What is Prostate?

The Prostate Gland and BPH. Basic Science



Function

Secretory
Produces 30% of the volume of seminal fluid
Provides nutrients for sperm
Proteases such as PSA (chymotrypsin) maintain semen fluidity by acting as an anticoagulant
Neutralises acidity of vagina
Antibiotic function of some secretions from the central zone.

Muscular pump
Smooth muscle surrounding the glands forces ejection of prostatic fluid to mix into seminal fluid during ejaculation


Development

Wk 7 male and female identical.
Mullerian ducts degenerate in male
Wolffian ducts differentiate - ejaculatory ducts, SV, vas and central zone of prostate
Wk 10-15 prostate derived from urogenital sinus (UGS) (peripheral zone)
Prostatic utricle is remnant of Mullerian or paramesonephric duct
3rd trimester gland quiescent till puberty


Structure

70% glandular / 30% fibromuscular


Zonal anatomy (McNeal 1968)

TZ - 5-10% glandular tissue

CZ - 25% glandular tissue structurally / immunohistochemically distinct from other zones.

Possibly originated from Wolffian duct

PZ - 70% glandular tissue

Derived from urogenital sinus


Transition zone BPH, 20% cancers
Central zone, 1-5% cancers
Peripheral Zone, 70% cancers


Blood supply: Inferior vesical and middle rectal arteries - branches of internal iliac artery
Venous drainage:
Prostatic venous plexus - sides & base of prostate
Located between capsule + fascial sheath
Drain to internal iliac veins
Communicate with vesical venous plexus, vertebral venous plexus

Innervation

Via cavernosal nerves which follow arterial supply
Parasympathetic fibres arise from pelvic splanchnic nerves S2, S3, & S4, promote secretions
Sympathetic fibres derived from inferior hypogastric plexuses, contraction of SM of capsule & stroma

Sphincters:

Rhabdosphincter (distal sphincter/urethral sphincter mechanism)
Three components: smooth muscle, then striated muscle, then periurethral component of levator ani (pubourethral sling)
Under conscious control
Signet ring shaped, deficient posteriorly

Bladder Neck
Both sexes, at bladder neck, cholinergic innervation, continence mechanism

Preprostatic sphincter
Males, supraverumontanal, adrenergic innervation, genital sphincter
Separate from rhabodosphincter
Smooth mucle, not under conscious control



Lymphatic drainage:
Lymph vessels terminate mainly in internal iliac and obturator lymph nodes
Some travel to external iliac lymph nodes & presacral nodes


Seminal vesicle
Pear shaped structure, 5cm long
Lies between fundus of bladder and rectum / (ureter enters bladder medial to tip of SV)
Provide majority of volume of seminal fluid, does not store sperm
Join vas deferens to form ejaculatory duct, opens posterior wall of prostatic urethra
Blood supply - sup / inf vesical arteries



Ejaculation
Emission of semen into urethra: peristalsis of vas / seminal vesicles, contraction of smooth muscle in prostate - sympathetic
Ejaculation clonic spasm bulbospongiosus muscles – parasympathetic
Sequence:
Bladder neck tightens
Emission of vasal ampullary sperm
Contraction of bulbospongiosus
Contraction of prostatic smooth muscle
Urethral sphincter mechanism overcome
Further contraction of prostate and seminal vesicle contraction




Seminal plasma

2ml seminal vesicle secretion, 0.5ml prostatic secretion, 0.1ml Cowper’s glands and glands of Littré

Role of seminal plasma
Optimise fertilisation
(ejaculated sperm v aspirated sperm)
protective effect
enhance motility and survival directly
Protective effect on urinary tract
biological esp. Zn, spermine, Ig
mechanical washing
Lubrication


Prostatic secretions

o Proteins: Acid phosphatase, PSA, Leucine aminopeptidase, Diamine oxidase, Β Glucuronidase, Plasminogen activator, Complement C3 and C4, transferrin, transferritin, Growth factors, annexin 1

o Non-proteins: Citrate (240-1300x conc elsewhere), Spermine, Spermidine, Putrescine, Zinc (high concentrations), Myoinositol, Cholesterol

o Functions: zinc for the structure of sperm chromatin and antibacterial. PSA for semen liquefaction. Cholesterol may stabilize sperm against temperature and environmental shock Citrate is important for electrochemical neutrality in combination with zinc and polyamines


