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1、Management of LUTS due to BPH,Made possible under an educational grant from:,Case 4,Learning objectives,Discussion of this case will assist urologists to:Advise patients on the choice of-blockers,5-reductase inhibitors,and phytotherapyDefine the role of noninvasive techniques(especially TUNA),Case P
2、resentation,Albert Scoffield,64 y.o.engineerHypercholesterolemiaSmokesNo major illnesses or operationsMarried,sexually active,History,Increasing LUTS for 10 yearsRecent increase in irritative symptomsAUA symptom score 18,bothersome score 5ExaminationGeneral examination-normalProstate-75 gm,smooth,ru
3、bbery gland.No nodules,Investigations,InvestigationResultSerum PSA2.8 ng/mLUrinalysisNormalSerum creatinine85 mol/L UroflowmetryAverage maximum flow on 3 readings=5.2 mL/secPVRLess than 20 mL,Discussion Point#1,The patient wants relief of his symptoms.Which therapeutic agent or class of agent would
4、you suggest?,Medical Management of LUTS due to BPH,PhytotherapySaw palmetto,numerous herbal extractsLittle long-term efficacy dataMeta-analysis suggests saw palmetto better than placebo,as effective as finasteride,(Wilt T.JAMA 1998;280:1604),Medical Management of LUTS due to BPH,5-reductase inhibito
5、r(finasteride)long-term complications of BPH,may need for surgery More effective with larger prostates(30 to 40 gm)May prostate volume 20%to 30%Erectile dysfunction in 5%,(McConnell J.N Engl J Med 1998;338:557),Medical Management of LUTS due to BPH,Alpha-blockersMore effective in ing symptoms and in
6、g uroflow than finasterideRapid responseCan cause abnormal ejaculation(up to 5%)Tamsulosin gives fewer cardiovascular side effects than terazosin or doxazosin,(Goldenberg S.Can J Urol 1998;5:551),Discussion Point#2,The patient is worried about sexual side effects,has heard about thermotherapy,and re
7、quests your advice.What would you say?,Transurethral Needle Ablation of the Prostate(TUNA),Produces temperature of 100 CDestroys nerves(permanent-blockade),dessicates/shrinks tissueDone under topical anesthesiaAs effective as TURP in ing symptoms,not as good at ing flow rateLess expensive than TURP,
8、fewer complicationsLong-term data not available,Discussion Point#3,The patient decides on a TURP,but requests laser.What are the arguments for and against laser TURP?,Laser TURP,Holmium laser produces very localized temperature of 2000 CLess bleeding than conventional TURPShorter in-hospital staySom
9、e centres use local anesthesiaUsually shorter catheterization period,may not be necessary,Discussion Point#4,The next day,this well-informed but unfortunate patient has a large MI,complicated by ongoing atrial fibrillation,requiring warfarin therapy,and ongoing angina requiring multiple medications.
10、In hospital,he develops urinary retention and fails two trials of voiding.What now?,A Complicated Case of BPH,Indwelling catheter used for six months,but risk of infection,bleeding,discomfort,are concernsCIC considered,but risk of bleeding because of warfarinLaser surgery could be done under local a
11、nesthesia,but pain could provoke anginaProstatic stent probably the best option,MajpjMVcyzj21HLfrvy96dv02lPPfYgxUS7IYmZkyEmZ0kGeYZS3bpLCkYH1lt4EK7CxmUX3ijoYSOer7ZuaVWYgz4EpZrUirVpMzzvNtf1XZw5oswSXOtFaejnOcmfE1lZgnN1RSXg8wLCG8CVQ3XPJMvodPFWcpiYJgZazNSEPNIaklYSu7qSd1UpaxmZDlpN9zW7kljfsLCLi26Yv109ffbnD
12、H8LbUN1G6ACURQ39eG12KHL9tXsZ1jzgoCK8g1kuNOh5eFvcmVT5ZYVQt9zk3rp3qLnf02FovEXxVRxjCcFRNppiJljNiOuk6fONnyX7fyGg7sXZ49BmCN5oy9VesHpKzdjTKwjrkCEQCFDehVmGax3lrOEbw63VscA3YSijtUKoCyiLzAlVRp7l4QgPNHxvJFFDyjUVN3oHlMah0XBd4uTbkfPIhHtw0evPmYOrdhEDoPwvYhzlGplU1AU9mpyiCXH8gpPCBRYjq77VcnbXumNE1yGfyTsbSj89J63kRTKD
13、kKUg3mdS5sJ4X5cQ8dK7oW9IkScssECQdz2O9UTlpRjAFPChjhLdzopQzwxQf8ozdzOhogwAooXpUF83BX4C3jRgjDJiiXEUDMaNz4vQ4n164vspddHvOIVuBBdMA4xp1YhiHk0vOJ8TL1BxogzVlMpmod6ianYGmksQq6NWCEd56hZF4wfaNyZcrGfNxnPiG6ZAxSkfmhJAKtNmCqbRmppeXp8inz4eq3HkWCMSORyMMX522xpHG6basNr6KQfbZsFbHjzyNlJrruLolKFcC84dqfijBO5Dy2NaBcNEBPgQrT12PgpcKx2or2YChN5DPjs80zzdtdAdTKuW4uVv9bbZu3K2SZ2aEhTlIC1UqrIWibkzwHh6p8gLv26zr01mJybfOzFc4T7kQH1IpPwOzMDnAKPLsLrznXGjFNIA9bSWWms6ibKZwQIKrMzalwbFrQJvOP1rPH8rx2KkyYqrtQk5VRwM1HSX,
