Kruglov Sergey Vladimirovich

Kruglov Sergey Vladimirovich, Professor,Doctor of Medical Sciences, Honored Doctor of the Russian Federation, surgeon of the highest qualification category,

Page editor:

Semenisty Maxim Nikolaevich

Leading specialists in the field of pelvic surgery:

Kasatkin Vadim Fedorovich

Kasatkin Vadim Fedorovich, Professor, Academician of the Russian Academy of Medical Sciences, Doctor of Medical Sciences, surgeon of the highest qualification category, Head of the Thoracic-Abdominal Department of the Russian Scientific Research Institute, Honored Doctor of the Russian Federation

Perepechai Vadim Anatolievich

Perepechai Vadim Anatolievich, Candidate of Medical Sciences, Head of the Department of Urology, Clinical Hospital No. 1, Honored Doctor of the Russian Federation.

Data regarding the incidence of this disease are very inconsistent depending on whether they are based on clinical, pathological and histological observations. More often we have to take into account data based on pathological studies.

According to pathological autopsies, adenoma to one degree or another occurs in 35-45% of men aged 50-60 years and in 75% of men aged 60-70 years. These data also indicate that not every prostate adenoma is accompanied by clinical symptoms of the disease.

The pathological anatomy of prostate adenoma is currently well studied.

The weight of the adenoma and its size are subject to significant fluctuations. In the initial stages it is small, but as the process develops it reaches significant sizes. It is often possible to observe an adenoma weighing 50-70 g, as well as 120-200 g. Some authors have reported adenomas weighing up to 400 a and more.

Adenomas come in various shapes, but round ones (cylindrical and pear-shaped) are more common. Their surface is usually smooth and the consistency is elastic. A tumor with dense cartilaginous areas makes one suspect a malignant transformation of the latter.

A cross-section of a prostate adenoma shows that the tissue enlargement is not homogeneous, and that there are limited nodes periurethral towards the bladder, sometimes single, sometimes multiple. These nodes are closely connected with the mucous membrane of the urethra. The development of individual groups of glands causes an increase in the lateral lobes and the middle lobe.

Depending on the relationship of the prostate adenoma with surrounding organs, three types of adenoma are distinguished - intravesical, when its growth is directed towards the bladder, subvesical, when its growth is directed under the bladder, and a mixed form.

In the first, intravesical type, the changes concern mainly the internal opening of the urethra, which is covered by the tumor. Tumors in the form of small, and in some places in the form of large nodes, can fill the bladder to its apex.

This type of adenoma is characterized by the presence of a so-called middle lobe, the shape of which can be round or pear-shaped with the apex facing the neck of the bladder. Its surface, covered with the mucous membrane of the bladder, can be smooth or bumpy. In some cases, the tumor is located on a thin stalk, but more often on a broad base. A pedunculated adenoma, located on the lower wall of the bladder neck, can serve as a valve and cause urinary retention. Adenomatous growth, surrounding the mouth of the urethra in the shape of a half-wreath or horseshoe, also interferes with the normal emptying of the bladder.

Under the influence of the growth of the adenoma, the sphincter ring gradually stretches. Changes in the sphincter are expressed in thinning of muscle fibers, and in some cases even in atrophy. Stretching the sphincter disrupts its obturator function. The internal opening of the urethra changes its shape: the normal opening turns into a slit or takes the form of a crater.

Adenomatous nodes protruding into the bladder are located directly under its mucous membrane, and therefore isolating an adenoma from the surrounding tissues does not present any particular difficulties, with the exception of areas adherent to the prostatic part of the urethra.

The prostatic urethra changes both in terms of length and direction, and lumen. Due to the advancement of the tumor towards the bladder, not only the urethra lengthens, but the vesical triangle also rises. The length of the urethra between the seminal tubercle and the sphincter increases significantly and can reach 10 cm or more. Simultaneously with the growth of the lateral nodes of the tumor, the wall of the urethra is stretched in the dorsoventral direction. In its prostatic part, the urethra has a spindle-shaped shape. Its direction also changes: instead of the normal arcuate curvature of the urethra, a depression is formed on its posterior wall in the area of ​​the seminal tubercle, resulting in curvature of the urethra with the formation of an obtuse or even acute angle. This change in the direction of the urethra often poses a serious obstacle to catheter passage. Thus, in patients with prostate adenoma, difficulties during catheterization are caused by: I) the angle formed in the area of ​​the seminal tubercle; 2) lengthening of the urethra; 3) adenomatous nodes located in the area of ​​the bladder neck; 4) swelling of the urethral mucosa.^

In the second, subvesical, type of prostate adenoma, the adenoma does not grow through the sphincter into the bladder. The entire growth of the gland is directed towards the rectum, under the bladder. In such cases, the entire bottom of the urinary tract rises

In addition, when the bladder is filled, the triangle does not take part in stretching and emptying the latter. Consequently, the triangle is the last to undergo anatomical changes. Yet it is often raised, compressed and shortened. The interureteric ligament, due to the ever-increasing intravesical pressure, hypertrophies and sometimes turns into a wide fold, which itself is an obstacle to emptying urine. The muscle elements in the triangle and the lower part of the ureter are also subject to connective tissue degeneration. As a result of this, a loss of elasticity occurs, atony is created, which can lead to reflux, i.e., backflow of urine into the ureters, pelvis and calyces. Anatomical changes caused by prostate adenoma in the ureters, renal pelvis and kidneys appear with prolonged urinary retention. Like the bladder, the ureters have great difficulty in expelling urine. The muscles of the ureter first hypertrophy, then gradually loss of elasticity of the fibers occurs, the ureters stop contracting and vigorously eject urine ■ - they begin to expand.

The histological structure of prostate adenoma is composed of glandular cells of uneven size and shape (Fig. 105). In the enlarged lumens of these glandular cavities, epithelial growths such as papillary villi are observed. The lumens of the glands are empty; sometimes made of secretion, desquamated epithelium; in some places they contain protein formations.

In individual cells, the epithelium is located in several rows. Columnar epithelium with a well-stained nucleus at the base of the cell is visible everywhere. All glandular papillary formations are located in the central part of the gland, under the urethral mucosa. A significant increase in glandular tissue resembles the nature of the neoplastic process. In some cases there are muscle growths, in others - connective tissue. In proportion

Depending on the predominant tissue, it is customary to distinguish the following forms: adenomatous, found in the overwhelming majority; fibroadenoma and fibromyoadenoma. The adenomatous form of the prostate gland occurs in 80-75% of all adenomas. Mixed forms account for 20-25%.

Etiology and pathogenesis. Enlargement of the prostate gland in old age and urinary disorders caused by this enlargement have been known since ancient times. Morgagni directly linked urinary disorder to an enlarged prostate gland, while others saw the cause in a disease of the whole body, in a decrease in tone, in its aging.

One of the first theories according to which the so-called prostatic hypertrophy was considered not as a local disease, but as a manifestation characteristic of old age, a manifestation of general sclerosis that affected the entire urinary system, was the Guyon concept. According to this concept, dysuric phenomena were explained not by a mechanical obstacle caused by an enlarged gland, but by atony of the bladder, which occurred as a result of general sclerosis.

