Obstructive uropathy

(BPH,uretheral stricture)
Dr. Gedion G(MD, General Surgeon)
Assistant professor of Surgery
Yirgalem Hospital Medical College,
Department of Surgery
Outline
• Objective
• Anatomy
• Physiology
• Benign prostatic hyperplasia
• Carcinoma of the prostate
• Urethral obstruction:
Objective
• Explain the anatomy of the male urinary tract and the physiology of voiding.
• Classify the causes of urinary outflow obstruction by the site of obstruction:
• a. Within the lumen
• b. Within the wall
• c. Extrinsic compression
• Distinguish between the symptoms of upper and lower urinary tract obstruction.
• Describe the range of laboratory tests and imaging techniques used in the investigation of patients
with urinary outflow obstruction, in particular the role of the PSA test.
• Explain the pathology of the following common causes of urinary tract obstruction, and their medical
or surgical management:
• a. Benign prostatic hyperplasia
• b. Malignant tumours of the urinary tract.
• State the complications of untreated urinary tract obstruction.
Anatomy
• The bladder is a muscular reservoir that receives urine via the ureters and
expels it via the urethra.
• In children up to 4 years of age, it lies predominantly in the abdomen; in
the adult it is a pelvic organ, well protected in the bony pelvis.
• Superiorly, the bladder is covered with peritoneum, which separates it from
loops of small bowel, the sigmoid colon and, in the female, the body of the
uterus.
• Posteriorly lie the rectum, the vas deferens and seminal vesicles in the
male, and the vagina and supravaginal cervix in the female.
• Inferiorly, the neck of the bladder transmits the urethra and fuses with the
prostate in the male and with the pelvic fascia in the female.
Anatomy cont…
• The bladder is composed of whorls of detrusor muscle, which in the
male become circular at the bladder neck.
• They are richly supplied with sympathetic nerves that cause
contraction during ejaculation, thereby preventing semen from
entering the bladder (retrograde ejaculation).
• There is no such sphincter in the female.
• The bladder is lined with specialised waterproof epithelium, the
urothelium.
• This is thrown into folds over most of the bladder, except the trigone
where it is smooth.
Anatomy cont…
• The male urethra is 20 cm long; the prostatic urethra descends for 3 cm
through the prostate gland, and the membranous urethra is 1–2 cm long and
intimately associated with the main urethral sphincter, the rhabdosphincter.
• The spongy urethra is 15 cm long and is surrounded by the corpus
spongiosus throughout its complete length, opening on the tip of the glans
penis as the external meatus.
• The spongy urethra is further subdivided into the proximal bulbar urethra
and the distal penile urethra.
• The female urethra is 3–4 cm long, descending through the pelvic floor
surrounded by the urethral sphincter and embedded in the anterior vaginal
wall to open between the clitoris and the vagina.
Anatomy cont…
• In the male, the prostate is pyramidal, with its base uppermost.
• It resembles the size and shape of a chestnut and surrounds the prostatic
urethra.
• Traditionally described as having a median and two lateral lobes, it is better
considered as being composed of a small central and a larger peripheral
zone.
• The prostate is surrounded by a venous plexus, which lies between its true
and false capsule.
• Enucleation of the prostate gland in open prostatectomy leaves behind both
the capsules since the plane of separation is between the enlarged adenoma
and the compressed peripheral zone, which is prone to carcinoma.
Physiology:
Neurological control of micturition
• Detrusor contraction is mediated through cholinergic
parasympathetic nerves arising from the nerve roots S2–S4, and
relayed through ganglia lying predominantly within the detrusor.
• Sympathetic nerves arise fromT10 to L2 and relay via the pelvic
ganglia.
• Their exact role in the control of micturition is unclear.
• It is known that α-adrenergic receptors and their nerve terminals are
found mainly in the smooth muscle of the bladder neck and proximal
urethra.
• The α-receptors respond to noradrenaline (norepinephrine) by
stimulating contraction, thereby maintaining closure of the bladder
neck.
