Prostate adenoma: diagnosis and treatment of the prostate gland in men

The most common urological pathology for which men over 45 years of age consult a urologist at the Yusupov Hospital is prostate adenoma. The presence of this pathology significantly worsens the quality of life of men. One of the most dangerous possible consequences of the pathological process is the degeneration of benign prostatic hyperplasia into a malignant tumor.

To combat prostate adenoma, surgical and drug treatment methods are used. Specialists at the Yusupov Hospital select the most effective medications or surgical methods taking into account the stage of the disease, the general condition and age of the patient, as well as the presence of concomitant pathologies. The surgery clinic has created comfortable conditions for treating patients.

Causes of development of prostate adenoma

The occurrence of adenoma is most often associated with age-related changes in the prostate, namely, changes in its structure and increase in size.
As a result of such changes, the urethra, which is located in the thickness of the prostate gland, is gradually compressed and disturbances in the urination process appear. Prostate adenoma in men develops as a result of hormonal changes in the body associated with age-related changes. The level of testosterone (male hormone) gradually decreases with age, while the concentration of the female sex hormone (estrogen), on the contrary, increases. This phenomenon is called male menopause.

The development of prostate adenoma may be due to the following risk factors:

The age of the patient - an enlarged prostate gland is extremely rarely found in men under forty years of age, and after sixty years of age it is diagnosed in almost every second one;
Hereditary predisposition - if prostate adenoma was diagnosed in close blood relatives of a man, he has a huge risk of inheriting this disease in adulthood;
Diabetes mellitus, cardiovascular diseases - a benign tumor (adenoma) of the prostate can arise not only as a result of these diseases themselves, but also the harmful effects of medications for their treatment (for example, beta blockers);
Improper lifestyle – the risk of developing prostate adenoma is increased in men with obesity and insufficient physical activity.

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What causes prostate hyperplasia?

Until now, the exact causes of this disease are not known. There is no clear relationship between the occurrence of prostate adenoma and excessively high or low sexual activity, alcohol abuse and smoking. The main role is played by imbalance in the levels of androgens and estrogens.

With age, against the background of hormonal imbalance, paraurethral glands grow in the central zone of the prostate. Histologically (under a microscope), the number of not only the glands themselves, but also the connective tissue may increase, so histologists distinguish glandular, stromal and glandular-stromal forms of prostate adenoma. Macroscopically, a nodule (or many nodules) forms in the prostate gland, which grows and gradually deforms not only the prostate gland itself, but also compresses the urethra. At the same time, the middle and lateral lobes are formed in the prostate depending on the number of nodes and their direction of growth. Therefore, the main symptom of the disease is primarily a deterioration in the quality of urination. Prostate hyperplasia itself is a benign process. It does not metastasize or grow into other organs, like prostate cancer. However, one way or another, the risk of the cells inside it degenerating into malignant ones exists. Therefore, it is necessary to monitor PSA levels and be sure to undergo regular examinations with a urologist.

Symptoms of prostate adenoma

Prostate adenoma in men can be suspected when a man develops the following symptoms, the most typical for this disease:

increased urge to urinate;
the need to tense the abdominal muscles to urinate;
the presence of painful sensations, burning, sluggish stream of urine;
discomfort and insufficient emptying of the bladder;
increasing the duration of the urination process.

Prostate adenoma leads not only to a decrease in a man’s quality of life, but also to acute urinary retention, which requires the use of surgical treatment methods.
To avoid surgery, many patients use special medications to treat prostate adenoma, eliminating symptoms and restoring normal prostate function. However, only a qualified specialist can suggest the best remedy for prostatitis and prostate adenoma. You should contact him when the first symptoms of the disease appear. Treatment of prostate adenoma is individual for each patient. Drugs for the treatment of prostate adenoma, their dosage and duration of use are prescribed by the attending physician. Taking medications for prostatitis and prostate adenoma on your own can be not only ineffective, but also dangerous. Due to the presence of some “personal” chronic diseases in older men, drugs for the treatment of prostate adenoma in older people should be selected taking into account concomitant pathologies.

Why can the prostate become enlarged? What is the probability of getting sick?

Throughout life, the activity of organs is regulated by 2 systems: nervous and humoral. The latter includes hormonal regulation. It's no secret that the balance of hormones changes with age. In men, the amount of estrogen gradually increases, which leads to an increase in the activity of 5-alpha reductase. Under the influence of the enzyme, reactions occur:

testosterone in prostate tissue is converted to dihydrotestosterone (DHT);
DHT promotes increased division of prostate cells;
hyperplasia leads to the formation of nodes from the paraurethral glands;
as a result, the prostate tissue is pushed to the periphery.

Prostate adenoma develops under the influence of 2 main mechanisms:

Enlargement of the prostate gland. This process leads to a gradual narrowing of the lumen of the urethra and, accordingly, urinary retention.
Increased tone of smooth muscle fibers. The tense stroma of the prostate and posterior urethra leads to an even greater narrowing of the canal, aggravating the existing problem.

All cells of the organ participate in the enlargement of the prostate gland and the formation of nodes. “Adenoma” is more of a historical term, since it does not fully reflect the essence of the pathophysiological process in the organ. The term “benign prostatic hyperplasia” is able to more accurately reflect the essence of the pathology, since the formation of nodes occurs not only due to glandular tissue, but also the stroma.

In most modern documents, the abbreviation “BPH” is fixed, but “benign prostate adenoma” also remains common in colloquial speech.

How does prostate adenoma develop?

Prostate adenoma is characterized by gradual development, which can be divided into three stages.

The first stage of the disease occurs with minimal urination disturbances. There may be a slight increase in frequency, especially at night, and a sluggish stream of urine. The first stage can last from one year to 12 years or more.
The second stage of prostate adenoma is characterized by more pronounced urination disorders: intermittent urine stream, the need to strain when urinating and a feeling of incomplete emptying of the bladder. Residual urine, which is retained in the bladder and urinary tract, causes an inflammatory process, which is accompanied by pain, a burning sensation when urinating, pain in the lumbar region and above the pubis.
The third stage is characterized by periodic or constant involuntary leakage of urine, which forces the patient to use a urinal.

