Article 119: Assessment of the Degree of Benign Prostatic Hyperplasia, Cancer Differentiation, and Treatment Principles

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Treatment and recuperation of common diseases

Does a larger prostate mean a more severe condition?

Doctors typically classify benign prostatic hyperplasia (BPH) into three degrees based on the size of the enlargement through a digital rectal examination.

The prostate gland is anatomically divided into five lobes: anterior, posterior, left, right, and middle. The proximal lobe is the inner layer of glands surrounding the urethra, and the outer layer is the outer layer. In a normal prostate, the outer glands occupy the majority of the prostate, while the inner glands occupy only a very small central area. However, the situation changes when the prostate enlarges (BPH). If the enlargement mainly occurs in the inner layer of the prostate, and the inner glands tightly surround the urethra, even a slight enlargement can easily compress the urethra, causing difficulty in urination. In this case, even a digital rectal examination may not detect prostate enlargement. The situation is different with the outer glands. Because the outer glands may grow primarily outwards, sometimes they may grow very large, even reaching grade III, but they do not compress the urethra. Therefore, there may be no urethral obstruction symptoms, or the symptoms may be mild. It is clear that the grading of BPH only indicates the size of the prostate gland and does not indicate the severity of the disease.

How to differentiate between benign prostatic hyperplasia (BPH) and prostate cancer?

Typical cases are generally not difficult to identify. However, in complex cases, identification can be approached from the following aspects:

1. General condition: Patients with benign prostatic hyperplasia (BPH) are generally in good general condition, while prostate cancer is often accompanied by progressive weight loss, fatigue, loss of appetite and other symptoms.

2. Incidence: Benign prostatic hyperplasia (BPH) is a common and frequently occurring disease in elderly men, while the incidence of prostate cancer is very low.

3. Digital rectal examination: In cases of prostate cancer, a hard, stone-like mass can be felt in the prostate, which varies in size and extent.

4. Acid phosphatase test: Generally, a level exceeding 10 units is sufficient to diagnose prostate cancer, and elevated levels are also common in patients with metastases.

5. X-ray of the pelvis and lumbar spine: Metastatic cancer lesions can be seen. The lesions are mostly osteoblastic, with increased density and loss of bone trabeculae.

Treatment principles

Since the fundamental cause of urinary tract pathological changes in benign prostatic hyperplasia (BPH) is bladder outlet obstruction, leading to bladder and even kidney damage, the primary principle of BPH treatment should be to alleviate or even relieve the obstruction as quickly as possible, protecting the function of the bladder detrusor muscle and kidney function. Furthermore, because these patients are often elderly, and some may have serious complications (such as cardiovascular or cerebrovascular diseases), treatment measures must be tolerable and effective. In some patients, prostatic hyperplasia stops progressing after reaching a certain stage; therefore, surgery is an effective but not the first-line treatment. Insufficiently satisfactory drug treatment may be related to a lack of understanding of the causes of BPH.

Surgical indications for benign prostatic hyperplasia

Despite the emergence of new drugs and treatments, surgery remains a crucial method for treating benign prostatic hyperplasia (BPH). However, surgery carries inherent risks, and since BPH primarily affects older men who often have concurrent heart, lung, and kidney dysfunction, their tolerance to surgery is even lower. The International Coordinating Committee on Prostate Disease has established the following absolute indications for surgery:

1. Urinary retention (at least once after catheter removal, the patient was unable to urinate).

2. Recurrent hematuria.

3. Kidney failure caused by benign prostatic hyperplasia.

4. Comorbid bladder stones.

5. Recurrent urinary tract infections.

6. Giant bladder diverticulum.

What examinations are needed before prostatectomy?

When considering prostatectomy in elderly patients, it is important to pay attention to the treatment of complications and the improvement of the patient's overall health. Before the operation, it is necessary to fully assess the patient's tolerance to anesthesia and surgery, and to conduct a comprehensive and careful examination of the patient's cardiovascular, respiratory, endocrine and nervous system conditions.

1. Routine Examination: Routine examinations should include uroflowmetry, electrocardiogram, chest X-ray, and various laboratory tests such as routine blood, urine, and stool tests, bleeding and clotting times, liver and kidney function tests, electrolytes, blood glucose, and prostate-specific antigen (PSA). Ultrasound examination can reveal the size, shape, and texture of the enlarged prostate, as well as changes in the upper urinary tract caused by prostatic obstruction.

2. Special examinations: In order to identify benign prostatic hyperplasia complicated with bladder stones, tumors, or hematuria, urine cytology, intravenous urography, and cystoscopy should be performed.

If nodules are present, a prostate biopsy can be performed.

Some patients may have mild benign prostatic hyperplasia but severe urinary retention. In order to rule out neurogenic bladder, a full set of urodynamic tests is required.

3. Urinary drainage: Long-term obstruction caused by benign prostatic hyperplasia can lead to hydronephrosis and renal impairment. In severe cases, symptoms may include decreased appetite, nausea, anemia, and significantly elevated blood urea nitrogen and creatinine levels. For patients with chronic urinary retention and renal insufficiency, timely drainage of the bladder to relieve obstruction is crucial for improving and restoring renal function. Surgery should only be performed after the patient's renal function has returned to normal or near-normal levels and their overall condition has improved.

4. Preoperative management: Patients with urinary tract infection should be given antibiotics before surgery, have 200-800 ml of blood prepared before surgery, have their skin shaved, and have an enema before surgery.