Fructose

§ From seminal vesicles
§ Patients with congenital absence of seminal vesicles don’t have fructose in ejaculate [Barak 1994]
§ Concentration has some androgenic regulation but also depends on nutritional status and frequency of ejaculation
§ Provides anaerobic and aerobic energy source for sperm
§ Indirectly linked to forward sperm motility through prostasome function [Fabiani et al 1995]

Prostaglandins

§ Seminal vesicles are richest source in body (originally thought to be from prostate – hence the name) many types
§ Very potent pharmacological actions
§ Erection, ejaculation, sperm motility and transport
§ Effects on cervical mucus and vaginal secretions

Cell biology

Cellular organization is of a complex ductal system of epithelial cells embedded in a
stromal matrix

Epithelial: Exocrine and neuroendocrine cells
3 types: basal, luminal and neuroendocrine
Have different functions but are believed to originate from a common progenitor stem cell
Separated from stromal cells by the basement membrane
DHT formed mainly in these cells, and DHT then diffuses to stroma (where there are most of the androgen receptors)
Stromal nuclei produce growth factors, which then drive epithelial cells

Stroma: smooth muscle cells and fibroblasts
Has most of the androgen receptors
DHT diffuses from stromal cells, which produce growth factors, and these factors then work in an autocrine and paracrine fashion, stimulating epithelial cells

Cell type Function
Basal cells Proliferation
Luminal cells Secretion of prostatic fluid
Neuroendocrine Unknown - control growth and secretion?

Fibroblast Secrete growth factors (androgen dep)
Smooth muscle Contraction to eject prostatic fluid


Cellular organisation in the glandular prostate

Epithelial Cells

Neuroendocrine
Morphologically found in two forms
Open ended flask shaped cells with long extension towards the glandular lumen.
Closed cells without dendrite luminal extensions but with occasional horizontal processes.
Prostate has largest number of NE cells of any urogenital organ.
Function: Unknown but may play a role in the regulation of the normal growth and gland development (paracrine and autocrine) and may be important in the development of disease.

Basal cells
Spindle shaped, lying parallel to the basement membrane
Cigar shaped nuclei and high nucleus to cytoplasm ratio
81% of all proliferation occurs in the basal layer
Ratio of basal cells to luminal is 1:3 in normal and BPH tissue and 1:6 in hyperplastic situations
Major function: Proliferation
Includes stem cells

Luminal cells
Tall, columnar cells high in cytoplasm
Secretory cells contributing to the seminal fluid
PSA - Prostate specific antigen
PAP - Prostatic acid phosphatase
Only 1/10 the proliferative index of basal cells
Function - secretory - androgen dependent, as is survival
These cells most abundantly express the adrenoreceptor in BPH, cf basal cells

Cytokeratins:
Prostate: K5/14 basal cells and K8/18 in luminal cells

Stromal cells

Smooth muscle cells and fibroblasts
Little information about stromal cell types
Fibroblasts appear to initiate glandular growth and then differentiate into smooth muscle cells.
In cancer loss of muscle and gain of fibroblasts is associated with increased epithelial cell division
In culture a cell type called myofibroblasts appears and this may be an intermediate cell type
Both cell types express andrenoreceptors in BPH
98% of all α-adrenoreceptors in the prostate (90% α1 (60% α1a), 10% α2)



Stromal epithelial interaction theory

Interation between the stroma and the epithelium is important in growth and maintenance of the prostate
Reischauer suggested this first in 1925, and the theory was adopted by Cunha (1973)
Cunha showed that murine embryonic prostatic stroma could induce adult bladder epithelial cells to replicate and form prostate like glandular structures from the bladder cells. This effect does not occur in castrated animals, thus indicating the importance of androgens.
This interaction is thought to be the driving factor in the development of BPH, with androgens stimulating the local production of growth factors. These factors are responsible for the abnormal proliferation of the prostatic stroma and the appearance of micronodules and macronodules

Other Theories for BPH development

Embryonic reawakening: McNeal suggests that the initial abnormality in nodule genesis is a spontaneous reversion of a clone of stromal cells to the embryonic state

Oestrogen hypothesis: oestradiol modulates the action of androgens by altering the sensitivity of the prostate to androgens. A small increase in oestradiol concs results in an increased number of androgen receptors and prostate size. A large increase in oestradiol has the opposite effect. With aging, the oestrogen to androgen ratio increases, and these changes mimic those seen in BPH. Glandular BPH has been induced in castrated dogs by oestrogen and androgen administration (Walsh and Wilson, 1976)

Stem cell hypothesis: Isaacs and Coffey 1989. Number of stem cells, which is the rate limiting factor in prostate growth, slowly increases over time.