The inconsistency of this theory did not require much proof, and it was soon abandoned.

Loeschke, Adrion and Kausch tried to restore the meaning of the statements of Guyon and his school, explaining the changes in the prostate gland by the different blood supply to its peripheral and central parts. They were able to establish unequal blood supply to both parts of the prostate. The prostatic artery divides into two branches before entering the prostate gland. One of these branches supplies the inside of the prostate gland, the other - the outside. The internal branch has a wide network of anastomoses with the vesicourethral artery, while the external branch has no anastomoses. Thus, the inner part of the gland is in better conditions of blood supply. Consequently, even with arteriosclerotic changes in the arteries, the blood circulation of both parts of the gland is disturbed unevenly: the external one is stronger than the internal one.

Uneven damage to the prostate arteries by arteriosclerosis leads to atrophy of the outer part of the gland. At the same time, due to the good vascularization of the internal part and the imbalance in the blood supply, the central part of the prostate gland increases.

However, these assumptions are questionable, especially since a more abundant blood supply to the central part of the gland compared to the peripheral part has not yet been proven. Even if we admit the possibility of differences in the blood supply to individual parts of the prostate, it is still difficult to imagine that only this would lead to their compensatory mutual replacement. Nowhere in general pathology do we find

partial hypertrophic changes caused by arteriosclerosis; on the contrary, the sclerotic process causes atrophy and necrosis with subsequent scarring.

Subsequent pathological work by Kasper and Motz completely refuted the Guyon concept.

Kasper, based on a histological study of twenty-four “hypertrophied” prostate glands taken from men over 50 years of age, found that sclerosis of the renal vessels was observed in 8 cases, of the bladder in 2, of the prostate in 4, and sclerosis of the aorta in 4 cases. all 24 cases. Motz, with his research, confirmed the correctness of Kasper’s work: he found sclerotic vessels in 9 out of 30 “hypertrophied” glands.

At present, Guyon's views are of historical interest only.

The following explanation of the origin of prostate adenoma belongs to Ciechanowsky. According to the views of this author, the so-called prostatic hypertrophy is caused by a long-term chronic inflammatory process, the result of which is the proliferation of connective tissue. Localization of the process in the central parts of the gland and the development of connective tissue, mainly around the excretory ducts, lead to compression, gradual emptying and complete obliteration of the ducts, subsequent expansion of the alveoli and stagnation of secretions and desquamated epithelium in them. Thus, the increase in the size of the prostate gland supposedly occurs due to the expansion of the alveoli. When the process spreads more in the peripheral parts of the prostate stroma, the connective tissue, compressing the alveoli, gradually replaces the glandular tissue, causing atrophy of the prostate gland.

This view at one time had a large number of supporters, since it was believed that the widespread occurrence of gonorrhea, often complicated by prostatitis, leads to the formation of prostatic hypertrophy.

Thus, prostatitis and prostatic hypertrophy were considered to be different phases of the same process. Now the issue of prostatitis has been well studied and it has been proven that prostatitis does not lead to hypertrophy, but, on the contrary, to tissue atrophy and its destruction. Based on data from our clinic, covering more than 500 observations of patients with prostate adenoma, only 18 patients had gonorrhea in the past and 10 had prostatitis. The given figures clearly refute the role of inflammatory changes in the etiology of the so-called prostatic hypertrophy.

P. A. Herzen assigned a certain role to the inflammatory process in the etiology of prostatic hypertrophy, but did not exclude the possibility of its tumor nature. He was of the opinion that the enlargement of the gland does not occur due to passive expansion of the alveoli as a result of compression of the excretory ducts,

as Ciechanowsky thought, but due to the active growth of epithelial tissue and the subsequent reaction from the stroma. P. A. Herzen points out that in many patients with clinically detectable prostatic hypertrophy, a neoplastic process is histologically detected.

Subsequently, the “theory of neoplasm” attracts attention. Albarran and Halle, based on histological studies, came to the conclusion that gland hypertrophy is a benign neoplasm that has the property of turning into malignant. A number of subsequent works by A.P. Grinenko, Loeschke and others proved that we are talking about a neoplasm of glandular tissue, an adenoma.

F.I. Sinitsin, Ramm and others believed that prostate adenoma is based on senile changes in the testicles. The decline of testicular function and abnormal ejaculation lead to stasis in the gland, dilation of the alveoli, development of cysts, chronic inflammation and subsequently the formation of false hypertrophy of the prostate.

Some authors (L.I. Dunaevsky), on the contrary, associated the so-called prostatic hypertrophy with abnormally long-term activity of the seminal glands. Conclusions about the effect of increased function of the gonads on the development of prostate hypertrophy do not correspond to clinical and physiological observations. The testicles of persons with so-called prostatic hypertrophy are somewhat reduced in volume. Quantitative determination of the male sex hormone in the urine of patients with so-called prostate hypertrophy showed a decrease in the release of the sex hormone compared to its release in a healthy person.

Clinical and experimental observations indicate a close connection between the testicles and the prostate gland. It has been proven that in people castrated in early childhood, the prostate gland is not detectable at all. Removal of the testicles in adulthood causes prostate atrophy.

The close connection and mutual influence of the pituitary gland and gonads is confirmed by numerous experiments (S. Kh. Arkhangelsky and others), thanks to which, despite the difficulty of extirpating the pituitary gland, it was possible to make valuable observations on animals over a long period of time.

The results of surgical interventions on the pituitary gland vary depending on whether the experiments were carried out on sexually mature or immature animals. In young animals, in addition to disturbances in general metabolism and slow growth, the gonads were in their infancy. Removal of the pituitary gland in mature animals led to atrophy of the gonads and loss of sexual desire. Transplantation of the pituitary gland into infantile animals caused increased growth of secondary sexual characteristics. In castrated animals, the transplant had no effect.

Thus, the product of the anterior lobe of the pituitary gland, without having a specific sexual effect, is involved only in the stimulation of the gonads. Luteinizing hormone stimulates Leydig cells, and follicle-stimulating hormone stimulates the glands that produce non-androgenic testicular hormone, i.e. Sertoli cells. Asano (1965) showed that prolactin is one of the gonadotropic hormones that has a luteinizing effect. Prolactin in urine was more active in cancer patients than in healthy people and patients with prostate adenoma. Therefore, it is possible that prolactin plays a significant role in the pathogenesis of prostate cancer. The presence of a large amount of estrogen hormone has a depressing, inhibitory effect on the pituitary gland and hypothalamus. A decrease in pituitary prolactin is observed with estrogen therapy. Thus, both experimentally and clinically it has been proven that large doses of the female hormone reduce the amount of prolactin produced by the pituitary gland.

It is known that irradiation of the pituitary gland with X-rays caused degenerative changes not only in the testicles, but also in the adrenal glands.

