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Anatomi prostat

Apa itu kelenjar prostat?
• Kelenjar prostat adalah organ yang berukuran seperti almond yang terletak tepat di bawah kandung kemih dan terdiri dari dua daerah ter tutup oleh lapisan luar dari jaringan. Iniadalah salah satu komponen utama dari sistem reproduksi lakilaki dan memainkanperan penting da lam pengembangan organ seks pria. •

otot prostat kontrak dan me ndorong ejakulasi keluar dari penis • • • . Ini melindungi semen terhadap asam alami yang dihasilkan oleh vagina.Apa fungsi dr kelenjar prostat? • Fungsi utama kelenjar prostat adalah untuk menambahkan cairan penting ke dalam semen untuk membantu menghasilkan sper ma saat ejakulasi. Selama orgasme. Mengeluarkan semen yang membawa sperm a.

. • Selama orgasme.Understanding the prostate • Mengeluarkan semen ya ng membawa sperma. otot pr ostat kontrak dan mendo rong ejakulasi keluar dari penis.

kel enjar prostat mengelilingi urethra pada titikdi mana uretra terhubung ke kandung kemih. • .Dimana letak kelenjar prostat? • Kelenjar prostat terletak t epat di bawah bagian bawah kandung kemih dan di atasrektum. Pada gambar menunjukkan.

Surrounds superior portion of urethra D. Conical shape . Posterior to pubic symphysis C.I. Anterior to rectum (palpation. Introduction/General Information A. Attached inferiorly to urinary bladder by ligaments B. ultrasound) E.

Capsule extends into lobes . Fibrous connective tissue 2.Introduction. continued … F. Prostate Gland. Smooth muscle 3. Walnut sized 1. 4 cm trans x 2 cm A/P x 3 cm Sup/Inf G. Lightly encapsulated 1.

Anatomy of the Male Pelvis .

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Largest male accessory gland B. Located in subperitoneal compartment (between pelvic diaphragm & peritoneum) Prostate Gland.II. Mid-sagittal Section . Prostate Gland: Detailed Anatomy A.

Inferiorly.Prostate Gland: Detailed Anatomy C. Enclosed in fascial sheath prostatic sheath) (aka: 1. sheath is continuous with superior fascia of urogenital diaphragm 2. Posteriorly. sheath forms part of retrovesical septum .

Fibrous portion contacts gland 2. Venous plexus lies between .Prostate Gland: Detailed Anatomy D. External capsule formed by pelvic fascia 3. Double Capsule 1.

Posterior View .Male Reproductive System.

anterior.Detailed Anatomy. right & left inferolateral 2. Prostatic urethra enters middle of base close to anterior surface . Conical shape with base (sup). Surfaces: posterior. Base (aka: vesicular surface): superior a. Attached to neck of urinary bladder b. apex (inf). four surfaces 1. contined … E.

Prostate Anatomy Prostatic Urethra .

Rests on superior fascia of urogenital diaphragm muscle b. Apex: inferior a. contined … 3.Detailed Anatomy. Associated with sphincter urethrae c. Contacts medial margins of levator ani muscles .

Posterior surface: triangular. Meet with anterior surface b. flat 5. Anterior surface: narrow. convex 6. Inferiorolateral surfaces a. Rest on levator ani fascia above urogenital diaphragm . contined … 4.Detailed Anatomy.

anterior and posterior lobes . contined … F. indistinct 2. two lateral lobes b. one median lobe c. Lobes of the Prostate 1. Usually divided into a. Divisions are arbitrary.Detailed Anatomy.

continued … 3. Median lobe a. Utricle lies within lobe 1. Sometimes called “uterus masculinis” . May project into urinary bladder c.Lobes of the Prostate. Vestigial remains of uterine homolog 2. Lies posterior and superior to prostatic utricle and ejaculatory ducts b.

Contain most secretory tissue c. Glandular tissue with varying amounts of fibrous tissue . Comprise the greatest mass of the gland b. Are continuous posteriorly 5. Lateral lobes a.Lobes of the Prostate. continued … 4.

Lobes of the Prostate. continued … Prostate Gland in situ .

Middle rectal artery . Internal pudendal artery b. Inferior vesical artery c.Detailed Anatomy. Arteries derived from: a. Blood & lymph 1. continued … G.

Communicate with vesical & vertebral venous plexuses . Drain into internal iliac veins c. continued … 2. Form venous plexus b. Veins a.Blood & Lymph.

Blood & Lymph. continued … 3. From posterior: to external iliac nodes (unable to palpate) . Most terminate in internal iliac & sacral nodes (unable to palpate) b. Lymphatics a.

Detailed Anatomy. Serous glands b.50 different glandular elements a.30 ducts empty into prostatic urethra 2. Glandular tissue 1. 30 . 20 . Most are posterior & lateral to urethra . contined … H.

alkaline (looks like skim milk) b. Make up ~ 1/3 of semen . Prostatic secretions a. Thin.Blood & Lymph. Discharged at ejaculation c. continued … 3. milky.

