PROSTATE

NEONATAL
HYDDRONEPHROSIS
URETHRAL
GWK Duarsa STRICTURE
LUTS

➢One of the most common clinical

complaints in adult men
➢The prevalence of LUTS increases with
ageing
➢A result of either a failure to store or a
failure to empty
 Prostatisme Syndrome

(lower urinary tract symptoms)

Voiding OBSTRUCTIVE Storage (IRITATIVE)

Hesitancy, intermittency Urgency, Incontinence

Weak flow, terminal dribbling Frequency (polakisuria)
Streaming
Incomplete bladder emptying Nocturia
Urine Retention Dysuria
Overflow Incontinence
URINARY RETENTION

UNABLE TO MICTIE

URINE VOLUME >>

BLADER CAPACITY
(350-450cc)
IPSS
 ETIOLOGY BLADDER
Bladder neuropathy, OAB
Neurological Detrusor sphincter Disinergy
Parkinson’s disease
Cerebrovascular event BOO
Multiple sclerosis Meatal stenosis, PUV
Drug-induced Urethral stricture
Antidepressants Bladder neck stenosis
Anticholinergics Bladder &/ Urethral stones
Anti muscarinic BPH- Prostate Carcinoma
Diuretics
Prostatitis, cystitis,
Clot Retention
Phymosis, Paraphymosis
Posterior Urethral valve
Scibala
Bladder tumor
Medicines
Introduction

What is the prostat ?

• The major accessory sex gland of the male
• 15% of the ejaculate
• Its intimate anatomic relation with bladder neck and urethra increases
the importance of these pathologic changes
• Increasing life expectancy  BPH >>
Anatomy
 Health Care 

QOL 

Aging Male Population

BPH  SGH 2011

NORMAL aging process

Not a preventable condition
Can be treated well
PREVALENCE

BPH ~ Ages
Autopsy 35 yo : BPH nidus
> 60 yo : 50%
>80 yo : 90% - 100%
Clinic 50-60 yo : 21%
> 80 yo : 53%
BPH is a progressive condition characterised by:

• Increasing prostate volume

• Worsening of LUTS
• Decreasing urinary flow rate
• Increased risk of AUR
• Increase in incidence of BPH-related
surgery
PATOPHYSIOLOGY
 Ethiology (unknown)
Theory Cause Effect
Dihydrotestosteron  5- reductase and Epithelial and stromal
hypothesis androgen receptors hyperplasia
Oestrogen-testosteron  Estrogens Stromal hyperplasia
imbalance  Testosterone

Stromal-epithelial  Epidermal growth Epithelial and stromal

interactions factor/fibroblast hyperplasia
growth factor
 Transforming growth
factor 

Reduced cell death  Estrogens  Longevity of stroma

and epithelium cells
Stem cell theory  Stem cells

Inflamation
 ZONE Mc NEAL

➢ 70% Peripheral zone

15-20% Central zone
10-15% Transitional zone
 History Taking
Physical Examination
IPSS
DRE :
➢ Size
➢ Nodule
➢ Consistency
➢ Surface
➢ Pain
➢ Symmetry
➢ Mobility
TB#17
UROFLOWMETRY
Max.flow rate (ml/sec)
> 15 ml/sec
10 - 15 ml/sec
< 10 ml/sec
TRUS

Hypoechoic lesion

DR 2009
RESIDUAL URINE (TAUS)

Before voiding After voiding

IPP
 Intravenous urogram

• It shows a benign prostate

gland which is sufficiently
massive as to cause an
indentation of the base of
the bladder
Treatment Option of BPH

Watchful waiting/active surveilance

Medical

Complementary and Alternative Medicines (CAM)

Minimally Invasive Surgical Treatments

Surgical
American Urological
Association (AUA)
guideline algorithm for
management of benign
prostatic hyperplasia
(updated 2006)
 Terapi BPH

I-PSS UROFLOW
• Konservatif: observasi (watchful waiting) 0- 7 > 15 ml/sec
• Medikamentosa (Tx medik) 8 - 18 10 - 15 ml/sec
• Pembedahan: 19 - 35 < 10 ml/sec
• terbuka
• endoskopik: TURP, TUIP
• Invasif minimal:
• balloon dilatation
• stent
• microwave (thermotherapy)
• laser ablation
Medical therapies
➢ Alpha-Blockers
- Alfuzosin
- Doxazosin
- Tamsulosin
- Terazosin

