MANAGEMENT of LOWER

URINARY TRACT
OBSTRUCTION
MOHD BADRUL HISYAM B.HASHIM
Benign Prostate Hyperplasia
Prostate Carcinoma
Bladder Carcinoma
 Assessment
Evaluated using International Prostate Symptom Score
(IPSS) questionnaire.
It gives information regarding severity of symptoms.
LURT
• mild 0-7 • Moderate 8-19 • Severe 20-35

Uroflowmetry
• Noninvasive test to detect lower urinary tract
obstruction.
• Qmax<10ml/sec=BOO
• Qmax>15mls/sec=no BOO
• Low flow rate suggests BOO.
 Post void Residual Volume (PVR)

PVR is a safety parameter

Men with a significant PVR should be monitored
more closely if they elect non-surgical therapy.
It can be measured accurately non- invasively with
trans abdominal US
Elevated residual volume-stasis of urine can increse
the risk of UTI and bladder stones.
 TREATMENT
 WATCHFULL WAITING and conjuntion with fluid restricton and reduced caffiene
intake.
-Indicate for men with mild and not bothersome symptoms. Flow rate > 15ml/s and
residual volume < 100ml.
• Drug Therapy.
α-Blockers
• Relax smooth muscles in the prostate fibromuscular stroma.
• Achieve a dose dependent improvement in maximum urinary flow rate and symptom
score
Examlpes- terazosin(hytrin),doxazocin(cardura),tamsulosin(floma
x/contoflo),alfuzosin(xatral/uroxatral)
5α-reductase inhibitors- finasteride (proscar) inhibits type II 5α- reductase. Detasteride
(Avodart) inhibits type I and type II 5α-reductase .
The enzyme that converts testosterone to DHT
Low DHT leads to:
-↑max urinary flow rate by approximately 10%
- Improves symptom
-↓ the risk BPH progression
-↓total PSA by 50% after 6 month of treatment .
Combination therapy is better than either agent alone
 Surgery Indication

Failed a preliminary trial of medical therapy

Present of BOO.
Haematuria.
Combination of severity of symptoms and low flow
rate.
Complication of BPH such as bladder diverticuli,
hydroureter, UTI and stone.
TURP – Gold standard
Open surgery
 TURP

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

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

The enlarged prostate is removed through an open

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

Use some form of heat to destroy excess prostate tissue.

The heat may be delivered by:
* Radio frequency: Transurethral needle ablation
(TUNA)
* Microwave: Transurethral microwave thermotherapy
(TUMT)
* Electrical current: Transurethral electrovaporization
(TUVP)
* Laser: Interstitial laser coagulation (ILC) and holmium
laser enucleation of the prostate (HoLEP)
PROSTATE CARCINOMA
TNM Staging
 Treatment
 Treatment option for prostate cancer depend on stage of disease,
life expectancy and patient preference.
 Conservative treatment:
 Localized T1a - T1b disease for men in their 70s.
 Radical prostatectomy:
 In younger fitter men ( < 70 years) with T1 –T2 form of the
disease.
 T1 and T2 also can be treated by radical radiotherapy. Eg External
Beam Radiotherapy and Brachytherapy.

 Locally advanced T3 and T4. These patients are at significant risk

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

Other
Therapies
Cryosurgery of the Prostate
 Prostate Cancer
Chemotherapy

Using Agents:

Doxorubicin
Cisplatin
cyclophosphamide
Bladder Carcinoma
 TNM Staging
T - Tumor N - Regional M - Distant
Lymph Node Metastasis

TX - Primary tumor cannot be evaluated NX - Regional MX - Distant metastasis

T0 - No primary tumor lymph nodes cannot cannot be evaluated
TIS - Carcinoma in situ ("flat tumor") be evaluated M0 - No distant
Superficial Tumor. N0 - No regional metastasis
Ta – Tumor confined to the urothelium lymph node M1 - Distant metastasis
T1 - Tumor invades connective tissue under metastasis
the epithelium (involvement of lamina N1 - Metastasis in a
propria) single lymph node <
Invasive Tumor. 2 cm in size
T2 - Tumor invades muscle N2 - Metastasis in a
T2a - Superficial muscle affected (inner single lymph node >
half) 2 cm, but < 5 cm in
T2b - Deep muscle affected (outer half) size, or Multiple
T3 - Tumor invades perivesical (around the lymph nodes < 5 cm
bladder) fatty tissue in size
T3a – microscopically N3 - Metastasis in a
T3b - macroscopically (e.g., visible tumor lymph node > 5 cm
mass on the outer bladder tissue) in size
Fixation Tumor.
T4 - Tumor invades any of the following:
prostate, uterus, vagina, pelvic wall,
abdominal wall and fixation to pelvic wall.
 Treatment
 Non-muscle invasive (Superficial) tumors :
 a) Ta (G1 or G2 ) :
Transurethral Resection (TUR).
 b) Ta G3 (high risk of recurrence):
TUR + 6 weekly intravesical instillation of BCG
started 3-4 weeks after TUR.
 c) Tis (precursor for invasiveness):
TUR + intravesical instillation of BCG once
weekly for 6 weeks.
T1 ( G1 or G2, solitary , not associated with Tis ) :
Same as Ta (G1 or G2).
T1 (G3, multifocal, associated with Tis, vascular invasion or
recurrent after BCG):
TUR + intravesical instillation of BCG, OR radical
cystectomy and bilateral pelvic lymphadenectomy.

Muscle invasive tumors (T2, T3 and T4a)
Radical cystectomy (cystoprostatovesiculectomy with
bilateral pelvic nodal dissection up to the bifurcation
of the common iliac LN) together with urinary
diversion.
External beam radiotherapy – option for unfit patient
@ declined cystectomy.
Neoadjuvant cisplatin – base chemotherapy to
improve survival rate.
Downstages the tumor by radiotherapy @
chemotherapy to enable cytectomy.
 Follow-up

* Every 2 months in the first year, every 3 months in

the 2nd & every 6 months thereafter.
* CXR and CT abdomen & pelvis are performed
every year.
* Bone scan to be performed whenever necessary.
 Follow up:

- At every follow up visit the physician

should be able to evaluate:
Tumor response: No evidence of disease, site & size
of recurrence; local, bone, chest, liver, …etc.
 REFERENCES

Bailey & Love's Short Practice of Surgery

http://emedicine.medscape.com/
http://www.umm.edu/

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