Stages of disease development

Experts identify several stages of pathology development, each of which is distinguished by certain symptoms:

Compensated stage. It is characterized by a change in the dynamics of the act of urination: the procedure is repeated often, but the intensity decreases. The patient has a need to visit the toilet several times a night. As practice shows, at the first stage of development the disease does not cause concern: frequent night urination is often associated with age-related insomnia. During daylight hours, normal frequency of urination is maintained. Over time, the frequency of urges increases; at the same time, the volume of urine decreases; In addition, unexpected urges arise more and more often. The stream becomes sluggish and flows in a vertical direction, hypertrophy of the bladder muscles is observed, but the efficiency of emptying does not decrease. It should be noted that at the first stage the functionality of the kidneys and pelvic organs is not impaired.
The subcompensated stage is characterized by expansion of the bladder and the formation of dystrophic changes in its walls. The volume of urine that remains in the bladder after emptying increases; in the process of urination, the patient needs to strain - the abdominal muscles and diaphragm are involved, and this causes an increase in pressure on the bladder and inside it. The procedure for visiting the toilet becomes repeated and intermittent; the passage of urine through the upper tract is disrupted, which negatively affects the elasticity of the muscles and contributes to the expansion of the urinary tract. Kidney function is impaired; a constant feeling of thirst, polyuria and other signs of renal failure appear.
Decompensated stage. Men with this diagnosis experience a distended bladder, usually overflowing with urine. It is easy to determine by palpation and visual inspection. Often the bubble enlarges and reaches the level of the navel or rises higher. Successful urination becomes impossible even in the case of maximum muscle tension. The desire to go to the toilet does not stop, which can cause particular pain in the abdominal area. The pain and frequent desire to go to the toilet do not subside for long after dripping urine.

With the development of stage 3 pathology, urinary retention or, conversely, ischuria is observed - when the bladder is full, urine is excreted systematically in drops. Due to persistent obstruction of the urinary tract, the function of the renal parenchyma is impaired; this causes an increase in pressure in the collecting system. The clinical picture of kidney failure is growing. In the absence of appropriate treatment, the patient dies.

Complications of prostatitis

In some men, prostate adenoma does not impair the quality of life and proceeds without complications. However, in some cases, the disease can cause the following negative consequences:

Acute urinary retention - it is characterized by a sudden inability to empty the bladder and pain in the suprapubic region. In such a condition, the patient requires emergency medical care with catheterization or minor surgery;
The occurrence of infections in the urinary tract - stagnation of urine, which creates favorable conditions for the proliferation of pathogens, leading to the development of cystitis and pyelonephritis;
The formation of stones in the bladder is also a consequence of stagnation of urine;
Damage to the bladder - when the bladder is not emptied regularly, it stretches and formation of protrusions (pockets) in the walls of the organ in which urine stagnates;
Kidney damage – increased pressure in the ureters and bladder has a direct damaging effect on the kidneys, resulting in renal failure.

Prostate adenoma and potency

Prostate adenoma and potency are closely interrelated. Adenoma disrupts the structure of the gland tissue, which, in turn, leads to damage to another, no less important organ - the testicles, which are responsible for the production of androgens. Thus, prostate adenoma can cause impotence, requiring long-term and complex therapy.

What is the prostate

The content of the article

The prostate is a unique organ located in the male pelvis between the bladder and rectum at the beginning of the penis. The organ surrounds the cervical part of the bladder and the initial part of the urethra. It consists of connective tissue, smooth muscle and glandular tissue.

The glands of the prostate produce secretions, which during ejaculation (the release of sperm during sexual intercourse) penetrate the urethra and mix with the secretion of the seminal vesicles. The role of the secretor is to ensure the viability and fertilization of sperm cells with the carbohydrates, enzymes, minerals and other ingredients it contains.

Diagnosis of the prostate gland in men

A simple and effective way to establish a preliminary diagnosis is for the patient to keep a diary of urination, recording quantitative and qualitative parameters: volumes of urine excreted, characteristics of fluid consumed, imperative urges, night urges. The main physical examination method for suspected prostate adenoma is a digital rectal examination of the prostate to detect its enlargement and exclude some other pathologies. Diagnosis of prostate adenoma at the Yusupov Hospital is carried out using the following laboratory and instrumental methods:

General blood and urine tests;
Biochemical blood test for markers of kidney condition, urea and creatinine levels;
PSA level analysis (to rule out prostate cancer);
Transrectal ultrasound examination (ultrasound);
Uroflowmetry (to determine the speed of urine flow);
Determination of residual urine volume (using ultrasound);
Electromyography of the pelvic floor;
Urethrocystoscopy;
Excretory urography.

Can an adenoma transform into prostate cancer? Malignant neoplasm?

Prostate adenoma is a benign tumor. Its cells are well differentiated and perform their functions fully. Health problems develop precisely due to the increase in size of the organ. Adenoma cells cannot metastasize and grow into neighboring structures.

Previously, there was an opinion that the lack of treatment for prostate adenoma leads to the development of an oncological process. However, most modern studies deny this pattern. Most benign tumors in the human body are incapable of malignant transformation.

Treatment of prostatitis - the most effective methods

Treatment of prostate adenoma is aimed at relieving symptoms of the lower urinary tract, improving the patient’s quality of life and preventing the development of complications of the disease. Patients with mild symptoms that do not impair the quality of life are often prescribed dynamic monitoring with regular examinations by a urologist, who monitors the course of the disease and gives recommendations on how to stop the growth of prostate adenoma. During this period, attention is focused on non-drug therapy. The methods described above can be an addition to conservative treatment, which consists of taking the following medications:

Alpha blockers (Tamsulosin, Alfuzosin);
5-alpha reductase inhibitors (Finasteride);
Phosphodiesterase type 5 inhibitors (Sildenafil);
Combinations of 5-alpha reductase inhibitors and alpha blockers;
Muscarinic receptor blockers or M-anticholinergics.

For patients with advanced stage prostate adenoma, surgical treatment is recommended, which can be performed by several methods: transurethral excision, transurethral resection and removal of the prostate.
There are certain indications for the use of surgical treatment:

Recurrent urinary retention;
Renal failure caused by prostate adenoma;
Bladder stones;
Recurrent urinary tract infections;
Recurrent hematuria.

In addition, surgical intervention is necessary for patients in the absence of effectiveness of drug treatment.
During conservative therapy or in the postoperative period, patients require constant medical supervision with standard studies (determination of urine flow rate, ultrasound, analysis of PSA levels).

