Prostate - Bph

Front 1

What is the principle androgen in the prostate?

Back 1

DHT (Dihydrotestosterone)

Front 2

What converts Testosterone into DHT?

Back 2

*5 alpha reductase

Front 3

Which is more potent in the prostate DHT or Testosterone?

Back 3

*DHT
*They both bind to the same androgen receptors, but DHT binds with a much higher affinity and therefore is more potent.
*It also appears that once bound it is a more stable mate than Testosterone

Front 4

So how exactly does androgen withdrawal work to involute the prostate?

Back 4

* Well firstly if there is less DHT then there will be less activation of AR, with subsequent less activation of certain genes
*There is then less downstream production of those proteins and subsequent gland involution.
*There is also upregulation of other genes that are associated with programmed cell death.

Front 5

So is Testosterone or DHT a direct mitogen for prostate cells?

Back 5

*We know that this isn't true b/c circulating Testosterone levels do not correlate with prostate size.
*We also know based on expiremental evidence that incubated with Testosterone or DHT prostate cells do not grow and divide.
*This gives credence to the theory that obviously the effect on the prostate of these hormones is indirect.

Front 6

The penis & the prostate are two androgen dependent structures, yet how are they different?

Back 6

*In relation to their ability to respond to circulating levels of androgens is that the prostate never loses that ability and therefore continues to grow throughout life in some men.
*The penis loses that ability after puberty, in that the androgen receptors are no longer expressed & therefore it doesn't continue to grow.
*In fact expirements have also shown increasing expression of androgen receptors in the prostates of men with BPE as compared to normal controls.

Front 7

True or false. There is a clear relationship between the concentration of circulating androgens and prostate size in aging men.

Back 7

False. However, an intact androgen signaling pathway is required for development of BPH, but androgens do not cause the disease.

Front 8

What percentage of prostatic androgen is DHT?

Back 8

Converting testosterone into DHT occurs by 5-alpha reductase in the prostate, and 90% of total prostatic androgen is DHT.

Front 9

What is the pharmacological difference between proscar (finasteride) and avodart (dutasteride)?

Back 9

Avodart inhibits both type 1 and type 2 5-alpha reductase, while proscar inhibits only type 2

Front 10

Which type of 5-alpha reductase is critical to normal development of the prostate and hyperplastic growth later in life?

Back 10

Type 2. The fact that avodart and proscar lead to almost identical reduction in prostate size has lead to this understanding. However, if avodart has a clinical utility over proscar, it is likely to be due to inhibition of peripherally produced DHT.

Front 11

What is the most abundant adrenoreceptor subtype in the prostate?

Back 11

Alpha 1A, which clearly mediates active tension in prostatic smooth muscle

Front 12

Describe the two basic types of obstruction-induced changes in the bladder.

Back 12

*Changes that lead to detrusor instability or decreased compliance are clinically associated with symptoms of frequency and urgency.
*Changes associated with decreased detrusor contractility are associated with further deterioration in the force of the urinary stream, hesitancy, intermittency, increased residual urine, and occasionally detrusor failure.
*The initial response of the bladder is development of smooth muscle hypertrophy that may lead to instability and impaired contractility

Front 13

True or false. In cross sectional studies, total prostate volume increases from approximately 25 mL for men in their 30s to 35-45 mL for men in their 70s, and total transitional zone volume increases from 15-25 mL for similarly aged men.

Back 13

True that

Front 14

What are the commonly accepted maximum flow rates that may indicate obstruction?

Back 14

<10 mL/sec high probability of obstruction, >15 mL/sec low probability, with 10-15 mL/sec intermediate

Front 15

True or false. Symptoms, flow rate, and prostate volume can all reliably predict presence and degree of obstruction.

Back 15

False.

Front 16

The Olmsted County Study of Urinary Symptoms and Health Status among Men is a longitudinal population-based study that is the most informative natural history study to date on the subject. What data has emerged from this study regarding the longitudinal changes in symptoms, flow rate, and prostate volume over time?

Back 16

*92 month (7-8 years) data showed an annual change of 0.34 points per year, and men in their 60s reported an annual increase of 0.6 points per year.
*Peak urinary flow rate decreased 2.1% per year in 6 year followup. Peak flow rate declined more rapidly with decreasing baseline rate, increasing baseline age, prostate volume, and symptom severity.
*The growth of the prostate in men 40-79 years old was estimated to be about 0.6 mL per year or 6 mL per decade of life

Front 17

How much more common are bladder stones in men with BPH? Is screening indicated?

Back 17

*8 times higher (3.4% versus 0.4%).
*Only if clinical circumstances warrant it, e.g. hematuria, stuttering of urination

Front 18

What direct evidence is available to support that delayed intervention for BPH might lead to progressive irreversible loss of bladder function?

Back 18

None

Front 19

When speaking of AUR, what defines spontaneous AUR and precipitated AUR, and how does the prognosis change when referring to one versus the other?

Back 19

*Precipitated AUR occurs after a triggering event such as non-prostate-related surgery, catheterization, anesthesia, or ingestion of a medication, while all other AUR episodes are spontaneous.
*Following spontaneous AUR, 15% of patients had another episode and 75% underwent surgery, whereas after precipitated AUR only 9% had an episode of spontaneous AUR and 26% underwent surgery

Front 20

What are some of the reported risk factors for AUR?

Back 20

Increased age, high baseline symptom severity, flow rate less than 12 mL/sec, prostate volume >30 mL, PSA greater than 1.4

Front 21

What components of the medical history are important in evaluating a man for BPH? Physical exam? Labs?

