Management of Benign Prostatic Hypertrophy - part 1 pptx

DONAHUE, MD • Department of Urology, National Naval Medical Center; Center for Prostate Disease Research, Department of Surgery, Uniformed Services University of Health Sciences, Bethesd

Edited by

Management of

Benign Prostatic

Hypertrophy

Humana Press

MANAGEMENT OF BENIGN PROSTATIC HYPERTROPHY

C URRENT C LINICAL U ROLOGY

Eric A Klein, SERIES EDITOR

Essential Urology: A Guide to Clinical Practice, edited by Jeannette

Prostate Cancer Screening, edited by Ian M Thompson, Martin I.

Resnick, and Eric A Klein, 2001

Bladder Cancer: Current Diagnosis and Treatment, edited by Michael

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Printed in the United States of America 10 9 8 7 6 5 4 3 2 1

E-ISBN: 1-59259-644-4

Library of Congress Cataloging-in-Publication Data

Management of benign prostatic hypertrophy / edited by Kevin T McVary.

p ; cm (Current clinical urology)

Includes bibliographical references and index.

ISBN 1-58829-155-3 (alk paper)

1 Benign prostatic hyperplasia.

[DNLM: 1 Prostatic Hyperplasia therapy 2 Bladder

Diseases etiology 3 Prostatic Hyperplasia complications 4.

Prostatic Hyperplasia diagnosis WJ 752 M2673 2004] I McVary, Kevin

T II Series.

RC899.M36 2004

616.6'5 dc21

2003007891

v

Benign prostatic hyperplasia (BPH) is the most common neoplastic dition afflicting men and constitutes a major health factor impactingpatients in every part of the world Bladder neck obstruction secondary toBPH can result in significant medical complications including renal fail-ure, urinary retention, recurrent urinary tract infection, bladder stones, sig-nificant hematuria, and marked and disruptive bladder symptoms Currentstudies estimate that upwards of 30% of males will require some type ofsurgical or other significant intervention to correct this problem sometime

con-in their lives Because there is a major restructurcon-ing of the treatment rithms used to manage this important clinical problem and because of new

algo-medications and advances in technology, a great need for Management of Benign Prostatic Hypertrophy has arisen.

How best to approach patients is a common question posed by urologists.What is to be made of these newer therapies, and what are their roles vis-

a-vis our more established treatments? Management of Benign Prostatic Hypertrophy is designed to address those needs for the practicing urologist

who is often caught in the middle of these newer therapies and confused bythe significant hype Despite this clear need for interpretation of new data,

a text that is not grounded in the principles and hallmarks of our specialtywill offer little to budding urologists; rather, this text serves as a singlesource for quick reference on most aspects of this broad spectrum of BPHtreatments

Management of Benign Prostatic Hypertrophy is divided into three main

categories: (1) pathophysiology and natural history of BPH, (2) ology: definitions and prevalence of the disease, and (3) the urodynamicevaluation of lower urinary tract symptoms The first category is also but-tressed by a more current understanding and treatment of postobstructivediuresis, a significant medical complication and frequent source of uro-logic consultation A second component of the text addresses medical thera-pies for BPH, namely α-adrenergic antagonists, 5α-reductase inhibitors,and their combination in the treatment of BPH The most extensive portion

epidemi-of the text is an up-to-date, concise evaluation epidemi-of each epidemi-of the minimallyinvasive therapies as well as the time-tested surgical treatments

I think you will find Management of Benign Prostatic Hypertrophy

concise, readable, and up-to-date

Kevin T McVary, MD

`

Preface vList of Contributors ix

1 Prostate Anatomy and Causative Theories, Pathophysiology,

and Natural History of Benign Prostatic Hyperplasia 1

Jeffrey A Stern, John M Fitzpatrick, and Kevin T McVary

2 The Definition of Benign Prostatic Hyperplasia:

Epidemiology and Prevalence 21

Glenn S Gerber

3 Pathophysiology, Diagnosis, and Treatment

of the Postobstructive Diuresis 35

Chris M Gonzalez

4 Urodynamics and the Evaluation

of Male Lower Urinary Tract Symptoms 47

J Quentin Clemens

5 α-Adrenergic Antagonists in the Treatment

of Benign Prostatic Hypertrophy-Associated

Lower Urinary Tract Symptoms 61

Ross A Rames and David C Horger

6 5α-Reductase Inhibitors 79

Robert E Brannigan and John T Grayhack

7 Transurethral Needle Ablation of the Prostate 97

Timothy F Donahue and Joseph A Costa

8 Transurethral Microwave Thermotherapy 109

Jonathan N Rubenstein and Kevin T McVary

9 Transurethral Incision of the Prostate 125

Robert F Donnell

10 Interstitial Laser Coagulation and High-Intensity Focused Ultrasoundfor the Treatment of Benign Prostatic Hyperplasia 141