Prostate size changes 1.Detailed Anatomy. 5. Small at birth Enlarges at puberty Maximum at about 13 Progressive enlargement after 40 Sometimes: undergoes atrophy . 2. 3. continued … I. 4.

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What is PSA?
• PSA or prostate specific antigen is an enzyme produced by the prostate cells. PSA levels can be used as an indicator of prostaterelated diseases, especially prostate cancer. As part of a general prostate health program, your doctor may recommend that you have a PSA blood test perform periodically.

Using PSA to evaluate prostate health
• Elevated PSA is often associated with prostate cancer, however there are other conditions that cause an increased PSA. Benign prostatic hyperplasia (BPH or enlarged prostate), prostate cancer, and prostatitis are the most common reasons for an elevated PSA. • While an elevated PSA does not always indicate prostate cancer, ruling out prostate cancer should continue to be the first priority. A PSA score of greater than 4.0 is generally referred to follow-up to rule out prostate cancer, and PSA scores are normally evaluated over time in order to track any unusual or sudden change in levels.

Understanding prostate problems
• After age 40, most men begin to experience some degree of symptoms of prostate disorders, and the likelihood of symptoms arising may continue to increase over time. There are 3 major diseases associated with the prostate. They are prostatitis, benign prostatic hyperplasia (BPH), and prostate cancer. It is very important that you understand the symptoms and the warning signs of prostate disease and tell your doctor about any that you experience. Even in the absence of urinary symptoms your doctor may perform periodic prostate exams and regularly monitor your prostate specific antigen (PSA) level.

Prostatitis .

Urinary Tract Infection • Upper urinary tract Infections: – Pyelonephritis • Lower urinary tract infections – Cystitis (“traditional” UTI) – Urethritis (often sexually-transmitted) – Prostatitis .

bladder outlet obstruction. fluroquinolone or other broad spectrum antibiotic – 4-6 weeks of treatment Risk Factors: – Trauma – Sexual abstinence – Dehydration .Prostatitis • • Symptoms: – Pain in the perineum. chills. lower abdomen. bladder irritation. pelvic/perineal pain. cloudy urine) – The finding of an edematous and tender prostate on physical examination – Will have an increased PSA – Urinalysis. malaise. testicles. myalgias. and with ejaculation. urine culture • • Treatment: – Trimethoprim/sulfamethoxazole. and sometimes blood in the semen Diagnosis: – Typical clinical history (fevers. dysuria. penis.

lower pelvic pressure and pain in the pubic area. Prostatitis is generally treated with antibiotics. and painful or uncomfortable feeling before or during ejaculation. pain during urination. . Some of the signs and symptoms include fever and chills.Prostatitis • Prostatitis is an inflammation of the prostate that can affect men of all ages.

+ post-massage urine culture > 3 months of symptoms. Inflammatory Incidental finding. + leukouria > 3 months of symptoms.Prostatitis Classification Class Definition Acute Bacterial Chronic Bacterial Inflammatory CPPS Non-Inflam. . UCx. CPPS Comment Dysuria.leukouria I II IIIa IIIb IV Asymptom.UCx . . systemic symptoms > 3 months of symptoms. UCx.

Prostatitis • Lifetime prevalence: 1 in 6 men • Most common urologic complaint in men under 50 • 90% of cases are chronic abacterial (Classes IIIa and IIIb) • Most cases of bacterial prostatitis are chronic as well (Class II) .

Acute Prostatitis • • • • • • Rare ( < 1% of cases) Often fulminant presentation Moderate to marked elevation of PSA High risk of bacteremia Avoid prostatic massage Tx: ABX – Parenteral  Oral Alpha blockers Bladder drainage may be indicated .

Physiology • +Gz – dependent venous pooling • AGSM – ↑ Venous return – ↑ Intrabdominal pressure – ↑ Intravesicular pressure .

Pelvic Venous Plexus .

with rapid onset – Improve pain and urinary symptoms • NSAIDs • Diazepam .Treatment – Acute Prostatitis • ABX (Quinolones and/or TMP-SMX) – Probably should not wait for cultures – significant chance of false negative • α-blockers – Effective.

Treatment – Chronic Prostatitis • α-blockers • 5α-reductase inhibitors – Slower onset than α-blockers – Better side effect profile • Lifestyle modifications .

Herbal Therapy • Probably Effective – β-Sitosterols – Saw Palmetto • No evidence of effectiveness – Cernilton – Pygeum africanum .

disqualifying – Clinically recovered but on suppressive therapy – case by case based on medication effects .Guidelines • ICAO – Acute infections -.

Guidelines • USN – Ground during acute episode – Waiver possible for patients with chronic prostatitis if asymptomatic – even on chronic suppressive medication .

prolonged sitting) may markedly exacerbate mild symptoms . even on suppressive meds – Rigors of flying (vibration.Guidelines • USAF – Ground during acute episode – Waiver available only if asymptomatic. heat.

