医学精品课件：（参考翻译）14.3 BPHnephrosis.ppt

1、LOGO 何卫阳何卫阳重庆医科大学附属第一医院泌重庆医科大学附属第一医院泌尿外科尿外科Urinary Obstruction 尿路梗阻尿路梗阻&Benign Prostatic Hyperplasia 良良性前列腺增生性前列腺增生(BPH)IntroductionEtiologyClinical ManifestationDignosisTreatmentBenign prostatic hyperplasia(BPH)Anatomy and physiologyThe prostate 前列腺前列腺 is a part of the male reproductive system 生生殖系

2、统殖系统 Function is to store and secrete a clear fluid(Prostatic fluid 前列腺液)that constitutes 10-30%of the volume of the seminal fluid 精液Pass way of urine located below the bladder 膀胱膀胱 In front of the rectum 直肠直肠 surrounding the urethra 尿道尿道Anatomy and physiologyDefinition BPH is a nonmalignant 非恶性的 en

3、largement of the prostate gland caused by cellular hyperplasia 细胞增生 of both glandular 腺 and stromal elements 基质元素 that leads to troublesome 麻烦的 lower urinary tract symptoms(LUTS)in some men It is the most common benign tumor in men and is not a precancerous condition 癌前病变 Zonal 带状带状 Anatomy(McNeal-1

4、972)Peripheral Zone 边缘带边缘带 70%of the young adult(60-70%of CaP)Central Zone 中央带中央带 25%(5-10%CaP)Transition Zone 过渡带过渡带 5%(10-20%CaP)BPHEtiology of BPH Androgens 雄激素雄激素 Ageing Lifestyle Hereditary 遗传的遗传的(genetic)/Race 种族种族Androgen(Functional testicle 睾丸):the prostate is an androgen dependent organ,thu

5、s the hyperplasia of prostate rely on functional testicle.The eunuch 太监 Ageing:Male elder than 50 are more liable 有倾向的有倾向的 to BPH,and the incidence increases as the age increases.Life Style&Race Men who lead a western lifestyle have a much higher incidence of symptomatic 症症候的候的 BPH than men who lead

6、 a traditional or rural lifestyle Animal protein,Green tea,tomato,bean American blackswhitesAfrica blacksAsians(prostata cancer 前列腺癌前列腺癌)Adapted from Nordling J et al.In Benign Prostatic Hyperplasia.Plymouth,United Kingdom:Health Publication,2001:107-166.Pathophysiology of Clinical BPH:Overlapping b

7、ut Independent FeaturesSlide I.2LUTSEnlargedprostateBOOLUTS:lower urianry track symptom 下尿路症状BOO:bladder outlet obstruction 膀胱出口梗阻Lower Urinary Tract Symtoms-LUTSVoiding 排泄排泄/Obstructive symptoms:Hesitancy 犹豫犹豫 Intermittency 间歇间歇 Incomplete voiding 排泄排泄不完全不完全 Weak urinary stream 弱尿弱尿流流 Straining 竭力竭

8、力 to pass urine Prolonged micturition 长长时间排尿时间排尿 Terminal dribbling 尿末滴尿末滴沥沥Lower Urinary Tract Symtoms-LUTSStorage 储存储存/Irritative 刺激刺激 symptoms:Frequency of urination 尿尿频频 Nocturia 夜尿夜尿 Urgency 急迫急迫(compelling 强迫强迫 need to void that can not be deferred 推迟推迟)Urge incontinence 急迫性急迫性尿失禁尿失禁Clinical M

9、anifestation Irritation symptoms:nocturia 夜尿夜尿 frequency 尿频尿频 urgency 尿急尿急 urgent incontinence 尿失禁尿失禁 The effective volume of the bladder decreaseLow bladder compliance 顺从顺从 for longtime obstructionObstruction symptoms:Hesitancy 犹豫犹豫 Intermittency 间歇间歇 Incomplete voiding 不完全排尿不完全排尿 Weak urinary stre

10、am 弱尿流弱尿流 Straining to pass urine 竭力排尿竭力排尿 Prolonged micturition 排尿延长排尿延长 Terminal dribbling 尿末滴沥尿末滴沥 Complications:Infection Cystic calculus Hematuria Hydronephrosis Chronic renal failure Inguinal hernia&Anal prolapseDiagnosis History:(LUTS).Use IPSS 国际前列腺症状评分国际前列腺症状评分 Physical Examination:digital

