Download - Bph
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Dr. DIDIT PRAMUDHITO Sp.U
Departemen Bedah RS Perjan dr.Moh.Hoesin/FK UNSRI
Palembang
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BPHBENIGN PROSTATE HYPERPLASIATumor jinak pada prostatKemajuan kesehatan Kualitas hidup Populasi orang tua BPH
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PREVALENSIBPH Usia priaOtopsi> 60 tahun : 50 %> 80 tahun : 90 %Klinis
50 -60 tahun : 21 %> 80 tahun : 53 %
s
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Diketahui sejak 1500 S.M.Diketahui sejak 1500 S.M.
1000 tahun kemudian didiskusikan oleh 1000 tahun kemudian didiskusikan oleh HippocratesHippocrates
Insidensi: 50% (klinis) pria 60-69 tahun, Insidensi: 50% (klinis) pria 60-69 tahun, k.l. 100% pada umur 80 tahun k.l. 100% pada umur 80 tahun (mikroskopik sejak umur 35 tahun)(mikroskopik sejak umur 35 tahun)
BPH
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Patogenesis BPH
Syarat terjadinya BPH :
* Testis yg memproduksi androgen
* Ketuaan ( ? )
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Theory
Dihydrotestosteronhypothesis
Oestrogen-testosteronimbalance
Stromal-epithelialinteractions
Reduced cell death
Stem cell theory
Theories for the cause of BPHCause
5- reductase and androgen receptors
Oestrogens Testosteron
Epidermal growthfactor/fibroblastgrowth factor Transforming growthfactor
Oestrogens
Stem cells
Effect
Epithelial and stromalhyperplasia
Stromal hyperplasia
Epithelial and stromalhyperplasia
Longevity of stromaand epithelium
Proliferation of transitcells
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Simptomagenesis
Prostatisme
Sindroma Prostatisme
LUTS(lower urinary tract
symptoms)
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Fungsi unit Vesiko Urethral
1. Penyimpanan
2. Mengeluarkan urin periodik
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BPHLUTS keluhan obstruktif:
1. Hesitansi2. Pancaran lemah3. Mengejan4. Kencing lama5. Terasa tak habis6. Retensi urin7. Overflow Incontinence (ischuria paradoxa)
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BPH LUTS keluhan iritatif
-1.Urgensi Urge incontinence
-2.Frekuensi
-3.Nokturia
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International Prostate Symptom Score International Prostate Symptom Score (IPSS)(IPSS)
Doddy M.Soebadi, 1999
I-PSS (International Prostate Symptom Score)
Dalam 1 bulan terakhir:
• 1. Terasa sisa kencing 0 1 2 3 4 5
• 2. Sering kencing 0 1 2 3 4 5
• 3. Terputus-putus 0 1 2 3 4 5
• 4. Tidak bisa menunda 0 1 2 3 4 5
• 5. Pancaran lemah 0 1 2 3 4 5• 6. Mengejan 0 1 2 3 4 5
• 7. Kencing malam 0 1 2 3 4 5
Total …….