Guidelines • FAA – No specific guidance – Flight Safety Journal (1993): No perceived risk to flight safety identified • USA – No specific mention of condition .

waiverable .Aeromedical Disposition • Acute prostatitis – Grounding • Chronic asymptomatic prostatitis – CD.

peripheral neuropathy) • TMP/SMX – CD. waiver possible . waiver possible (concern with pneumonitis. No waiver 5α-reductase inhibitors – CD.Aeromedical Disposition • • • • α-blockers – CD. waiverable Ciprofloxacin – NCD Nitrofurantoin – CD.

Aeromedical Disposition • Herbal Therapy – Saw Palmetto – Class B Supplement – β-Sitosterols – Class C Supplement (not included in Waiver Guide) – Cernilton. P. Africanum – not effective and Class C Supplement .

Synopsis • Some risk involved in delaying treatment of acute prostatitis • Rigors of aviation medicine may predispose individuals to acute episodes • Acute episodes are grounding • Chronic well controlled prostatitis may be compatible with flight • Therapy must be tailored to aviation environment .

BPH .

Affects ~90% of men >50 .III. Pathology A. Benign prostatic hypertrophy (BPH): 1.

Nocturia b. Urgency d. Back-pressure effects e. Complete obstruction can occur . Common cause of urethral obstruction: causes a.BPH. Dysuria c. continued … 2.

dan kesul itan buang air kecil. .merupakan pem besaran nonkanker dari prostat yang dapat menyebabkan terganggunya gejalakencing da n memiliki dampak yang signifikan terhadap kualitas hiduppenderit a. Gejala urin meliputi peningka tan frekuensi. urgensi. sering disebut sebagai pemb esaran prostat.Benign Prostatic Hyperplasia • Benign prostatic hyperplasia (BP H).

5 dapat menunjukka n pembesaran prostatlanjutan da n peningkatan risiko buruknya gejala urin.Enlargement of the prostate gland and PSA levels • Pembesaran prostat adalah salah satu penyebab tersering yg menimbulkan masalah berkemih.PSA lebih besar dari 1. dan akhirnya membutuhkan intervensi bedah seiring waktu. • . reten si urin akut.

BPH n Ukuran prostat membesar secara mikroskopik sejak usia 40 tahun. By the time men reach their 70’s and 80’s.. 80% will experience urinary symptoms But only 25% of men aged 80 will be receiving BPH treatment n . Sebagian laki2 dewasa diatas usia 60 tahun dapat menyebabkan pembesaran prostat.

What is Benign Prostatic Hyperplasia? Peripheral zone Transition zone Urethra .

Peripheral zone Transition zone Urethra .

What causes BPH? n BPH is part of the natural aging process. like getting gray hair or wearing glasses BPH cannot be prevented BPH can be treated n n .

What’s LUTS? Voiding (obstructive) symptoms • Hesitancy • Weak stream • Straining to pass urine • Prolonged micturition • Feeling of incomplete bladder emptying • Urinary retention Storage (irritative or filling) symptoms • Urgency • Frequency • Nocturia • Urge incontinence LUTS is not specific to BPH – not everyone with LUTS has BPH and not everyone with BPH has LUTS Blaivas JG. Urol Clin North Am 1985.12:215–24 .

8–19 (moderate). total score 0–7 (mild). PSA may be used as a prognostic marker for BPH 1 .• Symptom assessment Diagnosis of BPH – the International Prostate Symptom Score (IPSS) is recommended as it is used worldwide – IPSS is based on a survey and questionnaire developed by the American Urological Association (AUA). specifically TZV men with larger prostates have higher PSA levels PSA is a predictor of disease progression and screening tool for CaP as PSA values tend to increase with increasing PV and increasing age. 20–35 (severe) • eighth standalone question on QoL • Digital rectal examination(DRE) – inaccurate for size but can detect shape and consistency • PV determination.ultrasonography • Urodynamic analysis – Qmax >15mL/second is usual in asymptomatic men from 25 to more than 60 years of age • Measurement of prostate-specific antigen (PSA) – – – – high correlation between PSA and PV. It contains: • seven questions about the severity of symptoms.

6 1.7 4.6 Sexual Activity Decreases with n=12.0 3.5 7.6 50–59 years 60–69 years 70–79 years Rosen et al. Eur Urol 2003 n=12815 .Interfere with sexual life 9 8 7 6 5 4 3 2 1 0 4.6 3.7 IPSS 8–19 IPSS 20–35 6.815 Age and LUTS: MSAM-7 Survey IPSS = 0 IPSS 1–7 5.9 8.7 4.7 5.5 2.

When should BPH be treated? BPH needs to be treated ONLY IF: n Symptoms are severe enough to bother the patient and affect his quality of life Complications related to BPH n .

Choosing the right treatment n Consider risks. benefits and effectiveness of each treatment Consider the outcome and lifestyle needs n .