Currently, in addition to a large number of steroids (about 30) obtained from the adrenal glands, male and female sex hormones have been isolated. The influence of the adrenal cortex on the development of the reproductive system - on the development of secondary sexual characteristics - is of great importance. The pathological condition of the latter - hyperplasia, tumors - caused premature maturation in children, feminization in men and masculinization in women.

Some authors call the adrenal glands “second sex glands.” This makes clear the great importance of coordination of function between the prostate, gonads, adrenal glands and pituitary gland. Dysfunction or development of a pathological process in one of the organs causes changes in the other. Violation of the normal relationships between male and female sex hormones leads to pathological processes in the prostate gland and pituitary gland.

The complexity of this problem has so far consisted in the fact that although the existing mutual correlation and connection between the endocrine glands, the autonomic nervous system and the prostate gland have been more or less studied, until hormones were obtained in a chemically pure form, it was difficult to show their significance in the origin of neoplasms prostate gland.

The synthetic reproduction of hormones in chemically pure form has made it possible to establish their physiological and pharmacological effects.

It is also important that in their structure, sexual hormones have much in common with carcinogenic substances, both in their general chemical structure and in their effect on the body. Except

Moreover, it is known that the chemical structure of folliculin and carcinogenic substances is very close to derivatives of bile acids and cholesterol, which does not exclude the possibility of their formation from these substances.

The first experimental evidence of the involvement of sex hormones in the genesis of tumors was the production of mammary gland cancer in mice as a result of long-term administration of folliculin. Similar tumors can be obtained using synthetic substitutes - sinestrol, diethylstilbestrol, etc. Currently, cervical cancer (Ya. S. Klenitsky), uterine cancer (E. L. Prigogina), fibroids have been obtained by subcutaneous injections or implantation of estrogen substances prostate gland (B.V. Klyucharyov).

Not only experimental studies, but also clinical observations have shown the dependence of the tumor process of the gonads on hormones. For example, nulliparous women are more likely to develop breast cancer than those who have given birth. In women - “old maids” who are not sexually active, tumors of the gonads are more often observed than in those who have a normal sexual life.

In women who took large doses of estrogen hormones for a long time, cancer of the mammary glands and genital organs was observed. Thus, if dishormonal relationships or certain predisposing physiological conditions arise in the body, the female sex hormone can be a factor contributing to tumor formation.

Having determined the behavior of the female sex hormone in antiphysiological conditions of the female body, it was very interesting to test the behavior of the female hormone in the male body. For this purpose, in 1947, we carried out experiments on male mice, which throughout their lives were injected with estrogenic hormones - polyanol - under the skin. Macroscopically, a strong expansion of the bladder, ureters and renal pelvis was observed, and from the genital area - atrophy of the seminal vesicles and a decrease in the volume of the testicles. During microscopic examination, we noted mainly changes in the prostate glands (in mice there are three lobes of the gland), proliferation and changes in their epithelium, as well as thickening and hyalinosis of the stroma. All these changes led to an increase in the total volume of the prostate gland.

A characteristic feature was the focal nature of the process, the localization of which was initially limited to the central glands or prostate I. Expansion of glandular cells, proliferation of epithelium, papillary outgrowths, retention of secretions and desquamated epithelium in individual cells - all these changes characteristic of prostate adenoma, we could observe in the first phase of the development of the process in experimental animals at low dosages of polyanol.

We saw an undoubted similarity in the final clinical picture of the process being studied, which leads to urinary retention, dilation of the bladder and renal pelvis and death from causes associated with urinary retention.

V.P. Konoplev injected male mice with the male hormone. As a result of these studies, it was found that the changes that occur in the mouse prostate gland when an androgenic drug is administered differ from the pathological process during the so-called prostatic hypertrophy. In contrast to focal, nodular growths of the epithelium in the so-called prostatic hypertrophy, an artificial increase in the amount of androgenic hormones in the mouse body causes diffuse hyperplasia of the epithelium of all three lobes of the prostate gland.

During a microscopic examination of prostate gland I (where the adenoma forms), the epithelium of this part of the gland is morphologically no different from the epithelium of the gland of control and normal animals (V. P. Konoplev). As you can see, the work of V.P. Konoplev does not at all contradict our research, as L.I. Dunaevsky and A.S. Portnoy point out.

The possibility of the action of estrogenic substances on the human prostate gland is confirmed by pathological changes in the prostate gland, described by some authors, in newborn boys, explained by the action of estrogenic substances passed in excess to the child from the mother.

The presence of a large amount of estrogenic substances in the body of pregnant women has been proven by many authors. In light of this fact, the long-observed cases of urinary retention in newborn boys in the first days of post-uterine life become understandable. A significant amount of estrin was found in the urine and blood of such newborn boys in the first days after birth.

At the end of the last century, Aschaff showed the presence of multilayered epithelium in the “male uterus”, prostate and periurethral glands of the newborn.

Based on experimental work, the concept of hormonal genesis of prostate adenoma seems to us to be the most convincing and worthy of attention. Similar examples of dishormonal hyperplasia are given by M.F. Glazunov in his work on fibroadenoma of the mammary gland.

The circulation of endogenous substances in the human body and their chemical relationship with the female sex hormone give us a certain right to draw a parallel and establish similarities between experiments using the female sex hormone on male mice and the effect of estrin on the human prostate. In old age, the exchange of sex hormones is disrupted - the release of male and female sex hormones decreases. Less male hormone is produced in the body, and more female hormone;

this is indicated by studies by Vernet, Novakowski and Schmidt and other authors.

Engle and others found that 17-ketosteroids are secreted continuously in normal individuals from the adrenal glands and testes in a ratio of 5:3. Hamilton, Johnsen and others, studying the release of 17-ketosteroids, established a gradual decrease in the hormone in men, starting from 35 years of age until old age.

Steinachs also pointed out that in old age the testicles undergo physiological involution like the ovaries. But for many years they disagreed with this. Currently, new research methods and new data on the morphology and physiology of the testicle have emerged, which confirm the assumptions made long ago by Steinachs. Studies by Teem, Sargent and McDonald, Tillinger, Stieve, Sirnson and others have proven a decrease in the number of Leydig cells after 50 years of life. However, the function of the testicles is determined not only by the number of Leydig cells, but also by their size, structure, function, and the amount of hormone released.

Herchen and others found a direct relationship between hormone release and plasma changes in Leydig cells. Histochemical studies have shown that large mature Leydig cells contain a large number of tiny droplets of sudanophilic lipoids. These fat droplets contain cholesterol and cholesterol ester, which are the starting material for the formation of androgens.

According to studies by Lynch and Scott, the lipid content in Leydig cells decreases with age. After almost all spermatogenic elements disappear, Sertoli cells become clearly visible. Lynch and Scott saw the accumulation of lipoids in Sertoli cells, which explains the increase in the amount of estrogen produced in old age.

Consequently, the available data on the morphology and physiology of the testicle indicate its involution in old age. Initially, the endocrine activity of the testicle is affected and the production of testosterone is reduced. Well-functioning Sertoli cells continue to produce female hormone.

