Benign proplasia of the prostate is a benign development of the prostate gland, causing physical and physical disorders in the neck of the bladder, especially hindering the outflow of urine from the bladder.

The frequency of prostate enlargement increases with age, but it is not related to diet, race and social composition. In the world, it is estimated that there are about 30 million people with prostate enlargement.

Usually appears in men > 45 years old.

According to Berry at the age of 40-50: 20% have TLT hypertrophy, 51-60: 50%. At the age of 70: >70% of men have TLT hypertrophy. At the age of 80: 75%.

1. Anatomy of benign prostatic proliferation pathology

• In general, the prostate gland has a uniform round shape consisting of two lateral lobes located on both sides of the urethra, sometimes there is a third lobe in the back, often located deep towards the bladder and obstructs the bladder neck, which is the middle lobe, these lobes are wrapped in a shell – called the prostate cortex.
• In 30-year-olds, the average prostate weight is 20g. The average prostate weight in the group of patients with prostate enlargement is 33 grams, the largest glandular weight announced in the medical literature is 820 grams. 4% of patients with prostate enlargement weigh over 100 grams.

The weight of an enlarged prostate can vary from 10-300gr.

• In 1988, McNeal used the noun central and peripheral areas of the prostate and the transition zone connecting these two regions.
• According to McNeal; The prostate is divided into 5 regions:
  • The peripheral area – corresponds to the tail area according to the division of Gilvernet. The largest part, accounting for about 70%, is located at the back and sides of the urethra. Is the part that often arises prostate cancer.
  • The central area, smaller, is located behind the urethra, which is the area where the vas deferectal passes through the mountain
  • The transition zone, the smallest accounting for 5% of the prostate volume in 30-year-olds, is located on both sides of the urethra, it develops with age, depends on male hormones. This is the area that causes prostate enlargement and forms two lateral prostatic lobes.
  • The glandular area around the urethra, it develops as a sleeve along the length of the prostate urethra. This is also the place where the middle lobe of the prostate gland develops.
  • The anterior myomyal fibrous area, corresponding to the striated splints in front of the prostate.

The benefit of this division is that it is clearly visible on ultrasound. Prostate enlargement often develops in the transition area

• Microscropotically: Prostate enlargement consists of 3 components: Adenomyo fibrome.

2. Pathology of benign prostatic proliferation

Currently, the cause of the disease is unknown. However, two important factors of benign prostatic hyperplasia are: old age and functional testicles. At the beginning of high age, hormonal control changes. Total and free testosterone decreases, increased estrogen has an indirect effect on the receptor of testosterone dihydrotestosteron (DHT) causing benign prostatic hyperplasia.

DHT has five times stronger affinity than testosterone with prostate cells. The study found that the concentration of 5 alpha reductase increased in the buffer organism of patients with benign prostatic hyperplasia. This confirms the role of DHT in benign prostatic proliferation disease and the effect of finesteride blocking the enzyme 5 alpha reductase in treatment of benign prostatic hyperplasia.

The rate of benign prostatic hyperplasia in 40-year-olds is 8%, in 90-year-olds is 90%. Once the tumor appears, it continues to grow. It is estimated that the prostate increases by an average of 20 grams in 10 years.

The role of testicles:

Huggins 1941 noticed that testicular dogs did not have prostate enlargement, applied testicularectomy to treat prostate hypertrophy (less effective).

Gloyna, Garnet 1989 injecting dihydrotestosterone to experimental dogs with testicles causing prostate enlargement.

Pathological physiology:

• Prostate proliferation stimulates receptors in the bladder neck, the prostate crust causes smooth muscle spasms that create lower urinary tract syndrome (LUTS).
• The mass of prostate hypertrophy and fibrous tissues that grow a lot also cause urinary tract obstruction.
• Response of bladder muscles. When there is a urinary flow blockage, the bladder muscles increase contraction, gradually hypertrophy because collagen fibers are more susceptible to unstable stimulation, and at the same time, it also reduces the response of normal reflexes that cause urinary incontinence, urinary incontinence, urination, and nocturinal urination. Along with prolonged obstruction, the bladder gradually enlarges, there is weakness in the diverticle, stagnation or reflux of the bladder – ureter – kidney: urinary tract infection and kidney failure. About 10% of patients with prostate hypertrophy have renal failure of varying degrees.