Treatment options n “Watchful waiting” n Medication Surgical approaches Minimal invasive nTURP nInvasive “open” procedures n n .

“watchful n waiting” For mild symptoms. follow up1 to 2 times yearly n Offer suggestions that help reduce symptoms n Avoid caffeine and alcohol n Avoid decongestants and antihistamines .

Harnalidge) n 5 α reductase inhibitor .Shrink the prostate gland (Proscar.Medication n First line of defense against bothersome urinary symptoms Two major types: n n α blockers .relax the smooth muscle of prostate and provide a larger urethral opening (Hytrin.Doxaben. Avodart) .

Medication Benefits n n Disadvantages n Convenient No loss of work time Drug Interactions n n Must be taken every day Manages the problem instead of fixing it n Minimal risk .

Possible side effects of n • Impotence n Dizziness • n Headaches • n Fatigue • n Loss of sexual drive • medication .

. B. D) Schwinn DA.-Adrenergic Blockers: Rationale • Prostate smooth muscle tone is mediated via 1-adrenergic receptor • Blockage of the receptor leads to improvement of flow rate and LUTS1 • Central -receptors and the effect of agents on these receptors likely play an additional role • Density of adrenergic receptors changes with prostate size and age • Three 1-adrenergic receptor subtypes have been identified (A.86(suppl 2):11-22. 2000. BJU Int.

Distribution of 1-Adrenergic Receptors .

Localization of 1-Adrenergic Receptors (1-ARs) .

Alfuzosin • Long-acting selective 1-blockers – Terazosin – Doxazosin • Long-acting selective 1A-subtype – Tamsulosin – Alfuzosin-SR .-Blockers • Nonselective – Phenoxybenzamine • Short-acting selective 1-blocker – Prazosin.

1-Adrenergic Blockers: Summary • All currently available 1-blockers induce fast improvement in LUTS and flow rate parameters with similar efficacy • They are all well tolerated. fatigue. and asthenia – Tamsulosin induces more ejaculatory disturbances • None of the 1-blockers alter urodynamic parameters. the adverse event spectrum differs between the agents – Terazosin and doxazosin induce more dizziness. however. prostate volume or serum PSA • None have been shown to alter the natural history of the disease or prevent AUR / Surgery .

seminal vesicle. Br J Urol.5-Reductase Inhibitor: Rationale • Prostatic differentiation & growth depend on androgenic stimulation • Testosterone is converted to dihydrotestosterone (DHT) within the prostatic stromal & basal cells facilitated by 5-reductase enzyme • 5-reductase inhibitor: deprive the prostate of its testosterone support • 5-reductase enzyme: Type I: skin & liver Type II: stromal & basal cells of prostate.149:342-344 . 1993. epididymis Kirby RS et al.70:65-72 Tammela TLJ et al. 1992. J Urol.

Regulation of cell growth in the prostate in BPH Serum testosterone (T) Serum Dihydrotestosterone (DHT) T 5AR (1 and 2) DHT Growth factors Prostate cell DHT-androgen receptor complex Cell death Increased Cell growth Unbalanced .

Dual (type 1&2) 5ARI Proscar(finasteride) .Only type 2 5ARI .5-reductase inhibition Mode of action OH OH 5 -reductase type 1 and 2 O NADPH Testosterone NADP O H Dihydrotestosterone Avodart (dutasteride) .

Combination therapy with 5aRIs and a1 blockers .

inducing apoptosis.Rationale for Combination Therapy • Alpha blockers relax the smooth muscle of bladder neck and prostatic capsule/adenoma. thereby improving symptoms and flow rates. by shrinking the prostate improve symptoms. and. relieving obstruction • 5 ARIs reduce the action of androgens in the prostate. atrophy. relieve obstruction and prevent AUR & prostate surgery 5ARIs 1-adrenergic ? blockers Arrest disease progression Rapidly relieve symptoms .

Medical Therapy of Prostatic Symptoms (MTOPS) .

001) Finasteride 5.001) 10 8 Median point decrease from baseline Median baseline AUA SS = 17.0 .0 (p<0.0 2 (p<0.0 Doxazosin 6.0 (p<0.047) Combination 4 6 7.Change in AUA Symptom Score at Year 4 Placebo 4.

4 Doxazosin 2.6 .Change in Qmax at Year 4 Placebo 1.7 (p<0.001) Finasteride 2.2 (p<0.5 (p<0.047) Combination 3.001) 1 2 3 4 5 Median point decrease from baseline Median baseline Qmax = 10.

Conclusions • Single arm therapy with alpha blocker – Improve symptoms and prevent symptom progression – Does not alter natural history or cross over to invasive therapy • Single arm therapy with 5 ARI – Treats symptoms only when LUTS associated with BPH (ie enlargement or high PSA) – Alters natural history in pts at risk (large gland. high PSA) • Combination (doxazosin+finasteride) therapy is the most effective form of treatment for LUTS and BPH – Improve symptoms and flow rate – Prevent AUR and/or surgery – Alter the natural history of the disease .

followed by dutasteride monotherapy Entry criteria: • • • IPSS  12 PV  30 cc. estimated by DRE PSA 1.Symptom Management After Reducing Therapy: SMART–1 SMART–1 was designed to examine short-term dutasteride and a1-blocker combination therapy.0 ng/ml Barkin et al (2002) .5 – 10.