Physiology:
Neurological control of micturition cont…
• The distal sphincter mechanism is innervated from the sacral segments S2–S4 by
somatic motor fibres that reach the sphincter either by the pelvic plexus or via
the pudendal nerves.
• Afferent nerves are carried in both the parasympathetic and pudendal pathways,
and transmit sensory impulses from the bladder, urethra and pelvic floor.
• These sensory impulses pass to the cerebral cortex and the micturition centre,
where they produce reflex bladder relaxation and increased tone in the distal
sphincter, so helping maintain continence.
• Cortical control is a basic part of the micturition cycle described below.
• The higher centres suppress detrusor contractions and their main function is to
inhibit micturition until an appropriate time.
The micturition cycle
• The micturition cycle has two phases.
• Storage (or filling) phase
• Due to the high compliance (elasticity) of the detrusor muscle, the bladder fills steadily
without a rise in intravesical pressure.
• As urine volume increases, stretch receptors in the bladder wall are stimulated,
resulting in reflex bladder relaxation and reflex increased sphincter tone.
• At three-quarters of bladder capacity, sensation produces a desire to void.
• Voluntary control is now exerted over the desire to void, which temporarily disappears.
• Compliance of the detrusor allows further increase in capacity until the next desire to
void.
• Just how often this desire needs to be inhibited depends on many factors, not the least
of which is finding a suitable place to void.
The micturition cycle cont…
• Emptying (or micturition) phase
• The act of micturition is initiated first by voluntary and then by reflex relaxation of the
pelvic floor and distal sphincter mechanisms, followed by reflex detrusor contraction.
• These actions are coordinated by the pontine micturition centre.
• Intravesical pressure remains greater than urethral pressure until the bladder is empty.
• The normal control of micturition requires coordinated reflex activity of autonomic and
somatic nerves, as described above.
• These responses depend on normal anatomical structures and normal innervation.
• There are thus two main types of disorders of micturition: structural and neurogenic.
• Examples are extensive carcinoma of the prostate that has damaged the sphincter
mechanism (structural), and spinal cord injury that has damaged the innervation
(neurogenic).
Benign prostatic hyperplasia:
Pathology
• From about the age of 40 years, the prostate undergoes enlargement as the
result of hyperplasia of periurethral tissue, which forms adenomas in the
transitional zone of the prostate.
• Normal prostatic tissue is compressed to form a surrounding shell or capsule.
• There is considerable variation in the growth rates of the adenomas and in
the proportions of stromal and epithelial tissue.
• Adenomas with an epithelial preponderance can grow to form large discrete
masses weighing more than 100 g, and have a characteristic rubbery
consistency, referred to as benign prostatic hyperplasia (BPH).
• Enlarging adenomas lengthen and obstruct the prostatic urethra, causing
outflow obstruction and detrusor muscle hypertrophy.
Benign prostatic hyperplasia:
Pathology cont…
• The muscle bands of the bladder form trabeculae, between which saccules form
diverticula.
• Occasionally, a diverticulum may become quite large, even larger than the
bladder.
• Bladder diverticula empty poorly and are liable to the main complications of
urinary stasis: infection and stone formation.
• With progressive inability to empty the bladder completely (chronic retention),
the risk of urinary infection and stone formation increases.
• Eventually, the residual urine volume may exceed 1 L. In high-pressure chronic
retention, progressive obstruction and dilatation of the ureters (hydroureter) and
pelvicalyceal system (hydronephrosis) occurs, ultimately leading to obstructive
renal failure.
Clinical features
• Symptoms may be obstructive (poor flow, hesitancy, intermittent
stream, straining to empty) or storage symptoms due to secondary
detrusor overactivity (frequency, urgency and urge incontinence).
• Increasing frequency may deceive the patient into believing that an
adequate amount of urine is passed, whereas the bladder has a small
functional capacity and may be almost full all of the time (chronic
retention).
• In high-pressure chronic retention frequency may progress to continual
dribbling incontinence (especially nocturnally), leading over time to
signs and symptoms of obstructive uraemia, including drowsiness,
anorexia and personality changes.