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Other tests

Intravenous urography.
The urinary system (kidneys, urinary tract, bladder, urethra) can be examined using intravenous urography. The patient is given an injection of a contrast agent, then an x-ray of the abdominal cavity is taken.
Endoscopic examination
. Lower urinary tract endoscopy is also not a routine test. The test involves inserting a small device with a small camera at the end through the urethra and into the bladder. The image transmitted by the camera appears on the screen, allowing the doctor to assess the condition of the lower urinary tract. The method is also suitable for histological sampling if a malignant process is suspected.

Drugs for the treatment of prostatitis and prostate adenoma

There is a certain scheme according to which specific drugs are prescribed for the treatment of prostatitis and prostate adenoma.
High effectiveness of treatment is achieved through the use of drugs from the group of alpha-reductase inhibitors and alpha-blockers. These drugs for the treatment of prostate adenoma in men help eliminate the main symptoms of the disease, as well as restore sufficient urination. What are the most effective and widely used tablets for prostate adenoma? The list is topped by alpha1-adrenergic receptor blockers. In addition, this list includes 5-alpha reductase inhibitors, vitamins and minerals.

The complex of drug therapy includes not only drugs. For prostate adenoma, conservative treatment can be supplemented with biologically active additives - dietary supplements, which enhance the therapeutic effect of drugs and ensure a speedy recovery. Some of them contain zinc. This macroelement is directly involved in spermatogenesis and testosterone synthesis. Plant phytosterols normalize urination.

Treatment with drugs from the group of alpha1-adrenoceptor antagonists

These drugs for the treatment of prostatitis and prostate adenoma provide relaxation of the smooth muscles of the urinary system and improve the process of urine discharge.
Tamsulosin, with the same name as the active substance, which is included in other drugs (Alfuzosin, Omnic, Silodosin, Urorek, etc.), is a highly selective drug that has a selective effect on alpha1-adrenergic receptors of the muscles of the prostate gland, prostatic urethra and bladder. Due to the decrease in muscle tone, the outflow and excretion of urine is facilitated. Tamsulosin, like all selective drugs, has minimal side effects, does not affect vascular tone and can be prescribed to patients with chronic hypertension. Alpha-adrenergic antagonists must be used continuously, thereby achieving a gradual reduction in irritation and obstruction in prostate adenoma. The drug Omnic in the treatment of prostate adenoma occupies a well-deserved priority in the prescriptions of urologists. It is produced by the Japanese company Astellas Pharma in the form of capsules and tablets (Omnic Okas). How long can you take Omnic without interruption? This directly depends on the stage of the disease. It is strongly recommended that for the risk of exceeding the dosage, consult your doctor about taking the drug and its dosage limits.

The tablet form of the drug is considered more progressive, since thanks to the controlled release of tamsulosin, the active substance is in the body in a constant concentration. The medicine enters the bloodstream evenly, thereby reducing the likelihood of developing the main side effect of drugs from the adrenergic blocking group - a sharp decrease in blood pressure.

An equally effective drug with the active ingredient tamsulosin is Urorek. Taking this drug is not accompanied by the following undesirable effects: orthostatic hypotension, tachycardia, increased frequency of angina attacks in patients with coronary heart disease, so it can be prescribed to men with cardiac pathologies. Properly selected dosage and compliance with all rules for the use of drugs from the alpha-blocker group make it possible to achieve a good therapeutic effect with an almost complete absence of side effects.

Medicines from the group of reductase inhibitors (blockers)

Drugs of this pharmacological group (Finasteride, Penester, Alfinal, Dutasteride, Avodart) help facilitate the outflow of urine, and, therefore, eliminate the main symptoms of the disease.
A stable therapeutic effect occurs within two to three weeks after the start of the course. All symptoms disappear completely after three months. According to the results of clinical studies, maximum effectiveness is achieved after six months of therapy with these drugs. Finasteride and Dutasteride are specific inhibitors of type 2 5-alpha reductase (the cellular enzyme responsible for the transformation of testosterone into dihydrotestosterone). The growth of the prostate gland in prostate adenoma is directly related to a similar transformation of testosterone. Thanks to 5-alpha reductase inhibitors, the production of intraprostatic dihydrotestosterone is blocked and its concentration in the blood is significantly reduced.

Finasteride and Dutasteride are used for the following purposes:

Treatment and control of prostatic hyperplasia;
Improving the outflow of urine and eliminating the symptoms of prostate adenoma;
Reducing the risk of developing acute urinary retention and the need for surgical intervention.

Finasteride and Dutasteride have a pronounced antiandrogenic effect, i.e. help reduce the level of male hormones in the blood. In addition, these drugs have a teratogenic effect, so they should be taken with caution. With the help of modern medications, it is possible to stop the growth of the prostate and prevent the need for surgical treatment.

Specific antibody preparations

Humanity has long discovered the effect of antibodies. These are special molecules that are produced by cells of the immune system to recognize foreign antigens. Subsequently, antigen binding and destruction occurs. Antibodies are specific. This means that they recognize only their antigen or determinant group (a separate fragment). One antigen may contain several such determinant groups and different antibodies will be formed to them. When an antigen is introduced into the body, a large number of different types of antibodies are formed, directed exclusively at one type of antigen. This allows for adequate immune protection. Antibodies are widely used in the treatment of many diseases.

Afalaza, tab. d/rass. - complex preparation, includes active ingredients - antibodies to endothelial NO synthase, affinity-purified, 0.006 g each, and antibodies to prostate-specific antigen (PSA), affinity-purified, 0.006 g each, which are applied to lactose in the form of a mixture of three active aqueous-alcoholic dilutions of the substance, respectively 10012, 10030, 100200 times. The combined use of components in the drug is accompanied by a synergistic effect.

Affinity-purified antibodies to prostate-specific antigen modify the functional activity of endogenous PSA. The regulatory influence of the antigen on functional and metabolic processes in prostate tissue is enhanced.

The drug has a pronounced anti-inflammatory, decongestant and vegetative stabilizing effect. The combined use of components improves spermatological indicators: increasing the concentration of sex hormones, the number of sperm and their motility, reducing the viscosity of seminal fluid, normalizing prostate secretions. Regenerative and repair processes are activated in patients who have undergone surgery and the likelihood of developing complications after surgery is reduced. It is possible to carry out a second course of treatment after 1–4 months. The course of treatment and dosage (primary and repeated) is determined by the attending physician.