3. Diagnosis of benign prostatic hyperplasia

3.1. Muscle symptoms:

It is an early or late manifestation of lower urinary tract syndrome due to tumor location, inflammation or cervical neural disorders. The concept of “Lower urinary tract symptoms (LUTS)” was introduced in 1994 and reaffirmed in 2002.

Symptoms caused by stimulation:

1. Urinating the most often at night causes insomnia, nocturnal urination.
2. Urgent urination: suddenly the patient has a strong feeling of sadness, there is a feeling of urine pouring out uncontrollably.
3. Urinary incontinence is often associated with urinary tract infections.

Symptoms of compression: (Obstructive syndrome) patients have difficulty urinating, have to push, weak urine jet, do not feel comfortable after urinating.

Sometimes the patient shows symptoms:

• Complete urinary retention: 25% of patients with prostate enlargement come to the doctor because of acute urinary retention.
• Urinary tract infections (cystitis, prostatitis, epidiymitis).

3.2. Clinical examination:

• Assess the difficulty level of sin the IPSS scale

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LEVEL ASSESSMENT ACCORDING TO IPSS SCORE

• Mild symptoms: 1-7 points
• Moderate symptoms: 8-19 points
• Severe symptoms: 20-35 points

• Examination of the kidneys, hypogastric area of the bladder and bilateral testicles. Penis foreskin.
• Rectal examination: Is a basic examination.

• The patient lies on his back, brings his index finger to the rectum in coordination with the hand in the hypochondria.
• Found in the anterior and rectal wall right behind the pubic bone, a round, smooth, elastic, homogeneous, painless mass. It is necessary to examine the surface as well as the circumference of the gland to estimate the size.
• Sometimes it is seen that the irregular gland has a hard core or is firmly attached to the pubic bone, which is a manifestation of prostate cancer. Detected 14-30% of K TLT cases when PSA is normal.
• Detection of anorectal diseases: sphincter tone, rectal tumor…

3.3. Subclinical examinations:

3.3.1. Ultrasound:

Can be done along the line on the pubic bone or through the rectum.

Seeing that the homogeneous prostate mass usually has two symmetrical nodes across the middle line. Allow to estimate the weight of u through the formula: V=(L x H x W)/2

Allows to probe the two kidneys, bladder and measure the amount of urine residue in the bladder.

It can be seen that negative hollow foci, heterogeneous prostate lobes are suspicious signs of K TTL.

3.3.2. Prostate-specific antigen (PSA)

It is specific to the prostate, which is valuable in diagnosing prostate cancer because PSA cancer is often elevated. Normal PSA <4ng/ml. PSA>10ng/ml 50% risk of cancer requires prostate biopsy. PSA 4-10 ng/ml is the recording range that needs to be monitored.

3.3.3. Venous urograph:

little value for TLT hypertrophy.

3.3.4. Cystoscopy, urethra:

help diagnose the causes of hematuria caused by prostate or bladder tumors. Determine the cause of difficulty urinating due to the bladder, prostate, or urethral stenosis.

3.3.5. The Other tests:

Urinary kinetics, evaluation of bladder pressure, urethra and urine flow. Determine the time of a urination (15-17 seconds). Volume per urine (250-350ml)

Qmax sub-flow rate 19.6 ml/gy. When Qmax>15ml/gy is considered to have no urinary tract blockage, Qmax10-15ml/gy: follow up. Qmax<10ml/gy urethral obstruction or weak bladder muscle.

Measure the amount of urine retention by: ultrasound or placing a urinary ventures after urinating. R>200 ml of urine stagnation has pathological significance of BPH.

Biochemical test: Ure, Creatircine blood.

Urine bacteria implantation.