Back 21

*IPSS, hematuria, UTI’s, diabetes, nervous system diseases, stricture disease, history of AUR, aggravation of symptoms by cold or sinus medications, full medication history, history of urologic surgery

*DRE, focused neurologic exam, GU exam, abdominal exam

*U/A dip or micro to rule out UTI and hematuria, cytology should be considered for men with severe irritative symptoms and dysuria especially with a history of smoking, PSA should be performed in patients in whom the identification of cancer would alter BPH management, (creatinine is no longer recommended for the standard patient)

Front 22

Describe the scoring for the IPSS (AUA Symptom Index).

Back 22

7 questions, each with a 0-5 point response, producing a total of 0-35. Mild (0-7), moderate (8-19), and severe (20-35)

Front 23

What additional tests should be considered part of the standard workup?

Back 23

*The international Consensus recommends urinary flow rate and PVR

*Cysto should not be done routinely but is optional during later evaluation if invasive treatment is strongly considered

Front 24

When is surgery recommended? What testing is recommended when one these are present?

Refractory retention, recurrent UTI, recurrent gross hematuria, bladder stones, renal insufficiency, or large bladder diverticulae.

Back 24

*No further diagnostic testing is indicated if one of the above are present, but VURDS may be helpful if you think the retention may be due to detrusor hypocontractility, cysto is appropriate to help plan the most prudent operative approach

Front 25

What is the bottom line with PVR testing? What is the threshold volume defining a poor outcome?

Back 25

*It’s best viewed as a “safety parameter,” and men with significant PVRs should be monitored more closely

*Campbell’s doesn’t provide one, it’s “uncertain”

Front 26

What predictive value does endoscopic demonstration of kissing lateral lobes or bladder trabeculation have in whether surgery will succeed or fail?

Back 26

None

Front 27

When is watchful waiting a good option?

Back 27

Symptoms are not bothersome, complications of treatment are perceived to be greater than the inconvenience of the symptoms, or there is a reluctance to take a daily pill owing to side effects or cost

Front 28

How are alpha blockers classified? What is a nonselective alpha blocker, long acting alpha-1 blockers, and a subtype selective alpha blocker?

Back 28

According to alpha AR selectivity and half-life

Phenoxybenzamine is a non-selective alpha blocker that is very effective but has a high incidence and severity of AE’s

Long-acting alpha-1 blockers are terazosin, doxazosin, alfuzosin

Tamsulosin (Flomax) has selectivity for the alpha-1-a subtype receptor

Front 29

What is one of the potentially desirable features to using hytrin (terazosin) or doxazosin (cardura) to treat BPH? For the same reason, for whom must they be more closely monitored?

Back 29

They also treat hypertension

In the elderly, dizziness and orthostatic hypotension can be adverse effects

Front 30

What’s the cost difference between flomax 0.8mg and hytrin 10mg and cardura 8mg?

Back 30

Campbell’s says flomax is twice the cost of the equivalent hytrin and cardura

Epocrates prices: cardura 8mg = $56, cardura xl 4mg = $56, hytrin 10mg= $14, flomax 0.4mg = $110, uroxatral 10mg = $98

Front 31

What are the two major types of prostatic stents?

Back 31

*Permanent
*Temporary

Front 32

Are the angles of the needles leaving the TUNA catheter fixed or free & who cares?

Back 32

*The final change concerns the angle between the catheter and the needles, which is at present not fixed. This means that a high bladder neck that is hypertrophied or a genuine median lobe enlargement can now be treated easily by this technique.

Front 33

Can you do the TUNA procedure in the office?

Back 33

*Yes, you just need topical anesthesia

Front 34

How do you know where the tip of your needle is for TUNA?

Back 34

*TUNA catheter is advanced under vision with the 0-degree fiberoptic telescope, which also allows the urologist to see the needles being advanced accurately into the prostate. The exact position within the prostate of the needle tip can be visualized by transrectal ultrasonography.

Front 35

How far must the needle tip be from the surrounding tissue of the prostate when viiewed by TRUS for TUNA?

Back 35

*It is important to remember that the thermal lesion may extend for up to 5 to 6 mm beyond the position of needle deployment with lesions measuring up to 20 × 10 mm. When the position is deemed satisfactory, the Teflon shield on the proximal part of the needle is advanced to protect the urethral epithelium and the underlying tissue. Therefore, the tip of the needle should not lie within 5 to 6 mm of the outer rim of the prostate, and the urethra is protected by the shields that extend from 5 to 6 mm from the TUNA catheter itself.

Front 36

There was a randomized clinical trial in the US comparing TUNA to TURP, what where the results?

Back 36

*At 1 year, 59 of the TUNA group (90%) and 47 of the TURP group (84%) were available for evaluation
*TUNA group, the symptom score improved from 24.7 to 11.1 (13.6 symptom units) and the peak urinary flow rate from 8.7 to 15.0 mL/sec.
*TURP group, the symptom score improved from 23.3 to 8.3 (15.0 symptom units) and the peak urinary flow rate improved from 8.4 to 20.8 mL/sec.

Front 37

What is the most common complication from TUNA? What are others?

Back 37

*By far the most common complication reported, however, is post-treatment urinary retention, occurring at a rate between 13.3% and 41.6%
*irritative voiding symptoms, occurring in about 40% of patients in the early period after treatment
*Bleeding (32.3%), urinary tract infection (7.7%), and urethral stricture (1.5%).
*There was no adverse effect of any kind on sexual function in patients treated by TUNA.
*There was also a different randomized trial in the US comparing TUNA to TURP showing a retreatment need in the TUNA group of about 15%

Front 38

What is the instrument shown used for?

