence and a too vigorous curettage of 501 00:39:34.730 --> 00:39:39.930 the bladder neck is associated with scarring and in the late feature 502 00:39:40.030 --> 00:39:44.830 it can result in contractures. The TURP syndrome is when you find 503 00:39:44.830 --> 00:39:48.230 that as a result of opening of of the venous plexuses and 504 00:39:48.230 --> 00:39:52.630 you use an irrigating solution, you find that it can result in 505 00:39:52.730 --> 00:39:56.830 a dilution. There is more absorption of water and as a result 506 00:39:56.830 --> 00:40:01.530 of which you can have hyponatremia and you can also have the 507 00:40:01.530 --> 00:40:05.930 occurrence of lightheadedness as a result of the low sodium. But today 508 00:40:05.930 --> 00:40:11.230 when we are using solutions like normal saline or isotonic saline, we 509 00:40:11.230 --> 00:40:17.430 often don't see this particular complications in the present population. Now 510 00:40:17.430 --> 00:40:22.430 these are more anecdotal in the completion of the discussion of the 511 00:40:22.430 --> 00:40:26.030 topic and you we used to do a transverse cycle, the so-called 512 00:40:26.130 --> 00:40:30.330 open procedure used to be done and today the neither the transverse 513 00:40:30.330 --> 00:40:35.430 cycle or the retroperitoneal or the perineal prostatectomies are ever done and 514 00:40:35.430 --> 00:40:39.730 I think medical students today hardly see this. This is more of 515 00:40:39.730 --> 00:40:44.830 historical application. Now there are some amount of minimal 516 00:40:44.830 --> 00:40:50.330 invasive therapies. Now when I say minimal invasive therapies, these are indicated 517 00:40:50.630 --> 00:40:55.830 in patients who are not fit candidates for anesthesia. 518 00:40:56.230 --> 00:41:01.230 Some of them are being tried in controlled settings like 519 00:41:01.230 --> 00:41:06.230 clinical trials and you find that some of them are also experimental 520 00:41:06.330 --> 00:41:11.130 in nature. So these are informations that I just want you to 521 00:41:11.130 --> 00:41:15.330 listen to and be familiar with them and rather not use it 522 00:41:15.330 --> 00:41:20.030 as the first answer in any of your discussions. So you find 523 00:41:20.030 --> 00:41:25.030 that instead of doing a transurethral resection of the prostate, you 524 00:41:25.030 --> 00:41:27.930 can go ahead and make an incision. This is something like the 525 00:41:27.930 --> 00:41:32.030 dorsal slit that we do when we are talking about a circumcision, 526 00:41:32.130 --> 00:41:37.030 right? So quite like that instead of actually resecting elements away, you 527 00:41:37.030 --> 00:41:40.330 can do it in a patient who is a high risk, who's 528 00:41:40.330 --> 00:41:43.930 not going to withstand a long procedure, who cannot tolerate the blood 529 00:41:43.930 --> 00:41:48.430 loss. So this is something that can be offered. It's like partially 530 00:41:48.630 --> 00:41:52.630 cutting something that's producing a constricting effect. You kind of opening it 531 00:41:52.630 --> 00:41:57.630 out without actually shaving it all up. Now lasers are something that 532 00:41:57.630 --> 00:42:02.330 are available today and you find that several forms of laser beams 533 00:42:02.430 --> 00:42:07.430 are available for prostatic management. So you find that the what 534 00:42:07.430 --> 00:42:12.030 we call as the KTP laser, the holmium laser are some things 535 00:42:12.030 --> 00:42:16.630 which are used both as a cutting as well as a vaporizing 536 00:42:16.630 --> 00:42:19.230 tool. All right. So not only can you use it as a 537 00:42:19.230 --> 00:42:23.830 cutting instrument, you can use it to vaporize it and as a 538 00:42:23.830 --> 00:42:27.730 result of which it helps to reduce the amount of prostate which 539 00:42:27.730 --> 00:42:32.830 is present and thereby reduce the amount of obstruction that is 540 00:42:32.830 --> 00:42:35.930 present. So you today we can go ahead and do what we 541 00:42:35.930 --> 00:42:41.330 call as the transurethral vaporization or transurethral 542 00:42:41.730 --> 00:42:47.030 ablation using some of these lasers. Of course when you're using lasers, 543 00:42:47.030 --> 00:42:50.630 you need to be familiar with it because there is no tactile 544 00:42:50.630 --> 00:42:55.030 feedback. All right. It's a light source and you find that it 545 00:42:55.030 --> 00:43:00.130 it can end up causing perforation in the process of 546 00:43:00.130 --> 00:43:04.830 the early learning curve. We can also go ahead and do do 547 00:43:04.830 --> 00:43:08.330 what we call as microwave. So all of this works on the 548 00:43:08.330 --> 00:43:12.230 concept that you are using an energy source. You remember when I 549 00:43:12.230 --> 00:43:15.330 was talking to you about TURP, I spoke to you about it 550 00:43:15.330 --> 00:43:20.030 being an electrical energy. So instead of the electrical energy here today, 551 00:43:20.230 --> 00:43:23.830 you can go ahead and use a microwave, you can use an 552 00:43:23.830 --> 00:43:28.030 ultrasound, you can use a radio frequency or you can use a 553 00:43:28.030 --> 00:43:32.630 