Surgery: BPH and Prostate Cancer Flashcards
How common BPH is?
50% men aged over 60
Lower urinary tract symptoms that may present in BPH
- Sensation of incomplete emptying of bladder
- Frequency – urinating every 2 hours or less
- Intermittency – stop/start stream
- Hesitancy
- Urgency – difficult to postpone urination
- Nocturia – number of times urinating at night
- Weak stream
- Straining
(2) ways of medical management of BPH
- Alpha-Blockers (e.g. Tamsulosin)→ relax smooth muscle of prostate
- 5 - alpha - reductase inhibitors (e.g. FInasteride)→ block the metabolism of testosterone *this is used if Tamsulosin does not work
Tamsulosin
- how quickly it should work
- side effects
Tamsulosin (alpha-blocker →smooth muscle relaxation)
- should provide symptomatic benefit within few days
- Side effects: postural hypotension, rhinitis, retrograde ejaculation, Floppy Iris Syndrome (if undergoing cataract surgery), lack of energy
Finasteride
- how long it would take to work
- common side effects
Finasteride (5 alpha-reductase inhibitor) → less testosterone is converted to DHT
- can take up to 6 months for symptomatic benefit
- side effects: sexual dysfunction (impotence - common), breast changes (uncommon)
What’s TURP?
Surgical management of BPH (considered if medical treatment fails)
TransUrethral Resection of the Prostate (TURP)
What does TURP involve?
Endoscopic removal of obstructive prostate tissue using a diathermy loop to increase the urethral lumen size
Possible complications of TURP
- haemorrhage
- sexual dysfunction
- retrograde ejaculation
- urethral stricture
What’s HoLEP?
HoLEP is the surgical option for management of BPH
Holmium Laser Enucleation of the Prostate (HoLEP)
What does HoELP involve?
- Holmium:YAG laser used to heat and dissect sections of prostate into the bladder
- it is becoming increasing more prevalent in use due to excellent outcomes and reduced post-operative complications
- its use only being limited due to it being a technically challenging procedure
What are possible complications of BPH?
- high-pressure retention → urinary retention → post-renal kidney injury
- recurrent UTIs
- significant haematuria episodes
What’s TURP syndrome?
- potentially life-threatening complication of TURP surgery
- TURP using monopolar energy requires use of hypoosmolar irrigation during the procedure which can result in significant fluid overload and hyponatremia as the fluid enters the circulation through the exposed venous beds
TURP syndrome
- presentation
TURP syndrome (fluid overload and hyponatremia)
- confusion
- nausea
- agitation
- visual changes
Management of TURP syndrome
- address the fluid overload
- carefully reduce the level of hyponatremia
What is the management option for a patient with prostatic obstruction and unsuitable for TURP?
Long-term management with catheter:
- Long term indwelling catheter (LTC)
- Intermittent self-catheterisation (ISC)
Complications of catheter
- UTI
- catheter erosion
- Haematuria
- calculus formation
- inconvenience
Non-modifiable risk factors for prostate cancer (4)
- Age → the incidence of prostate cancer increases with age
- Ethnicity → black African or Caribbean ethnicity twice as likely (one in four) to be diagnosed with prostate cancer in their lifetime when compared to white Caucasian men
- Family history of prostate cancer → but only 9% of prostate cancers are thought to be truly inherited
- BRCA2 or BRCA1 gene are at greater risk.
Modifiable risk factors of prostate cancer
- obesity
- diabetes mellitus
- smoking (associated with increased risk of prostate cancer death)
- degree of exercise (considered protective)
Clues from History that may point to prostate cancer
History
- LUTS (lower urinary tract symptoms)
- Bone pain
- Haematuria
- Family history
Clinical examination of prostate cancer (2)
- Digital rectal examination (DRE)
- Palpable bladder
Possible presentation/symptoms of prostate cancer
LUTS → weak urinary stream, increased urinary frequency, and urgency
More advanced localised disease may also cause:
- haematuria
- dysuria
- incontinence
- haematospermia
- suprapubic pain, loin pain
- rectal tenesmus
Any metastatic disease may cause:
- bone pain
- lethargy
- anorexia
- unexplained weight loss
Differential diagnosis of prostate cancer (3)
- Benign prostatic hyperplasia (BPH) → cause LUTS symptoms initially
- Prostatitis → present with perineal pain, with neutrophils seen on urinalysis
- Other causes of haematuria: these may include bladder cancer, urinary stones, urinary tract infections and pyelonephritis
Initial investigations for prostate cancer
- Prostate specific antigen (PSA)
- Prostate biopsy
- Imaging (TRUS, CT, MRI)
PSA
- what is it produced by?
- role of PSA
•Produced almost exclusively by the epithelium of the prostate gland
•Liquefies the ejaculate increasing sperm motility
Normal PSA values according to the age
Is there a screening programme for prostate cancer?
- no national prostate cancer screening programme in many Western countries
- remains questions regarding the benefit of widespread screening and concern regarding over-diagnosis and over-treatment in screened populations
What other conditions (than prostate Ca) can BPH be elevated in?
–Prostatitis
–DRE (digital rectal examination)
–UTI
–Catheter
–Urinary retention
–Cycling
What can decrease PSA?
•Reduced by approx 50% with 5-alpha-reductase inhibitors (e.g. Finasteride)
*If on this medication double result for interpretation
What PSA is used for?
