Background

Benign prostatic hyperplasia (also known as BPH, nodular hyperplasia, and benign prostatic hypertrophy) is a very common condition affecting adult men. Almost half a million TURPs are performed yearly. The symptoms are familiar to many men with urinary frequency, nocturia (frequent urge to urinate at night), dribbling, and dysuria (painful urination). In some cases, there may be an acute retention leading to emergency catheterization. If the disease is left unchecked, urinary retention and secondary infection is common. In severe cases, backflow of the urine may affect the kidney leading to hydronephrosis. The cause is a hyperplasia of both the glandular and stromal components of the prostate. This is a hormonally driven disease caused by excess dihydrotestosterone (DHT), which is derived from testosterone by the enzyme 5 alpha-reductase. An intact testis is necessary for this condition since this is where the enzyme exists.

The prostate may exceed 100 grams (normal weight is about 20 grams). Most of the changes occur in the preprostatic region in the periurethral areas of the middle and lateral lobes. Carcinoma, in distinction, occurs most commonly in the posterior lobe. Under the microscope, there is glandular and stromal proliferation with papillary infoldings within the ductal lumina. There is a well-defined basal epithelial layer which is the hallmark of benign glands.

OUTLINE

Epidemiology
Disease Associations
Pathogenesis
Laboratory/Radiologic/ Other Diagnostic Testing
Gross Appearance and Clinical Variants
Histopathological Features and Variants
Special Stains/ Immunohistochemistry/ Electron Microscopy
Differential Diagnosis
Prognosis
Treatment
Commonly Used Terms
Internet Links

 

PATHOGENESIS	CHARACTERIZATION
MITOGEN ACTIVATED PROTEIN KINASES
Regulation of proliferation/apoptosis equilibrium by mitogen-activated protein kinases in normal, hyperplastic, and carcinomatous human prostate. Royuela M, Arenas MI, Bethencourt FR, Sanchez-Chapado M, Fraile B, Paniagua R. Department of Cell Biology and Genetics, University of Alcala, and the Department of Urology, Hospital Principe de Asturias, Alcala de Henares, Madrid, Spain.	Hum Pathol 2002 Mar;33(3):299-306 Abstract quote This study investigate the expression of the mitogen-activated protein kinases (MAPKs) in normal prostate, benign prostatic hyperplasia (BPH), and prostatic cancer (PC), and also the possible relationship between the activity of these MAPKs and the apoptosis/proliferation index. Immunochemical techniques were carried out using 2 mouse monoclonal antibodies against human extracellular signal-regulated protein kinase (ERK) and Jun N-terminal kinase (JNK), and 1 goat polyclonal antibody against mouse p38. To compare the results obtained in the 3 specimens, the average percentages of both epithelial and stromal immunostained cells were calculated on immunostained sections. For each of the 3 kinases studied, the percentage of immunostained stromal cells did not change with prostatic alterations. For both ERK and p38, the percentage of immunostained epithelial cells increased significantly in BPH and even more so in PC. For JNK, the percentage of immunostained epithelial cells increased significantly only in PC. These results suggest that ERK could be involved in the elevated proliferation indexes reported in BPH and PC, whereas p38 might contribute to the increased apoptotic index reported in PC. The most probable action of JNK in PC would be cell proliferation stimulation. Overexpression of MAPKs, involved in the development of prostatic hyperplasia and neoplasia, might be secondary to the overexpression of several growth factors.

 

HISTOPATHOLOGY

CHARACTERIZATION

Should the diagnosis of benign prostatic hyperplasia be made on prostate needle biopsy? Viglione MP, Potter S, Partin AW, Lesniak MS, Epstein JI. Departments of Pathology, Urology, and Neurosurgery, The Johns Hopkins Medical Institutions, Baltimore, MD.

Hum Pathol 2002 Aug;33(8):796-800 Abstract quote Pathologists frequently sign out benign prostate needle biopsies as "benign prostatic hyperplasia (BPH)". There are no data indicating that a diagnosis of BPH on biopsy correlates with either gland weight or with the International Prostate Symptom Score (IPSS) used to measure urinary obstructive symptoms. We examined biopsies for average percentage of glands and average percentage of glands with papillary infolding per case, maximum percentage of glands and maximum percentage of glands with papillary infolding per core per case, and presence of any stromal nodules per case. BPH was measured in 2 ways: (1) IPSS grouped into 3 categories (mild, moderate, severe) and (2) prostate weight at radical prostatectomy in men with limited cancer. IPSS was classified as follows: mild (n = 12), moderate (n = 13), and severe (n = 10). There was no correlation with IPSS and any of the histologic features measured. For the 41 radical prostatectomy specimens, the average weight was 65.3 g (median, 56.0 g, range, 22 to 117 g). There was no correlation between gland weight and the average or maximum percentage of glands, or average or maximum percentage of glands with papillary infolding. Stromal nodules on biopsy correlated with gland weight. In the 30 cases without stromal nodules on biopsy, the mean gland weight was 51.4 g. In the 11 cases with stromal nodules on biopsy, the mean gland weight was 77.4 g (P = 0.0125). However, stromal nodules were not specific for a large prostate (i.e., a 15 g prostate had stromal nodules on biopsy). With the exception of stromal nodules found on biopsy, histologic findings on biopsy are not specific for either clinical or pathologic BPH. Thus benign prostate biopsies should be signed out merely as "benign prostate tissue."