Back 38

This is for TUMT and a fluid is run through the catheter to keep the urethral mucosa cool and to allow the prostate to heat.

Front 39

What does the Nd:YAG laser stand for?

Back 39

*neodymium:yttrium-aluminum-garnet laser

Front 40

What is the KTP laser?

Back 40

*potassium titanyl phosphate (KTP) laser uses a KTP crystal to double the frequency of an Nd:YAG laser and produces a 532-nm wavelength.
*Only half the depth of tissue penetration is reached compared with that of the Nd:YAG laser

Front 41

What is the Ho:YAG laser?

Back 41

*holmium:yttrium-aluminum-garnet (Ho:YAG) laser emits light at a frequency of 2100 nm. The energy is emitted in a series of rapid pulses over a few milliseconds, the Q-switched laser.

Front 42

How can the energy from laser fibers be delivered?

Back 42

*End firing
*Side firing
*Interstitial

Front 43

What were the two unique findings in the PLESS study compared to all prior studies?

Back 43

*PLESS stands for Proscar long term safety and efficacy study. ((Study aid to use is the word Less in the PLESS neumonic))

*They found that there was a significant decrease in risk of AUR and need for surgery in finasteride group (~55% relative risk reduction) and this risk reduction was dramatically different for men with enlarged prostates (>55mL) in whom a 70% relative risk reduction was found

Front 44

You are consulted on a 65yo patient with diagnosed BPH for gross hematuria after foley catheter insertion. What medication should be started to decrease the long-term risk of continued hematuria?

Back 44

Finasteride (study by Foley et al revealed a risk of hematuria 63% vs 14% in placebo vs finasteride over 1 year)

Front 45

What should be done prior to starting a patient on finasteride and why?

Back 45

Check a PSA- finasteride shown to decrease PSA by 50%
Of note, PLESS showed no difference in detection of prostate cancer in placebo and finasteride groups (finasteride does not mask prostate cancer)

Front 46

What are the three proposed mechanisms of action of phytotherapeutic agents?

Back 46

Anti-inflammatory properties

5a-reductase inhibitors

Growth factor alteration

Front 47

Name the three most commonly used phytotherapies for BPH.

Back 47

Serenoa repens (Saw palmetto)

Pygeum africanum (African Plum)

Hypoxis rooperi (South African Grass Star)

Front 48

When discussing the risks of TUNA, what % will you quote for failure rate (requiring another intervention)? What are the most common complications you will discuss with the patient? Your patient is concerned about sexual dysfunction following the procedure. What should you tell him?

Back 48

14% risk of re-intervention within 2 years
Most common complication is urinary retention (40%) followed by irritative voiding (~40%), UTI (3%), stricure (1.5%), and hematuria (common but usually mild and self-limiting)
Sexual dysfunction is rare after TUNA.

Front 49

What are the three determinants for whether coagulation or vaporization occurs when using a laser?

Back 49

Power density of laser beam (higher power, more vaporization)

Total energy delivered

Time for which energy is applied

Front 50

What are the usual symptoms associated with TUR Syndrome and at what Na concentration do these manifest?

Back 50

Mental confusion, N/V, HTN, bradycardia, visual disturbances
Na < 125mEq/dL

Front 51

What risk factors are associated with TUR syndrome?

Back 51

Size > 45g

Resection time >90 minutes

Height of irrigant > 60cm (60-70 cm change will increase absorption 2-fold)

Front 52

What is the mechanism behind transurethral vaporization of the prostate? How does it compare to TURP?

Back 52

It combines both vaporization (high heat) and dessication (low heat-coagulation)
Most randomized trials show similar results between the two with decrease catheter duration, hematuria, transfusion rate and LOS lower in TUVP but OR time, ED and incontinence lower in TURP. But these trials were poorly done and so difficult to draw meaningful conclusions

Front 53

How does the BPH relate to androgens in the male?

Back 53

*Although androgens do not cause BPH, the development of BPH requires the presence of testicular androgens during prostate development, puberty, and aging.
*We know that androgen deprivation can lead to prostate involution.
*It is important to remember though that there is no clear relationship between circulating testosterone levels in the male patient and prostate size.

Front 54

Other than BPH, what else contributes a significant portion of LUTS in aging men?

Back 54

Age-related detrusor dysfunction

Front 55

What exactly is hyperplasia, as a term within BPH?

Back 55

An increased number of epithelial and stromal cells (as opposed to the frequent misnomer hypertrophy, which would indicate an increase in cell volume)

Front 56

In addition to being required for cell proliferation within the prostate, what else to androgens actively promote there?

Back 56

They actively inhibit cell death, which may throw off the equilibrium between cell proliferation and death leading to cell accumulation in both epithelial and stromal compartments.

Front 57

What signaling pathways may have an effect on the development of BPH?

Back 57

*Growth stimulatory factors such as FGF-1, -2, -7, and -17, VEGF, IGF, may play a role, with DHT augmenting the growth factor effects. FGF-7 is the leading candidate for the factor mediating the stromal cell-based hormonal regulation of prostatic epithelium.
*TGF-beta may normally exert a restraining influence over epithelial proliferation that is lost or downregulated in BPH

Front 58

Describe the inheritable genetic component of BPH.

Back 58

*Probably autosomal dominant, and approximately 50% of men undergoing prostatectomy for BPH at less than 60 years of age can be attributed to the inhertible form, while only 9% of men over 60 undergoing prostatectomy for BPH have a familial risk.
*Familial BPH is characterized by a much larger prostate size, with mean volume of 83 mL compared to 55 mL in men with sporadic BPH.
*Essentially, large volumes and surgical intervention at a young age

Front 59

Where anatomically in the prostate does BPH develop? What clinical entity does periurethral hyperplasia develop into?