Growth Factors


FGF
IGF
TGFα all stimulatory (TGFα accounts for 20% of stimulatory factors)
EGF

TGFβ inhibitory

They all regulate the epithelial and mesenchymal interactions responsible for prostate development.
TGFβ inhibits prostate epithelial growth, but stimulates prostatic mesenchymal cells.

Following androgen withdrawal, there is decreased production of EGF, IGF and FGF, and an increase in expression of TGFβ1 and 2 receptors. This leads to prostatic involution.

Growth Factors in BPH:

bFGF stromal/epithelial autocrine/paracrine stimulatory
KGF stromal paracrine stimulatory
TGFβ1 stromal autocrine/paracrine inhibitory
TGFβ2 epithelial autocrine/paracrine inhibitory
IGF stromal paracrine stimulatory

In BPH there is no change in EGF, a large increase in FGF2, and keratinocyte growth factor and IGF appear.


Apoptosis and programmed cell death

Apoptosis is important in the development of BPH.
Activation of endonucleases occurs relatively early in the apoptotic pathway. This results from the hydrolysis of DNA, and the endonucleases are Ca2+/Mg2+ dependent.
Prostate stroma expresses α1a receptors, and pts treated with terazosin and doxasosin show induction of apoptosis, without affecting proliferation. Apoptitic index is higher in pts treated with an α blocker and proscar. Expression of TGFβ1 is increased with all therapies. However, α blocker treatment is not associated with a decrease in size of the prostate clinically.




BPH
LUTS
Urodynamic obstruction
BPE


LUTS, anatomical hyperplasia and urodynamic obstruction are interrelated.
Some pts have all three.
However, a large number have anatomical hyperplasia and urodynamic obstruction without LUTS.
Other have LUTS and urodynamic obstruction without anatomical hyperplasia, such as with bladder neck obstruction or a urethral stricture.
The last group have anatomical hyperplasia and symptoms of LUTS without urodynamic obstruction, and such pts may have a slow stream when voiding, but this is due to detrusor failure.

Anatomical hyperplasia
BPH consists of a mixture of glandular tissue and stromal components developing in a nodular fashion.
Glandular tissue that participates in BPH nodule formation is derived exclusively from branches of the few small ducts that join the urethra at or near its point of angulation at the base of the veru.
Nodules develop either in TZ or in periurethral stroma
Very different histologically: periurethral nodules are purely stromal in character or show only a few small glands. (TZ nodules are a proliferation of glandular (epithelial) tissue with a reduction in the relative amount of stroma ? correct)
In BPH stromal to glandular (epithelial) tissue is 5:1, while normally it is 2:1 in normal prostates
BPH has been described as primarily a stromal process
Causes obstruction in 2 ways
Static obstruction from increased tissue mass
Dynamic obstruction from contraction of the bladder neck, prostatic fibromuscular stroma and capsule
This sympathetic mediated obstruction may be responsible for upto 40% of bladder outflow obstruction




Natural History and Epidemiology

Initial development of BPH starts age 25-30 yrs, with a prevalence of 10% in that age range (data from autopsies involving 1075 prostates, Berry et al, J Urol 1984)
6th decade prevalence is >50%
by age 85, 90% affected
Data from Berry showed normal prostates weigh 20 +/- 6g in men 20-30 yrs, and remains constant throughout life
In pts with LUTS aged 60-80 yrs average weight is 40-50g


Risk factors and androgens

Age
Functioning testes leading to production of testosterone
BPH develops when test levels are on the decline
Role of androgens likely to be facilitative rather than causative

Intracellular androgens:
Testosterone metabolized to DHT, by 5 alpha reductase
Types 1 5a red (skin and liver) and type 2 (intraprostatic)
DHT: testosterone in prostate is 5:1
Both DHT and test bind to androgen receptors, DHT > testosterone, leading to greater subsequent intracellular changes of DNA activation and mRNA production
Males with 5a reductase def have no prostates

Androgen control:

Gene encoding 5a red enzyme type 1 found on Chr 5: expressed in nongenital skin and liver (inhibited by dutasteride)
Gene encoding 5a red enzyme type 2 found on Chr 2: expressed in prostate (stroma and basal epithelial cells) and genital skin (inhibited by finasteride and dutasteride)

Lasers and Stents for the enlarged prostate

Lasers and stents


Lasers

•Light Amplification by the Stimulated Emmision of Radiation
•Flash-lamp with high intensity light bombards resonator cavity with photons
•Electrons excited, decay with emission of photon
•Cascade effect
•Photons leave resonator cavity as coherent laser beam