4. Differential diagnosis:

4.1. Prostate cancer:

The disease is also common in the elderly, so it is necessary to pay attention to avoid misdiagnosis with prostate cancer, which should be based on:

• Rectal examination: Solid prostate or irregularly bounded solid nucleus.
• Ultrasound: Inogerous prostate, with acoustic hollows, asymmetrical nododes
• High PSA in cancer TLT > 10mg/ml.
• If in doubt, a biopsy is required to confirm the diagnosis.

4.2. Distinguish from other causes of difficulty urinating such as:

4.2.1. Bladder neck sclerosis.

• Clinical examination of elderly patients (over 60 years old)
• Difficult to urinate, sometimes urinary retention requires a urethral catheter. Rectal examination of the prostate is not enlarged
• Ultrasound: no normal PSA prostate enlargement was detected
• Urodynamics identifies difficulty urinating due to bladder neck obstruction Urethral cystoscopy: images of cervical bladder fibrosis

4.2.2. Nerve bladder

• Patients with a history of spinal cord injury, stroke.
• Difficulty urinating with urine leakage.
• Clinical examination showed enlarged bladder bridge.
• Rectal examination of the prostate is not large.
• Ultrasound of the prostate gland is not enlarged, the bladder dilates urine retention, sometimes both ureters are reduced. Normal blood PSA
• Urinary kinetics: no contraction signal of the bladder muscle is seen.

4.2.3. Urethral stenosis

Patients with a history of urethral trauma or urethral intervention.

Go to the doctor because of difficulty urinating or urinary retention.

Examination with bladder bridge, prostate rectum examination does not enlarge. Sometimes there is a narrowing of the outer urethra due to inflammation of the foresing.

Ultrasound of the prostate gland is not enlarged, the bladder dilates urine retention, sometimes both ureters are reduced. Normal blood PSA

Urinary kinetics: image of urethral obstruction.

Retrograde urethral cystography: urethral stenosis image

4.2.4. Inflammation or abscess of the prostate

Rare in the elderly, often in middle age.

5. Treatment:

5.1. Principle treatment:

Treatment is prescribed based on the severity of symptoms, the level of attention and aspirations of the patient. Information about the risks and benefits of choosing treatment for benign prostatic proliferation should be explained to all patients.

5.1.2. Treatment method by changing the way of living and monitoring, waiting

Indications: Patients with mild symptoms (for example, IPSS <7) should be advised about a combination of lifestyle modification to suit the treatment of monitoring and waiting.

 Specific treatment:

Patients are monitored and visited by a follow-up doctor periodically.

Optional: The doctor suspects the initial condition, the severity of irritation syndrome, prostate mass and/or serum PSA to advise patients at risk of developing acute urinary retention symptoms or in the future need for surgery related to BPH (risk factors that identify patients at risk for progression).

A series of lifestyle changes can be recommended for patients with symptoms.

• Limit drinking water before going to bed
• Avoid caffeinated drinks, spicy foods
• Avoid using certain drugs (for example, diuretics, decongestants, antihistamines, antidepressants)
• Practicing urination helps the bladder work well.
• Exercises to increase pelvic floor strength
• Avoid or treat constipation

5.2. Internal medicine treatment:

5.2.1. Designation:

• Optional treatment for moderately uncomfortable patients (for example, IPSS 8 – 18).
• Indications for stages 1 and 2 of the disease mean that the tumor has not caused much an obstacle to the urinary system. The amount of urine remaining in the bladder < 100ml.
• Has antispasmodic and edema effects on the neck of the bladder TLT.
  
  – Alpha – Adrenergic antagonists.

It has the effect of relaxing smooth muscles thanks to the action on alpha-adrenergic receptors in the neck of the bladder and TLT. These drugs can lower blood pressure.

. Doxazosin (cardural) inhibits alpha – adrenergic after sinape, dose 2mg/24h.

. Tamsulosin (Flomax) inhibits alpha 1 specific receptors, dose 0.4-0.8 mg/24h.

– The drug acts on the metabolism of androgens with the intention of preventing the growth of the prostate.