Back 59

*Primarily the transition zone, but also in the periurethral zone
*Median lobe

Front 60

Describe the relationship between vasectomy and the development of BPH.

Back 60

No relationship

Front 61

Does obesity affect the incidence of BPH?

Back 61

The evidence at present suggests a positive relationship between obesity and prostate volume and LUTS

Front 62

What is the relationship between PSA and prostate volume? What epidemiological factors affect this relationship?

Back 62

There is a strong relationship between the two, but it’s dependent on age and racial/ethnic origin. Older patients have a greater increase in prostate volume per unit of serum PSA. Asian men tend to have a smaller and lower correlation.

Front 63

In patients presenting with BPH is upper tract imaging every necessary?

Back 63

Hematuria, UTI, renal insufficiency (u/s recommended), stones, history of urinary tract surgery

Front 64

Who is the ideal candidate for medical therapy?

Back 64

They should have bothersome symptoms that negatively impact their QOL

The patient should be willing to make a longterm commitment to therapy

Medical therapy should not be offered to patients with absolute indications for surgery

Front 65

What percentage of men with BPH also have hypertension?

Back 65

30%

Front 66

Which of the alpha blockers has been described as the uroselective drug because of its lack of adverse effects and blood pressure changes?

Back 66

Alfuzosin (Uroxatral)

Front 67

What advantage do SR alfuzosin, tamsulosin, and doxazosin XL have over the other alpha blockers (doxazosin IR, terazosin)?

Back 67

A therapeutic dose can be administered at the onset of treatment, without the need for titration

Front 68

What does TUNA stand for?

Back 68

*Transurethral needle ablation of the prostate.

Front 69

How does the TUNA system work? What type of energy does it use?

Back 69

*consists of a special catheter attached to a generator. At the end of the catheter are two adjustable needles that are withdrawn into two adjustable shields made from Teflon. The needles are advanced into the prostatic tissue and can be placed accurately into the required position.
*The generator produces a monopolar RF signal of 490 kHz, which allows excellent penetration and uniform tissue distribution.
*The patient has a grounding pad placed over the sacrum, and the current passes toward this through the prostatic tissue. In other words, tissue heating is created because of tissue resistance to the current as it flows from the active to the return electrode. The active electrode has a small surface area, with the RF current being concentrated in an area immediately surrounding it. The return electrode is large, and so the diffusion of the RF current is greater. This arrangement allows heat to be concentrated near the active electrode early, thus accurately controlling the tissue effect.

Front 70

What determines the size of the lesion produced by TUNA?

Back 70

*The size of the lesion caused by RF relates to the position and depth of insertion of the electrode as well as the power used and the duration of the treatment.

Front 71

Is RF energy affected by blood flow?

Back 71

*nterestingly, heat is lost by convection, and so increased vascularity can have an effect on the degree of localization of the lesion. RF is very much affected by blood flow and has almost no effect on vessels larger than 2 to 3 mm in diameter

Front 72

What is the difference in the thermal therapies for BPH as in the differemce between TUMT vs TUNA?

Back 72

*Microwaves treat a broad area and can penetrate tissue more deeply than RF. The central temperature is therefore lower than with RF in order to maintain safe heat levels at the treatment rim. Therefore, treatment with microwaves takes longer than RF to produce coagulative necrosis. RF, however, has a much hotter central area with a very quick decline in temperature as the distance increases from the treatment needle. This results in faster generation of the necrotic lesion but of a smaller area

Front 73

What is this instrument?

Back 73

UNA catheter is, in fact, a specifically designed endoscopic instrument. This has evolved from what was a device through which a panendoscope lens could be inserted. A number of other changes have also been made. The most up-to-date version of the TUNA catheter is called the Pro Vu system, and part of this device is reusable, unlike previous models. The new system also contains a markedly improved optical system. Previously, the needles were introduced either blindly or under transrectal ultrasound guidance, which had the advantage in the latter case of seeing how close to the surrounding tissues the needles lay. However, an adequate visualization of the needle entering the prostate tissue gives the urologist a better idea of the treatment area. The final change concerns the angle between the catheter and the needles, which is at present not fixed. This means that a high bladder neck that is hypertrophied or a genuine median lobe enlargement can now be treated easily by this technique.

Front 74

How do you determine the number of lesions for TUNA?

Back 74

*number of lesions depends on the size of the prostate, but because there are two needles, each time power is switched on in the generator, two lesions are produced. It is usually advised that one pair of lesions should be used to treat 20 g of prostate tissue; it can also be expressed in terms of length, with one pair of lesions, or treatment plane, being used for less than 3 cm of prostatic urethral length, two planes for 3 to 4 cm, and one extra plane of treatment for every extra centimeter of urethral length. The procedure is then repeated in the opposite lobe.

Front 75

How much power is used and for how long do you leave the generator on when creating the lesions with TUNA?

Back 75

*The RF power that is delivered is 2 to 15 W for 5 minutes per lesion. In earlier models, the treatment was begun at a low power, but now the whole thermal process is automated, with temperature levels at treatment areas preset. The temperature at the tip of the needle varies from 80° to 100° C. The urethral temperature is kept below 46° C, and the temperature in the lesion is sustained for the treatment period.

Front 76

There was a cost analysis study of TUNA vs medical management of BPH discussed in the Campbell's chapter what was the results?

Back 76

*They found that over 5 years tamsulosin was less expensive than TUNA, and that finasteride cost the same as TUNA.
*Combination therapy was more expensive, reaching a break-even point at 2 years and 7 months of treatment.