Thus, in the second half of life in men, as most authors have shown, predominantly the female sex hormone circulates. It is quite natural that the female hormone acts selectively on tissues related to it. Such related tissues are the periurethral glands, the central part of the prostate gland, or the anterior, cranial part of the gland.

It is possible that the same glands are described and called differently by different authors. For us, as for most, it is clear that this group of glands reacts to estrogens in the same way as in women, estrin stimulates the epithelium of the vagina. In these glands

contains the remains of the female reproductive apparatus, rudiments of the Müllerian and Wolffian ducts. As you know, the uterus is formed from the Müllerian duct, and the vagina is formed from the Wolffian duct. The female sex hormone, acting on these glands, causes hyperplasia, proliferation and leads to prostate adenoma. The prostate gland itself or its posterior part, the caudal one, reacts to the action of androgens, causing diffuse hypertrophy of the prostate gland and, under certain conditions, cancer, and not focal growths, not adenoma.

Thus, prostate adenoma is a dishormonal disease caused by sexual imbalance. There is a disturbance in the ratio of male and female sexual balance. Prostate adenoma is a male menopause, which, unlike the female menopause, lasts much longer.

However, it must be borne in mind that the development of prostate adenoma depends not only on hormonal changes occurring in the body, but also on individual characteristics, living conditions, nutrition, climate, local processes in the prostate gland and testicles. There are other views on the emergence and development of prostate adenoma (L.I. Dunaevsky), which we are not able to cover here due to the limited size of the book.

Clinical picture. In the clinical course of prostate adenoma, three degrees are distinguished. The first is the initial, or precursor stage, the second is the stage of residual urine and the third is paradoxical ischuria, which is characterized by complete chronic urinary retention with significant distension of the bladder and a kind of urinary incontinence.

In the first stage, the bladder is still able to overcome obstacles encountered in its path and empty it completely. Symptoms in the first stage are expressed in a frequent urge to urinate day and night and difficulty urinating. Frequent urges are often the only symptom of the disease for a long time. The reason for these frequent urges to urinate is seen in the hyperemia of the prostate gland, which occurs in a supine position under the influence of heat. Some authors explain the frequent urge to polyuria, as a result of a reflex going from the overfilled bladder to the kidney parenchyma.

During the day, when the patient is on the move, blood circulation conditions in the gland improve, and hyperemia and swelling of the bladder neck disappears. And, conversely, with prolonged sitting, constipation, heavy meals, consumption of alcoholic beverages and other factors that contribute to congestion in the pelvis and, in particular, in the prostate, the urge to urinate increases. Simultaneously with the increase in frequency of urination, the urge becomes imperatively uncontrollable. When the urge appears, the patient should

satisfy him immediately. He is also unable to interrupt the flow of urine. The third symptom of the first stage of adenoma is difficulty urinating. It is expressed in the fact that the patient must wait for some time until urine production begins. The stream becomes sluggish, loses its arc shape, falls vertically downwards, sometimes it is interrupted, and the discharge occurs in drops. Trying to empty the bladder faster, patients contract their abdominal muscles.

All these symptoms, mild at first, gradually intensify over time.

With appropriate care, in some cases the first stage can remain for months and sometimes years. However, in most cases the transition to the second stage occurs quite quickly. Symptoms of the first stage persist into the second. But in the second stage, something new appears: a situation is created where the bladder is unable to empty itself of all the urine in it. After each act of urination, a certain amount of so-called “residual urine” remains in it. Its appearance depends on the weakening of the muscle strength of the bladder and increasing changes in its neck. Symptoms of the first period are more pronounced in the second. The urge to urinate becomes more frequent and painful. Due to the fact that the bladder always contains residual urine, it fills faster and the need to empty it appears more often. The daily amount of urine increases, and the amount of night urine is greater than daytime. Urination occurs in a sluggish stream, sometimes in drops.

Painful, frequent and ineffective night urges lead to a deterioration in the general condition. This is often accompanied by constipation. All this favors the occurrence of infection and various complications of the upper urinary tract. Dull pain sometimes appears in the bladder area. The amount of residual urine from 50-100 ml reaches 500 or more. The second stage can last for a number of years. Possible acute urinary retention during this period is eliminated by catheterization. If these delays are repeated, the patient is forced to resort to daily catheterization or undergo surgical intervention - urine diversion. However, there are cases when one or two catheterizations restore urination for a long period.

Chronic urinary retention leads to severe bladder distension and tissue degeneration. The contractility of the bladder decreases and it cannot produce even a small amount of urine. In some cases, the bubble stretches to the level of the navel or even higher. Along with the contractility of the bladder, its sensitivity decreases. Patients suffer less from delays and believe that their health has improved. Patients sleep more peacefully at night,

how to use a urinal where urine involuntarily flows. During the day, the urge, although frequent, does not cause much suffering, tension or pain. Finally, the urge to urinate disappears, voluntary urine output stops - complete retention occurs. ”

The urine accumulated in the bladder overcomes the resistance of the sphincter, and a small amount of it is involuntarily released in drops (ischuria paradoxa). During this period (the third stage of the disease), the most significant anatomical changes occur in the muscular wall of the bladder. Many diverticula are formed. Stagnation leads to the formation of stones and contributes to the development of infection. By this time, changes are observed not only in the bladder, but symptoms of renal failure also appear. The concentrating ability of the kidneys sharply decreases, polyuria intensifies, and azotemia increases. The general condition of the patients deteriorates sharply. They lose weight, turn pale, lose appetite, and complain of headaches and nausea; the tongue becomes dry, severe thirst appears, and bad breath appears. All this represents a clear picture of chronic poisoning of the body by protein breakdown products. The accompanying infection accelerates the already growing phenomena of urosepsis. This difficult period is the shortest compared to others.

In all three periods, acute urinary retention may occur, that is, a condition when the patient cannot urinate on his own, although there is a significant amount of urine in the bladder.

The mechanism of development of acute urinary retention is explained by adenomatous changes in the prostate gland and the associated congestive hyperemia and swelling of the mucous membrane. Contributing conditions may include sudden cold, prolonged constipation, alcohol abuse, nervous shock, etc.

The patient complains of pain in the lower abdomen, which gradually increases as the bladder stretches. The urge to urinate becomes more and more disturbing. To empty the bladder, patients take various positions, press on the bladder, and unsuccessfully strain the abdominal muscles. When examining the patient: in the suprapubic region, a distended bladder rises noticeably - round or ellipsoidal; a dense elastic formation is palpable, and upon percussion - a sharp dullness of sound.

After catheterization and urine discharge, the “tumor” in the suprapubic region disappears, which confirms the correctness of the diagnosis.

Complications. The usual course of prostate adenoma is often worsened by various complications that cause a number of

new disorders. The most common complications are infection, hematuria, bladder stones, and urosepsis.

The main cause of complications is infection. Despite observing all the rules of asepsis, pathogenic flora is often introduced into the urethra during periodic or continuous catheterization. Under the influence of micro- or macrotrauma caused by the catheter, conditions are created for the development of infection in the urethra.