Principles

•Coherence, collimation and monochromaticity




•Differ with respect to wavelengths, power and mode of emission (pulsed or continuous)


Mechanism of Action
•Heat treatment
o 45-50ºC Desiccation
o 50-100°C Coagulation
o >100°C Carbonisation and Vapourisation
•Effect dependent on power of laser and length of time applied
•NB. Can be used if anti-coagulated or coagulation disorder


Laser types

•Nd:YAG (neodymium, yttrium, aluminium, garnet)
o 1064 nm wavelength
o absorption length in tissue of 0.5 to 1.75 cm, giving it excellent haemostatic properties
o VLAP uses the NF-YAG laser in a non contact mode using a side firing laser
o Contact laser ablation (CLAP) uses NDYAG via a sapphire tipped fibre. Direct contact between laser fibre and tissue causes tissue vaporisation at the point of contact
o CLAP and VLAP show similar improvements at 2 years in flow rates and SS, but at 4 yrs CLAP has a 23% reop rate. CLAP harder to learn, and has been abandoned

•KTP:YAG
o Beam from Nd-YAG passed through a potassium titanyl phosphate crystal (KTP) which doubled the frequency and halves the wavelength (532 nm)
o Good incisional and vaporization properties, with tissue penetration depth of 3mm
o Causes vaporization of tissue, and can result in an immediate TURP like channel

•Ho:YAG
o Wavelength of 2140 nm
o Penetration depth of only 0.4mm, with excellent incisional and haemostatic properties
o Laser ablation of prostate involves vaporization of prostate tissue using a side firing fibre
o Laser resection of the prostate divides the lobes into fragements small enough to irrigate from the bladder
o Laser enucleation of the prostate, whole lobes cut away, and then morcellated for removal

•Diode
o Wavelength of 830 nm
o Used for interestitial laser coagulation
o Coagulation necrosis occurs via a fibre inserted directly into interstitium of prostate
o Usually needs spinal or GA


Methods

Side-firing
TRUS guided Laser induced Prostatectomy (TULIP)
Visual laser ablation of the Prostate (VLAP)
Interstitial Laser Coagulation (ILC)
Ho laser resection of the prostate (HoLRP)


TULIP

‘Blind’
Side-firing Nd:YAG
Useless
Abandonded

Visual laser ablation of the Prostate (VLAP)

Mixture of coagulative necrosis and vapourisation
Nd:YAG laser(1064nm) at 40-90W for 60s
Quadrant / Sextant spot application technique via cystoscope
Tissue sloughs away
Results
85% have ³ 50% improvement in SS or Qmax
Significant reduction in BOO (80-95%)
No irrigation required
Best if gland < 50-60g
Not suitable if UTI / bacterial prostatitis
Complications
Prolonged catheterisation (3-4 weeks) & dysuria
Serious complications in 12%
Impotence 0%
Incontinence 0%
Urethral stricture 2%
Bladder neck contracture 4%
Ret ejaculation 22%
Retreatment rate 2%/year (Costello) – 8%/year (Puppo)


Interstitial Laser Coagulation (ILC)

Coagulation necrosis used to reduce prostate volume
Secondary atrophy & regression of prostate rather than sloughing
Nd:YAG or diode laser
Fibres placed into prostate tissue cystoscopically
1-2 fibres per 5-10ml prostate volume
Results and complications
Similar improvement in LUTS & BOO to TURP at 1 year follow-up (Muschter)
8% ILC subsequently required TURP
Mean catheterisation – 18 days
Complications
Ret ejaculation 12%
Stricture 5%
Impotence 0%
Incontinence 0%
Retreatment 3%/year for first year rising to 10%/year subsequently

Ho laser resection of the prostate (HoLRP)

Pulsed solid-state laser, l = 2140nm
Ho:YAG l is strongly absorbed by water
Zone of coagulative necrosis, 3-4mm, is adequate for haemostasis
Peak power causes intense vapourisation and precise cutting
550mm end-firing quartz fibre via continous flow resectoscope with normal saline irrigant
80W Ho:YAG laser
Results
Gilling et al (J Urol 1999; 162: 1640) Prospective RCT, TURP v’s HoLRP with 1 year follow-up
Similar improvements in SS, Qmax and PdetQmax
Complications
Dysuria 10%
Impotence 0%
Ret ejaculation 75-80%
4 yr follow up: J Urol 2004. Similar outcome to TURP with less morbidity

