Benign prostatic hyperplasia is one of the most common chronic diseases in older men, and its incidence varies across China, with the total incidence of prostatic hyperplasia in people over 60 years of age ranging from 33% to 63%.
The site of hyperplasia in the prostate is the prostatic migratory zone, which generally begins with the appearance of multicentric fibromuscular nodules (stromal hyperplasia) in the submucosal glands of the prostate segment of the urethra, which in turn stimulates glandular epithelial hyperplasia and forms glandular nodules. Pathologically, hyperplastic prostates can be classified into five types according to the main components of the hyperplastic tissue: fibromuscular hyperplasia, muscular hyperplasia, fibroadenomatous hyperplasia, fibromuscular adenomatous hyperplasia and stromal hyperplasia.
The proliferating tissue compresses the surrounding prostate tissue causing it to degenerate and transform into fibrous tissue, forming a hard grayish-white pseudo-envelope, known as the “surgical envelope”, which has a loose potential gap between it and the proliferating tissue, thus providing an anatomical basis for peeling the proliferating gland from the “surgical envelope” as a whole. This provides an anatomical basis for peeling the hyperplastic gland from the “surgical envelope” as a whole.
Prostatic hyperplasia leads to mechanical and dynamic obstruction of the urinary outflow tract, and patients experience a range of symptoms of urinary difficulty and other symptoms accordingly. Combining the patient’s age, symptoms (I-PSS, QOL), rectal examination, and PSA, ultrasound, and urinary flow rate, the diagnosis of BPH is not difficult in clinical practice.
For the treatment of BPH, it currently consists of.
1. Watchful waiting
Watchful waiting can be used in patients with mild lower urinary tract symptoms (I-PSS score ≤7) and in patients with moderate or greater symptoms (I-PSS score ≥8) while quality of life has not been significantly affected. Various comorbidities related to BPH should be excluded before performing watchful waiting.
2. Drug treatment
Alpha-blockers (tamsulosin, etc.) + 5-alpha reductase inhibitors
3.Surgical treatment
①Patients with severe BPH or those whose lower urinary tract symptoms have significantly affected the quality of life of patients can choose surgical treatment, especially those who have poor results with drug therapy or refuse to receive drug therapy.
②The presence of BPH-related complications
Recurrent urinary retention (inability to urinate after at least one extubation or two urinary retention)
Recurrent hematuria and ineffective treatment with 5α reductase inhibitors
Recurrent urinary tract infections
Bladder stones
Secondary upper urinary tract hydrops (with or without renal impairment)
(iii) Patients with BPH combined with large bladder diverticula, inguinal hernia, severe hemorrhoids or prolapse are difficult to treat without relieving lower urinary tract obstruction.
Patients who can be treated medically, but cannot maintain long-term treatment for economic reasons, I personally believe that surgical treatment can be the first choice.
Before performing surgical treatment, it is necessary to perform urodynamic examination to understand bladder function for patients without clear neurological pathology, which can help doctors predict the immediate and long-term effects of surgery, and also help patients to establish correct psychological expectations for surgery.
4.Surgical treatment modalities
BPH surgical treatment includes open surgery and minimally invasive transurethral surgery, the former is basically eliminated, due to the progress of minimally invasive surgery, even for the treatment of the huge prostate does not need to perform open surgery.
The most common clinical application is electrosurgery of the prostate, but due to the limitations of the technology itself, this procedure has the following insurmountable disadvantages.
(1) Intraoperative bleeding, which limits the application to high-risk patients.
(2) The occurrence of TUR syndrome cannot be completely avoided, endangering patients’ lives.
(3) Long postoperative bladder flushing time (2-3 days), long urinary catheter retention time (5-6 days), long postoperative hospital stay (usually more than one week), greater patient pain, and higher chance of secondary bleeding after surgery.
(4) Treatment of large volume prostate is limited.