. Finasteride (Proscar) inhibits the conversion of testosterone to dihydrotestosterone (DHT), dose 5mg/24h.

– Herbal medicines have anti-inflammatory and anti-edema properties.

Research by Madersbacher and colleagues in 2004 and Roehborn in 2008 showed that; treatment with alpha-adrenergic antagonists had an improved effect on symptoms and urinary flow, this effect was clearly false for 1-2 weekstreatment. However, treatment with Finasteride also has the effect of reducing tumor volume and reducing the risk of acute urinary retention and surgery. The 2003 study of Mc Connell and colleagues showed that combination treatment was better than monotherapy. However, this effect is evident after 1 year of treatment.

5.3. Scal treatment:

5.3.1. Designation

The determination of treatment methods for benign prostatic hyperplasia depends on the size of the tumor. Indication for surgical treatment in cases:

• U causes a lot of effects on the urinary tract, the amount of urine residue > 100ml, difficulty urinating Qmax < 10ml/s.
• Acute urinary retention requires a urethral probe.
• Bacterial urinary tract infection, bladder stones, diverticum BQ.
• Severe hematusis, kidney failure (about 10% of patients with TLT hypertrophy show signs of kidney failure).

5.3.2. Laparoscopic method through urethral:

is considered the golden standard method in HBP surgical treatment.

Indicated for benign and moderate prostate hyperplasia with weight < 70g.

Purpose: removal of the entire TTL hypertrophic organization, starting from the inside of the urethra, stopping at the TLT shell. At the upper limit is the bladder neck, the lower limit is the mound.

Advantages:

• As a less traumatic method, it is increasingly widely applied (80-90% of patients are treated with this method in advanced countries).
• Short hospital stay.
• Good efficiency in terms of urination.
• Currently considered as the standard method in the treatment of benign prostatic hyperplasia. The recurrence rate after laparoscopic surgery is 18%, the mortality rate is 0.23%.

The risk of complications of surgery is often associated with benign prostate proliferation with a large size of > 45g, surgery duration > 90 minutes.

The risk of tumor recurrence after 5 years is 5%.

The rate of benign prostatic proliferation surgery by endoscopy in the US and northern European countries is 97%, in France and Japan is 70%.

5.3.3. Upper cross-line surgery method:

Indication for large u > 50g, (according to other documents > 75g).

Hypertrophes are combined with other diseases: bladder diverticle, stones, or in patients who cannot place an endoscope…

The two surgical methods used are:

Millin method – surgery after the pubis: This surgery was first performed by Terrence Millin for benign prostatic hyperplasia in 1945

Surgical steps:

• White skin incision in the middle under the navel
• Revealing the front of the bladder and TLT
• Bleeding stop suture, open the front of TLT
• Peel the organization of TLT hypertrophy, stop bleeding of the neck BQ
• Place the probe 3 ND, sew the TLT opening again.

Hryntchak method – cross-bladder surgery. Open to BQ to peel the TLT hypertrophy organization Set the ND probe and Drain BQ

5.3.4. Other methods:

Endoscopic cut with an incision from the bladder neck to the mound. In the case of young patients with benign proliferation of small prostate. However, these methods are not considered standard methods because they do not bring a sure and thorough effect.

Urethral TLT with a ball.

Method heat treatment.

Use laser.

Place the barrel instruments in the TLT urethra.

 Temporary treatment in case of patients with acute urinary retention: emergency urethral catheterization or optical bladder drainage is required if the urethral catheter cannot be placed.

Patients with kidney failure: two kidneys have water retention due to bladder neck obstruction, bladder drainage should be used to treat kidney failure.

5.3.5. Postoperative care.

General follow-up care.

Special care.

Continuous bladder washing:

After TLT hypertrophy surgery or laparoscopic tumor removal, the bladder must be washed continuously.

The purpose is to avoid blood clots in BQ and blockage of BQ drainage pipes.

Washing water usually uses HTM 0.9% or distilled water.

The speed of translation depends on the rate of bleeding, if the translation is light pink.