Stents

10-15% BPH patients unfit for surgery
AUA guidelines: only for use in unfit pts
A number of small studies using prostatic stents in unfit men with retention
Various materials used
Metallic alloys, bioresorbable, polyurethane, thermosensitive
Urolume
Self-expanding superalloy wire
Placed cystoscopically or US guided
Over a few weeks to a few months they become covered with normal transitional epithelium

Urolume North American Clinical Trial
13% required stent removal
Side effects
Urgency (67%), dysuria (50%), perineal pain (50%), persistent retention (10%), incontinence (<1%), haematuria, encrustation, occlusion,
TITAN Stent
Seamless titanium tubing
Expanded with non-compliant balloon
Placed cystoscopically with iv sedation & prostate block
Results inferior to Urolume

Benign Prostatic Hyperplasia and Urodynamics

Facts:

BOO is present in 90% of men with larger prostates
(>80 ml), in those with small volumes (<40>15 ml/s only about 1/3 [3]. These data indicate that urine flow studies are not sufficient for the definitive
diagnosis of BOO (Abrams, BJUI 1995)

Obstructed patients do not always fare well with TURP (success rate: 79–93%) and conversely, unobstructed men do not always fail with success rates of 55–78% (Homma, BJUI 2001)

The EAU guidelines.

Who should have UDx prior to TURP?
(i) previous unsuccessful invasive treatment of LUTS;
(ii) elderly men (>80 years);
(iii) younger men (e.g. <50 years);
(iv) post-void residual volume >300 ml;
(v) suspicion
of neurogenic bladder dysfunction;
(vi) previous radical pelvic surgery


Previous unsuccessful invasive treatment

Nitti et al. have performed urodynamics studies in 50 consecutive patients referred because of persistent LUTS after prostatectomy. In this series, 62% of these men were urodynamically unobstructed, 22% were in the equivocal zone and only 16% were urodynamically obstructed; detrusor instability was present in 54%. Symptoms were unreliable in predicting urodynamic findings. These data clearly demonstrate that another deobstructing procedure (i.e. 2nd TURP) is unlikely solve the problem in this group of patients. Only pQs (urodynamics) can guide the appropriate treatment in these patients (Nitti, J Urol 1997)

Elderly patients

For two reasons, geriatric patients (>80 years) should undergo pQs prior prostatectomy. First of all, because morbidity of prostatectomy in this high age group is increased. Secondly, and equally important, is the fact that the ageing urinary bladder reveals a number of age related urodynamics changes in men [17,18]. Among these is a decrease of Qmax, an increase of post-void residual volume, a decline in bladder capacity and of bladder compliance. As a consequence
the percentage of patients without BOO despite a reduced Qmax of 10–15 ml/s and an interrnational Prostate Symptom Score (IPSS) exceeding 7 increases substantially in men older than 70 years and particularly above 80 years (Fig. 3) [17,18]. This observation is a strong argument for routine pQs in this high age group. The real predictive value of urodynamics on the outcome after surgery is also questionable. In a recent paper, van Venrooij (J Urol 2002) showed that in 32 unobstructed or equivocal patients, there was a 40% increase in mean effective capacity of the bladder after surgery which was correlated with the improvement
of symptoms. Furthermore, 50% of unstable bladders became stable after surgery, and this could not be predicted from urodynamics. Numerous studies show that more than 50% of
patients who would have been eliminated from surgery, according to PFS, are, in fact, improved after surgery.
This confirms that all symptoms in the presence of BPH do not correspond to obstruction, and that the latter may have different profiles on PFS. Patients with a weak detrusor should not be systematically eliminated from surgery. We should consider that the weaker the detrusor contraction is, the more important is the impact of an increase of urethral resistance. In such
patients, the relief of any degree of obstruction should improve micturition. There is an inherent limitation of PFS in detecting obstruction, when obstruction and a weak detrusor coexist, and a low detrusor pressure does not necessarily contraindicate prostatectomy. Operate on those who suffer failure with their conservative management. Some patients could benefit from minimally invasive therapies, but it has not yet been proven that urodynamics is able to differentiate
indications.


Urodynamics and success with TURP: Does obstruction make any difference to outcome.