Front 77

What is the reoperation rate for TUNA & when does it usually occur?

Back 77

*Although a 14% requirement for reoperation because of lack of efficacy of the primary treatment with TUNA may seem low, it occurred in less than 2 years.

Front 78

What patient is most likely to benefit from TUNA?

Back 78

*The patient most likely to benefit from TUNA would be one who had lateral lobe enlargement and a prostate of 60 g or less (Naslund, 1997).

Front 79

What are the factors that determine whether vaporization or coagulation occur when using the laser?

Back 79

*Therefore, the factors determining whether coagulation or vaporization occurs are essentially the power density of the laser beam itself, the total energy delivered, and the time for which it is applied.

Front 80

Name the four classes of androgen suppression used for BPH.

Back 80

*GnRH analogs (leuprolide, nafarelin, cetrorelix)

*Progestational agents (17-hydroxycortisone, megestrol)

*Antiandrogens (flutamide, oxandolone, bicalutamide, zanoterone)

*5a-reductase inhibitors (finasteride, dutasteride)

Front 81

When taking 5a-reductase inhibitors, when is the maximal reduction of prostate size achieved? What is the usual amount of prosate size reduction?

Back 81

6 months, 20%

Front 82

Name the three largest finasteride trials. What were their main findings? What was the largest bias and why is this important?

Back 82

North American Finasteride Trial

International Finasteride Trial

PLESS (Proscar Long-Term Efficacy and Safety Study)

Findings: Significant differences in prostate volume, PFR, and symptom response in finasteride compared to placebo
Bias: Majority of subjects had greatly enlarged prostates- bias toward reducing prostate size. However, two trials (Anderson and Marberger) enrolled smaller prostates and found similar findings (but smaller differences)

Front 83

Has other androgen suppression therapy panned out for BPH? Why/why not?

Back 83

Zanoterone (steroidal AR antagonist) and flutamide (nonsteroidal anti-androgen) both proven ineffective in small studies
Cetrorelix (GnRH antagonist) proven effective but expensive and requires injections.

Front 84

Describe the main findings of the two largest combination therapy trials.

Back 84

VA Cooperative Study-Compared placebo, finasteride, terazosin and combination. Endpoints were changes in AUASI, impact index, PFR. Unequivocal superiority of -adrenergic blockade over androgen suppression for treatment of BPH over 1 year

MTOPS- Compared placebo, finasteride, doxazosin, and combination. Endpoints were disease progression (any of the below listed findings):
AUASI rise of 4, 50% increase in Cr, AUR, ≥2 UTIs or 1 urosepsis, Incontinence, 67% risk reduction in combo group compared to monotherapy (~30% risk reductions in either group alone)

Front 85

Describe the main mechanisms thought to be related to TUMT efficacy.

Back 85

Higher temperatures causes necrosis

Lower temperatures for longer time causes apoptosis

Disruption of alpha 1-adrenoreceptor nerves in SM of prostate

Front 86

What are the four types of lasers that may be employed for treatment of symptomatic BPH and what are their basic differences?

Back 86

Neodymium:Yttrium-Aluminum-Garnet (Nd:YAG)- lots of coagulation

Potassium Titanyl Phosphate (KTP)- Intermediate coag-vaporization

Holmium:Yttrium-Aluminum-Garnet (Ho:YAG)- more vaporization

Diode- small and portable because doesn’t need a huge cooling device

Front 87

What are the specific temperatures at which prostate tissue dessication, coagulation and vaporization occur?

Back 87

45-50 Celsius: dessication

50-100 Celsius: coagulation

>>100 Celsius: vaporization

Front 88

What is the AUA’s recommendation regarding the use of antibiotics for TURP?

Back 88

1st generation cephalosporin with or without gentamicin prior to the procedure and continued until the catheter is removed

Front 89

What type of fluid is the most recommended for TURP and why?

Back 89

1.5% glycine or mannitol- water is still sometimes used but glycine/mannitol are non-hemolytic

Glycine is, by the way, a small amino acid. The principal function of glycine is as a precursor to proteins. It is also a building block to numerous natural products.

Front 90

What are the 3 main intraoperative problems one might face while performing a TURP? How does one manage each?

Back 90

Bleeding

Arterial: re-insert resectoscope and coagulate bleeder

Venous: Fill bladder with 100mL, balloon with 50mL, traction x 7 minutes

TUR Syndrome

Stop procedure, if necessary correct with 200mL 3% saline slowly and give lasix

Intraoperative Priapism

Inject alpha adrenergic agent into corpora

Front 91

How is a transurethral incision of the prostate performed?

Back 91

The initial procedure as developed by Orandi started with incisions just distal to the ureteral orifice on both sides all the way through the prostatic urethra just lateral to the veromontanum. In larger prostates it says he would use go through the prostatic capsule which is associated with significant bleeding.

Most of the modifications today state that you don't need to extend the incisions through the bladder neck at all and that in not doing so can help to prevent retrograde ejaculation.

A Collins knife makes incision at 5 and 7 o’clock starting just at the prostatic urethra down to the capsule is the most common technique. For single incision techniques the most common is at the 6 o'clock position.

Depth should be where you see fine filaments of capsule

from smith's textbook of endourology.

Front 92

In comparison studies, how did TUI fare compared to TURP?

Back 92

Very little perioperative differences, especially with smaller prostates but decreased incidence of retrograde ejaculation with TUI

Front 93

List three possible future therapies with regard to prostate ablation for BPH.

Back 93

Water-induced thermotherapy

Transurethral ethanol ablation of the prostate

Rotoresection of the prostate

Front 94

The effect of finasteride on serum and intraprostatic testosterone is what?

