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
IPSS
URINARY RETENTION

UNABLE TO MICTIE

URINE VOLUME >>

BLADER CAPACITY
(350-450cc)
 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
BENIGN PROSTATE
HYPERPLASIA

Is BPH a disease ?
Might be YES or NO
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
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
UROFLOWMETRY
Max.flow rate (ml/sec)
> 15 ml/sec
10 - 15 ml/sec
< 10 ml/sec
 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 Symptomatic

of disease with 5ARIs treatment 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
 Minimally Invasive Therapies

➢ Transurethral needle
ablation (TUNA)

➢ Transurethral
microwave
thermotherapy
(TUMT)
TURP
 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 18th 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
➢ FlexibleUretheroscopy
➢ 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
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
➢ themost 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
 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

➢ FollowUp
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%)
 Reference
Smith’s General Urology 17th Edition ➢ Campbell Walsh Urology 10th
edition,2012
p 208-210 ➢ American Urological Association
Education and Research,
Guideline on the Management of
Benign Prostatic Hyperplasia
(BPH), 2010
➢ Kevin T.McVary, Management of
BPH, 2004
➢ Roger S Kirby, An Atlas of
Prostatic Diseases, third
edition,2003
➢ Pamella Dull, et al, Managing
BPH,vol 66,2002
➢ American Urological Association,
BPH : a patient’s guide, 2003
➢ Ashutosh Tewari, et al, Minimally
Invasive Therapy of Benign
Prostatic Hypertrophy, 1999
➢ Jonathan L. Edwards, Diagnosis
and Management of Benign
Prostatic Hyperplasia,2008