Clinical features cont…
• Urinary infection, cold weather, anticholinergic drugs or excessive alcohol
intake can provoke acute or acute-on-chronic retention.
• A bladder stone may result in obstructive symptoms during micturition, and
may also cause bladder pain at the end of micturition.
• Examination reveals little except rubbery, symmetrical and smooth prostatic
enlargement, with a median groove between the two lateral ‘lobes’.
• Asymmetry or a hard consistency raises the suspicion of malignancy.
• In patients with chronic retention, the painless, enlarged bladder rises out
of the pelvis, almost to the umbilicus.
• The overlying area will be dull on percussion.
Investigations
• A good history and examination are paramount.
• A urinary frequency volume chart should be completed over 3 days.
• International Prostate Symptom Score (IPSS) (Table 1) provides an objective measurement of symptoms
and also helps in monitoring response to treatment.
• Other mandatory assessment includes blood for renal function, electrolytes and following counselling
PSA.
• Prostate cancer can occur with normal PSA values (0–4 ng/mL), while BPH can cause elevated values, so
careful interpretation is required (Table 2).
• If digital rectal examination (DRE) raises suspicion, TRUS-guided biopsy is indicated.
• Urine flow rate assessed by uroflowmetry and US assessment of postvoid residual will quantify a
reduction in urinary stream and the need for intervention.
• In some patients, especially the elderly, neurological or pharmacological causes for changes in micturition
must be considered.
• A pressure-flow urodynamic assessment may be necessary for equivocal symptoms or investigations.
Table 1: International Prostate Symptom Score (IPSS)
Table 2: Factors affecting the level of prostate-specific antigen
Management
• Patients can be divided into three treatment groups depending on the
degree of bother of symptoms and the presence of complications, if
any.
• Conservative management
• In patients with mild symptoms (IPSS symptom score of 0–7) and no
interference of daily activities, watchful waiting can be tried.
• The prerequisite is absence of any complication arising due to BPH.
• Patients can be informed that a third of patients will have stable
symptoms, a third will deteriorate and the remainder will show
symptomatic improvement.
Management cont…
• Medical management
• Patients with moderate symptom scores (IPSS symptom score of 8–19) or those with a lower
score opting for treatment are initially started on medical therapy.
• Availability of better drugs and improved understanding of the pathophysiology of the disease
has resulted in a reduction in the need for surgery by almost half.
• The drugs used in treatment of BPH are of two broad categories:
• α-blockers. These act at the α1 adreno-receptors present in the bladder base and the prostatic
capsule, and smooth muscle.
• Prostate-specific α1a blockers have been developed which have minimal systemic side effects
that were common with the older nonselective agents.
• They include tamsulosin, doxazocin and alfuzosin, and act rapidly (three doses) by opening the
bladder neck and relaxing the prostatic capsule.
• These agents are preferable in symptomatic patients with a smaller prostate
Management cont…
• 5α reductase inhibitors.
• These drugs prevent the intraprostatic conversion of testosterone to its 9-
times more active form, dihydrotestosterone, which is responsible for the
growth and enlargement of the prostate.
• These drugs are therefore useful in large glands (>30 g) or in patients with a
PSA >1.4 μg/L, causing the prostate to shrink.
• The commonly used agents are finasteride and dutasteride, but they take
4–6 months to have a full effect.
• A combination of both classes of agents may be needed in patients who
have severe symptoms, or those who do not improve on single-agent
therapy.
Management cont…
• Surgical management
• Patients with severe symptoms (IPSS >19), those failing medical treatment, not able
to tolerate the side effects of the drugs, not willing to try medical management or
presenting with one of the complications of BPH are candidates for surgery.
• The absolute indications for surgery in a patient with BPH are:
• refractory urinary retention,
• recurrent UTI,
• recurrent haematuria,
• bladder stones,
• and/or diverticulae and high-pressure chronic urinary retention leading to renal
insufficiency.
Management cont…
• Acute retention
• This condition usually requires emergency admission to hospital and intervention to relieve
obstruction.
• A self-retaining Foley catheter is passed using strict asepsis and connected to a closed drainage
system.