Total IPSS score: 0-7: ringan, 8-18 : sedang, 19-35 : berat
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Provokator Retensi Urine Akuta
1. Minum alkohol Stimulan simpatetik Tonus Prostat &
otot polos bladder outlet
2. Bepergian jauh3. Masukan cairan banyak4. Konstipasi5. Agen anti cholinergik
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DRE (digital rectal examination) = RT = CDDRE (digital rectal examination) = RT = CD
SizeSize
Consistency: Consistency: smooth or smooth or elastic /hard /nodule elastic /hard /nodule /tender /tender
MobilityMobility
Anatomical limits: Anatomical limits: lateral /cranial /medial lateral /cranial /medial sulcussulcus
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PSA PSA interpretationinterpretation
PSA valuePSA value
0.5 - 4 ng/ml0.5 - 4 ng/ml
4 - 10 ng/ml4 - 10 ng/ml
> 10 ng/ml> 10 ng/ml
rise of > 20%/yearrise of > 20%/year
InterpretationInterpretation
NormalNormal
20% chance of Ca20% chance of Ca
50% chance of Ca50% chance of Ca
Refer for biopsyRefer for biopsy
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UroflowmetryUroflowmetry
Max.flow rate Max.flow rate (ml/sec)(ml/sec)
> 15 ml/sec> 15 ml/sec
10 - 15 ml/sec10 - 15 ml/sec
< 10 ml/sec< 10 ml/sec
InterpretationInterpretation
NormalNormal
Mild obstructedMild obstructed
ObstructedObstructed
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TRUS TRUS (Transrectal ultrasound)(Transrectal ultrasound)
Accurate measurement of the prostateAccurate measurement of the prostate
Hypoechoic focusHypoechoic focus
Prostatic biopsy (if indicated)Prostatic biopsy (if indicated)
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Diagnosa BPHDiagnosa BPH
Anamnesa:Anamnesa:– I-PSSI-PSS
Pem.fisik: Pem.fisik: – buli-bulibuli-buli– CD / RTCD / RT
Pem.tambahan:Pem.tambahan:– lab: UL,DL,RFT,PSAlab: UL,DL,RFT,PSA– pencitraan: USG/BOF/TRUS/IVPpencitraan: USG/BOF/TRUS/IVP
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Terapi BPHTerapi BPH
Konservatif: observasi Konservatif: observasi (watchful waiting)(watchful waiting) 0 - 7 0 - 7
Medikamentosa (Tx medik)Medikamentosa (Tx medik) 8 - 188 - 18
Pembedahan:Pembedahan: 19 - 3519 - 35– terbukaterbuka
– endoskopik: TURP, TUIPendoskopik: TURP, TUIP
Invasif minimal:Invasif minimal:– balloon dilatationballoon dilatation– stentstent– microwave (thermotherapy)microwave (thermotherapy)– radiofrequencyradiofrequency– laser ablationlaser ablation
I-PSSI-PSS
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Kontra-indikasi Tx medik BPHKontra-indikasi Tx medik BPH
Retensi urin (akut atau kronik) Retensi urin (akut atau kronik)
Insufisiensi renalInsufisiensi renal
Dilatasi traktus atasDilatasi traktus atas
Hematuria berulangHematuria berulang
ISK berulangISK berulang
Batu buli-buli / divertikelBatu buli-buli / divertikel
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Terapi medik BPHTerapi medik BPH
Alpha blockerAlpha blocker– terazosinterazosin– prazosinprazosin– tamsulosin, dlltamsulosin, dll
Supresi AndrogenSupresi Androgen– 5 alfa-reduktase inhibitor5 alfa-reduktase inhibitor
FitoterapiFitoterapi
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Morfometri BPHMorfometri BPH
Rasio of epithelium terhadap stroma:Rasio of epithelium terhadap stroma:
epith : stroma = 21.6 - 50 % : 60 - 78 %epith : stroma = 21.6 - 50 % : 60 - 78 %
BPH simtomatik: proporsi stroma lebih BPH simtomatik: proporsi stroma lebih tinggitinggi
Respons terhadap Tx:Respons terhadap Tx:predominan otot polospredominan otot polos : alpha blocker: alpha blocker
predominan epithelpredominan epithel : supresi androgen : supresi androgen
predominan fibrosispredominan fibrosis : bedah: bedah
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Rasional penggunaan alpha blockerRasional penggunaan alpha blocker
Kontraksi otot polos prostat dimediasi oleh : Kontraksi otot polos prostat dimediasi oleh : stimulasi simpatis reseptor alphastimulasi simpatis reseptor alpha
Kontraksi otot polos (kapsul, adenoma, leher buli) : Kontraksi otot polos (kapsul, adenoma, leher buli) : merupakan 40% dari penyebab obstruksi saluran merupakan 40% dari penyebab obstruksi saluran keluarkeluar
Alpha blocker : Alpha blocker : – relaksasi otot polos prostatrelaksasi otot polos prostat– mengurangi simtommengurangi simtom– memperbaiki pancaran kencingmemperbaiki pancaran kencing
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Distribusi reseptor Distribusi reseptor alphaalpha
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Intervensi urologis di SurabayaIntervensi urologis di Surabaya
Balloon dilatationBalloon dilatation
Prostatic stentProstatic stent
ThermotherapyThermotherapy
TUIP (transurethral incision of the TUIP (transurethral incision of the prostate)prostate)
TURP (transurethral resection of the p.)TURP (transurethral resection of the p.)
Laser TURPLaser TURP
Open prostatectomyOpen prostatectomy