Back 94

Finasteride blocks 5-alpha redutase type II only wheras dutasteride blocks both. Regardless the medicine blocks the conversion of testosterone to DHT and therefore serum and intraprostatic testosterone concentrations will increase.

Front 95

What is polyuria?

Back 95

This is not the same thing as frequency. Polyuria is the excessive production of urine, usually greater than 2.5 to 3 liters of urine a day. this is not the same thing as frequency which is a subjective term based on symptoms.

Front 96

What is the etiology of BPH?

Back 96

*Well no one really knows for sure do they...but we do know that there is a hyperplasia of stromal and epithelial (or glandular) tissue. The chapter in Campbell's states that new epithelial gland formation usually only occurs in fetal development and thus this is a strange thing to occur.

We know that there are stromal / glandular interactions, androgen, and estrogen plays a role. There is also an increase in cell number which may be due to these epithelial and stromal proliferation or to impaired programmed cell death leading to accumulation it is still not clear.

Front 97

So how do androgens affect cellular hyperplasia in the prostate and thus BPH?

Back 97

*Well it seems like in animal models the introduction of androgens and other growth factors stimulates cell proliferation .

The transition from the bench to actual applications in humans in not there however. The reason is that in humans there is no clear evidence of an active proliferative process in BPH. This may mean that when staining histological specimens there isn't markers of increased DNA synthesis or cells undergoing division, etc.

*What scientists have seen however is either equal or even reduced rates of cell replication, but also they have discovered that increased androgens will decrease cell death in the prostate....interesting huh, why would that be?

Front 98

What is a eunuch?

Back 98

*A eunuch (pronounced /ˈjuːnək/; Greek: "Ευνούχος") is a castrated man, usually one castrated early enough to have major hormonal consequences.
The term usually refers to those castrated (without their consent) in order to perform a specific social function, as was historically common in many societies.

The word comes from greek and literally means bed keeper, eunuch would likely be a servant or a slave who, because on their function, had been castrated, usually in order to make them safer servants of a royal court where physical access to the ruler could wield great influence. Seemingly lowly domestic functions—such as making the ruler's bed, bathing him, cutting his hair, carrying him in his litter, or even relaying messages—could in theory give a eunuch "the ruler's ear" and impart de facto power on the formally humble but trusted servant. Similar instances are reflected in the humble origins and etymology of many high offices (e.g., chancellor began as a servant guarding the entrance to an official's study). Eunuchs supposedly did not generally have loyalties to the military, the aristocracy, or to a family of their own (having neither offspring nor in-laws, at the very least), and were thus seen as more trustworthy and less interested in establishing a private 'dynasty'. Because their condition usually lowered their social status, they could also be easily replaced or killed without repercussion.

Way to remember would be how it sounds.....eunuch....you aint got no nuts...

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In 50 year old men what is the lifetime risk of intervention for BPH?

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*So looking at the PLESS trial from the NEJM the introduciton paragraph states that the lifetime incidence of surgical or medical therapy for BPH in 50 year old men is 20-30 percent.

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Is there any truth that there is a hereditary component to BPH?

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*Yes in fact there is. The chapter in Campbell's describes the patterns seen in studies to be consistent with an almost autosomol dominnant pattern.

In men that had surgery for BPH, either transurethral or open, if those men were less than 60 years of age then they had a hazard ratio of like 4 for the increased likelihood to have a first degree releative that had BPH and got treatment for it. Whereas men greater than 60 were much less likely.

Front 101

Are men with a familial component to BPH more likely to have a large or small prostate?

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*They were found to be more likely to have a large prostate. with a mean volume of 82.7mls.

Front 102

What other mammalian species besides man develops BPH?

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Dogs! In fact they also get prostate cancer...dogs can even be treated with finasteride or castration with great success.

Front 103

So what is the rationale behind an incision of the prostate capsule for the treatment of BPH?

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*Well the thought is that it is the presence of the capsule which is a restraint to tissue expansion and so with the increased cell proliferation or decreased cell death whatever it really is that is accompanying BPH really increases pressure transmission to the urethra because there is a capsule.

This is also thought because the only other species that gets BPH, which is dogs, really doesn't get symptoms of BPH such as LUTS, they tend to get like constipation and straining to defecate.

The other argument for this is that the symptoms of LUTS is not necessarily in any way related to the size of the prostate....this finally kind of makes sense...that it is realted to other factors such as the endopelvic fascia, the prostatic capsule, etc.

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Is there always a "median lobe" in patients with BPH?

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*No...the other thing that is interesting is that the median lobe is thought, at least by the author of the Campbell's chapter, to not be of the transition zone, because they say there is no transition zone in that area....they say it is of periurethral zone....but the interesting thing to think about if it is truly from a distinct area is that if you could look at patient factors to see if there is a way to predict if a patient will have a median lobe.

Front 105

Is benign prostatic hypertrophy a good term for BPH?

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*No you shouldn't use it.

Front 106

So in your mind you think that finasteride and dutasteride effect the glandular component of BPH and not the stroma or muscular component of BPH....so big glands respond to these medicines but smaller muscular glands don't...right?

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*Well as always this is an oversimplification....one of the reasons that this was initially thought...and it may still be true is that in androgen deprivation the glandular component decreases but the stromal doesn't....but it is known that the stromal cell turnover is much slower or takes longer and so the author of the Campbell's chapters states that it might take a year or more of therapy before you would know if the stromal component is affected...also the muscular component has been shown in studies to be affected by androgen withdrawal affecting adrenergic stimulatuion.

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What is the most abundant alpha receptor in the prostate?