Most useful for surveillance after treatment
Indications (2) for prostate biopsy
- Persistently raised PSA
- Suspicious DRE
Risks associated with prostate biopsy
- Sepsis
- Bleeding
- False-negative result
- Urine retention
- Over-diagnosis
Name (2) types of prostate biopsy
- Transperineal (Template) biopsy
- TransRectal UltraSound-guided (TRUS) biopsy
Advantages and disadvantages of population screening with PSA
What does Transperineal (Template) biopsy involve?
Advantages (2)
Transperineal (Template) biopsy
- involves sampling prostatic tissue transperineally in a systematic manner
- done as a day case under general anaesthetic
- the transperineal approach allows better access to the anterior part of the prostate and also has a lower risk of infection
What does TransRectal USS guided biopsy involve?
TransRectal UltraSound-guided (TRUS) biopsy
- sampling the prostate transrectally
- usually under local anaesthetic
- 12 cores are taken bilaterally in equal distribution from base to apex
- Transrectal biopsies are associated with a 1-2% risk of sepsis
What scoring system is used to histologically grade prostate cancer?
Gleason grade
What does a clinical staging of prostate cancer consist of?
Clinical staging is based upon the tumour-node-metastases (TNM) classification system
- T1 - T2 organ confined cancer
- T3 - T4 locally advanced cancer
- N0 - 3 absence or presence of lymph node disease of varying size
•M0-1 absence or presence of distant metastasis
*staging may be performed digitally, MRI, CT or isotope bone scan
Describe the Gleason grading system
- how is it calculated
- interpretation
Calculation:
sample of prostate tissue is assigned a score according to its differentiation → Gleason Score is then calculated as the sum of the most common growth pattern + the second most common growth pattern seen
Interpretation:
- the lowest score that can be assigned to an individual with prostate cancer is Gleason 3+3
- higher Gleason scores are associated with a poorer prognosis
What Gleason score is used for?
- Gleason scores alone are not used to determine prognosis and recurrence risk
- the score is used in conjunction with PSA levels and TNM staging
What does the management of localised prostate cancer depend on?
Management of localised cancer relates directly to risk stratification based on PSA levels, Gleason score, and T staging (from TNM)
Management of low-risk localised prostate cancer
Low risk disease:
- offered active surveillance
- radical treatments offered to those who show evidence of disease progression
Management of intermediate and high - risk localised prostate cancer
Intermediate and high risk disease:
- radical treatment options should be discussed with all men with intermediate-risk disease and high-risk
- intermediate risk can also be offered active surveillance (should not be offered for high risk disease)
What can be used as a management of metastatic prostate cancer? (2)
- chemotherapy agents
- anti-hormonal agents
Management of castrate-resistant prostate cancer
Castrate–resistant disease:
Those who demonstrate evidence of hormone-relapsed disease
- considered for further chemotherapy agents (e.g. Docetaxel)
- corticosteroids → as third-line hormonal therapy after androgen deprivation therapy and anti-androgen therapy to men with hormone-relapsed prostate cancer
Watchful waiting approach to prostatic cancer
- what is it
- group of patients offered to
- a symptom-guided approach → definitive therapy is often deferred → hormonal therapy is initiated at time of symptomatic disease
- generally reserved for older patients with lower life expectancy
- can be offered for any stage of prostate cancer
- no pre-define follow up protocol
- management is largely guided by patient goals of care and maintaining quality of life.
Active surveillance
- group of patients offered to
- what does it consist of
Active surveillance
- offered to select patients with low-risk disease and for some cases of intermediate-risk
- requires monitoring of patients with 3-monthly PSA, 6 month to yearly DRE, and re-biopsy at 1-3 yearly intervals assessing for progression and intervening at the appropriate time
- Mp-MRI is also being used increasingly in AS protocols
What is the mainstay surgical treatment of prostate cancer?
Radical prostatectomy
What does radical prostatectomy involve?
- removal of the prostate gland
- resection of the seminal vesicles along with the surrounding tissue
- +/- dissection of the pelvic lymph nodes
How radical prostatectomy can be performed? (3)
- open approach
- laparoscopically
- robotically
Side effects of radical proctectomy (3)
- erectile dysfunction (affecting 60-90% of men)
- stress incontinence
- bladder neck stenosis
Types of radiotherapy used in management of prostate cancer (2)
- External-beam radiotherapy
- Brachytherapy
(both commonly used alternatives as a form of curative intervention for localised prostate cancer)
Group of patients with prostate cancer to whom chemotherapy is indicated
only indicated in patients with metastatic prostate cancer
Why do we use androgen deprivation therapies as a treatment of prostate cancer?
- prostate cancer growth is stimulated by circulating androgens (testosterone) → androgen deprivation therapies are regularly used
What do we use for androgen - deprivation therapy in prostate cancer?
- luteinizing hormone-releasing hormone (LHRH) agonists (e.g. goserelin or triptorelin)
OR
- gonadotrophin-releasing hormone (GnRH) receptor agonists (e.g. degarelix)
- Alternatively, another method of androgen deprivation is through an orchidectomy
Side effects of androgen-deprivation therapy
- Hot flushes
- Loss libido/erections
- Osteoporosis
- Impaired glucose tolerance
- Lethargy
From which zone do over 75% of prostate cancers arise from?
Peripheral zone
The majority of prostate cancers are of which type
The majority of prostate cancers (>95%) are adenocarcinomas