5mg + tamsulosin 0.SMART-1: study design DT24 + D12 DT36 Placebo run-in Combination dutasteride 0.4mg once daily dutasteride 0.5mg + placebo (tamsulosin) Combination Placebo 4 weeks Single blind Barkin et al (2002) 24 weeks Single blind 12 weeks Double blind Wk 30 1 week Single blind Wk 36 .

SMART-1: primary endpoint question at week 30 by baseline IPSS 100 80 60 40 Severe pts need longer AB treatment 20 0 DT36 DT24 + D12 DT36 DT24 + D12 % patients better/same Barkin et al (2002) 57.5% 93% Moderate (baseline IPSS <20) (n=220) 84% Severe (baseline IPSS 20) (n=82) 86% .

1998。2.7 4 -27.2 -57% -48% -6.7% 4yrs5.3% Symptoms Urinary Flow Rate Risk of AUR Risk of BPH Surgery -2.M.1 1.7 Continue Reduction Continue Reduction Note: Not from a comparative trial. T. N Engl J Med 349(25):2387-98. McConnell JD et al.3% 4 -18% 4 -19% Dutasteride* 2yrs4 2 -25.51:677-86. Urol.5 2. Roehrborn CG et al.9 -57% -55% -5.2003。4.5 α Reductase Inhibitors臨床療效 成份 Compared to Baseline Duration (yr) Total Prostate Volume Finasteride PROWESS1 PLESS2 MTOPS3 2 -15.Debruyne et al.60:434-41. McConnell JD et al. PROWESS=Proscar Worldwide Efficacy and Safety Study.1998。3. Marberger MJ.2 -68% -64% -4. all result abstracted from treatment group. PLESS=Proscar Long-term Efficacy and Safety Study. MTOPS=Medical Therapy of Prostatic Symptoms *: Avodart Phase III trial為在2年的double blind 後再延長2年至4年的open-label study References: 1.6.Tammela et al.6 3. F. 2004 EAU Abstract。7.Emberton et al.Urol. N Engl J Med 338(9):577-63.5 -57% -40% -3.2002。5.3 1.5 2. 2004 EAU Abstract。 6. 2004 EAU Abstract。 .

dutasteride can be used in combination with tamsulosin to achieve fast symptom relief that is maintained with alpha 1.Conclusions • In MTOPS study.且可 明顯地減少急性尿滯留及需要BPH相關的手術的機會 • In SMART-1 study.且可在合併治療的6個月後移除alpha blocker .可預防BPH病程惡化的效果.blocker is removed after 6 months 為了有效且快速的緩解因BPH引起的惱人症狀.Avodart 可與alpha blocker合併使用. finasteride afforded long-term reduction in risk of AUR on surgery when combined with alpha 1-blocker doxazosin 5ARI 與alpha blocker長期合併使用.

Medical Therapy Algorithm Patient IPSS ≤7 No or little bother Prostate small PSA low Prostate large PSA high IPSS >7 Moderate to severe bother Prostate small PSA low Adrenergic Blocker Prostate large PSA high No Treatment Preventive therapy 5-Reductase Inhibitor 5-Reductase Inhibitor Combination Rx IPSS <19 (Moderate) Short term IPSS >19 (Severe) Long term .

Surgical treatment .

McConnell JD et al. Plymouth.Treatment Modalities for BPH • Watchful waiting • Medical therapy – – – – Phytotherapy -adrenergic blockers 5-reductase inhibitors Combination therapy • Surgicenter/Hospital-based treatment – – – – – – – TURP (gold standard) TUIP Open surgery (prostatectomy) TUVP ILC VLAP Prostatic stents • Office-based treatment – TUMT – TUNA – WIT Chatelain C et al. . In: Chatelain C et al. Benign Prostatic Hyperplasia. eds. 2001. UK: Health Publication Ltd.519-534. Number 8. Clinical Practice Guideline. Benign Prostatic Hyperplasia: Diagnosis and Treatment.

UFR cystoscopic findings. image study. residual urine .Indication of surgical intervention • • • • • Acute urinary retention Gross hematuria Frequent UTI Vesical stone BPH related hydronephrosis or renal function deterioration • Obstruction IPSS≧8. prostate size.

Conventional Surgical Therapy • Transurethral resection of the prostate (TURP) • Open simple prostatectomy .

TURP (transurethral resection of the prostate) n n “Gold Standard” of care for BPH Uses an electrical “knife” to surgically cut and remove excess prostate tissue Effective in relieving symptoms and restoring urine flow n .