No says Hakenberg et al: BJUI 2003

Variable
N
Age (yrs)
IPSS change
QOL



(improvements)
Pre Post
Ag Number














<15>40
46
72.5
9.5
5 1







AG# = Pdet at Qmax – 2(Qmax). >40 is obstrcucted, <20 is unobstructed, 20-40 equivocal



Outcome of TURP in pts with High Pressure Chronic Retention (Styles and Neal, J Urol 1991)
68 men with bladder outflow obstruction and chronic retention (residual urine greater than 300 ml.) Postoperatively, upper tract dilatation (present in 28 men preoperatively) resolved in all but 2 men and serum creatinine levels improved significantly. Irritative and obstructive symptom scores improved postoperatively (p less than 0.00006), although 17% of the men still had significant symptoms. Residual urine volumes decreased and flow rates improved (p less than 0.00006) 32% of the men still had a residual urine of greater than 200 ml.

Types of Penil prosthesis

1-Soft
2-Semi-rigid
3-Bendable metallic core
4-Interlocking segments
5-Inflatable- 1,2 & 3 part

1 Soft
Subrini
SSDA, Virilis
Rarely used in UK
Peyronnie's surgery
Augments natural erection by providing core bulk

2 Semi-rigid
Cheap
Simple
Reliable: No moving parts
Hard to conceal, ‘bendability’
Limited width
Erosion

Mentor Accuform
9.5 mm, 14-23 cm
11 mm, 16-25 cm
13 mm, 18-27 cm (hard to bend)
Bendability ~ 90 degrees
RTE 0-1 cm

AMS
600 series
9.5 mm & 11.5 mm width

650 series
11 mm & 13 mm width
Tip extenders, both ends
length 12-20 cm
Bendability ~110 degrees

AMS
Dura II
Interlocking PTFE segments with steel spring
10,12 mm
13 cm + tip extenders both ends
Bendability ~150 degrees

Inflatable

Concealment
‘Natural’
Rigidity
Expensive
Infection
Mechanical failure
Manual dexterity


Inflatable – 2 piece
AMS Ambicor
Combined cylinders + reservoir
Pump
limited fluid volume

Mentor Mark II

Inflatable-3 piece

AMS 700CX, CXM, CXR
Triple layer
Expands in width
Smallest 12 cm
AMS Ultrex
Expands in length and width
Antibiotic coating (inhibiZone)
Rifampicin & Minocycline

Inflatable-3 piece

Mentor Alpha 1, Titan & narrowbase
Smallest 10cm
Expands girth++
Oval
Bioflex
Lockout valve
Hydrophilic antibiotic adsorbant surface

Bladder cancer and BCG Immunotherapy

Bacillus Calmette-Guerin
First used 1921

Morales et. Al. 1976 (successful treatment in 7 of 9 patients of recurrent Ta and T1 tumours)
Live attenuated M.Bovis. (Freeze dried vaccine)

All derived from Pasteur Institute strain.
Connaught 81 mg or 180 * 10 8 CFU
Tice 12.5 mg or 2-8 *10 8 CFU
Pasteur
Frappier
Tokyo

Indications:
Mulitiple G2 pT1
G3 pTa / pT1, CIS

I am a lower pole calculus of 2 cm. My preferred treatment is:

Percutaneous nephrolothotomy

Why?

Lower pole study group (Albala, Clayman and et al, J Urol 2001):

122 pts, lower pole stone and symptoms, under 3cm, randomised to PCNL vs SWL, stratified by stone size

CLEARANCE RATES

LOWER Pole stone PCNL ESWL
1cm 100% 63%
1-2cm 92% 23% (but 56% by Lingman)

>2cm 85% 14%






SWL: stent for size >2.5 cm
PCNL: single stage procedure, used flexible endoscopy and fragmentation with laser, uss, lithoclast
Outcome: fragmentation to fragments less than 3mm
Clearance rate 11-20mm stones 23% vs 92% for SWL vs PCNL, 14% vs 100% for stones 21-30mm

No effect found from lower pole calyx anatomical factors
(cf Elbahnasy, where infundibulopelvic angle under 90°, length over 30mm and width <5mm all associated with poor clearance rates of stones using SWL)

Cost effectiveness to be stone free
Stones 11-19mm SWL 133% more than PCNL
Stones >20mm cost of SWL 411% greater than PCNL
No statistical difference in morbidity




Lower pole study group 2:
Ureteroscopy versus PCNL
1-2.5 cm lower pole stone
31% stone free in urs versus 76% for pcnl
Stone Ureteroscopy PCNL
1-2.5 31% 76%




Ureteroscopy versus ESWL for stone < 1cm (pearl, lower pole study 3 ) no diff between urs and eswl. (35% versus 50% statistically not significant) (Pearl Jurol 2005)