"Afala" , tab. d/rass. — the active component of the drug is affinity-purified antibodies to prostate-specific antigen, 0.003 g each. When using the drug, inflammation and swelling are reduced, urodynamics are improved, the volume of residual urine is reduced, dysuric disorders are reduced and the tone of the lower urinary tract and the functional state in the prostate gland are normalized. The drug is used for BPH stages I and II. The drug is part of the complex therapy of acute and chronic prostatitis, as an anti-inflammatory and analgesic. It is used for dysuric disorders, such as frequent urge to urinate, including at night, difficulty urinating, pain or discomfort in the perineal area.

Important! Contraindication is increased individual sensitivity to the components of the drug. Not recommended for use in patients under 18 years of age due to insufficient data on efficacy and safety for this age. Afala does not affect the ability to drive vehicles and other potentially dangerous mechanisms.

Antispasmodics and painkillers for exacerbation of the disease

The main purpose of antispasmodic and analgesic drugs during exacerbation of prostate adenoma is to alleviate the general condition of the patient and eliminate pain.
Non-steroidal anti-inflammatory drugs (Diclofenac, Ibuprofen) have an anti-inflammatory and analgesic effect. They help fight not only the pain that occurs during urination, but also the constant pain in the groin and perineum. Thanks to the action of non-steroidal anti-inflammatory drugs, the inflammatory process is reduced, swelling of the prostate gland is reduced, body temperature is normalized, and unpleasant symptoms are eliminated. Non-opioid analgesics, available in the form of tablets or suppositories, help relieve pain during exacerbation of prostate adenoma. The most accessible of them is Analgin. However, this drug is intended rather for one-time use, since it can only affect mild pain. In addition, analgesics with lidocaine, benzocaine, anesthesin and novocaine (Ichthyol, Anestezol, Procto-Glivenol) are effective.

Why is acute urinary retention dangerous?

Acute urinary retention is an insidious disease in which an enlarged prostate gland leads to obstruction of the urethra. If measures are not taken to force the outflow of urine (installation of a tube into the bladder through the anterior abdominal wall), then the following may develop:

uremic coma;
ascending pyelonephritis;
urethritis;
prostatitis;
urolithiasis disease;
hematuria;
erectile disfunction;
mental disorders (due to intoxication of the body);
uncontrolled urination.

Lack of treatment leads to rapid deterioration of the patient's condition.

Vitamin E 400

Tocopherol acetate or vitamin E is often included in the complex treatment of prostate adenoma as an antioxidant, radioprotective agent and an indispensable link in reproductive processes.
Vitamin E in a dosage of 400 mg is prescribed by urologists to patients with disorders of erectile function and spermatogenesis associated with prostate adenoma. Treatment of such a serious chronic disease as prostate adenoma should be prescribed and monitored by a urologist. Taking certain medications on your own, without prior consultation with your doctor, is strictly prohibited, since self-medication in this case may not only be ineffective, but also dangerous for men’s health. Only a qualified specialist can tell you which tablets for prostate adenoma are the most effective in each specific case, and which of them can cause negative consequences.

Structure and functions of the prostate gland

The prostate is an organ that synthesizes and secretes a complex secretion that is part of the seminal fluid of men. It contains:

acid phosphatase;
lemon acid;
fibrinolysin;
prostate-specific antigen;
protein complexes.

It is thanks to the secretion of the prostate that sperm become more mobile, which increases the possibility of fertilization. This fluid is released into the urethra during ejaculation.

Another important feature of prostate secretion is the ability to change the pH of the partner’s vagina. This results in sperm being able to survive for a longer period of time, which also increases the likelihood of conception.

The prostate gland is capable of growth throughout a person's life. This feature is associated with a thin capsule of the organ, which is well nourished by blood vessels. Significant enlargement of the prostate gland leads to pain and discomfort due to pressure on neighboring organs and systems. Therefore, men require complex treatment.

Operations

Urologists at the Yusupov Hospital masterfully perform classical and minimally invasive surgical interventions and use innovative methods of surgical treatment of prostate adenoma.
Each patient is selected for the operation that suits him best. The generally accepted standard in the surgical treatment of prostate adenoma is transurethral resection of the prostate. The operation is highly effective. After the intervention, patients get rid of bladder outlet obstruction (narrowing of the urethra) and associated symptoms. The rehabilitation period is short. During or after surgery, bleeding and “water intoxication” syndrome may develop in the body.

Alternative methods of treating prostate adenoma include the following surgical interventions:

Stenting;
Balloon dilatation;
Hyperthermia;
Thermotherapy;
Ultrasound, laser and needle ablation;
Interstitial coagulation.

After them, complications occur less frequently, but these techniques are inferior to transurethral resection in terms of effectiveness, both clinically and economically.
Laparoscopic removal of prostate adenoma is used when the tumor has grown significantly, and removing it using transurethral resection is problematic. This operation is more complicated and is performed under anesthesia. Through small incisions, the surgeon inserts special instruments into the body cavity, which are used to remove the prostate adenoma. The operation is carried out using images from video cameras, which are displayed on the screen. The main advantages of the intervention are minimal blood loss and low likelihood of complications. After the operation, the patient does not need long-term rehabilitation.

When there are signs of prostate adenoma in men, doctors use a high-tech method of treating adenoma - laser enucleation. The intervention is carried out when the tumor is large. Excess tissue is removed using a laser. The operation is performed through the urethra. The tumor is separated, divided into small parts, and then removed. The method is considered minimally invasive. It has a number of significant advantages: it does not violate the integrity of cavities and does not cause unnecessary damage.

Laser vaporization involves destroying the adenoma by laser evaporation. The urologist inserts a special device through the urethra, brings it to the tumor and precisely targets it with a strong green laser. The depth of penetration of the laser and the accuracy of its impact make it possible to avoid damage to neighboring areas. The method is minimally invasive, bloodless, fast and effective. Its only drawback is the inability to take tumor tissue for histological examination.

In some situations, the inevitable method of treating prostate adenoma is abdominal surgery - adenomectomy. It is performed when other methods cannot help the patient. During surgery, the surgeon uses a scalpel to access the prostate gland and manually, using surgical instruments, removes the adenoma. As a result of the operation, significant blood loss and complications may develop. After surgery, the patient needs long-term rehabilitation.

Removal of prostate adenoma using transvesical (transvesical) adenomectomy involves radical excision of hyperplastic prostate tissue through a longitudinal incision in the anterior abdominal wall and bladder. The operation is performed in advanced stages of the disease, when the tumor reaches a large size, the bladder is overstretched due to its overflow with accumulated urine, and renal failure develops.

