Benign prostatic hyperplasia and prostate cancer diseases seen more with the human life span in the world and Turkey.
We now have very modern treatment methods for these diseases, which are used to be treated only by removing the testicles (eggs) and inserting catheter 150 years ago.
The prostate gland is an accessory sex cloth weighing 15-20 grams surrounding the urethra at the base of the bladder, which we call urethra. The reason why it is called an accessory is that the prostate is removed by surgery and sexual life is not impaired. The reason why the urinary tract surrounds the urinary tract is that it passes through the prostate gland, 40-50% of the liquid part of the semen is provided by the prostate gland. The prostate glands that produce this fluid open to the posterior upper part of the posterior urethra, where it covers the prostate through 25 main channels. The prostate gland consists of two sides, one in the front, the back and middle lobes, and the inner and outer group glands in comparison to another separation.
Benign prostatic enlargement begins as microscopic hyperplasic focus in the periurethral glands in the prostatic urethra after the age of 30-40. However, the adenoma mass, which occurs as a result of the combination of these foci by not growing as soon as possible, narrows the bladder outlet and generally causes difficult urination after the age of 60, and can not urinate by blocking the urinary tract. Although the exact cause of prostate enlargement is unclear, it is thought to be hormonal and the result of imbalance between male and female hormone in men. Evidence of this is that patients are comfortable with the removal of two eggs (testicles) for the treatment of prostate enlargement in the 1850s.
Generally, the growth of two lateral and middle lobes (trilobe hyperplasia) and sometimes the growth of two lateral lobes cause disease. The urinary tract (posterior urethra) in the narrowed prostate gland is lengthened. It deviates from the midline and shifts the location of the bladder neck. Passing urine through this narrowing duct works hard and bladder muscle to overcome urethra resistance. Urine (residue) begins to remain in the bladder. If the person does not have surgery within the years, the bladder muscle becomes tired and bankrupt and the patient becomes unable to urinate. Urine inflates the bladder like a balloon. We call this ‘globe vesical’. Urea of these patients has increased. Their bladders are emptied immediately and the bladders are emptied and their urine returns to normal within a week when the catheter is left in place and the patient drinks plenty of water to extract 1.5-2 liters of urine per day. Then these patients undergo prostate surgery. Infection and bladder stones are now common in patients due to urine.
The most important and disturbing complaint of the patients is to urinate frequently at night after going to bed. While a normal person does not urinate at night, prostate patients urinate 2-3 or even 8-10 times at night. However, these patients do not urinate so often during the day. The reason for this is that the edema water collected in the legs of the patient, whose age has already advanced, is filtered through the kidneys in the evening and excess urine is produced. The amount of urine (volume) is increased with little release of the anti-diuretic hormone-ADH, which absorbs water from the kidneys secreted from the pituitary gland during the night. Also, the conscious urinary retention reflex in sleep decreases. The second important patient complaint is thinning of the thickness (diameter – caliber) of the urine and decreasing the urine flow rate (projection). As the obstruction of the prostate increases, these complaints increase.
Other complaints are waiting for urine, not starting urine immediately, feeling a little more urine left after urinating, urinating a little more once out of the toilet. All these complaints often increase more at night. Because most of the bad things are births, deaths, urgent illnesses usually occur at night. For this reason, Arabic songs are always built on ‘leyl-night’.
When urinating, burning is seen when there is a urinary tract infection or bladder stone. Blood in urine is formed as a result of rupture of the vein that expands on the bladder wall.
If the patient’s urea is elevated, it is sluggish and the language is very dry. Nausea, vomiting, loss of appetite is seen.
On examination, urine in the bladder can be detected in the abdomen. In the globe vesical, the lower part of the abdomen is swollen. Prostate examination from the breech by finger is the most important examination. Here the size, shape and consistency of the prostate gland are understood. Benign prostatic enlargement is rubbery and homogeneous. This examination is 65-70% guiding in distinguishing normal prostate enlargement from prostate cancer. In prostate cancer, the prostate gland is handled as hard areas or all of them are hard. Of course, for a definitive diagnosis, it is necessary to see normal prostate enlargement or prostate cancer in prostate biopsy.
The prostate gland is large when it comes to rectal finger examination, and it may not require surgery. In order to have a prostate surgery, the patient must either become obstructed and have a catheter, urinate too often at night, or have stones in the bladder and frequent urinary tract infections. While a small prostate can urinate the patient a lot and even clog, a rather enlarged prostate can cause minor complaints. Therefore, prostate size alone is not a reason for surgery.
For the diagnosis, the patient’s complaints, urinalysis, PSA, breech finger abdominal ultrasound are sufficient. On ultrasound, when the state of all abdominal organs, kidneys, bladder and prostate is full, the volume of bladder and residual urine remaining in the bladder after urination is seen. If the residual urine exceeds 100 cc and the patient’s complaints are high, then it is time for medical treatment or surgery. Measuring the urine flow rate helps in selecting the treatment time and shape. A normal man makes 20-25 cc of urine per second. Under 15 medical treatments and 10 surgeries may be required. It is appropriate to repeat this test several times. Because, the patient may not be able to urinate comfortably in a foreign environment with anyone else. In benign prostate enlargement, PSA is below 4 ngr / ml. However, in suspicious cases, prostate biopsy should be performed to eliminate prostate cancer in patients above PSA 2.5 ngr / ml.
For the decision of surgery, 7 questions are asked about the patient’s complaints and 0-5 points are given for each question. This is called the International Prostate Symptom Score (IPSS). If the score is below 7, general measures are recommended for the patient. These are not eating bitter spring, not chilling, sitting for a long time, not riding a horse, not drinking alcohol, and having 1-2 sexual intercourse per week. If the score is between 8-20, medical treatment is applied first. If there is a urinary tract infection in medical treatment, it is treated. Alpha adrenergic blocking drugs are used to reduce the resistance of the prostate gland to block the flow of urine. These are 6-7. They can be very useful. Resistance may develop when used for 5-6 years. It is necessary to change. These drugs do not shrink the prostate gland. 5 Alfareductase inhibitors are used in prostates larger than 40 grams, which slightly reduces the prostate gland. It can be very useful but should be given to patients after 70-75 years of age. Because it makes sexual coldness (impotence). After using it for 6 months, it reduces the PSA level in half and misses the possibility of prostate cancer. It may show the same effect in a drug obtained from stunted palm leaves, a phytotherapeutic drug that shrinks the prostate without sexual coldness.
If the patient is relieved with medical treatment, it is continued for years. Despite medical treatment, if the complaints increase or the patient becomes clogged, surgical treatment is performed. Surgical treatment is endoscopic (performed with instruments – closed) and open surgery.
Companies have produced a wide variety of instruments for closed surgeries. These are balloon enlargement of the prostate, stenting the prostate, melting the prostate with ultrasound (HIFU), hyperthermia, prostate vaporization. These are not very beneficial forms of surgery. There are many dr uses. Transurethral prostatectomy (TUR-P) performed by master hands and prostatectomy performed by Holmium laser (HOLEP) are the most used and useful of closed surgeries.
Open prostate surgery is the most beautiful form of surgery, especially in prostates larger than 60 cc. Although it was first made in the 1890s, it is still up to date, expensive instruments do not require endoscopes, can be made by any urologist, and most importantly, it is the most comfortable form of surgery.
Have a healthy day.
Prof. Ibrahim BOZKIRLI, M.D.