• If it is not possible to pass a urethral catheter, the bladder is drained directly by puncture with a
suprapubic catheter.
• A specimen of urine is cultured and, if there is microbiological evidence of an infection, antibiotics
are given.
• If the history of urinary symptoms is short, the catheter can be removed after 12 hours (known as
trial without catheter), following which normal voiding may occur.
• This is more likely if the patient is given α-blockers.
• If retention recurs, then definitive treatment with endoscopic transurethral prostate resection is
performed.
Management cont…
• Chronic retention
• It is essential to determine whether the patient has any complications of obstruction, especially
renal damage.
• If the patient is well, with no haematological or biochemical disturbance, there is no indication
for preliminary bladder drainage and management may be planned in the usual way.
• Relief of high-pressure chronic obstruction is almost always followed by a diuresis, due partly to
an osmotic (urea) diuresis and partly to renal tubular changes resulting from back pressure.
• Accurate intake/output fluid charts in addition to daily weights can detect these losses.
• The blood pressure, both lying and standing, should be monitored and intravenous fluid
replacement may be necessary if there is a >20 mmHg postural drop in blood pressure.
• Medical therapy is contraindicated in patients who present with renal failure secondary to BPH;
long-term catheter or endoscopic transurethral prostate resection.
Endoscopy transurethral prostate resection
• The gold-standard endoscopic management of bladder outlet obstruction due to prostatic
enlargement is transurethral resection of the prostate (TURP).
• TURP entails removing the prostate piecemeal by electroresection using a resectoscope.
• The advantages are patient acceptance, short hospitalisation (2–3 days) and the precision of
removal of the obstructing tissue.
• However, serious damage can be inflicted on the prostatic sphincter mechanism by inexpert use
of the resectoscope.
• Prolonged resection can occasionally result in excessive absorption of glycine irrigating fluid and
electrolyte imbalance (TURP syndrome).
• Favourable results are seen with laser prostatectomy, with improved haemostasis, reduced
hospital stay, earlier catheter removal, and promising long-term follow-up data.
• The different types of laser prostatectomy are green-light laser prostatectomy and holmium laser
ablation of the prostate (HoLAP), resection of the prostate (HoLRP), and enucleation of the
prostate (HoLEP).
Endoscopy transurethral prostate resection
cont…
• Retrograde ejaculation is a common sequel to any operative procedure on the
prostate and all patients should be advised preoperatively of this effect.
• Any associated bladder stone may be crushed with a lithotrite or intracorporeal
lithotripsy using holmium or pneumatic energy.
• After endoscopic prostatectomy, the bladder must be allowed to drain freely via a
urethral catheter while the prostatic bed heals and bleeding stops.
• After TURP, the catheter is normally removed on the second postoperative day.
• The main postoperative hazard is bleeding.
• If postoperative bleeding is excessive, clot may lead to obstruction (clot retention).
• This hazard can be minimised by continuous irrigation through a three-way
urethral catheter.
Open prostatectomy
• Open procedures are now rarely performed and are reserved for very
large adenomas (>100 g) or patients with associated intravesical
complications (stones or diverticulae).
• The various approaches for performing open prostatectomy are
transvesical (Freyer’s), retropubic (Millin’s) and perineal (Young’s).
• Apart from the length of hospitalisation (7–10 days) and the presence
of an abdominal wound, enucleation of smaller adenomas may
damage the external sphincter and cause incontinence.
• This is a particular problem with more fibrous glands and those that
contain a focus of cancer.
Carcinoma of the prostate:
Epidemiology
• In the UK, this is the most common malignancy in males, with a
prevalence of 105 cases per 100,000 population.
• It is the second most common cause of cancer death in men in the UK.
• The tumour is common in northern Europe and the USA (particularly in
the black population), but rare in China and Japan.
• It rarely occurs before the age of 50 years but the incidence rises sharply
from 50 to 54 years, peaking at 75–79 years of age.
• The mean age at presentation is approximately 70 years.
• The aetiology is unknown, but genetic, hormonal and possibly viral
factors are implicated.