Christopher M Dixon

11 Transurethral Resection of the Prostate 163

Harris E Foster, Jr and Micah Jacobs

12 Transurethral Vaporization of the Prostate 195

Joe O Littlejohn, Young M Kang, and Steven A Kaplan

Contents

14 Suprapubic Transvesical Prostatectomy

and Simple Perineal Prostatectomy for the Treatment

of Benign Prostatic Hyperplasia 221

James M Kozlowski, Norm D Smith, and John T Grayhack

Index 263

JOSEPH A COSTA, DO • Department of Urology, National Naval Medical Center; Department of Surgery, Uniformed Services University

of Health Sciences, Bethesda, MD

CHRISTOPHER M DIXON, MD • Division of Urology, New York University School of Medicine, New York, NY

TIMOTHY F DONAHUE, MD • Department of Urology, National Naval Medical Center; Center for Prostate Disease Research, Department

of Surgery, Uniformed Services University of Health Sciences, Bethesda, MD

ROBERT F DONNELL, MD, FACS • Prostate Center, Clinical Trials

(Urology), The Medical College of Wisconsin, Milwaukee, WI

JOHN M FITZPATRICK, MD • Department of Surgery, Mater Misericordiae Hospital; University College of Dublin, Dublin, Ireland

HARRIS E FOSTER, JR., MD • Section of Urology, Yale University School

of Medicine, New Haven, CT

GLENN S GERBER, MD • Section of Urology, Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL

JAY Y GILLENWATER, MD • Department of Urology, University

of Virginia Health Sciences Center, Charlottesville, VA

CHRIS M GONZALEZ, MD • Department of Urology, Northwestern

University Feinberg School of Medicine, Chicago, IL

JOHN T GRAYHACK, MD • Section of Urologic Oncology, The Robert H Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, IL

DAVID C HORGER, MD • Department of Urology, Medical University

of South Carolina, Charleston, SC

MICAH JACOBS, BA • Yale University School of Medicine, New Haven, CT

YOUNG M KANG, MD • Department of Urology, College of Physicians and Surgeons, Columbia University, New York Presbyterian Hospital, New York, NY

x Contents

STEVEN A KAPLAN, MD • Department of Urology, College of Physicians and Surgeons, Columbia University, New York Presbyterian Hospi- tal, New York, NY

JAMES M KOZLOWSKI, MD, FACS • Section of Urologic Oncology,

The Robert H Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, IL

JOE O LITTLEJOHN, MD • Department of Urology, College of Physicians and Surgeons, Columbia University, New York Presbyterian Hospi- tal, New York, NY

KEVIN T MCVARY, MD, FACS • Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL

ROSS A RAMES, MD • Department of Urology, Medical University of South Carolina, Charleston, SC

JONATHAN N RUBENSTEIN, MD • Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL

NORM D SMITH, MD • Section of Urologic Oncology, The Robert H Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, IL

JEFFREY A STERN, MD, MPH • Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL

Chapter 1 / Prostate Anatomy 1

1

From: Management of Benign Prostatic Hypertrophy

Edited by: K T McVary © Humana Press Inc., Totowa, NJ

INTRODUCTION

The prostate is the major accessory sex gland of the male It providesexocrine function, but it has no established endocrine or secretory func-tion Its secretion provides fluid that comprises 15% of the ejaculate.These secretions produce a volume-expanding vehicle for sperm, yet noreproductive function has been identified The gland has been the sub-ject of much study because it is the site of infection as well as benign andmalignant neoplasm The prostate’s intimate anatomic relationship withthe bladder neck and urethra increases the importance of these patho-logic changes and is the focus of this chapter