Long-term catheterizations, the use of a permanent catheter and prolonged urethritis are a source of new complications - inflammation of the appendages and testicles.

In some cases, prolonged use of an indwelling catheter causes only minor urethritis. Sometimes the use of a permanent catheter contributes to the occurrence of purulent urethritis with copious bloody-purulent discharge from the external opening of the canal with redness and swelling of the latter. Treatment of this type of urethritis does not present any particular difficulties. Removal of the permanent catheter for several days leads to the disappearance of inflammatory phenomena in the urethra.

The most common complication accompanying prostate adenoma is inflammation of the bladder. One can even definitely say that almost every patient who is forced to resort to a catheter usually experiences bladder inflammation.

In the first stage of adenoma, you usually have to deal with acute inflammation of the bladder. The second and third stages are characterized by a chronic course of cystitis. The phenomena of acute cystitis, which sharply worsen the symptoms of the underlying disease, usually do not last long, and the process passes into the stage of chronic inflammation.

Often a complication of prostate adenoma are bladder stones, sometimes reaching large sizes. Stone formation is facilitated by the presence of residual urine, usually containing a large amount of phosphates, as well as concomitant infection. Such secondary stone formation is the source of frequently observed hematuria. Removing stones without eliminating the underlying cause (adenoma) does not relieve patients from relapses, therefore the presence of recurrent stones is an indication for radical adenomectomy.

The sudden onset of acute pyelonephritis with violent symptoms of fever and pain is observed with prostate adenoma relatively rarely. More often, this complication occurs without an acute reaction and quickly becomes a chronic condition. The dilation of the renal pelvis resulting from the obstruction to the free outflow of urine with the presence of stagnant urine in it significantly contributes to such a sluggish course of pyelonephritis. This complication is accompanied by lumbar pain, deterioration of general condition and increased temperature in the evenings. The urine becomes cloudier and contains high amounts of protein.

In acute pyelonephritis, the disease begins with tremendous chills, high temperature (up to 39-40°), headache, vomiting, and dry tongue. The general condition becomes serious. The course of pyelonephritis is very different. Sometimes, under the influence of appropriate treatment, the temperature decreases, pain in the lumbar region disappears, the tongue becomes moist, and the general condition improves. However, this course of the disease is not always observed; more often, a gradual deterioration in the general condition is observed. This especially happens in the last stage of prostate adenoma, when there are large anatomical changes in the kidneys. Sometimes pyelonephritis due to poor outflow of purulent contents ends in pyonephrosis.

Purulent-hematogenous pyelonephritis, nephritis and pyonephrosis can result in an even more serious complication - azotemia and urosepsis.

Arbitrary hematuria with prostate adenoma is relatively rare: according to our observations, it occurs in 8-10% of all patients with adenoma. Congestion in the pelvis creates favorable conditions for hematuria. Swelling of the mucous membrane of the bladder, posterior urethra, as well as associated infection, dilated veins above the adenoma contribute to the occurrence of hematuria.

Most often, bleeding occurs as a result of trauma to the prostatic urethra and bladder neck caused by a catheter or other instrument.

Prostate adenoma, changing the shape, length, direction of the urethra, in some places narrowing its lumen, makes the walls looser, complicates catheterization and contributes to the formation of false passages. Sometimes even the insertion of a soft rubber catheter causes disruption of the mucous membrane of the prostatic urethra with subsequent bleeding. The formation of false passages, i.e. penetration of the catheter and other instruments into the glandular tissue, with inept catheterization can also cause bleeding.

Prolonged bleeding leads to the formation of clots. By closing the opening of the urethra, these clots cause acute urinary retention. Catheterization is often difficult, the catheter becomes clogged with clots, and it has to be changed many times. In such cases, it is recommended to flush the bladder with hot solutions through a catheter with a wide bore and lumen.

Acute urinary retention is usually accompanied by a significant rush of blood to the bladder and the formation of many hemorrhages under the mucous membrane of the bladder, which can cause hematuria. Dangerous bleeding can occur with chronic complete urinary retention. Rapid emptying of the bladder using a catheter changes the

intravesical pressure causes an energetic rush of blood to the mucous membrane of the bladder, resulting in bleeding.

I received a letter from one of the students - a cadet at the State University of Education and Science, in which the author reports an observation of practical interest, and therefore we considered it possible to present it here.

The patient was taken to the urology department from the area with acute urinary retention. Doctor Sh. took a catheter of the largest diameter and immediately released two liters of urine. After rapid emptying, profuse bleeding occurred. All measures taken to stop the bleeding (blood transfusion, plasma transfusion, calcium administration, etc.) were unsuccessful, and the patient died of bleeding. Apparently, if the patient had had the bladder opened and tamponade performed, the outcome could have been different.

The most severe course of the disease is in cases where the prostate adenoma has turned into cancer. According to the observations of our clinic, as well as L.M. Shabad, the frequency of cancerous transformation of prostate adenoma is 5-6%.

Diagnostics. The age, medical history and symptomatology of prostate adenoma are so characteristic that making a diagnosis does not present any particular difficulties.

However, the final diagnosis is made on the basis of an objective examination of the patient. The main method of examination is finger palpation through the rectum of the surface of the prostate gland. The study should be carried out with an empty bladder, since the overflow of the latter causes a large protrusion of the adenoma into the intestinal lumen and creates an inaccurate picture of it. Usually a symmetrically contoured body of a round shape, elastic consistency, smooth surface, protruding into the intestinal lumen is palpated. The sizes of adenoma are very different. It must be borne in mind that the transition of the tumor to the pelvic walls, the identification of individual dense nodes of cartilaginous consistency indicate the presence of prostate cancer. However, based only on palpation sensations, it is not always possible to determine the final diagnosis. Palpation diagnosis is especially difficult in the intravesical type of prostate adenoma, when its growth is directed not towards the rectum, but through the internal opening of the urethra into the bladder.

In the pre-cystoscopic period, percussion examination of the location of the bladder was used to diagnose prostate adenoma. This study has retained some significance to this day. Sometimes, even without palpation examinations above the pubis, slightly below the navel, it is possible to observe how a distended and full bladder protrudes. - Percussion in the second and third stages of the disease

Levanya is able to determine the degree of distension of the bladder, as well as the approximate amount of residual urine without the help of a catheter. The amount of residual urine can be used to judge the functional capacity of the bladder.

Urography provides a significant service for determining the presence of residual urine without the use of a catheter. For this purpose, sergosine is administered intravenously and 20 minutes later, when there is usually a sufficient amount of contrast agent in the bladder along with the urine, an x-ray is taken. The second picture is taken after the patient has emptied his bladder of urine. The presence of a contrast agent in the bladder indicates residual urine. Of course, this test provides only indirect data indicating the possibility of adenoma, since there may be other reasons causing incomplete emptying of the bladder.