11、rectal exam 直肠指检直肠指检 prostatitis 前列腺炎前列腺炎:tenderness,soft,bogginess 泥沼泥沼样样;prostate cancer:harder;Abdominal exam-distended bladder 膀胱膨胀膀胱膨胀 Urinalysis 尿分析尿分析-by dipstick 量油计量油计 and routine microscopy 常规显微镜常规显微镜,urine culture and sensitivity to infections and hematuria 血尿血尿 Serum PSA 前列腺特异抗原前列腺特异抗原-o

12、ptional to Prostate CancerDiagnosisu Upper tract imaging(IVP 静脉肾盂造影静脉肾盂造影,CT,U/S 超声检超声检查查)only in presence of 提示提示 concomitant 伴随伴随 urinary tract disease or complications-hematuria,UTI 尿路感染尿路感染,renal insufficiency 肾功能不全肾功能不全,stone diseaseu Cystometrograms 膀胱内压测量图膀胱内压测量图 and urodynamic profile 尿动力学概要

13、尿动力学概要-for patients with suspected neurologic disease or those who failed prostate surgeryu Flow rate 流量流量,post-void residual urine determination 排泄后余尿量测定排泄后余尿量测定 and pressure flow 逆逆流流 IPSSu Mild(score 0-7)u Moderate(score 8-19)u Severe(score 20-35)Differential Diagnosis Pre-prostatic 前列腺前的 Urethra

14、l stricture 尿道尿道狭窄狭窄 Bladder neck contracture 膀胱颈挛缩膀胱颈挛缩 Bladder tumors Neurogenic bladder 神神经性膀胱功能障碍经性膀胱功能障碍 Bladder calculi 结石结石 Urinary tract infectionsProstatic Prostatitis 前列腺炎前列腺炎 Prostate Cancer 前列腺前列腺癌癌Management of BPH Goal-rapid and sustained 持续的持续的 relief of symptoms:Decrease bladder outl

15、et 出口出口 obstruction Improve bladder emptying 排空排空 Reverse renal insufficiency Prevent future episodes 发作发作 of gross hematuria 肉肉眼血尿眼血尿,UTI and urinary retention 尿潴留尿潴留 Quality of life and sexuality 性欲性欲 Management depends on severity 严重程度严重程度 Treatment of BPH Lifestyle modification 改变生活方式改变生活方式 Watc

16、hful Waiting Medical Therapy Phytotherapy 植物疗法植物疗法(alternative)Surgical Treatment:Conventional 传统的传统的 Surgical or Minimally Invasive Treatment 微创手术治疗微创手术治疗Lifestyle Changes Enriched diet with ample amounts of fresh fish,fruits and vegetables Reduce stress regular Exercise Weight within normal limits

17、 Limit fluid intake,decrease bladder irritants-caffeine 咖咖啡因啡因,alcohol;avoid anticholinergic drugs 抗胆碱药物抗胆碱药物,narcotics 麻醉剂麻醉剂 and skeletal muscle relaxants 肌松药肌松药 See your doctor if you develop nocturia 夜尿夜尿 Be aware of interaction 相互作用相互作用 of botanical 植物植物/中药中药 and medical 药物药物/西药西药 treatmentWatc

18、hful Waiting The risk of progression or complications is uncertain In men with symptomatic 有症状的有症状的 BPH,progression is not inevitable 并非不可避免的并非不可避免的 and some men undergo spontaneous 自发性自发性 improvement or resolution 解决解决 of their symptoms Appropriate management of men with mild symptom scores(0-7)Med

19、ical TreatmentAlpha blockers Alpha-blockers are a class of drugs considered to be first-line treatment for BPH.Alpha-blockers work by blocking the alpha-1a receptor in the prostate and the bladder.Alpha-blockers relax the muscles of the bladder neck and prostate.Alpha-blockers are very effective in

20、the treatment of BPH;roughly 50 percent of men see an improvement in symptoms within the first 48 hours to one week after therapy initiation 开始.However,patients may only retain symptom relief for up to 4 years,and alpha-blockers do not shrink 收缩 the prostate or slow down BPH progression.Alpha-blocke

21、rs are also used to treat high blood pressure.Examples of alpha-blockers used in the treatment of BPH include:Examples of alpha-blockers used in the treatment of BPH include:uTerazosin 特拉唑嗪特拉唑嗪(Hytrin 高特灵高特灵)uDoxazosin 多沙唑嗪多沙唑嗪(Cardura 可多华可多华,Cardura XL)uAlfuzosin 阿夫唑嗪阿夫唑嗪(Uroxatral)uTamsulosin 坦索罗辛

