Complication of BPH

Mortalitas
• Terjadi peningkatan kematian dari tahun 1950 -1990 sekitar 13,681.
• di US
Batu empedu
• Pada praktisi klinis, resiko batu berkembang kecil dan dilakukan
skrining jika ada indikasi seperti hematuria, nyeri saat urinasi
Bladder Decompensation
• Urologists search for a progression from a normal mucosa to advancing
trabeculation and development of cellules and diverticula, with
ultimate detrusor muscle failure in mind, when evaluating the bladder
in men with BPH endoscopically. However, when the process starts,
whether it really is related to BPH and obstruction, and when an
intervention is necessary to prevent decompensation with resultant
inability to void are unclear.
• Biopsies from trabeculated, obstructed bladders show dense
connective tissue deposition, a finding similar to that seen in animals
experimentally obstructed. However, bladder fibrosis is seen in both
sexes with advancing age and may be a normal consequence of aging.
Urinary Incontinence
• Incontinence is one of the most feared complications from surgical
intervention for BPH. While it may be the result of BPH secondary to
overdistention of the bladder (overflow incontinence) or to detrusor
instability estimated to affect up to one half or more of all obstructed
patients (urge incontinence), it also is associated with aging, and in a
community study an incidence of incontinence of 24% in men and
49% women over 50 years of age was reported.
Urinary Tract Infections
• In older surgical series urinary tract infections (UTIs) constituted the
main indication for surgical intervention in about 12% of patients.
Although one might intuitively assume that increased amounts of
residual urine would predispose to the development of UTIs, clear
evidence is lacking. Hunter and colleagues (1996) quoted a rate of
5.2% self-reported episodes of UTI in a cross-sectional survey of 2002
men in Madrid, Spain. The best data to date come from the MTOPS
study, where the incidence of UTIs in the placebo-treated patients
was only 0.1 per 100 patient-years.
Upper Urinary Tract Deterioration
and Azotemia
• Patients in renal failure have an increased risk for complications following
TURP compared to patients with normal renal function, while the mortality
increases up to sixfold. In the large database of patients who had upper
tract imaging prior to surgery, 7.6% of 6102 patients in 25 series had
evidence of hydronephrosis, of whom one third had renal insufficiency.
• The term silent obstruction or silent “prostatism” has been used to describe
the constellation of asymptomatic patients who eventually develop renal
failure resulting from BOO, a situation both rare and important (Mukamel
et al, 1979). In the VA cooperative study, only 3 of 280 surgically treated
patients and 1 of 276 patients in the watchful waiting arm developed renal
azotemia, defined as a doubling of serum creatinine from baseline.
Hematuria
• It has always been recognized that patients with BPH might develop
gross hematuria and form clots with no other cause being identifiable.
Recent evidence suggests that, in those patients predisposed to
hematuria, the microvessel density is higher compared to controls.
Acute Urinary Retention
• Acute urinary retention (AUR) is for several reasons one of the most
significant complications or long-term outcomes resulting from BPH.
It has in the past represented an immediate indication for surgery.
Between 25% and 30% of men who underwent TURP had AUR as
their main indication in older series, and today most patients failing to
void after an attempt at catheter removal still undergo surgery.
• The etiology of AUR is poorly understood, and obstructive, myogenic,
and neurogenic causes all may play a role. Prostate infection, bladder
overdistention (Powell et al, 1980), excessive fluid intake, alcohol
consumption, sexual activity, debility, and bed rest have all been
mentioned (Stimson and Fihn, 1990). Prostatic infarction has been
suggested as being an underlying event causing AUR (Graversen et al,
1989
• AUR episodes are classified as spontaneous. The importance of
differentiating the two types of AUR becomes clear when evaluating
the ultimate outcomes of patients. Following spontaneous AUR, 15%
of patients had another episode of spontaneous AUR and a total of
75% underwent surgery, whereas after precipitated AUR, only 9% had
an episode of spontaneous AUR and 26% underwent surgery