X-ray examination provides valuable services for detecting prostate adenoma. Sometimes the contours of the prostate gland can already be detected on a plain X-ray. The shadow of prostate adenoma is clearly visible against the background of a gas-filled bladder (pneumocystography).

Pneumocystography technique. After the usual preparation for x-ray examination and removal of residual urine with a catheter, 150-200 mL of oxygen is injected into the bladder through the same catheter with a large syringe. Then radiographs of the bladder are taken in a straight position and in two oblique positions. On the obtained radiographs, the shadow of the adenoma, its shape and size are always clearly visible. It is determined above the symphysis pubis, against the background of a gas-filled bladder. Its shape can be cone-shaped, wedge-shaped, oval, round. The contours are always clear (Fig. 106).

Currently, tomographic examination of prostate adenoma is also used. Tomograms are performed at a depth of 9-12 cm with the patient positioned on his back. This research method is especially effective in combination with the introduction of air into the bladder - pneumocystotomography (B.V. Klyucharev, T.A. Osipkova and N.A. Ulitovskaya, N.A. Berman and L.M. Rabkova, N. M. Berman and V. E. Kagansky).

As a rule, we do not perform cytoscopies for prostate adenoma, since performing a cytoscope in these patients can often be accompanied by great difficulties. Under the influence of trauma and increased infection, cystitis, epididymitis, urethral fever, hematuria, etc. may occur. Cystoscopy is necessary if there is macroscopic hematuria of unknown etiology or when all examination methods have not given a clear picture of the disease.

The cystoscopic picture of prostate adenoma is distinguished by specific changes in the bladder neck. In the initial stages of adenoma in the area of ​​the transitional fold of the sphincter, which is in normal condition

appears in the form of a crescent with a slightly concave or straight edge, tuberous formations appear that disrupt the smooth edge of the crescent. With a more pronounced enlargement of the gland, protrusions formed by adenomatous nodes are visible at the site of the transitional fold.

Rice. 106. Pneumocystotomography.

Sometimes one or more asymmetrically located adenomatous nodes are visible in the sphincter area. If the lateral lobes are evenly enlarged, the tumor protrudes on both sides, resembling descending curtains. The middle lobe is usually clearly visible on the posterior wall of the transitional fold. Subvesical forms of prostate adenoma do not cause any special changes in the bladder, with the exception of elevation of the leaf triangle. Cystoscopically it is also possible to determine inflammatory and anatomical changes in the bladder mucosa. Trabeculae and diverticula are easily recognized, indicating increased intravesical pressure. Sometimes you can see hypertrophy

tubular interureteric fold, expansion of the ureteric orifices and other anatomical changes resulting from a long-term disease.

Differential diagnosis is often made between prostate adenoma, chronic prostatitis, tuberculosis and prostate cancer.

Differential diagnosis between prostate adenoma and chronic prostatitis does not present any particular difficulties. By palpation it is sometimes difficult to distinguish an enlarged prostate gland caused by prostatitis from an incipient adenoma. In such cases, the diagnosis is made on the basis of signs characteristic of prostatitis. Uneven enlargement of the prostate gland, painful and dense areas, the nature of urine and secretions after prostate massage, a positive three-glass test exclude the presence of an adenoma.

Considering that prostate adenoma is rare under the age of 50, complaints associated with prostate disease in young and middle age should be attributed to prostatitis rather than adenoma.

It is quite easy to distinguish between adenoma and... prostate tuberculosis. History, age, specific changes in the prostate gland and seminal vesicles with tuberculosis do not raise doubts about the diagnosis.

Treatment of prostate adenoma can be conservative and surgical. The group of conservative methods includes hormone therapy and catheterization. Surgical treatment methods, in turn, can be palliative and radical. Palliative treatments (vasectomy, transurethral electroresection of adenoma, epicystostomy) are aimed only at reducing urinary disorders caused by the adenoma. Radical surgery - adenomectomy aims to completely remove the prostate adenoma. There are various options for adenomectomy: two- and one-stage - with bladder drainage, one-stage - with a blind suture, retropubic, perineal and ischiorectal methods.

Hormone therapy. The idea of ​​using male sex hormone to treat prostate adenoma existed long before its discovery in a chemically pure form. In the treatment of these patients, powders and extracts prepared from the prostate and seminal glands of animals were previously used. Due to the difficulty of preparing extracts from animal glands and not always obtaining a positive therapeutic effect, they began to look for means of producing male hormone biochemically from urine and blood. However, the need for a large amount of starting material and a number of other inconveniences created difficulties for the widespread use of the hormone during this period.

In 1931, for the first time, a crystalline substance called Butenandt androsterone was obtained from the urine of a young man. In 1935, the synthesis of androsterone marked the beginning of further research in this direction. Due to the insufficient activity of androsterone, compared to testicular extracts, they began to seek and synthesize new substances that are similar in structure to androsterone, but have a stronger biological effect. Such a substance was soon obtained from a bull testicle and called testosterone. Testosterone was synthesized from cholesterol and dehydroandrosterone. The domestic industry produces male hormones: testosterone propionate and methyltestosterone. Those-

stosterone propionate is produced in a 5% solution, 2.5% and 1% oil solution. Methyltestosterone is prepared in tablets of 0.005 mg in each tablet. Testosterone propionate is used twice a week, 50 mg as intramuscular injection. A total of 1000 mg per course of treatment. Methyltestosterone is prescribed two tablets under the tongue three times a day. For a course of treatment 2000 mg. Methyltestosterone tablets are placed under the tongue and are absorbed there. Gastric juice destroys the hormone, and it loses its active effect.

Along with the male hormone, vitamin E is prescribed in drops (oil solution, extract) or in ampoules for intramuscular injection.

In the treatment of prostate adenoma, male and female sex hormones are used. Some authors suggest combining male and female hormones. I. N. Shapiro gives twenty units of male hormone and one unit of female hormone.

It has now been proven that neither male nor female hormones cure prostate adenoma and do not cause a process of reverse development in it. However, with this method of treatment, the tonic effect of hormones on the smooth muscles of the bladder is manifested, due to which some improvement in clinical symptoms is observed. There are supporters of treatment with male sex hormones, others - with female ones.

The first in the Soviet Union to propose treating prostate adenoma with female sex hormones were A. B. Topchan and A. A. Pomerantsev. The treatment method according to Topchan and Pomerantsev was as follows: daily intramuscular injections of 2% sinestrol, 2-3 ml, for 2 months, for the third month, 1-2 ml of sinestrol is administered. The first month the patient is in bed. To continuously drain urine into the bladder, a rubber catheter is inserted through the urethra. The patient receives penicillin injections as a prophylactic against complications that may arise from a long stay of the catheter in the urethra.

We still remember the time when there were no hormones, no antibiotics. At that time, some patients with prostate adenoma categorically refused surgical intervention, but asked to alleviate their suffering. In this group of patients, a rubber catheter was inserted into the bladder through the urethra for 20-30 days and disinfectants and diuretics were prescribed. After treatment, the patient felt better: he urinated less frequently, the urine stream was large in diameter, and the difficulty disappeared. This clinical improvement was temporary. It is quite natural that patients treated according to the method of Topchan and Pomerantsev received significant temporary improvement.