Carcinoma of the prostate:
Pathology
• Almost all malignant tumours of the prostate are carcinomas, with the most common being
adenocarcinoma (>95%).
• If a prostate is examined by serial section, a small malignant focus is detected in almost all
men over the age of 80 years.
• It is estimated that the prevalence of focal histological cancer in men aged 50–75 years is
approximately 40%, whereas the prevalence of clinical prostate cancer is approximately 8%,
one-quarter of whom will die from that cancer.
• The TNM system is used in classification (see Table 3).
• Metastatic spread to pelvic lymph nodes occurs early.
• One-third of clinically localised tumours at the time of presentation will have spread to
regional nodes.
• Metastases to bone, mainly the lumbar spine and pelvis, occur in some 10–15% of patients.
Table 3: TNM classification of prostate cancer*
Clinical features
• The Gleason score is used to grade prostate adenocarcinoma.
• Cells are graded 1–5 depending upon their level of differentiation
(grade 1¼most differentiated, grade 5¼least differentiated or most
anaplastic).
• The pathologist uses the two most common malignant cell types to
determine a Gleason score (most common type+second most
common type¼Gleason score).
• Therefore, Gleason scores range from 2 to 10 and are always
expressed as an equation (e.g., 4+3¼7); in practice the lowest Gleason
score apportioned is 3+3¼6.
Investigations
• PSA is the serum marker used to aid detection of prostate cancer.
• A PSA of <4 ng/ml is generally regarded as normal, although there are
age specific values that differ between regions.
• Metastatic disease is exceptional when the PSA level is <20 ng/ml, but
levels >100 ng/ml almost always indicate distant bone metastases.
• PSA is the main test for monitoring response to treatment and disease
progression.
• The diagnosis is confirmed by needle biopsy, usually performed under
TRUS guidance.
Investigations cont...
• TRUS biopsy should be performed in men with elevated PSA or abnormal
DRE.
• Histological examination of tissue removed at endoscopic resection for
outflow obstruction may also reveal prostate cancer.
• Multiparametric prostate MRI is being increasingly used to evaluate the
prostate for abnormal foci in men with a persistently elevated PSA with
previous negative prostate biopsy.
• MRI is also useful to assess pelvic lymphadenopathy and evidence of locally
advanced disease.
• A bone scan may be carried out at follow-up to localise and define the
extent of metastases.
Management
• Prostatic cancer is sensitive to endocrine influences as testosterone is a trigger for
moving prostate cells through the cell cycle, thereby stimulating mitosis.
• Management is best considered in three clinical groups, as follows.
• Organ-confined disease
• A patient with a small focus of well-differentiated carcinoma (Gleason score 3+3¼6)
may be managed by an active surveillance policy (close follow-up with DRE, PSA, MRI,
repeat TRUS biopsy), as usually these patients remain unaffected by their prostate
cancer for between 10 and 15 years.
• In patients with a life expectancy of >10 years and a less well-differentiated cell
pattern (Gleason score 7 or more) there is an increased risk of progression.
• In these cases, treatment with curative intent by either radical prostatectomy or
radiotherapy is suggested.
Management cont…
• The prostate can be removed laparoscopically, robotically or by the traditional open
route.
• Radiotherapy can be performed by external beam radiotherapy (EBRT), intensity-
modulated radiotherapy or by the insertion of radioactive seeds in the prostate
(brachytherapy).
• There are no data to support one treatment over the other in terms of overall
survival.
• However, each treatment modality has a different side effect and complication profile.
• Therefore, the choice of treatment tends to be based upon patient preference.
• Locally advanced disease
• This term refers to cases where the prostate cancer has invaded directly outside the
prostate but has not metastasised.
Management cont…
• There is an evolving role for surgery as part of multimodality treatment in these patients;
however, EBRT along with hormonal therapy is the standard of care.
• In patients not able to tolerate EBRT, hormone therapy alone or conservative
symptomatic treatment can be considered.
• Metastatic prostate cancer
• 20% of men with prostate cancer have metastatic disease at diagnosis.