➢ 5-ARIs- Androgen Supp

- Dutasteride
- Finasteride

➢ Combination Therapy
- Alpha blocker and 5-ARIs
- Alpha blocker+ anticholinergics

➢ Anticholinergic Agents
➢ CAM (Phytotherapy)
Cara kerja alpha bloker
➢ Hambat reseptor alpha
 diotot polos prostat,
 urethra pars prostatika

 leher vesica

➢ Relaksasi & tekanan berkurang

➢ obstruksi berkurang
 Mekanisme kerja α-blockers
Menghambat alfa 1a
Nerve ending
Causes prostatic
relaxation
& 1d pada otot polos
Norepinephrine
di uretra & prostat
(Blockade)
Harnal

α1A α1A α1A α1A

α1D
α1C α1B
prostate
α1A
α1A Relaksasi /
menurunkan tekanan
uretra bagian prostat

Nerve ending

Memperbaiki
Norepinephrine
gangguan buang air
kecil yg disebabkan
α1D α1C α1B α1B α1B α1B α1B Blood Vessel
Blood Vessel oleh BPH
(causes vascular contraction) = α1B
DR 2009
 Dutasteride :
dual inhibitor of DHT production

5-Reductase
Type 1

Testosterone DHT

5-Reductase
Type 2

Bartsch G et al. Eur Urol 2000;37:367–380.

 Alpha-blockers vs. 5 ARIS

Alpha-blockers 5 ARIS
Onset of action Few hours 6-12 weeks
Symptom score 40-60% 15%
improvement
Flow-rate improvement 1.0-4.0 ml/s 1.3-1.6 ml/s
Urinary retention/surgery May reduce incidence Reduces incidence
Side-effects Postural hypotension drowsiness Impotence, decreased
and headache, retrograde libido, breast tenderness
ejaculation
Treatable prostate size Any > 40 g
Effects on PSA None Halves
Effects on Prostate size None Reduce 20-30%
Stratifying Medical Treatment of BPH by Risk of
Progression

Patient age > 40 years

with symptomatic BPH

PSA  1.5 ng/mL PSA < 1.5 ng/mL

Prostate volume  40 mL Prostate volume < 40 mL

Increased risk of Disease not likely to

progression progress

Prevent progression of Symptomatic treatment

disease with 5ARIs with alpha-blockers

Bartsch G et al. BJU Int. 2004;93(Suppl 1):27–29.

Complementary and Alternative Medicines
(CAM)
• The saw palmetto plant
(Serenoa repens) & stinging
nettle (Urtica dioica)

• That extracts may have modest

efficacy in the treatment of
LUTS

• The AUA, EUA & IAUI does not

recommend the use of
phytotherapy
 INDIKASI TURP-OPEN PROSTAT
• IPSS > 18 atau uroflowmetri : obsturksi < 10 cc/dtk
• Terapi medikamentosa gagal
• BPH Komplikasi
• Retensio urine (akut/kronis)
• Hematuria
• ISK komplikata
• Colok Dubur abnormal
• Batu buli-buli
• PSA > 4 ng/ml
• Dekompensasi Buli, Hidronefrosis
• Penurunan Fungsi Ginjal
• Hernia-Hemorrhoid
Complications
Infravesical Obstruction
Complication
Minimally Invasive Therapies

• Transurethral needle
ablation (TUNA)

• Transurethral
microwave
thermotherapy (TUMT)
 Surgical

• Transurethral holmium laser of the prostate

• Retropubic prostatectomy
• Transvesica prostatectomy
URETHRAL STRICTURE

ANATOMY

➢Urethra : bladder neck- MUE

➢Length :
- male 20 cm
- female 2-4 cm
➢Narrowing of Urethral tube
caused by fibrotic tissue at
urethra and peri urethra
 URETHRAL STRICTURE
➢Def: an organic narrowing of the urethra caused by scarring of the urethral
epithelium and corpus spongiosum.
➢Described as their location
➢The incidence of male urethral stricture disease is unknown
➢Symptoms: LUTS as irritative - obstructive spraying urine, recurrent UTI,
Urinary retention, Peri urethral abscess and Its Complications
➢Complicated surgical problem, the treatment still evolve
➢The earliest recorded, metal dilator (Ayurveda)
➢Blind internal urethrotome by Civiale and followed by Otis 18 th century
Etiology

➢Inflammation (ex: lichen sclerosis)