The bladder is pre-catheterized and filled with a sterile solution of furatsilin or another substance. Then it is isolated and taken in two places on special holders, for which the wall of the organ is lifted. The surgeon cuts through the resulting fold and opens the bladder.

Along the inner end of the installed urinary catheter, the area of the bladder neck is determined and around the urethral opening that appears in the field of view, stepping back from it by 0.5-1 cm, an incision is made in the mucous membrane. After this, the operating urologist penetrates the thickness of the prostate with his finger, enters it between the tumor capsule and adenomatous nodes, and removes the latter. At the same time, with the finger of the other hand, which is first inserted into the patient’s rectum, the doctor moves the gland towards the anterior abdominal wall. It becomes more accessible to manipulation. Thanks to this technique, the operation time is reduced and blood loss is reduced.

Then the surgeon performs hemostasis (stopping bleeding) of the bed of the removed adenoma and suturing the bladder, leaving a thin drainage in the wound. It is designed to wash its cavity from formed blood clots. The urinary catheter inserted before the operation is not removed for 7-10 days. A new section of the urethra is formed around it instead of the prostatic part of the urethra excised during the operation.

Transvesical adenomectomy is one of the most traumatic of all techniques used for prostate adenoma. It is accompanied by the risk of developing the following complications:

Bleeding from the tumor bed;
Congestive pneumonia;
Violation of the motor-evacuation function of the intestines, manifested by constipation.

To avoid complications, after surgery at the Yusupov Hospital, the patient undergoes early activation. The following undesirable consequences of surgery to remove prostate adenoma may occur:

Insufficient drainage of the bladder;
Narrowing of his neck;
Urinary infiltration of peri-vesical tissue;
Formation of a “pre-bladder” (residual cavity in the place where the prostate adenoma was removed);
Formation of narrowing of the lumen of the urethra;
Urinary incontinence.

This negatively affects the quality of life of patients and prolongs the time required to restore adequate urination.
The consequences of the operation are less pronounced when the intervention is performed using a laparoscope. Laparoscopic surgery to remove prostate adenoma is one of the less invasive options for surgical interventions on the prostate gland. Urologists at the Yusupov Hospital use this technique if the patient has a sufficiently large prostate adenoma.

If the size of the prostate gland of a patient with adenoma does not exceed 120 cm3, transurethral resection of the prostate adenoma is recommended. But for 10% of patients who need surgical intervention, this option is not suitable, since the gland reaches a size of more than 120 cm3. Laparoscopic surgery to remove prostate adenoma is not performed for urolithiasis, inguinal hernia, bladder diverticula, or ankylosis of the joints of the lower extremities. In this case, the decision on the possibility of performing an operation is made collectively by a urologist, andrologist, abdominal surgeon and other specialists at the Yusupov Hospital.

With laparoscopic access, general anesthesia is used. Laparoscopic removal of prostate adenoma is carried out using specialized equipment. The surgeon uses trocars through which he passes laparoscopic instruments to the prostate gland. The trocar is equipped with a small video camera that transmits the image to the screen. This way, surgeons have the opportunity to perform all actions as accurately as possible.

Laparoscopic surgery to remove prostate adenoma has the following advantages over open adenomectomy:

During the operation, bleeding and complications occur much less frequently;
The pain syndrome is less pronounced, the patient does not need a large amount of analgesics;
Bladder catheterization does not last long;
Physical activity is restored faster, the next day after the operation the patient can walk without difficulty.
Hospitalization after laparoscopic adenomectomy takes much less time. The patient quickly returns to normal life. He has no cosmetic problems. The length of scars after surgery does not exceed one centimeter.

After laparoscopic removal of prostate adenoma, the need for repeated surgery is minimized, since a significant part of the prostate tissue is removed.
Embolization of prostate arteries is one of the most modern methods of treating adenoma. It is used more often abroad. The operation involves blocking the blood vessels supplying the prostate adenoma. An endovascular surgeon for large blood vessels brings a microcatheter to the source of blood supply to the tumor and injects a special composition that blocks the blood flow. As a result, the tumor does not receive oxygen and nutrients, and it decreases in size. Contraindications to the use of this method are malignant tumors, allergies to contrast and embolic agents, cardiovascular pathology, some chronic diseases of internal organs, and acute diseases.

Transurethral resection of the prostate (TURP) is a method of removing prostate adenoma without external incisions. The intervention is performed using a special instrument (resectoscope). The urologist inserts it into the patient’s bladder through the urethra. After examining the urethra, bladder and the actual area where the prostate adenoma is located (the border of the urethra and bladder), the surgeon removes the prostate adenoma using a special device - a loop. Transurethral resection of the prostate requires good visibility. It is ensured by a constant flow of fluid through one of the resectoscope channels and outflow through the other channel. Visibility may be impaired due to bleeding from blood vessels. During the operation, the surgeon stops the bleeding in order not to lose orientation in the tissues.

Transurethral resection of the prostate is used if the size of the prostate gland does not exceed 80 cm3. The adenoma is removed until the tissue of the gland itself is visible. After the prostate adenoma is removed, the tissue is washed from the bladder using a special instrument, and a control examination of the surgical site and the bladder is carried out. If necessary, additionally stop bleeding from blood vessels. After this, the surgeon removes the operating instrument (resectoscope). A special Foley catheter is passed through the urethra into the bladder. An inflating balloon is located at the bladder end of the catheter. After the catheter is inserted into the bladder, the balloon is filled with fluid. It takes the place of the removed adenoma, which helps stop bleeding from small vessels and prevents the catheter from falling out of the bladder. In this case, minimal consequences are observed after removal of the prostate adenoma. Patient reviews of the operation are excellent. Recovery after removal of prostate adenoma occurs quickly.

Transurethral resection of the prostate is one of the most complex and precious operations in the entire spectrum of endoscopic urological surgery. Urologists at the Yusupov Hospital have undergone special training. Surgeons are fluent in the technique of this surgical intervention.