• The basis of treatment in these cases is castration, either physically by androgen
depletion (bilateral orchiectomy), or more commonly chemically by androgen
suppression (gonadotrophinreleasing hormone analogues) and/or androgen receptor
antagonists.
• A small number of patients fail to respond to endocrine treatment; a larger number
respond for a year or two, but then suffer disease progression known as castrate-
resistant prostate cancer (CRPC).
Management cont…
• PSA levels are a useful marker of response, ideally falling to <0.01 ng/ml in well-controlled
cases.
• Oestrogens are useful but are limited by their thromboembolic effects.
• Chemotherapy with taxanes has shown a marginal improvement in both symptoms and
survival in patients with CRPC.
• Newer hormonal agents such as enzalutamide and abiraterone acetate also provide some
survival benefit in CRPC.
• PSA is a very useful marker to determine response to treatment in addition to monitoring
disease progression or recurrence.
• Bone-protective agents may be offered to patients with skeletal metastases (i.e., denosumab
and zoledronic acid) to palliate bone pain, prevent loss of bone mass and reduce the risk of
metastatic bone fractures.
• Radiotherapy is an effective treatment for localised bone pain.
Prognosis
• The life expectancy of a patient with an incidental finding of focal
carcinoma of the prostate is that of the normal population.
• With tumours localised to the prostate, a 15-year survival rate of 56–
87% can be expected; if metastases are present, this falls to <10%.
Urethral obstruction:
Pathology
• Obstruction of the urethra may be congenital, due to a stricture or
malignancy.
• Foreign bodies, including urinary stones, may also be responsible.
• The complications include infection with periurethral abscess,
fistulation and stone formation.
• Congenital valves in the posterior urethra occur only in boys.
• They lie at the level of the verumontanum and may cause gross
obstructive changes in the bladder and upper urinary tracts at birth.
• Increasingly, this diagnosis is being established during pregnancy by US
examination.
Urethral obstruction:
Pathology cont…
• If the diagnosis is established after birth, it is confirmed by
micturating cystourethrography.
• Treatment consists of endoscopic fulguration of the valves.
• Urethral diverticulum is a rare cause of obstruction.
• More commonly, it is secondary to obstruction and infection in
women.
• Urethral trauma or infection may result in a stricture, the severity of
which is related to both the site and the extent of the insult.
Urethral obstruction:
Pathology cont…
• A posterior urethral stricture following major trauma may be surrounded by
dense fibrous tissue, whereas healthy tissues may surround a stricture of the
bulb of the urethra.
• The former requires major reconstructive surgery, but urethral dilatation or
incision can readily manage the latter.
• Rough inexpert use of any instrument (including a catheter) in the urethra can
cause stricture formation.
• The principal organism responsible for inflammatory scarring and stricture of
the urethra is Neisseria gonorrhoeae.
• Long-term use of a self-retaining catheter, although not necessarily associated
with infection, can also cause an inflammatory reaction in the urethra.
Clinical features
• The diagnosis should be considered if there is a history of urethral
infection, instrumentation or trauma.
• The external meatus must always be examined and, if the foreskin is
present, it should be retracted for full inspection.
• The urethra is palpated.
• It is still possible for a patient to pass urine, albeit with difficulty, in
the presence of a urethral stone.
Investigations
• Urinary flow rate will help differentiate urethral strictures from
bladder neck and prostatic obstruction, the former giving a uniformly
low and prolonged (box-like) pattern.
• Postmicturition US may exclude an increased residual volume.
• An ascending and descending urethrogram will adequately
demonstrate the urethral anatomy.
• The final investigation to assess a urethral lesion is cystourethroscopy.
Management
• Many simple strictures are easily treated by repeated dilatation with
metal bougies, or may be incised under direct vision using a
urethrotome.
• Most short strictures in the region of the bulb respond well, but
recurrence is common (50%) and operative reconstruction
(urethroplasty) may be required.
• Short strictures can be excised and the healthy urethra
reanastomosed.
• Longer strictures can be patched with full-thickness skin flaps or
buccal mucosal grafts, to restore normal calibre.
References

• Bailey & Love’s Short Practice of Surgery, 27th Ed.

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