 

PROGNOSIS AND TREATMENT	CHARACTERIZATION
TREATMENT
FINASTERIDE
Comparison of the efficacy and safety of finasteride in older versus younger men with benign prostatic hyperplasia. Kaplan SA, Holtgrewe HL, Bruskewitz R, Saltzman B, Mobley D, Narayan P, Lund RH, Weiner S, Wells G, Cook TJ, Meehan A, Waldstreicher J. Columbia Presbyterian Medical Center, New York, New York, USA	Urology 2001 Jun;57(6):1073-1077 Abstract quote Objectives. To compare the efficacy and safety of finasteride 5 mg in older (65 years old or older) versus younger (45 to younger than 65 years old) men with benign prostatic hyperplasia (BPH). Methods. The Proscar Long-Term Efficacy and Safety Study (PLESS) was a 4-year, randomized, double-blind, placebo-controlled trial assessing the efficacy and safety of finasteride 5 mg in 3040 men 45 to 78 years old with symptomatic BPH, enlarged prostates, and no evidence of prostate cancer. The endpoints included urinary symptoms, prostate volume, occurrence of acute urinary retention and/or BPH-related surgery, and safety. Results. In both age cohorts, finasteride treatment led to a 51% reduction (P <0.001) in the relative risk for acute urinary retention and/or BPH-related surgery, a significant (P <0.001) and durable improvement in symptom score, and a significant (P <0.001) and sustained reduction in prostate volume. Within each age cohort, no significant differences were found between the placebo and finasteride-treated patients in the incidence of cardiovascular adverse events. Significant differences were evident between the placebo and finasteride groups in the incidence of the typical, known, drug-related adverse events, but no specific differences were associated with age. No drug interactions of clinical importance were observed in the finasteride-treated patients. Conclusions. The present analysis from PLESS demonstrates that in both older (65 years old or older) and younger men with symptomatic BPH and enlarged prostates, finasteride is highly effective in improving symptoms and reducing prostate volume in many men and in reducing the risk of acute urinary retention and BPH-related surgery. In addition, the safety profile of finasteride in both older and younger men is similar and no drug interactions of clinical importance were observed.
SURGERY
Extraperitoneal laparoscopic prostatectomy (adenomectomy) for obstructing benign prostatic hyperplasia: transvesical and transcapsular (millin) techniques. Rehman J, Khan SA, Sukkarieh T, Chughtai B, Waltzer WC. Department of Urology, School of Medicine, SUNY-Stony Brook University Medical Center, Stony Brook, New York.	J Endourol. 2005 May;19(4):491-5. Abstract quote   Purpose: We describe extraperitoneal laparoscopic resection of large prostatic adenomas (<100 g) as an alternative to open simple prostatectomy by both the transcapsular or Millin and the transvesical approaches. Patients and Methods: We have performed more than 20 laparoscopic prostatectomies (adenomectomies) for benign prostatic hyperplasia (BPH) for glands >100 g. The initial two cases, with follow-up longer than 1 year, are included in this report. Using an extraperitoneal approach, enucleation of the obstructing prostatic lobes was performed with the aid of a Harmonic Scalpel and laparoscopic claw forceps. Hemostatic sutures were placed at 5 and 7 o'clock. The urethrovesical junction (transvesical) or capsulotomy (Millin) were closed in an interrupted fashion using intracorporeal sutures. Results: Both procedures were successful. The total operative time was 180 minutes for first the case and 120 minutes for the second. The adenoma removed was approximately 138 g in the first case and 102 g in the second case. The estimated blood loss was <50 mL and <200 mL, respectively. The postoperative courses were unremarkable. Analgesic requirements were minimal, and the patient was discharged on postoperative day 2 and 3, respectively. A follow-up examination at 1, 3, 6, and 12 months showed that the flow rate is >20 mL and the postvoiding residual volume 0, with normal continence and sexual potency in both men. Conclusions: Extraperitoneal laparoscopic simple prostatectomy is a simple straightforward technique. Minimal bleeding, a reduced transfusion rate, shorter hospitalization, and faster recovery are additional advantages. This minimally invasive technique is a reasonable alternative to open simple prostatectomy for large glands with reduced morbidity.

Henry JB. Clinical Diagnosis and Management by Laboratory Methods. Twentieth Edition. WB Saunders. 2001.
Rosai J. Ackerman's Surgical Pathology. Ninth Edition. Mosby 2004.
Sternberg S. Diagnostic Surgical Pathology. Fourth Edition. Lipincott Williams and Wilkins 2004.
Robbins Pathologic Basis of Disease. Seventh Edition. WB Saunders 2005.
DeMay RM. The Art and Science of Cytopathology. Volume 1 and 2. ASCP Press. 1996.
Weedon D. Weedon's Skin Pathology Second Edition. Churchill Livingstone. 2002
Fitzpatrick's Dermatology in General Medicine. 6th Edition. McGraw-Hill. 2003.
Weiss SW and Goldblum JR. Enzinger and Weiss's Soft Tissue Tumors. Fourth Edition. Mosby 2001.

Squamous metaplasia-Benign metaplastic change of the columnar epithelium to squamous. Commonly seen in areas if chronic injury or following an infarction.

Suprapubic prostatectomy-Surgical removal of the entire prostate from the anterior approach .

Transurethral resection (TURP) -A common surgical procedure which removes most of the enlarged prostate through a transurethreal approach.

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Last Updated January 31, 2006

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