The wash needs to be monitored continuously, just stopping washing for a few minutes can cause blood clots and clogging of the BQ probe.

Washing time depends on the bleeding.

Usually bleeding a lot in the first 24 hours, less in the following days and about 3-4 days after clear urine.

If there is a lot of bleeding, there is a risk of blocking the BQ probe, you must pump the BQ to remove the blood clot.

5.3.6. Other complications.

Postoperative blood infection: Manifestations of malaria tremor, blood pressure drop < 90mmHg Need to transplant blood, inulate urine, inform the surgeon to resusculate and give appropriate KS.

Endoscopic syndrome: TUR Syndrome (2%). Endoscopic syndrome is a complication caused by the resorption of washing water during TLT endoscopic cutting. Studies show that the amount of water absorbed into the body per minute is 20ml. The amount of water absorbed in the first hour is 1000ml – 1200ml. 1/3 of this water is absorbed directly through the vein. Due to the water absorption into the lumen of the vessel, it causes hyponaemia, causing organizational edema. The consequences are pulmonary edema, cerebral edema, coma, cardiovascular disease, hemolysis, acute renal failure and shock.

Endoscopic syndrome occurs when the blood Na content is less than 125 mEq.

The basic treatment is to raise the blood Na concentration. The amount of Na in the blood to be compensated is calculated according to the formula: Na⁺ = (140 – existing Na concentration) x 0.6 x body weight. 1 liter of NaCl 9‰ contains 154 mEq, 1 liter of NaCl 3% contains 815 mEq Na. At the same time, use diuretics to increase water excretion and prevent kidney failure.

2.3 The indication of urethral sonderetral withdrawal after surgery depends on the surgeon.

For laparoscopic surgery, usually after 3-4 days. For upper sugar surgery, drunk 7-10 days. When removing the sonde, usually fill the BQ with the washing liquid before draining. After withdrawing the probe, let the urine BN reset the urine probe to measure the amount of urine residue and inculate urine bacteria.

5.3.7. Late symptoms

Death rate: Very low, often related to complications of surgical techniques.

Postoperative bleeding: Immediate bleeding after surgery rarely occurs. Sometimes there is bleeding during surgery.

Late bleeding 10-20 days. Often occurs after laparoscopic surgery due to peeling of the bleeding scars after laparoscopic surgery. Most hold it yourself, sometimes it requires placing a bladder probe to suck blood clots.

Difficulty ineing after surgery:

• Early: Often associated with inflammation, edema of the cervical bladder sometimes due to surgical techniques. Especially, laparoscopic surgery can not cut all the tumors, it is necessary to intervene again.
• Late: Sclerosis, fibrousitis TLT – -> re-intervene. Urethral stenosis after surgery: Nong or cutting in the urethra.
• In all cases of difficulty urinating after surgery, it is necessary to be alert to K TLT.
• Umore recurrence after 7-15 years (7- 15%).

Bedeater after surgery:

Only say true uress when it persists for many months after surgery (>6 months). Caused by the destruction of the urethral stingureous sphincter system. Very rarely occurs, Often seen after laparoscopic surgery.

 Treatment: artificial sphincter placement.

Infection after surgery:

• Cepidymitis.
• Phlebitis – pulmonary infarction:

+ Surgical treatment of benign prostatic hypertrophy becomes simple and results good, patients stay in the hospital for 5-10 days.

Reference documents:

1. Symptoms of Surgery. XB Medical House 2000.
2. Faculty of Medicine XB House 2000.
3. Urology Hospital Medical University 2003.
4. Henry Gray (1821–1865). Anatomy of the Human Body
5. Prostate Hyperplasia, Benign. Last Updated: November 18, 2010

Kidney and urinary stones are common medical conditions that can cause significant discomfort and lead to serious health complications if left untreated. These stones form when minerals and other substances crystallize in the kidneys or urinary tract. To effectively diagnose, treat, and prevent stone formation, it is essential to understand the underlying science and the key factors that contribute to their development. This article delves into the mechanisms of stone formation and the various influences that affect their growth.

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