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*So the alpha adrenergic system plays a role in the prostate active tension....the most abundant subtype of the alpha receptors is alpha 1a, and studies have also clearly shown that this system is responsible for active tension in the prostate....which is thought to play a role in urethral resistance.

Front 108

So what is the bladder's response to all of this obstruction by the prostate?

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*So the bladder changes should be thought of as those that lead to detrusor instability or decreased compliance as well as those that lead to detrusor contractility decreases.

Front 109

What is the histologic changes that are causing the morphologic change of increased trabeculation that we see in BPH patients?

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*I always thought this was muscular hypertrophy but the text states that it is increased detrusor collagen. Severe trabeculation is associated with significant residual urine (Barry et al, 1993), suggesting that incomplete emptying may be due to increased collagen rather than impaired muscle function. Severe trabeculation, however, is seen in fairly advanced disease. In experimental animal models, the initial response of the detrusor to obstruction is the development of smooth muscle hypertrophy (Levin et al, 1995, 2000). It is likely that this increase in muscle mass, although an adaptive response to increased intravesical pressure and maintained flow, is associated with significant intra- and extracellular changes in the smooth muscle cell that lead to detrusor instability and in some cases impaired contractility. Obstruction also induces changes in smooth muscle cell contractile protein expression, impaired energy production (mitochondrial dysfunction), calcium signaling abnormalities, and impaired cell-to-cell communication.

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How do you remember what is mild, moderate, and severe for the IPSS?

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*Well IPSS has two Ss in it and that is the first letter to the word seven..which is the amount of questions...then seven being the perfect number is the mild subgroup so that is 0-7....then i just think of the severe group ends at 35 and then starts at 20, which is a nice round easy to remember number...the rest is in the middle.

Front 111

When estimating prostate size with a TRUS what formula should one use?

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*The prolate ellipsoid formula...there was a question like this on the in-service one year.

Front 112

What is a normal flow rate?

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*Well that depends on a lot of things. The book states that less than 10ml/sec is obstructed and that greater than 15ml/sec is normal and the between is indeterminate.

It is also important to note that flow rates decrease as men age, so that if you remember there really isn't BPH in men in their 30s. So starting at 40 years of age the average flow rate is around 20ml/sec adn studies have show that for men age 75-79 that the flow rate is around 11ml/sec...the importance to note is that this is still greater than 10ml/sec.

Front 113

Is there an association between BPH and LUTS and ED?

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here is evidence suggesting a strong correlation between the severity of LUTS and impairment of sexual function, that is, erectile dysfunction (ED), as well as ejaculatory disturbances (Boyle et al, 2003; Chung et al, 2003; Rosen et al, 2003). Cross-sectional questionnaire-based data from various countries suggest that ED and ejaculatory disturbances increase with advancing age but also within each decade of life with increasing LUTS symptom severity (Fig. 86-12). Although these correlations do not necessarily imply a causative mechanism, it is possible that similar pathophysiologic events underlie the development of both problems in the aging male, the most obvious being ischemia in both the genital and lower urinary tract organs (McVary, 2005).

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Is there an increased relative risk for the development of BPH in men whom have had a vasectomy?

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*Sidney (1987) analyzed the Kaiser Permanente database and initially found a risk ratio (RR) of 1.2 for the diagnosis of BPH among men who had a vasectomy. However, after 5 years of follow-up, the RR was 0.97 and not significant. There does not appear to be a relationship between vasectomy and BPH development or prostate size (Jakobsen et al, 1988), and in the Massachusetts Male Aging Study, Meigs and colleagues (2001) did not find that vasectomy increased the risk of being diagnosed with BPH

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What is the difference between a dichotomous, continuous, and categorical variable?

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*The parameters and outcomes are dichotomous (yes or no, e.g., retention or no retention), categorical (grades of severity, e.g., grades of obstruction measured by pressure-flow studies), or continuous (scales of severity, e.g., symptom score, maximum flow rate). Accordingly, the most common ways to measure such outcomes are probabilities or rates of occurrences for dichotomous or categorical outcomes and measures of central tendency (mean or median) and variability (standard deviation [SD], standard error [SE], or CIs) for outcomes measured by continuous scales.

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What is the concept of regression towards the mean?

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Consider a simple example: a class of students takes a 100-item true/false test on a subject. Suppose that all students choose randomly on all questions. Then, each student’s score would be a realization of one of a set of independent and identically distributed random variables, with a mean of 50. Naturally, some students will score substantially above 50 and some substantially below 50 just by chance. If one takes only the top scoring 10% of the students and gives them a second test on which they again choose randomly on all items, the mean score would again be expected to be close to 50. Thus the mean of these students would “regress” all the way back to the mean of all students who took the original test. No matter what a student scores on the original test, the best prediction of his score on the second test is 50.
If there were no luck or random guessing involved in the answers supplied by students to the test questions then all students would score the same on the second test as they scored on the original test, and there would be no regression toward the mean.
Most realistic situations fall between these two extremes: for example, one might consider exam scores as a combination of skill and luck. In this case, the subset of students scoring above average would be composed of those who were skilled and had not especially bad luck, together with those who were unskilled, but were extremely lucky. On a retest of this subset, the unskilled will be unlikely to repeat their lucky break, while the skilled will have a second chance to have bad luck. Hence, those who did well previously are unlikely to do quite as well in the second test.
The following is a second example of regression toward the mean. A class of students takes two editions of the same test on two successive days. It has frequently been observed that the worst performers on the first day will tend to improve their scores on the second day, and the best performers on the first day will tend to do worse on the second day. The phenomenon occurs because student scores are determined in part by underlying ability and in part by chance. For the first test, some will be lucky, and score more than their ability, and some will be unlucky and score less than their ability. Some of the lucky students on the first test will be lucky again on the second test, but more of them will have (for them) average or below average scores. Therefore a student who was lucky on the first test is more likely to have a worse score on the second test than a better score. Similarly, students who score less than the mean on the first test will tend to see their scores increase on the second test.

