Cancer Prostate

CARCINOMA PROSTATE

      The disorder occurs in older men (65 years) and history of obstruction to the urethra and the resultant frequency is of shorter duration. The patient may also present with pain due to spread desease to bones (pelvis, vertebra). On rectal examination, the prostate or a part of it feels hard and there is fixity due to spread to surrounding structures. The mucosa of the rectum may also be fixed to the prostate.

12.1 DIAGNOSIS

1.    An acid phosphatase(prostatic fraction) is elevated in cases with bony metastasis

2.    Xray examination of spine, pelvis and chest may reveal sclerotic secondaries

3.    A bone scan (99Tc) can reveal early secondaries

4.    An estimation of prostate specific antigen(PSA) is required

5.    A needle biopsy of the prstate may be required

12.2 TREATMENT

1.    A radical prostectomy is recommended in early cases.

2.    Hormonal-Stilbestrol or Honvan were given earlier to provide relief for bony pain. Cyproterone acetate, amino glutathemide and Flutemide have also been used with success in cases hormone dependent tumours.

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Chronic retention treatment

TREATMENT

Medication

Alpha blockers

These drugs relax the muscles of the neck of the bladder urine thus passes with ease

These drugs have a positive effect in 2/3 of the patients with BPS you have to start with a low dose

Finastride (proscar, Propecia) symptoms are relieved because these drug cause shrunkage of prostate

 It takes 2 months to show its positive effects

The aims of therapy are :

*     Eliminate infection by antibiotics

*     Relieve retention if present by catheterisation

*     And to remove the obstructing prostate by any of

      the following surgical procedure:

      -     Transurethral resection of prostate Fig. 26.7

(Fig 26.7)

      -     Open prostectomy i.e. transvesicle or retropubic

Transuretheral prostotectomy (TURP)

A resectoscope is used and passed through the urethra into the bladder

It allows you to view the bladder and the prostatc urethra

It has a tungsten wire loop and a high frequency current passing through this loop allows this loop to cut through the prostate from inside

Small fragment of prostate can be washed out

The urethra is enlarged bleeding points can be touched with diathermy

A catheter is left in the bladder

Suprapubic prastatectomy

A suprapubic vertical or transverse incision is required

This approach to prostate is through the bladder

The enlarged prostate is removed by blunt finger dissection by the surgeon. The enlarged prostate is delivered into the bladder

The bleed points in the remaining compressed capsule of the prostate are touched with diathermy

A suprapubic and urrethral cathera left for draining urine

The bladder is closed around the supropubic catheter

A retropubic drain is inserted

Retropubic Prostatectomy

A suprapubic incision

The bladder is identified

The prostate capsule is incised 1.5cm beyond the bladder neck

The adenoma is mobilized by finger dissection

Adenoma removed and bleeding points diathermy touched

The capsule is closed with a urethral a catheter in bladder

If hemostasis is less than perfect a suprapubic catheter can also be kept

The retropubic space is drained

The wound closed

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Chronic Retention bladder 1

Chronic Retention

      This is a slow progress retention and is painless. The residual urine after micturation is over 300cc. These patients have the risk of back pressure effects on the kidney and bladder.

            Back Pressure effects Kideny

            -     dilated kreter

            -     dilated renal pelvis

            -     raised Blood urea

            -     raised serum creatnine

            Back Pressure effects on bladder

            -     Thick wall of bladder

            -     Diverticula of bladder

            -     Urine reflux into ureter

            -     Weak internal spinchter

            -     Overflow (incontiniouce)

These patient require urgent prostatectomy

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Benign Prostatic Hypertrophy

11. BENIGN PROSTATIC HYPERPLASIA

      The disorder appears most often after the age of 40 years, when 55% males show enlargement after the age of 80, however, 75% males show signs of enlargement.

The lesion is a nodular fibromatous hyperplasia which originates in the part of the gland situated close to the urethra mostly in the lateral lobes (Fig. 26.5). This results in narrowing of the urethra and obstruction bladder (BOO).

11.1 CLINICAL PRESENTATION

      The onset is insidious and most patients when questioned will admit to a reduction of force of the stream. Increased frequency of micturation is the earliest presenting symptom. At first it is nocturnal and later presents both by night and by day. The vesical sphincter becomes stretched, a little urine escapes into the prostatic urethra, causing a reflex desire to void, thus urgency is added to the frequency.

      Some patients notice that they must wait patiently for urination to start (hesitancy)

      Pain occurs with cysititis or acute retention of urine and stress incontinance is seen with chronic retention on coughing sneezing. The other symptoms encountered are haematuria and those related to renal insufficiency because of chronic retention.

      A rectal examination (P.R) is carried out in all cases to note the enlargement of the lateral lobes and the free mobility of the mucosa over the enlarged prostate.

      Among the tests required to assess the patient and to establish the diagnosis are examination of the blood for blood urea estimation. Examination of the urine for evidence of infection and presence of sugar. Intravenous urography to identify back pressure effects Fig.26.6. Urodynamics to estimate flow.

      Ultrasound examination to assess size of prostate and residual urine.

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