➢infectious disease (STD, tuberculosis)
➢post-traumatic or iatrogenic
 External trauma (fracture of the pelvis)
Internal traumatic lesions
mostly of the bulbar urethra
endoscopic instruments & urethral catheters
➢Congenital
➢Failed hyposphadias repair
Anatomy

• Urethra 4 cm Male Posterior : 2,5 cm

• US in women is rare Male Anterior : 15 cm
• Women with LUTS 2,7% Female Urethra : 4 cm
have stricture
Median
Umbilical lig. Ureter
Uterus
BladderPeritoneum

Pubovesical
Lig. Rectum
Urethra Vagina
Evaluation

➢Retrograde Urethrography
Static
Dynamic
BVUC
➢Flexible Uretheroscopy
➢Ultrasonography
➢Magnetic Resonance Imaging
MRI Urethrography
Grading by Jordan
Sonourethrography and MR urethrogaphy :
assess the thickness and length urethral stricture
• STENTS
• DILATATION
• INTERNAL URETHROTOMY
• DVIU – DILATATION
• URETHROPLASTY
URETHROPLASTY
➢anastomotic urethroplasty
➢substitution urethroplasty
Single/stage urethroplasty
Graft Flap urethroplasty
➢Perineal urethrostomy
Urethra is urethra, Penis is penis
Don’t touch penis
Dorsal Onlay BMG techniques
Barbagli Asopa Kulkarni 1996
2001 2009
Dorsal Inlay BMG Uretroplasty
 PROSTATITIS
➢Inflammation of the prostate
➢Affects men of all ages but tends to be more common in men < 50 yo
➢The symptoms  significant impact on a man’s quality of life
➢types of prostatitis :
Risk Factors

➢Intraprostatic ductal reflux

➢Phimosis
➢Specific blood groups
➢Unprotected penetrative anal intercourse
➢UTI
➢Epididymitis
➢Indwelling urethral catheters Transurethral surgery
➢Infected urine
Etiology

➢Gram-Negative Uropathogens
➢Gram-Positive Bacteria
➢Anaerobic Bacteria
➢Corynebacterium Infection
➢Chlamydial Infection
➢Ureaplasma Infection
➢Other Microorganisms
Histopathology

➢Pathologist prostatitis is defined as an increased number of

inflammatory cells within the prostatic parenchyma
➢may or may not be noted in patients with a diagnosis of prostatitis,
BPH, or prostate cancer
➢The most common pattern of inflammation is a lymphocytic infiltrate
in the stroma immediately adjacent to the prostatic acini
 Diagnosis of
Prostatitis
Meares -Stamey method Syndrome
Hydronephrosis
➢The dilation of the renal pelvis or calyces.
➢It may be associated with obstruction but may be present in the
absence of obstruction.
➢Definition is an obstruction represents any restriction to urinary outflow
that, if left untreated, will cause progressive renal deterioration

Campbell-Walsh Urology 10th. 2011

EAU Guidelines. 2015
➢The common causes of HN in children :
Pelvio-Ureteral junction obstruction (40%)
Megaureter
Vesico-ureter Reflux (18-25%)
Postero-urethral Valve (PUV)
Renal Multicystic Dysplasia
Others

Pediatric Urology. IAUI Guidelines. 2015

Guidelines on Paediatric Urology. EAU Guidelines. 2015
• Ultrasonography is the mainstay of prenatal imaging.
• Selective use of fetal MRI may further delineate anatomic
details and help with diagnosis and management.

Perinatal Urology. Campbell-Walsh Urology 10th. 2011

Diuretic renography
➢the most commonly used diagnostic tool to detect the severity and functional
significance of problems with urine transport
 PUJO - UVJO
• PUJO: impaired urine flow from
the pelvis into the proximal
ureter with subsequent
dilatation of the collecting
system and the potential to
damage the kidney.