Stone Ureteroscopy ESWL
<1 cm 35% 50%





stones <10mm URS vs SWL, stones 11-25mm URS vs PCNL
• Why?
o Stone free rates 11-20mm 71%, >20mm 65% with URS (Grasso, 1999)
o All stones greater than 2cm clearance rate of 91% after second look procedure in pts with renal stones who were poor PCNL candidates (Grasso, J Urol 1998)

Male urethral Trauma

The important factors that need to be considered in the management of the Ijury in the Immediate settings include:
Mechanism of injury
Has the patient voided? Haematuria? Increase in swelling after voiding? (extravasation)

Examination
Signs of shock?
Perineum – extent of haematoma. Confined to perineum/penile shaft then Buck’s fascia intact. If more extensive then suggests rupture of Bucks fascia and will be confined by Colles fascia
Blood at urethral meatus?–present in 75% of anterior urethral trauma
PR – prostate should feel normal
Is bladder distended?

Investigation
Usual trauma investigations including bloods.

Injury may be contusion or laceration of the urethra.
Urethrography – if urethra intact this is a contusion injuries and the haematoma usually resolves without complication. May wish to prescribe analgesia and antibiotics as prone to infection. Patient should be encouraged to void.

If laceration then needs catheter either single attempt urethrally or through the abdomen- probably best done under GA in child.
Laceration injuries may allow extravasation of urine which can extend along penile shaft, and up abdo wall, extension limited by Colles fascia. This may become infected and require draiage.

Will need further assessment of urethra with urethrogram (up and down) in 4/52.
Most common problem is stricture formation at site of injury. The majority of which do not require surgical intervention.
Those that do require surgical intervention should have delayed repair >3/12 after injury.
Options include simple debridement and anastomosis if short stricture (<1cm). Longer strictures will require grafts or flaps to bridge deficiency.

What is urethrogram?
12/14ch catheter in fossa navicularis ( in the penile opening). 2mls in balloon to occlude urethra. 20 mls of undiluted contrast injected slowly and films taken at 30 degree oblique angle.

BCG in my bladder!

BCG is a vaccine developed to combat the tuberculosis epidemic. The anti cancer potential of tuberculosis was known before the development of BCG. It had been seen in autopsy studies that people who had suffered from tuberculosis had lower incidence of having a cancer of the affected organ than the ones who did not. BCG was initially tried to treat skin cancers ( melanomas) with variable success. Later it was shown that BCG could protect against bladder cancer recurrence and progression (worsening aggressive nature). The BCG is put into the bladder and has to be retained there for 2 hours. The aim is to stimulate the immune system to reject the cancer. The standard practice is to use an induction course followed by a maintenance course. The induction course involves six cessions of BCG instillation at weekly interval followed by a telescopic examination usually about 3 months after the last dose to evaluate the response. This is followed by the maintenance schedule.
There are different maintenance schedules being used in different hospitals due to lack of consensus in this regards. There is a strong consensus that maintenance therapy following is more effective than induction therapy of BCG alone.
It is common for patients to experience burning sensation during voiding with an element of urgency to pass urine. Quite a few other side effects are possible with BCG use in bladder cancer and due to this reason it recommended for aggressive bladder cancers.

Urinary incontinence in women

The complaint of urinary incontinence in adult women can most commonly is either due to wekness of the sphinctor mechanism to keep her dry leading to leakage whenever the abdominal pressure rises like coughing sneezing jumping (Stress incontinence) or due to a bladder which contracts and pushes urine out when it should be holding it in, patient usually finds it difficult to hold whenever she gets this urge to pass urine (urgency to urinate)and cannot make it to the toilet in time (urge incontinence).
There can be quite a few other causes for urinary leakage but most common complaints fall in the above two groups.
The treatment is dictated by the type of incontinence.
With Stress Incontinence the target is to support the and strengthen the muscles that support the urethra and the pelvic organs including the bladder vagina uterus and rectum. treatment methods availible range from pelvic muscle strengthening exercises, abdominal operations to reposition prolapsing pelvic organs and vaginal operations to suuport the organs and to provide extra suppoert to urethra.
For Urge incontinence the aim to calm the bladder to damp down these uncontrolled bladder contractions. Bladder retraining tablets to controll the bladder and operations to paralyse the muscle (botox injection in bladder) or by cutting the nerve supply to bladder or by removing muscle layer partially from the bladder or by putting a piece of bowel in the bladder.