Many clinics, including us, do not support the treatment of prostate adenoma with sinestrol. Estrogen substances do not cure a patient from prostate adenoma, and temporary improvement postpones the time of radical intervention and thereby worsens the results of the operation. Many people remember the speech of A.P. Frumkin at the 2nd All-Union Conference of Urologists, in which he noted that many patients with prostate adenoma treated with synestrol were soon operated on due to the deterioration of their clinical picture. In addition, large doses of the female sex hormone cause chemical castration and lead to a sharp decrease in sexual function.

Patients with prostate adenoma often seek help at the age of 50-60 years with preserved sexual activity. We believe that at this age it is unacceptable to carry out biological and chemical castration. Treatment with sinestrol is possible in cases where the age of patients exceeds 70 years and they refuse surgery or adenectomy is contraindicated for them.

A contraindication for the treatment of patients with prostate adenoma with sinestrol is also the great difficulties that arise during enucleation of the adenoma in patients treated with hormones. Powerful cicatricial changes formed between the capsule and the adenoma greatly complicate the enucleation of the gland, lead to disruption of the capsule and bladder wall, and cause profuse bleeding. These observations were noted by us, V. M. Bliznyuk and others.

We consider it more appropriate to use the male hormone, since it does not have any negative side effects. After taking the male sex hormone, all patients note. improvement in general condition, a surge of energy, vigor, increased performance, etc. Hormonal treatment with the male hormone is used in the first and at the beginning of the second stage. However, as we indicated, neither male nor female hormones cause the reversal of adenoma. They are only

affect the smooth muscles of the walls of the bladder, enhancing its contractility. This is expressed in a decrease in the amount or complete disappearance of residual urine. It is very advisable to prescribe male hormone before adenomectomy, especially for patients suffering from renal failure and azotemia. Androgens increase blood flow in the kidney, have an anabolic effect and thereby improve the general condition of the patient.

Catheterization is a very common and affordable method of treating urinary retention in prostate adenoma.

Currently, there are fewer and fewer supporters of long-term treatment of a patient using only a catheter. Catheterization as an independent method of treating prostate adenoma is allowed only in patients who refuse surgical intervention, or when, due to the severity of the patient’s condition, it is not possible to perform surgery. Short-term catheterization to eliminate acute urinary retention and during the preparation of patients for simultaneous adenomectomy is an accessible and vital measure.

In the first stage of prostate adenoma, catheterization is usually not used, with the exception of rare acute urinary retention or local treatment of cystitis. In the second stage, with a small amount of residual urine (100-150 cm3) and the absence of infection, regular catheterization is unnecessary. If the amount of residual urine exceeds 300 ml, catheterization is performed every 8 hours for two to three weeks until the tone of the bladder is restored. Systematic excretion of urine at certain intervals brings the bladder closer to normal physiological conditions: clinical improvement occurs, and patients feel better for some time, urine passes more freely, and the urge becomes less frequent.

An indwelling catheter is more often used in cases where there are difficulties in passing it through the urethra, and to create a constant outflow. A short-term stay of a permanent catheter in the posterior part of the urethra and the neck of the bladder helps reduce swelling of the mucous membrane and creates favorable conditions for the outflow of urine after removal of the catheter.

The negative aspects of using a permanent catheter are the resulting urethritis, recurrent epididymitis, or frequent blockage of the catheter with purulent and mucous plugs. Urethral fever may occur here, as with other instrumental interventions in the urethra.

Due to developing urethritis, often with purulent discharge from the urethra, it is recommended to change the permanent catheter after one or two days. When changing the catheter, it is very necessary to rinse the urethra copiously with a warm disinfectant solution.

Vasectomy, i.e., cutting and excision of a piece of the vas deferens, was undertaken to improve the clinical course of prostate adenoma. It was believed that after this operation the endocrine function of the testicle increases and the hormonal influence has an effect on the entire body and on the function of the bladder. At one time, the “rejuvenation” operation proposed by Steinachs consisted of ligation of the vas deferens.

Ya. V. Voitashevsky, V. A. Speransky wrote that vasectomy performed for prostate adenoma significantly improves the clinical course of the disease. The number of daytime and nighttime urges decreased, residual urine disappeared. However, other authors could not confirm this opinion.

According to our observations, in a very small percentage of patients (6-8%), as a result of vasectomy, bladder function was temporarily restored, which is expressed in a less frequent urge and a slight decrease in the amount of residual urine. In the majority of patients, no significant improvement or reduction in symptoms of the disease was observed.

Transurethral electroresection. Back in 1874, Bottini proposed a device for dissecting an enlarged prostate gland using galvanocaustics. The operation was performed blindly, without an optical device, and therefore was not widely used. Over the past 10-15 years, new and improved devices with optics have appeared. Thus, it was possible to carry out all interventions under visual control.

Under visual control, the electric knife is directed to the area of ​​the bladder neck where the adenoma is located. The electric resector is continuously supplied with washing liquid, which cleans the surgical field of scab. The most common resectroscope systems: Mac Carty, Nesbit, Lichtenber, etc.

In the United States, this operation ranks first among other interventions on the prostate gland. The Mayo Clinic alone performed 11,522 electrical resections. In the Soviet Union, transurethral resection of prostate adenoma was performed in three or four urological clinics, and the number of patients was within 100.

At the beginning of the introduction of this method into widespread practice, there was a high mortality rate (10%). By improving the technique and developing indications and contraindications for transurethral

electrical resection, it was possible to reduce mortality to 3%. This intervention is often performed in the initial stages, when adenomectomy is not yet indicated, with only an enlarged middle lobe, with relapses after adenomectomy, and in some cases where there are contraindications to adenomectomy.

Contraindications to this operation are: poor kidney function, azotemia, inflammatory processes of the urinary tract.

Operation technique. Before the operation, 40 minutes before the operation, the patient is given an injection of morphine - 1 ml, before the operation itself, 10-15 ml of a 1% novocaine solution is injected into the urethra. Some authors (P. 3. Preiszen) perform electroresection under epidural anesthesia. The instrument is inserted into the urethra under eye control to the neck of the bladder, where the adenoma protrudes. Then, using an electroresectoscope, a tunnel or groove is burned out in the adenoma. The operation is performed in 1-3 sessions, and sometimes more. Bleeding is often a major obstacle to electrical resection. It obscures visibility and thereby lengthens the duration of surgery. After surgery, a permanent catheter is inserted. If urination is free and there is no bleeding, there is no need for a permanent catheter.

Frequent complications after this operation are bleeding, drop in blood pressure, hyponatremia (Creevy, Blirne, Madsen and Burns, etc.). Perforations of the bladder wall, formation of urinary leaks, and exacerbation of the inflammatory process are described.

Most domestic urologists, including us, believe that this operation will not find widespread use due to a significant percentage of deaths, serious complications and frequent relapses requiring repeated interventions.