22、坦索罗辛(Flomax)uSilodosin 西洛多辛西洛多辛(Rapaflo)Company Logo 5-Reductase 还原酶还原酶 inhibitors Combination TherapyCompany Logo Surgical Treatment For patient who do not experience response to medical treatment in 12-24 months;for those whose symptoms progress TURP(transurethral resection of the prostate 经尿经尿道前列

23、腺电切术道前列腺电切术)-Gold standardSurgical TreatmentSurgical Treatment Open Prostatectomy Not done routinely When prostate too large for TURP (100mL)Minimally Invasive Surgical treatment TUMT-transurethral microwave therapy 经尿道微波热经尿道微波热疗疗 TUNA-transurethral needle ablation 经尿道射频消融经尿道射频消融 Urinary Stents 尿道支架

24、尿道支架 Laser Prostatectomy-Holep holmium laser enucleation of the prostate 钬激光前列腺剜除术Minimally Invasive Surgical treatmentu TUMT(transurethral microwave therapy)u Performed as a single outpatient 门诊的门诊的 visit under local anesthesia and an oral analgesic 口服口服镇痛药镇痛药.Improves symptom scores and urinary fl

25、ow rates 尿流率尿流率Minimally Invasive Surgical treatmentuTUNA(transurethral needle ablation)uAn office procedure performed under local anesthesia-improves symptom scores and urinary flow ratesuIt uses specially designed catheter 导管导管 through which interstitial 间隙的间隙的 radio-frequency needles are deployed

26、 展开展开 from the tip 尖端尖端 of it.They will heat the tissue resulting in coagulative necrosis 凝固性坏死凝固性坏死uThe entire procedure lasts 30-60 minutes uA catheter is left for 1-4 days after the procedureMinimally Invasive Surgical treatmentu Intraurethral StentuLimited long term experienceuIncreases urine fl

27、ow rates but causes secondary obstruction by exuberant 丰丰富富 granulation tissue 肉芽组织肉芽组织 growth through and around the stentuDifficult to remove it;formation of bladder calculi in 50%of patientsuUsually for patients with limited life expectancy 预期寿命预期寿命 that are not good surgical or anesthetic candid

28、ates 候选候选uAbandoned by most urologistsMinimally Invasive Surgical treatmentu Laser Therapy-“The wave of the future”uNeodymium:yttrium-aluminium-garnet(Nd:YAG)-Visual Laser ablation of the ProstateuThe final result is coagulative necrosis of the prostatic urethra and adjacent inner prostatic tissue.T

29、he obstructive tissue starts to slough 4-8 weeks post-op leading to an open prostatic urethra uGreen light laser -Laser Vaporization 气化气化 of Prostate-causes rapid vaporization of the superficial tissue,with a minimal rim(2 mm)of coagulationuAdvantage:immediate TUR-like efect of the prostatic urethra

30、,resulting in shorter duration of Foley catheterization in the initial post-op period uHolmium-YAG-Laser resection 切除术切除术-prostatic lobes are resected into multiple small prostate chips that fall into the bladder,similar to standard electrocautery TURP uAdvantage:immediate anatomical patency of the

31、prostatic urethra,resulting in shorter duration of Foley catheterization and higher peak flow rates in the initial post-op period In SummaryBPH(Benign prostatic hyperplasia)becomes increasingly common as men ageMany men with BPH are asymptomatic 无症状的无症状的 or have only mild symptoms,and may not requir

32、e therapyMen who develop upper or lower tract injury will require surgeryAlpha-adrenergic antagonists provide immediate therapeutic benefits and are first line treatment for smaller prostates 40 mL mild to moderate symptomsIn SummaryCombined alpha adrenergic antagonist and 5-alpha-reductase inhibito

33、r therapy appears to be superior to either agent alone for long-term TrxThe choice of medical treatment may be made on the basis of cost and side-effect profile 简况简况 of the drugTURP is the GOLD STANDARD for men who require an invasive procedure and are in good healthUrinary ObstructionUrinary Tract

34、AnatomyReason of Urinary ObstructionHydronephrosis 肾盂积水肾盂积水Urinary Tract AnatomyReason of Urinary ObstructionHydronephrosis Hydronephrosis is a dilation 扩大 of the inside,or collecting part,of the kidney Caused by obstruction Hydronephrosis may also be due to abnormal backwash 逆流 or“reflux 退潮 of urine into the bladderDegrees of HydronephrosisKidney function:Minimally affected compensation damage If you have any questions,please dont hesitate to contact me E-mail：Cell phone：18602382599