2% .TURP • • • • “Gold standard” of surgical treatment for BPH 80~90% obstructive symptom improved 30% irritative symptom improved Low mortality rate 0.

The “gold standard”- TURP
Benefits
n
n n

Disadvantages
n

Widely available Effective Long lasting

Greater risk of side effects and complications 1-4 days hospital stay 1-3 days catheter

n n n

4-6 week recovery

Complication of TURP
• Immediate complication
bleeding capsular perforation with fluid extravasation TUR syndrome

• Late complication
urethral stricture bladder neck contracture (BNC) retrograde ejaculation impotence (5-10%) incontinence (0.1%)

Open Simple Prostatectomy
• “too large prostate” -- >100 gm • Combined with bladder diverticulum or vesical stone surgery • Suprapubic or retropubic method

Minimally invasive therapy
• During the last decade, numerous amounts of minimally invasive therapy modalities have been developed to challenge the traditional surgery of TURP • The aim of these therapies is to achieve results similar to TURP but with minimal anesthesia, complication, risk and hospital stay.

Minimally invasive therapy for BPH
• • • • • • • • • transurethral balloon dilatation of the prostate (TUBDP) transurethral incision of the prostate (TUI) intraprostatic stent transurethral microwave thermotherapy (TUMT) transurethral needle ablation of the prostate (TUNA) transurethral electrovaporization of the prostate (TUVP) photoselective vaporization of the prostate (PVP), Cryotherapy Transurethral ethanol ablation of the prostate (TEAP),

Minimally invasive therapy for BPH • • • • • • transurethral laser-induced prostatectomy (TULIP) visual laser ablation of the prostate (VLAP) contact laser prostatectomy (CLP) interstitial laser coagulation of the prostate (ILC) holmium:YAG laser resection of the prostate (HoLRP) holmium:YAG laser enucleation of the prostate (HoLEP) • high-intensity focused ultrasound (HIFU) coagulation • botulinum toxin-A injection of the prostate .

19. 172(5.8 +/.19.001) • Hospital stay: 59 +/.05) • Catheterization time: 31 +/.13 vs 57.HoLEP Vs.15 mins (p <0. Part 1 of 2):1926-1929.001) • Urge incontinence: more common in the HoLEP group • The overall complication rate was comparable in the 2 groups Journal of Urology. TURP 57 +/.17.9 vs 85. TURP • IPSS & urodynamic findings: no statistically significant differences • Operation time: HoLEP 74 +/.5 vs.9 hours (p <0.78 +/.5 hours (p <0. November 2004 .18.

TURP vs HIGH POWER (80 W) POTASSIUM TITANYL PHOSPHATE (KTP) LASER VAPORIZATION • Hemostasis: standardized ablation volume of 16 cm3 tissue (23. 171(6.01). p <0. p <0.9 vs 0. • 80 W KTP laser vaporization: bloodless ablative procedure. • Histological examinations: larger coagulation zones for the KTP group compared to conventional tissue resection (0. • Tissue ablation: more rapid in the resection group (100 vs 20 seconds.6 mm.001). June 2004 .3 vs 2. but more time-consuming Journal of Urology. Part 1 of 2):2502-2504. p <0.1 ml per minute.0001).

How does PVP work? n Uses a very high powered green laser and a thin. flexible fiber n Fiber is inserted into the urethra through a cystoscope .

How does PVP work? n Quickly and precisely vaporizes and removes the enlarged prostate tissue n The green laser energy is hemostatic. so there is almost no bleeding .

Enlarged Prostate n n After GreenLight PVP n n Urethra is obstructed Urine flow blocked Urethra is open Normal urine flow is restored .

less occurrence of hyponatremia. quicker recovery. • However. . and reduced risk of urethral stricture. • It is still too early to make a definitive conclusion concerning the future role of these minimally invasive therapies for the treatment of BPH.Summary • Minimally invasive therapies for the treatment of BPH has the advantages such as less blood loss. it also has the disadvantages such as long-lasting bladder irritation owing to higher temperature during therapy and possible longer catheterization period due to swelling of the prostate.

Kanker Prostat .

Prostate Cancer .

including the bladder.What is Prostate Cancer • Prostate cancer is cancer of the prostate gland in which cells grow out of control within the body. rectum. invading and destroying tissues and organs in the prostate. and bone. . This can spread to other parts of the body. colon. Routine blood tests and physical exams can help screen for prostate cancer at its earliest stages. Only your physician can diagnose prostate cancer.

and persistent bone pain. blood in the urine or semen. problems with urination such as the inability to urinate. . frequent urination. loss of appetite and/or weight. painful ejaculation. hips or upper thighs. weakened urine flow.Symptoms associated with prostate cancer • Some of the symptoms associated with prostate cancer are dull pain in the lower pelvic area. pain or burning when urinating. general pain in the lower back.