• VUJO: obstructive condition of

the distal ureter as it enters the
bladder, commonly called a
primary obstructive
megaureter.
 STONES
Paediatric stone disease
has its own unique features, different in
both presentation and treatment compared
to adult

Boys and girls are affected almost equally

Most paediatric stones are located in the UUT
Strongly implicating dietary factors
Endemic in Turkey, Pakistan and in South Asian-
America ,African
European Association of Urology (EAU),
2015
 Patophysiology
The formation of renal calculi is a complex process and depends on the
interaction of several factors, including

concentration of stone forming ions

Urinary pH

Urinary flow rate

The balance between promoter and inhibitory factors of

crystallisation, for example, citrate, magnesium, pyrophosphate

Anatomic factors that encourage urinary stasis, for example, developmental

anomalies, foreign bodies.
 Posterior Urethral Valve
➢First described by Hugh H. Young , 1919
➢Bladder obstruction :in spectrum of severity
➢Devided :3
I. Valve representing fold extending inferiorly from
veromontanum to membranous urethra (95%)
II. Bicuspid valve (<1%)
III. Valves as concentric diaphragms within the prostatic
urethra (5%)
➢PUV management and its sequelae is still a challenge to
most surgeons, due to late presentation and inadequate
facilities for long-term evaluation and treatment
➢Gold standard diagnosis is voiding VCUG  dilated -
elongated posterior urethra ec obstructing valves
➢Other procedure is Cystoscopy
Double System, Ureter Ectopic-Ureterocele

➢Reported incidence of 0.9% in autopsy series and 2–4% in clinical

series
➢80% affected females
➢Left side are more common
➢In complete duplication most patients present with recurrent UTI
 Associated abnormalities of Ureteral
Duplication
Urologic
➢Renal dysplasia, ectopic, agenesis
➢Pelvioureteric obstruction
➢Vesicoureteral reflux
➢Ureteroceles, Ectopic ureter Weigert-Mayer Law
➢Epididymal cyst
➢Malignancy
Non urologic :
➢Uterus bicornu
➢Imperforated anus
 Vesicoureteral Reflux (VUR)

➢VUR: characterized by the retrograde flow of

urine from the bladder to the kidneys.
➢associated with urinary UTI, HN, and abnormal
kidney development (renal dysplasia).
➢Unrecognized VUR with concomitant UTI may
lead to long-term effects on renal function and
overall patient health.
➢Some individuals are at an increased risk for
pyelonephritis, HT, and progressive renal failure
 Epidemiology VUR
➢HN in Infant, the prevalence 16.2%*
➢Normal children, the prevalence: 0.4–1.8%*
➢Children with UTI: (30–50%)*
➢UTIs are more common in girls than boys#
➢children with UTIs, boys are more likely than girls to
have VUR (29% compared with 14%)#
➢Some studies have described a prevalence of 40–60%
for VUR in children with LUTD^
➢VUR is secondary to LUTD (?) and treatment of LUTD
 correction of VUR^
*Estrada Jr CR, et al. J Urol 2009;182:1535–41
#Hannula A et al, Pediatr Nephrol 2010;25:1463–9.
^Ural Z, et al. J Urol 2008;179:1564–7
Voiding cystourethrogram

➢VCUG is the diagnosis method of choice

➢That must be detected include:
vesicoureteral reflux
Posterior urethral valves
Ureteroceles
 diverticula
neurogenic bladder
 Pathophysiology of Pyelonephritis and Renal Scarring

Lim R. Vesicoureteral Reflux and Urinary Tract Infection: Evolving

Practices and Current Controversies in Pediatric Imaging. AJR 2009;
192:1197–1208
 Conservative (Nonsurgical)
The objective: prevention of febrile UTI.
VUR resolves spontaneously:
mostly in young patients
unilaterally
80% in VUR grades I and II
30-50% in VUR grades III-V
VUR does not damage the kidney when
free of infection and
have normal LUT function
➢The conservative approach includes
watchful waiting,
intermittent or continuous AB prophylaxis,
bladder rehabilitation in those with LUTD
Circumcision

➢Follow Up
Regularly with imaging studies (US, VCUG)
Part of the conservative management
Indications for surgical

➢Febrile breakthrough infection

➢Medical non-compliance, new scars
➢Reflux persistence after endoscopic treatment
➢Grade IV and V reflux between 1-5 years
➢Associated malformations
Duplex systems, reflux and diverticula
Obstructive and refluxing megaureter
Large ureterocele and persistent reflux
Ectopic refluxing ureter
 Ureteral Reimplantation
➢Intra- and extravesical techniques
➢The basic principle of lengthening the intramural submucosal tunel of the
ureter
➢Technique
Cross trigonal reimplantation (Cohen technique)
Suprahiatal reimplantation (Politano-Leadbetter)
Infrahiatal reimplantation (Glenn-Anderson)
Extravesical procedure (Lich-Gregoir)
➢Successful rate (92-98%)