Can teblets controll my waterworks?

The urinary symptoms can simply considered to be of two types i.e. due to obstruction to the urine flow due to enlarged prostate (Hesitancy to start urine flow, weak flow and sense of incomplete emptying)and iritative symptoms due to incomplete emptying or premeture bladder contrations (frequent passing of urine, urgency to pass urine)
The drugs which have been used to controll the prostate related symptoms are of three types, the Alpha Blockers relax the bladder neck and thus reduce the resistance offered by the urethra to the urine flow, they donot effect the prostate size so with time as the prostate grows their effectiveness might go down. The Alpha reductase inhibitors can reduce the prostate volume if teken over an extended period of time. Both of these groups of drugs are focusing on the prostate, trying to reduce the resistance to urine flow by an enlarged or obstructing prostate. The Anti cholinergic medicines act on the bladder bladder, allowing it to hold a larger volume for longer period of time.

Viagra ‘The Miracle drug’

The Phosphodiesterase group of medicines (Viagra, Levitra, Cialis etc.) are a major step forward in the management of this important quality of life issue. These medicines are commonly associated with minor side-effects like, nasal stuffiness, facial flushing, heart burn. People with heart problems should have a frank discussion with their doctor before trying the medicine.
There is evidence that if the first dose doesn’t work still the subsequent dose might, so no need to despair!
It is becoming more and more recognised that a proportion of aging population has low testosterone levels, which are also contributing to the erectile dysfunction and improving the testosterone levels can improve their wellbeing and also increase chances of effectiveness of the Phosphodiesterase group (Viagra, Levitra, Cialis etc.).

Male infirtility

Irrespective of gender the dream of having one's own children is shared by many. The first test test usually requested by GP for male fertility evaluation is Semen Analysis ( examination under microscope of material ejaculated from the penis). The aim is to basically see whether the semen has sperms (besides some other features to ascertain the health of the semen).
If there are no sperms in the semen then either testis are not producing any sperms or the conduction mechanism i.e. the tube from testicles to the urethra is blocked.
The 'testicular biopsy' is commonly used operation to differentiate between the two. If facilities are availible then cryopreservation can be performed at the same time.
In case of obstruction being the cause of absence of sperms, srgical procedure to bipass the operation or direct retrieval of sperms from the testis through a variety of techniques is possible.
In patients with testicular biopsy failing to show any sperms, multiple biopsies might identify an island of sperm genesis.

kidney stones, the boulder in water

Kidney stones are a common urological problem encountered. the kidney stones can lead to a rather interesting course of complete silence with sudden symptoms usually severe excruciating pain (thought to be more severe than child berth!), nausea and vomiting. The kidney stones can pass spontaneously from kidney into the bladder leading resolution of pain but there is an inverse relation between the stone size and it's chance of being passed spontaneously.
the stone formation in the kidneys is a complex process and in simplest terms it can be due to increased concentration of constituents to an extent where they start sedimenting thus laying the foundation of stone formation or the constituent cannot be dissolved in the urine due to any reason and settles down. some stones can be seen on x-ray while other can't.
ways to treat the stones can be divided to non oprative and operative means.

Waterworks and the enlarged prostate

As the hair turn grey the water works can also become an issue. many a people consider prostate enlargement to be the cause. Prostate gland sits at the opening of the bladder and encircles the urethra. the prostatic enlargement can lead to compression of urethra thus compelling the bladder to work harder to push the urine through the tube ( urethra). with time due to slowly increasing obstruction the bladder becomes thicker with increase in its muscle bulk but there is a limit to the extent of force the muscles can generate and then there is the stage of progressive failure of bladder to empty completely and ultimately the bladder can fail completely perform the function of emptying itself (urinary retention needing a catheter in the bladder.
The treatment of urinary symptoms is directed at sorting the patient complaints to prevent a negative impact on one's quality of life. Not every patient with prostate enlargement will have urinary problems and vice versa.
The treatment of urinary symptoms due prostate can vary from just reassurance to tablets or even an Operation.

Erectile dysfunction: the surgical solution

Erectile dysfunction is a major male quality of life issue. the surgical solution of erectile dysfunction is either semi-rigid or inflatable penile prosthesis. It has to be appriciated that the prosthesis which ever type it may be, only provides mechanical means to have penetrative intercourse. the sensations might not be the same as it used to be with spontaneous or sexually stimulated erection. there is usually some loss of length. better understanding of the device that is to be implanted with reasonable expections of the outcome improve the overall satisfaction with this intervention