A biopsy of the prostate is usually then recommended. . prostate cancer is suspected. The biopsy is done from the rectum (transrectally) and is guided by ultrasound images of the area. A pathologist then examines the tissue under a microscope for signs of cancer in the cells of the tissue.How is prostate cancer diagnosed? • Prostate cancer is diagnosed from the results of a biopsy of the prostate gland. A small piece of prostate tissue is withdrawn through a cutting needle. If the digital rectal exam of the prostate or the PSA blood test is abnormal.

representing an intermediate degree of aggressiveness. The two scores are then added together. signaling a rapidly growing tumor with the worst prognosis (outcome). . on the aggressiveness of the tumor. indicating a slowly growing tumor. Sums of 7 to 10 are considered high. Gleason scores can be helpful in guiding treatment that is based. The scale is based on certain microscopic characteristics of the cancerous cells and reflects the aggressiveness of the tumor. at least in part. Sums of 5 and 6 are intermediate. Sums of 2 to 4 are considered low. the pathologist will then grade each of two pieces of the tissue from 1 to 5 on the Gleason scale.Grading of a cancerous tissue: Gleason Scale • When prostate cancer is diagnosed on the biopsy tissue.

Stage T2 refers to a larger cancer that may be palpated. nodes. and T4 describes cancer that is fixed to the surrounding tissues. Stage T1 describes a minimal cancer that can neither be palpated (felt) on physical examination nor seen by imaging techniques. Stage N1 signifies a spread to the nearby (pelvic) lymph nodes and M1 is for distant spread (metastasis). for example. to the bones. . liver. Nodes and Metastasis (TNM) Classification • A system for staging prostate cancer is called the tumor. T3 describes cancer that extends just beyond the capsule (coat) of the prostate. but that still is confined (localized) to the prostate gland. or lungs. and metastasis (TNM) classification.Staging of prostate cancer: Tumor.

combination of hormonal therapy and radiation N+ or M+ Spread to pelvic lymph nodes (N+) or distant organs (M+) Hormonal therapy. radiation therapy (radiotherapy) T3 or T4 Locally advanced Radiation therapy. experimental approaches .Type of Treatment Stages and Treatments of Prostate Cancer Stages T1 or T2 Characteristics Type of Treatment Localized in the prostate Surgery.

tumor stage. and a “bad reading” for any one of them will effect the treatment options and chances of success of treatment. Gleason score and PSA.Making Treatment decisions • Each one of three characteristics. . The three factors are combined to form three “risk groups” which guide your doctor in your management. is important.

Group One: Favourable risk • This group includes those tumors. If your prostate size is not too large. and a PSA reading of 10ng/ml or less. . Hormone therapy is seldom indicated because there is a very low risk of these cancers having spread elsewhere. which are stage T1 or T2a(involving half a lobe or less of the prostate). with a Gleason score of 6 or less. brachytherapy is an excellent option. and may be better for you if you have a large prostate. External beam radiotherapy is also a good choice. or if you already have difficulties passing urine(slow stream. getting up a lot at night).

it is not generally considered appropriate for tumors in this group. which are slightly larger.Group Two: Intermediate risk • This group includes tumors. or has a Gleason score of 7. T2b. . although it may be used as a “boost” in combination with a short course of external radiotherapy. or have a PSA reading between 10 and 20ng/ml. Since these tumors are somewhat more aggressive. there is a greater chance of spread through the capsule of the prostate into the adjacent tissues. Because the dose from brachytherapy is so tightly focused on the prostate and only extends 2-3mm beyond the prostate. Newer radiotherapy techniques such as 3 dimensional conformal radiotherapy. and intensity-modulated radiotherapy (IMRT) allow a highly effective dose to be delivered safety(daily for 8 weeks).

or have a PSA higher than 20 at the time of diagnosis. but will also include a prolonged period of hormone therapy which will suppress microscopic spread of the cancer to lymph nodes or bone. treatment will often be directed not only at the prostate. or are aggressive looking under the microscope with Gleason scores of 8. but it will almost certainly be combined with 2-3 years course of “hormone therapy”. 9 or 10. . Since these tumors have a tendency to seed elsewhere early on.Group Three: High Risk • This group includes tumors which are either locally advanced. The radiotherapy may include a wider field radiotherapy than group two to cover pelvic lymph nodes.

Prostate Brachytherapy .

• Using their hands they guided surgical needles. . • Because they could not see inside the prostate. inserting radioactive seeds one by one into the prostate gland. • Used an incision into the abdomen to expose the prostate gland. • This led to later abandonment of this procedure. seeds were placed unevenly.History • Started in the 1900’s by physicians at New York’s Sloan Kettering Memorial Cancer Center.

Along Comes Ultrasound Technology .

Ultrasound Technology • In the early 1980’s Dr. Haakon Ragde introduce ultrasound-guided prostate implantation to the United States. . • In 1985. Hans Holm of Denmark begins applying a new technology of transrectal ultrasound. Dr. John Blasko and Dr. This coupled with computerized imaging software allows a major step forward in the development of prostate brachytherapy.

they become inert.Brachytherapy Today • Today prostate brachytherapy involves the permanent implantation of 90 to 140 tiny radioactive seeds into the prostate. deliver an intense focused dose of radiation to the prostate. which then. After they have completed their job however. over the subsequent 6 months. . The seeds remain permanently.