Transurethral electrovaporization combines the advantages of standard transurethral resection (the possibility of immediate removal of tumor tissue, optical control of the intervention, clinical and economic efficiency) with a significant reduction in blood loss during and after surgery, preventing “water intoxication” of the body. Electrovaporization of the prostate also has disadvantages. “Roller vaporization” is technically simple, there is good endoscopic visibility, there is no bleeding, but, compared to monopolar transurethral resection, it has a lesser ability to remove hyperplastic tissue. Roller vaporization is used as monotherapy for prostate adenoma with a volume of no more than 40 cm3. Vaporizing resection is not inferior in efficiency and speed to standard transurethral resection. It is just as difficult to master, since the hemostatic effect of the vaporizing loop is not as pronounced as the “roller vaportrode”, and the technique of cutting and removing prostate adenoma requires considerable experience of the surgeon.

New methods of transurethral endoscopic treatment of prostate adenoma include rotoresection. The technique combines electrovaporization, coagulation and mechanical removal of the prostate tumor with a rotating electrode. Due to sufficient depth of coagulation, good bleeding control is ensured during surgery, and the simultaneous mechanical removal of dehydrated and carbonized tissue with a rapidly rotating rotoelectrode allows the urologist to continue effective ablation by evaporation. Patients of the Yusupov Hospital have the opportunity to receive all complex methods of treating prostate adenoma at partner clinics.

Benign prostatic hyperplasia. Modern treatment options.

By the age of 60 , according to various authors, from 13 to 50% of men suffer from this disease , and by the age of 90, approximately 90% of men have morphological changes characteristic of BPH. On average, half of these patients experience macroscopic enlargement of the gland, and 25% of patients develop clinical symptoms requiring treatment [4,6,7]. The social significance and relevance of this problem is emphasized by WHO demographic studies, which indicate that the global population over the age of 60 is growing, and its rate is significantly faster than the growth of the population as a whole. This pattern is also typical for our country. According to various estimates, by the age of 80, every 4th man will need treatment for prostatic hyperplasia. The numerous clinical manifestations and symptoms of BPH are extremely varied and depend on the progression of the disease, somatic and mental status, age, social status and medical awareness. The symptoms of BPH are varied, non-specific and very diverse, and therefore there is disagreement regarding the interpretation of the results of diagnostic examinations. Assessment of symptoms (their intensity, degree, frequency, duration and significance) is often subjective and depends not only on the patient, but also on the qualifications of the treating urologist. Such subjectivity not only complicates the diagnosis and prognosis of BPH, but also does not allow objective comparison of treatment results in different clinics and thereby assess the effectiveness of various methods of conservative and surgical treatment. Only in the last two decades in most countries of the world, including Russia, has there been a tendency towards the formation of uniform principles for the assessment and interpretation of BPH symptoms. This assessment is based on clarifying not only each symptom and their totality, but also their correlation with the data of an objective examination, the capabilities of which have increased sharply nowadays due to the advent of new technologies. Most symptoms of BPH are accompanied by two other prostate diseases - cancer and prostatitis. This should explain the need for differential diagnosis when examining patients with various types of urination disorders. The problem of diagnosis and treatment of benign prostatic hyperplasia is currently one of the most dynamically developing areas of urology. The basis for the revolutionary changes that have occurred are fundamental research in the field of molecular biology, physiology, immunology, morphology and hormonal regulation of the prostate gland, a detailed study of the epidemiology, etiology and pathogenesis of the disease, as well as the introduction into medical practice of high-tech achievements of scientific and technological progress.

Clinical manifestations of benign prostatic hyperplasia are determined by obstacles to the flow of urine and, accordingly, disturbances in the habitual act of urination - a typical symptom complex that is leading in all varieties of growth of hyperplastic nodes (Table 1). Changes in the act of urination are determined by obstruction of the prostatic part of the urethra, which is circularly or segmentally covered by adenomatous nodes, stretched in length and deformed. The characteristic clinical picture in an elderly patient at the first visit immediately allows the doctor to associate complaints with the development of BPH. In the initial stage, the patient notices only minor urination disorders, and frequent urination prevails, especially at night. The first sign of the onset of the disease is nocturia , which disrupts sleep and therefore causes concern for the patient. If the condition is not aggravated by new symptoms, he reconciles himself with the inconvenience that arises and does not consult a urologist. Functionally, urinary disorders are compensated by the detrusor muscles, which easily overcome the obstacle that has arisen. In practical urology, the division into symptoms of obstruction and symptoms of irritation has become quite widespread [9]. With this division, they try to emphasize not only the nature of the symptoms, but also their differences in severity. Obstructive symptoms are more dangerous in prognostic terms and seem to be targeted for surgical treatment. Irritative symptoms, although they significantly reduce the quality of life, are less dangerous and can be eliminated with proper conservative treatment.

BPH has a significant impact on the patient's quality of life . The more severe the symptoms, the worse the patient's quality of life and the greater their impact on his daily activities (Table 2). However, it is obvious that identifying obstructive symptoms and determining the amount of residual urine can only serve as the basis for a preliminary understanding of the disease and its prognosis. Often, when choosing a method of treatment for BPH, you need to focus on the predominance of a group of one or another complaint in the disease picture [3,5]. As a rule, obstructive and irritative symptoms are observed to varying degrees in the same patient and there is no direct relationship between the severity of these manifestations and the severity of the condition according to an objective examination [15]. This situation somewhat reduces their significance and makes the division into obstructive and irritative symptoms largely artificial. It is becoming clear that a more objective approach to assessing BPH symptoms is needed. This circumstance apparently explains the emergence of various systems for calculating and deriving a symptom index. To quantify the patient’s complaints and observed symptoms, it is recommended to use a questionnaire (“Symptom Index” developed by the American Urological Association) [10], filled out by the patient himself (Table 3). The symptom rating scale classifies symptoms according to severity, dividing them into mild (0–7 points), moderate (8–19 points) and severe (20–35 points). The questionnaire should be used when planning treatment and during subsequent routine examinations of the patient. This method is not an independent tool for diagnosing BPH, since the symptoms to which the questions relate are not unique to this disease. According to the recommendations of the International Consensus Committee on BPH, the parameters S–L–Q–R–V–PQ can be used to describe the clinical status of the patient (Table 4). When making a diagnosis, a urologist takes into account a fairly large number of symptoms and initial data (results of instrumental tests, medical history, etc.). However, it has been shown that the number of signs effectively considered by a doctor when making a diagnosis, as a rule, does not exceed 15, and about 50 thousand different combinations arise during diagnosis. Each urologist considers his own set of signs. However, when using computer diagnostic methods, it is possible to increase the number of criteria considered, since there are practically no restrictions on the complexity and number of options examined. Computer information systems are now successfully used to automate many aspects of human activity, for example, to support document flow and information processes. However, the use of computers in medicine is not limited to auxiliary accounting functions - it is associated with an attempt to automate diagnostics and involve computers directly in the patient’s treatment process. International consensus committees and groups of urological experts have defined the concept of a “standard” patient . Exclusion criteria from the concept of “standard patient”: – age less than 50 years; – presence of prostate cancer; – previous therapy for prostate hyperplasia, which did not bring positive results; – treatment-resistant diabetes mellitus, diabetic neuropathy; – presence in the anamnesis or physical examination of signs of a neurological disease; – a history of surgery or trauma in the pelvic area; – taking medications that can affect the bladder.