1 Prostate Anatomy

and Causative Theories,

Pathophysiology,

and Natural History

of Benign Prostatic Hyperplasia

Jeffrey A Stern, MD , John M Fitzpatrick, MD , and Kevin T McVary, MD

2 Stern et al.

ANATOMY

The prostate is a compound tubuloalveolar gland It is adjacent to thebladder neck proximally and merges with the membranous urethra torest on the urogenital diaphragm distally The intact adult glandresembles a blunted cone, weighing approx 18 to 20 g The gland mea-sures about 4.4 cm transversely across its base, and it is 3.4 cm in length

and 2.6 cm in anteroposterior diameter (1) The urethra enters the

pros-tate near the middle of its base and exits the gland on its anterior surfacejust before the apical portion The ejaculatory ducts enter the base on itsposterior aspect and run in an oblique fashion, terminating adjacent tothe verumontanum The capsule of the prostate gland is incomplete at

the apex and does not represent a true capsule (2) Fibrous septa emanate

Fig 1 This dorsal view of the prostate reveals its relationship with the seminal

vesicles, the ampulla, and the bladder The median sulcus separates the prostate into halves (23 d) The anterior layer of Denonvielliers fascia (26) comprises the dorsal capsule of the prostate The urogenital diaphragm (27) merges with

the distal end of the prostate (From 3 and 12 with permission.)

Chapter 1 / Prostate Anatomy 3

from the capsule, pierce the underlying parenchyma, and divide it into

glandular units called lobules (3) Most of these units empty their tents into the prostatic urethra near the verumontanum (4) The ana-

con-tomic details are illustrated in Figs 1 and 2

The endopelvic fascia represents the fusion of extraperitoneal nective tissue that forms a subserous covering for the pelvic viscera andenvelops its neurovascular supply A sheetlike proliferation of this fas-cia contributes to the formation of the puboprostatic ligaments Theyanchor the anterior and lateral aspect of the prostate to the posterior

con-aspect of the pubis (5).

The lateral pelvic fascia, also described as the parietal layer of theendopelvic or prostatic fascia, serves as the fascial envelope to the leva-

Fig 2 This frontal view of the prostate reveals its ductal system in continuity

with the bladder and the urethra The prostatic utricle rests atop the tanum The majority of the prostatic ducts drain distal to the verumontanum The bladder neck (internal sphincter) is comprised of the area extending from

verumon-the trigone to verumon-the termination of verumon-the prostatic urethra (From 3, with

permis-sion.)

4 Stern et al.

tor ani muscle and maintains continuity with the capsule of the prostatealong its anterior and anterolateral aspects Anatomic dissections byWalsh and Donker revealed that the major neurovascular bundles to theprostate were contained posterolaterally within the lateral leaves of this

fascia (5).

Neurovascular Supply

The prostatovesicular artery, the major arterial supply to the prostateand seminal vesicles, is a branch of the inferior vesical artery It origi-nates from the anterior division of the hypogastric artery and coursesmedially on the levator muscle to the bladder base The artery has tinybranches that go to the bladder base, prostate, and tip of the seminalvesicles These urethral and capsular branches are the prostate’s main

arterial supply (1) The urethral branches course along the posterolateral

aspect of the vesicoprostatic junction and usually enter the bladderneck and periurethral aspect of the prostate gland at the 5 and 7 o’clockpositions (Fig 3) The anterior division of the hypogastric artery alsosupplies the inferior aspect of the prostate, the seminal vesicles, and thevas deferens with accessory vessels from the middle hemorrhoidal and

internal pudendal arteries (1,3).

Wide, thin-walled veins on the lateral and anterior aspect of theprostate gland merge with veins of the vesical plexus and the deepdorsal vein of the penis to form the plexus of Santorini within thepuboprostatic space This confluence of veins empties into the hypo-gastric vein

In 1982, Walsh and Donker published landmark observationsdescr~2ing the anatomic relationship of the pelvic (autonomic)*ÿlexus

and the prostate gland (6) The prostate, the other pelvic organs, and

the corpora cavernosa receive their autonomic innervation from thepelvic plexus, a fenestrated 4-cm long, 2.5- to 3.0-cm high rectangular

plate lying retroperitoneally adjacent to the rectum (7) Both the

para-sympathetic and para-sympathetic divisions of the autonomic nervous tem contribute to the plexus Parasympathetic visceral efferentpreganglionic nerve fibers from the second through fourth levels ofthe sacral cord enter the plexus by way of the pelvic splanchnic nerve(nervi erigentes) This nerve is a composite of five or six branchesrather than a discrete entity The sympathetic component emanatesfrom the thoracolumbar center (T11 to L2) and courses through thehypogastric nerve

sys-Normal Internal Architecture

The proposed organization of the fetal, newborn, and adult prostate

into discrete lobes has been regarded with skepticism (8–12) With a