laser in order to create some form of an energy that allows 554 00:43:32.630 --> 00:43:37.630 you to peel, shape away all of this prostatic tissue and 555 00:43:37.630 --> 00:43:42.930 result in restoration of the passage. You find that mechanical approaches 556 00:43:43.030 --> 00:43:48.130 that are often experimental again, anecdotal probably in 557 00:43:48.130 --> 00:43:53.030 the con into the paragraph on recent advances. You can talk about 558 00:43:53.030 --> 00:43:57.730 the role of prostatic stent and arterial embolization. So you find that 559 00:43:57.730 --> 00:44:02.330 with that I come to my very last slide and this is 560 00:44:02.330 --> 00:44:07.130 basically a recap or uh you know a summation of all of 561 00:44:07.130 --> 00:44:10.830 what we spoke about spoke about. So when we have a patient 562 00:44:10.830 --> 00:44:14.730 who comes, the history is very very important because these are patients 563 00:44:14.930 --> 00:44:19.130 who are going to who are going to present either with obstructive 564 00:44:19.130 --> 00:44:23.830 symptoms or symptoms as a result of irritation. So you find that 565 00:44:23.830 --> 00:44:29.930 the symptoms are going to include hematuria, frequency, hesitancy, 566 00:44:30.030 --> 00:44:35.030 straining, weak stream and you find sometimes incontinence. You 567 00:44:35.030 --> 00:44:38.530 find that in these patients, so the very first box right on 568 00:44:38.530 --> 00:44:41.330 top. So what we're going to do is we're going to do 569 00:44:41.330 --> 00:44:46.330 a direct examination and we go ahead and do a focused physical 570 00:44:46.430 --> 00:44:50.830 examination. So when I say a focused physical examination, we are looking 571 00:44:50.830 --> 00:44:55.130 at the lobes and today the ultrasound is also considered as an 572 00:44:55.130 --> 00:44:59.530 extension of the patients of the clinicians. We would like to look 573 00:44:59.530 --> 00:45:03.330 at the urine to make sure that there is no urinary uh 574 00:45:03.330 --> 00:45:07.230 infection, that there are no crystals present, that there is no long 575 00:45:07.230 --> 00:45:10.830 standing. And you remember I spoke to you about the role of 576 00:45:10.830 --> 00:45:15.930 the prostate specific antigen in select patients, those with 40, those 577 00:45:15.930 --> 00:45:20.930 at 45 and those at 50. Then you find that when there 578 00:45:20.930 --> 00:45:26.330 are any kind of symptoms like gross hematuria, 579 00:45:26.630 --> 00:45:31.830 bladder stones, recurrent UTI and renal insufficiency. This is what I refer 580 00:45:31.830 --> 00:45:36.730 to as the complications as a result and that straight away is 581 00:45:36.730 --> 00:45:41.930 an indication for surgery. Otherwise I am looking at the AUA 582 00:45:41.930 --> 00:45:45.630 score or the IPSS score and then I'm going to decide whether 583 00:45:45.630 --> 00:45:51.330 the patients require surgery or whether they can be managed with modification 584 00:45:51.330 --> 00:45:56.430 of lifestyle, medication or whether they're going to progress. So when these 585 00:45:56.430 --> 00:46:00.530 symptoms are less than seven, you find that we are basically telling 586 00:46:00.530 --> 00:46:05.230 them lifestyle modification. So anything more than eight, then I have to 587 00:46:05.230 --> 00:46:08.530 take a call and I have to make sure that there are 588 00:46:08.630 --> 00:46:13.030 no other features of bladder neck obstruction. So I will do a 589 00:46:13.030 --> 00:46:17.330 uroflow. I will look at the post void residue. Remember the magic 590 00:46:17.330 --> 00:46:21.730 number 150 to 200 and then we will have a conversation with 591 00:46:21.730 --> 00:46:25.830 the patient about the treatment options. So then we're talking about the 592 00:46:25.830 --> 00:46:30.830 non-invasive where we're looking at the watchful waiting or the medical treatment 593 00:46:30.930 --> 00:46:34.430 and under medical treatment I spoke to you about the role of 594 00:46:34.430 --> 00:46:38.130 the alpha blockade. I also spoke to you about the role of 595 00:46:38.130 --> 00:46:43.330 the 5 alpha reductase inhibitors. Now when the patient decides to go 596 00:46:43.330 --> 00:46:47.630 in for surgery, then you know it is important for you to 597 00:46:47.630 --> 00:46:52.730 actually go ahead and do other tests including tests of evaluation 598 00:46:52.730 --> 00:46:57.530 for these patients for anesthetic fitness and then I will go ahead 599 00:46:57.530 --> 00:47:02.930 and offer surgery and the gold standard there is the transurethral resection 600 00:47:02.930 --> 00:47:08.030 of prostate. What are some of the complications of surgery? One is 601 00:47:08.030 --> 00:47:13.030 the occurrence of incontinence. Second is the possibility of retrograde ejaculation, 602 00:47:13.230 --> 00:47:18.730 long-term effects like bladder neck contracture and occasionally the TURP 603 00:47:18.730 --> 00:47:23.830 syndrome. The role of minimal invasive therapies is into the 604 00:47:24.430 --> 00:47:29.430 realms of recent advances. So with this I would like to 605 00:47:29.430 --> 00:47:30.030 conclude.