The minimum list of diagnostic measures when treating a patient with urinary disorders should include: – taking an anamnesis; – measurement of the total score according to the International System of Total Symptom Assessment for Prostate Diseases on a 35-point scale (IPSS); – assessment of quality of life on a 6-point scale (QOL); – digital rectal examination (DRE); - general urine analysis; – determination of serum urea and creatinine; – assessment of the morphofunctional state of the kidneys and upper urinary tract using X-ray or radioisotope examination methods; – ultrasound examination of the prostate gland, abdominal and transrectal; – urodynamic study (uroflowmetry); – determination of the presence and amount of residual urine (RV); – determination of the level of prostate-specific antigen (PSA) and, if necessary, determination of PSA fractions - “free” prostate-specific antigen in the blood. Dihydrotestosterone is the most potent fermentative product of testosterone and the predominant androgen of the prostate gland. Testosterone is converted to DHT by the enzyme 5? –reductases. There are 2 isoforms of 5? -reductases (type 1 and type 2), which are encoded by different genes - SRD5A1 and SRD5A2, respectively. The role of enzyme 5? -reductase was discovered after it was discovered that male pseudohermaphrodites deficient in 5? -reductase (mutation of the SRD5A2 gene) are characterized by a pronounced decrease in DHT, normal testosterone levels, small prostate gland size (throughout life) and the absence of BPH development. The basis for the development of inhibitor 5? -reductase type 2 was determined by the fact that a genetic deficiency of this enzyme leads to the involvement of DHT in the growth and development of the prostate gland. At the same time 5? –reductase is localized directly in the prostate. These facts suggested that targeted inhibition of 5? -reductase type 2 and therefore inhibition of DHT production may potentially influence an important causative factor of BPH. An imbalance of intracellular enzymes contributes to the rapid growth of BPH, which is manifested by: – proliferation of hyperplastic prostate tissue; – increased activity and tone? 1 – adrenergic receptors; – disruption of metabolic processes in prostate tissue, which leads to circulatory disorders and the addition of an inflammatory process. The role of DHT in the regulation of prostate function is great, because without it, the prostate cannot develop, differentiate, maintain and maintain its functions. In the normal prostate gland, the processes of proliferation and cell death are in dynamic equilibrium. This condition is maintained by the necessary level of androgenic steroids.

Modern methods of treating BPH

The development and implementation of fundamentally new scientific ideas into medical practice makes it possible to change the attitude towards the diagnostic and treatment process and radically improve the results of treatment of a particular pathological condition. The totality of treatment methods for BPH, currently used in clinical practice, is an impressive list and can be represented by the following classification.

I. Drug therapy.

II. Minimally invasive non-surgical (alternative) treatment methods. 1. Non-endoscopic thermal methods: – extracorporeal pyrotherapy; – transrectal focused ultrasound thermal ablation; – transurethral radiofrequency thermal destruction; transurethral microwave (or radio wave) thermotherapy; – transrectal microwave hyperthermia. 2. Balloon dilatation. 3. Stenting of the prostatic urethra. 4. Endoscopic thermal methods: – interstitial laser coagulation (ILC); – transurethral needle ablation (TUNA).

III. Surgical methods of treatment: 1. Open prostatectomy. 2. Transurethral resection of the prostate gland. 3. Transurethral electroincision of the prostate. 4. Transurethral electrovaporization of the prostate. 5. Transurethral endoscopic laser surgery of the prostate gland (vaporization, ablation, coagulation, incision and combinations of these techniques, including with ILC). 6. Transurethral cryodestruction of the prostate. According to the recommendations of the 4th meeting of the International Consensus Committee on the problem of BPH (1997), the absolute indications for surgical treatment are: – urinary retention (inability to urinate after at least one catheterization, or if catheterization is impossible); – repeated massive hematuria associated with BPH; – renal failure due to BPH; – bladder stones; – recurrent urinary tract infection due to BPH; - large diverticulum of the bladder. Despite the great achievements of modern high technologies, the operation performed does not always give brilliant results: – 63% are satisfied with the results of treatment; – completely dissatisfied with the results of treatment – 21%; – occurrence of new urinary disorders in the postoperative period – 24%; – feeling of complete recovery – 59%.

Drug treatment of BPH

Modern drug therapy for BPH, specifically designed to target the prostate gland, includes therapy? – adrenergic blockers and other drugs. The immediate goal of treating BPH is to relieve symptoms, and the long-term goal is to slow disease progression, minimize unwanted treatment effects, and maintain quality of life.

Indications for conservative (drug) treatment of BPH: – total IPSS score more than 8 and less than 19; – QOL at least 3 points; – maximum urine flow rate (Qmax) no more than 15 and no less than 5 ml/sec; – the volume of urination is at least 100 ml; – volume of residual urine no more than 150 ml; – presence of contraindications to surgical treatment due to concomitant diseases; – social reasons, in particular, the patient’s categorical refusal of an invasive treatment method.

Contraindications to conservative treatment of BPH: – suspicion of prostate cancer; – inflammatory diseases of the lower urinary tract in the acute stage; – neurogenic disorders; – cicatricial process in the pelvis; – bladder stones; – significant size “average share”; – frequent attacks of gross hematuria and severe renal and liver failure; – individual intolerance to drugs. The principles of using drugs for the treatment of BPH are based on modern ideas about the pathogenesis of the disease. The main directions of drug treatment for BPH are first-line drugs: inhibitors 5? –reductases, ? – adrenergic blockers. Herbal medicines, polyene antibiotics, amino acid complexes, extracts of animal organs and combinations of these groups of drugs are also widely used.