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How did the PLESS trial deal with the placebo affect?

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he Proscar Long-Term Efficacy and Safety Study (PLESS) observed a cohort of over 3000 men with moderate symptoms and enlarged prostate glands randomly assigned to treatment with finasteride 5 mg daily versus placebo over 4 years (McConnell et al, 1998). In most control arms, both placebo and sham, the combined placebo effect interfering with the natural history of the disease was maintained for the entire duration of the study. In this 4-year trial, however, both the mean symptom score and mean maximum flow rate slowly drifted back to baseline after a typical initial placebo response (McConnell et al, 1998). The changes occurring in measurable parameters after the initial placebo effect has taken place thus can be considered to represent the natural history of the disease. The rates of outcomes such as acute urinary retention or surgery, as well as changes in prostate volume, which are less or not at all susceptible to the placebo effect, are also valid measures of the natural history of the disease.

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In men with BPH should I screen them for bladder stones, should I be more concerned to screen them if they have bigger prostates, or worse symptoms?

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*No, n a large autopsy study the prevalence of bladder stones was eight times higher in men with a histologic diagnosis of BPH (3.4%) than in control subjects (0.4%), but no increased incidence of ureteral or kidney stones was found (Grosse, 1990). In a study comparing watchful waiting and TURP in men with moderate symptoms, only 1 of 276 patients assigned to watchful waiting developed a bladder stone in 3 years of follow-up (Wasson et al, 1995). The self-reported rate of a bladder stone in a cross-sectional study in 2002 Spanish men was 0.7% (Hunter et al, 1996).
In clinical practice, the risk of bladder stone development is small and screening is indicated only if clinical circumstances warrant it (e.g., hematuria, stuttering of urination).

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If we delay intervention is there a progressive loss of bladder function, in other words are we missing our window to cure for patients with BPH?

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*The critical question is whether or not delayed intervention might lead to progressive irreversible loss of bladder function and miss a window for cure. There is no direct evidence for this from longitudinal population or clinic patient studies. However, in the Veterans Affairs (VA) cooperative study comparing watchful waiting with TURP, the patients who crossed over from the conservative arm to TURP later in the trial had not as significant an improvement in symptoms and flow rate as those who underwent TURP at the beginning after randomization (Flanigan et al, 1998).

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Can you use PSA as a surrogate for prostate size?

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A strong correlation exists between serum prostate-specific antigen (PSA) levels and prostate volume (Roehrborn et al, 1999); and, as a consequence, in the absence of adenocarcinoma, the PSA value may be used as a surrogate for prostate volume (Roehrborn et al, 2001)

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What questions must you ask a patient when taking a detailed history of their BPH like symptoms to rule out other things?

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Specific additional areas to discuss when taking the history of a man with BPH symptoms include a history of hematuria, UTI, diabetes, nervous system disease (e.g., Parkinson's disease or stroke), urethral stricture disease, urinary retention, and aggravation of symptoms by cold or sinus medication. Current prescription and over-the-counter medications should be discussed to determine whether the patient is taking drugs that impair bladder contractility (anticholinergics) or that increase outflow resistance (α sympathomimetics). A history of prior lower urinary tract surgery raises the possibility of urethral stricture or bladder neck contracture. Use of a voiding diary (recording times and volume) may help identify patients with polyuria or other nonprostatic disorders.

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When should urine cytology be considered in men with LUTS?

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Urine cytology should always be considered in men with severe irritable symptoms and dysuria, especially if they have a smoking history. Carcinoma in-situ of the bladder is a diagnosis that may have serious consequences if overlooked.

Front 123

Who developed the IPSS?

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*The measurement board of the AUA, who knew that existed.

Remember IPSS - Its Important For U to Whiz Normally Sir....

Front 124

With the IPSS system for LUTS why is the mild (0-7), moderate (8-19), and severe (20-35)?

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The AUA score can be divided into "mild," "moderate," and "severe" symptom categories (Barry et al, 1992a). Only 1 of 120 men with scores from 0 to 7 was bothered more than a little by his symptoms; these men can be considered the mild symptom group. The majority of the 108 men with symptom scores from 8 to 19 were still bothered "not at all" or "a little." Only 4 of the 108 men were bothered "a lot." These men can be labeled as having moderate symptoms. Most men with scores from 20 to 35 were bothered by their condition "some" or "a lot" and can be considered to have severe symptoms.

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If a patient has a really poor flow rate does that mean that they won't benefit from a BPH surgical procedure?

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Very low rates do not appear to portend poor treatment outcome. In one study of 84 patients undergoing surgery for symptomatic BPH (Donkervoort et al, 1975), patients with a preoperative Qmax less than 7 mL/s improved symptomatically as much as patients with a Qmax greater than 7 mL/s.

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When using an alpha blocker to treat patients with BPH what other anti-hypertensive should you not use so as to prevent precipitous drops in blood pressure?

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Front 127

How are prostate infections associated with BPH?

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At the same time, microorganisms and markers of inflammation are frequently
present in the prostates of BPH patients. Moreover,
chronic inflammation is believed to be a major factor
in BPH progression and the development of urinary
symptoms. Immune cells release cytokines and growth factors that may promote the growth of epithelial and stromal prostatic cells. In addition, the stimulating effect of bacterial endotoxins on prostate growth has been noted