. any tumour cells located outside the prostate may not receive a sufficient dose to be eradicated. which either aren't palpable (felt) on rectal exam. • A presenting PSA less than 10 ng/ml • Outside these guidelines. Because radioactive seed implants have a very short range. there's considerable risk that prostate cancer cells have spread into tissue surrounding the prostate. • A Gleason score less than or equal to 6. or are palpable as small nodules.Who is Eligible? • The Cancercare Ontario Evidence-based Guideline recommends that this form of treatment be applied only to those men with: • T1c/T2a tumors.

The more the swelling.Technical Considerations • L prostate size (< 60 cc). Over 500 implants have been performed at the Princess Margaret Hospital of the University Health Network. . there is an increased risk of prostate swelling after the implant. the longer it takes to resolve. • no previous TURP ( less tissue to implant) • pubic arch configuration( hinders the needles and proper seed placement). If the patient has a bigger prostate or has had hormones to shrink his prostate.

Pubic Arch Interference .

the seed implant takes about two hours and can be done under either general or spinal anesthesia) – Avoids lengthy hospitalization – rapid return to normal activity – comparable 10 year outcome – perceived as low morbidity .Brachytherapy: Advantages • Personal : – simple outpatient procedure( Typically.

This map is followed closely. • Cross sectional images of the prostate are taken every 5mm and re-assembled on a computer to make a threedimensional model of the prostate. • Exact placement of each seed can then be determined. . • The team (doctor.After Deciding on Brachytherapy The volume study is the first step. physicist and dosimetrist) then takes a created map of the prostate into the operating room.

Volume Study Geometry .

Contouring And Planning .

Template Used to Guided Seed Insertion .

The Procedure .

8 p=0.3 cc vs 33.004 . AUA score • Depends on volume: 39. V200 and urethral dose.002 • Depends on # of seeds: 112 vs 102 p=0. V100.Urinary Morbidity: PMH • Acute urinary retention :16% • Independent of D90.

can feel like one is sitting on a golf ball • Burning sensation while urinating • Blood clots in the first few days following implant.Side Effects • Tenderness and bruising which can last 3-7 days in the perineal area. urine is strained for 3 days following implant • Frequency and urgency • In extreme cases--urinary retention requiring catheterization • Rarely are there complications to the bowel and rectum .

this medication lessens the burning sensation and feeling of urgency • Mobicox. improves urinary stream and bladder emptying by relaxing the smooth muscle around the bladder neck • Cipro. taken for at least one week to one month • Tylenol-Extra Strength or with Codeine--relieves pain from implant.Medications • Flomax-starts 7 days before implant and must continue for at least 3 months post implant. use only as needed .an antibiotic.reduces inflammation from the implant. is taken for 1 week starting the day of the implant • Pyridium-taken 3 times a day for the first 2 weeks following implant.

5 days Don’t stop the Flomax Trial of voiding (measure PVR ! ) Teach ISC Supra pubic if can’t do ISC Wait 8.12 months before TURP (minimal) .Management of Acute Urinary Retention • • • • • • In-dwelling Foley x 3 .

dose response) – NSAID’s. cox-2 inhibitors better – short course steroids .Management of Acute Urinary Morbidity • Patience!!! • Irritative/obstructive symptoms (high IPS score): –  blockers (Flomax.

PSA and bladder function at 6 months Biopsy at 2 year mark suggested .Follow Up • • • • • • Done at 1 month Every 2-3 months for first year 3-4 Months in second year Every 6 months thereafter DRE.

n=1048) @ 3. n=419) Combined with NHT @ 2 years : 50% (additional 25% partial) (Sanchez-Ortiz. 2000. 1998. n=209 incl Viagra) @ 5 Years: 85% (Sharkey. 2000. n=171) .5 Years: 90% ( Scherr. n=692) @ 2 Years:78% (Stone. 2002. 2000.Potency • • • • • @ 6 Years: 92% (Merrick.

Brachytherapy Results for Favourable Risk Patients • Negative biopsy @ 2 years: 87-95% • Negative biopsy @ 5 yrs: 86-93% • Negative biopsy @ 10 yrs: 71-87% .

it surpassed radical surgery as the treatment of choice for newly diagnosed localized prostate cancer in the United States. The favorable side effect profile however makes it an attractive and highly sought-after form of treatment. Fifteen years experience with brachytherapy and results for 1000’s of men have indicated that it has similar efficacy to surgery. In 2003.Summary Prostate brachytherapy is a highly effective form of treating early stage prostate cancer and involves the permanent implantation of 90 to 140 tiny radioactive seeds into the prostate. It offers men an alternative to radical surgery and can be performed as an outpatient procedure with considerably less impact on urinary and sexual function. .