5a-reductase inhibitors

The most common methods of drug therapy for BPH include the use of 5? –reductases (finasteride, episteride). Finasteride, which is a 4-azosteroid, becomes a competitive inhibitor of the enzyme 5? –P, predominantly of the second type, thereby blocks the conversion of testosterone to DHT at the level of the prostate gland. The drug does not bind to androgen receptors and does not have side effects characteristic of hormonal drugs. Currently, there is experience of its use for more than 3 years without significant adverse reactions. In addition to synthetic drugs, the property of inhibiting 5? –P is also present in herbal preparations containing, first of all, Serenoa repens extract

α-adrenergic receptor blockers

• First-line drugs for the treatment of BPH • Reliably effective for any prostate size • Effective against obstructive and irritative symptoms • Significant improvement in symptoms occurs in most patients in 2-4 weeks of treatment - the fastest effect • Does not affect PSA levels (diagnosis of prostate cancer glands) • Efficiency has been confirmed by numerous placebo-controlled clinical studies • Easy to use. Reason for appointment? -adrenergic blockers for BPH were based on accumulated data on the role of impaired sympathetic regulation in the pathogenesis of the disease. Of the side effects, the most serious is hypotensive, which can be excessive even against the background of basic arterial hypertension, which often forces patients to refuse therapy? – adrenergic blockers (J. Gillenwater, D. Mobley [13]). In general, drugs in this group are recommended for patients with predominantly irritative symptoms of BPH (M. Caine [12], R. Kirby [14], G. Martorana [16], N. Seki [17], J. Wasson [20]). BPH leads to an increase in the activity of sympathetic nerve fibers, which causes an increase in the tone of the smooth muscle structures of the base of the bladder, posterior urethra and prostate gland. The process of hyperplasia occurs predominantly due to the stromal component of the prostate gland, which contains up to 60% of smooth muscle fibers, which are the point of application? – adrenergic blockers. The basis of the mechanism of action? – blockers cause relaxation of the smooth muscles of the bladder neck and posterior urethra due to blockade? 1 – adrenergic receptors. This is the most popular and numerous group of drugs. Non-selective blockers? 1 / ? 2-adrenergic receptors are not currently used. Selective? 1 – adrenergic blockers: – alfuzosin; – doxazosin; – terazosin; Selective? 1 A-blockers: – tamsulosin. Research in recent years shows almost the same effectiveness of using different? – adrenergic blockers. A reduction in BPH symptoms was noted on average by 50–60%; increase in maximum urine flow rate by an average of 30–47%; and a reduction in the amount of residual urine by an average of 50%. However, due to the fact that tamsulosin’s ability to act on? 1 A-adrenergic receptors is 20 times greater than its ability to interact with? 1 B-adrenergic receptors, which are located in the smooth muscles of blood vessels, the drug does not cause any clinically significant decrease in systemic blood pressure in both patients with arterial hypertension and in patients with normal initial blood pressure.

Additional information: before the appearance of ? -adrenergic blockers, 60% of patients receiving this type of treatment would undergo surgery. At the same time, it should be noted that 13–30% of the effect from the use of ? – adrenergic blockers does not occur within 3 months of use. In this case, further therapy with drugs of this group is not advisable.

Herbal medicine

A number of clinicians, as a result of the study, concluded that Serenoa repens extract is also effective in reducing the symptoms of bladder outlet obstruction, like synthetic blockers of the enzyme 5? –P, and can be recommended for wide use (L.M. Gorilovsky [1], N.A. Lopatkin et al. [2], N. Bruchovski et al. [11], C. Sultan et al. [18 ], T. Tacita et al. [19]). Large-scale studies have revealed significant clinical efficacy of Pygeum africanum extract in the treatment of BPH, but without a significant reduction in prostate volume. Thus, analysis of the available data on the use of phytotherapeutic agents in the treatment of BPH allows us to state that these drugs can have a significant positive effect on the subjective and objective manifestations of the disease.

Other medicines

Clinical studies of the use of mepartricin , a polyene antibiotic derivative, are few and indicate a moderate significant reduction in the symptoms of BPH. Thus, drug therapy is undoubtedly an integral element of the treatment of BPH and can be used in patients with clinically significant symptoms of the disease with compensated bladder outlet obstruction of a dynamic type. In recent years, a large number of researchers have come to the conclusion about the need for combined treatment of BPH . Multicenter placebo-controlled studies conducted around the world confirm the validity of such treatment (H. Lepor, 1996; MTOPS, 2001; V.I. Kornienko, 1997; O.B. Laurent, 1995 and 2002). The data obtained indicate greater effectiveness of combination treatment? – adrenergic blockers and finasteride compared to monotherapy. The effectiveness of combination treatment was up to 96%, while in the monotherapy groups? – adrenergic blockers – 84% and 74% in the finasteride monotherapy group. Treatment of BPH is an important and not yet fully resolved problem in urology. To determine treatment tactics and develop indications for conservative and surgical methods, in addition to knowledge of clinical symptomatology, data from ultrasound, radiological, and functional studies are needed [8]. The widespread use of non-invasive diagnostic methods in urological practice allows the doctor to identify early forms of the disease and use appropriate therapy, which in the future will undoubtedly require correction in connection with the development and implementation in clinical practice.

Prevention of the prostate gland in men

There are certain rules for the prevention of prostate adenoma, following which you can maintain the health of this important organ:

Follow a diet - reduce consumption of red meat and fatty foods. A man's diet should be dominated by vegetables, fruits, and omega acids;
Increase physical activity – physical exercise has a positive effect on prostate health;
Control your body weight – this will significantly reduce the risk of developing prostate adenoma;
Minimize stress – will improve hormonal levels and slow down the development of the disease;
Have an active sex life;
After 45-50 years, be systematically examined by a urologist and take an analysis of the dog’s blood level.

Prostate adenoma, detected in the early stages of development, can be corrected with medication and non-surgically without any problems.
Timely contacting a urologist and unquestioningly following all his instructions for treating the disease in almost all cases guarantees stopping the growth of the gland and preventing urinary disorders. Late stages of the disease with symptoms that significantly reduce a man’s quality of life will require the use of surgical treatment methods. Therefore, early diagnosis of prostate adenoma is of great importance, which can be done in the modern medical center of Moscow - the Yusupov Hospital. The clinic’s high-tech diagnostic equipment ensures the most accurate research results, thanks to which Yusupov Hospital specialists select an effective individual treatment regimen for each patient, whenever possible, giving preference to non-surgical, gentle treatment methods.

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