Epicystostomy is performed as the first step of a two-stage adenomectomy or for health reasons in case of azotemia, uremia, etc.

Operation technique. The operation is performed under local novocaine anesthesia. An incision 8-10 cm long is made between the pubis and the navel along the midline. The skin, subcutaneous tissue, aponeurosis are dissected, and the muscles are retracted to the side. The peritoneal fold is moved upward, the bladder is placed on provisional ligatures, between which a trocar is inserted. The trocar is connected to a suction tube and the bladder is quickly drained. The trocar is removed, the wound is widened and the bladder is inspected. Then a drainage is inserted, which is fixed to the wall of the bladder with a purse-string suture. The bladder is fixed to the aponeurosis with two catgut sutures. Tampons - to the abdominal fold and into the paravesical space. Stitches on the wound.

During this operation, we pay special attention to ensuring that the fistula is placed high - at the top of the bladder. This is done so that during the second operation - removal of the adenoma - the incision can be expanded downwards, since the peritoneum hangs above and on the sides, damage to which in the case of infected urine is highly undesirable. We consider the second important point when applying a suprapubic fistula to be fixation of the urinary

bladder with a catgut suture to the aponeurosis. After such fixation, urine does not enter the peri-vesical space, does not cause a purulent-inflammatory process, and does not wash the pubic bones.

Radical adenectomy. In 1887, A. T. Podrez was the first to use partial excision of prostate adenoma through the suprapubic approach. S.P. Fedorov in 1898 proposed a method of complete removal of the entire prostate adenoma through the transvesical route. In 1906, B. N. Kholtsov developed a method of two-stage suprapubic adenomectomy.

Indications for simultaneous adenomectomy are: repeated acute urinary retention, increasing dysuria, the amount of residual urine exceeding 150 ml, an increase in residual nitrogen above normal, etc.

A contraindication to simultaneous adenomectomy is: severe renal failure, which is detected on the basis of functional tests according to Zimnitsky, intravenous urography, chromofunction, determination of residual nitrogen in the blood serum, urea clearance. Isosthenuria, hypoisosthenuria, specific gravity 1012 are contraindications for simultaneous surgery. Severe cardiovascular and pulmonary, renal failure, previous heart attacks, cerebrovascular accident, recurrent thrombophlebitis, frailty, etc.; acute urinary tract infection accompanied by a temperature reaction, liver failure, etc. are also contraindications.

Indications for a two-stage operation are contraindications for a one-stage intervention, and it must be borne in mind that not all patients, after the first stage of a suprapubic vesical fistula, must necessarily undergo the second stage - removal of the prostate adenoma. If, after several months of a patient with a suprapubic fistula, the concentrating ability of the kidneys has not improved and other general indicators are poor, the second point can be postponed indefinitely or forever.

The purpose of applying a suprapubic fistula is to improve the functional ability of the kidneys, relieve the body from intoxication by protein breakdown products - nitrogenous substances and improve the condition of the cardiovascular system, influence the bacterial flora of the urinary tract, etc.

Some authors (A.M. Gasparyan, V.V. Goldberg, etc.) give broader indications for one-stage surgery. In stages II and III of the disease, patients underwent careful preoperative preparation. In patients who had changes in the upper urinary tract with impaired renal function and infection, a permanent catheter was inserted for 10-12 days, and sometimes more. The catheter was kept until the general condition of the patients improved and the residual nitrogen decreased to normal levels. Simultaneously

preparations and measures were carried out to correct the cardiovascular system, liver function, eliminate pulmonary insufficiency, etc. If the condition of the patients did not improve after treatment, they resorted to applying a suprapubic vesical fistula.

Anesthesia for simultaneous adenomectomy varies. Some authors use spinal anesthesia, others - epidural, and still others - endotracheal anesthesia or other types of anesthesia.

The urological clinic of the Institute for Advanced Medical Studies uses presacral anesthesia in combination with local anesthesia of the anterior abdominal wall. Premedication is given before the operation. The bladder is washed and filled with furatsilin I: 5000 - 200.0 -300 ml. For presacral anesthesia, the patient is placed on the edge of the operating table with the legs brought to the stomach - in the gynecological position. The perineal skin is disinfected with alcohol and iodine. The skin between the coccyx and the anus is anesthetized with a 0.25% novocaine solution. A long needle is injected and passed along the middle inner surface of the sacrum, as suggested by A.V. Vishnevsky. 150 ml of 0.25% novocaine solution is injected through the needle.

Operation technique. The patient is placed in a horizontal position with the pelvis slightly elevated. Anesthesia is performed and an incision is made in the anterior abdominal wall above the pubis, as with a cystostomy. The bladder is opened and the latter is inspected. A gloved finger of the left hand is inserted into the rectum, and by pressing on the bottom of the bladder and the adenoma, the best conditions are created for its removal. Enucleation is performed with the second or third finger of the right hand. At the adenoma, above the area that protrudes into the bladder as much as possible, the bladder mucosa ruptures. We made an incision into the mucous membrane using a fingernail, since cutting it with a scalpel is accompanied by significant bleeding. Some authors cut the mucosa with an electric knife. Once in the layer between the capsule and the adenoma, desquamation is performed.

Basic conditions for enucleation of an adenoma: the finger must touch the surface of the adenoma, not come off it and not go deeper into the surrounding tissue. Digging into the surrounding tissue may cause the finger of the right hand to meet the finger of the left hand. In such cases, a vesico-rectal fistula is formed, which is very difficult to close. After the adenoma is bypassed on all sides, it is held in the area of ​​the internal opening of the urethra by the urethral mucosa. In this part, with the help of a nail, it is possible to prepare the urethra from the adenoma, and the adenoma becomes free from surrounding tissues. The adenoma is removed from the bladder either with a finger, or it can be grasped with a Luer clamp or Museau forceps. Most often, isolating an adenoma does not present any difficulties.

Strong adhesions of the adenoma to the surgical capsule (consequences of the inflammatory process or treatment with sinestrol) or germination of the capsule by elements of a cancerous tumor create significant difficulties in removing the adenoma. Often in such cases, desquamation with a finger fails, and one has to resort to cutting off the tumor with scissors or removing it in separate pieces using a scalpel. Such removal of an adenoma is associated with the risk of damage to the walls of the bladder, the occurrence of severe hematuria, damage to the capsule, etc.

In uncomplicated cases, bleeding that occurs after removal of the adenoma soon stops, especially after inserting a tampon with hydrogen peroxide. In the bed of the removed adenoma, a tampon with hydrogen peroxide is inserted through the cystic opening with long tweezers and squeezed between the fingers of the right hand located in the bladder and the finger of the left hand located in the rectum. To stop significant parenchymal bleeding, it is necessary to change several of these tampons. After making sure that there is no abundant

After bleeding, a narrow tampon of 3-4 m is inserted into the adenoma bed. A hemostatic sponge is inserted into the end of the tampon. A drain is inserted next to the tampon to drain urine. In the absence of bleeding from the bed, there is no need for tamponade, and we limit ourselves to only introducing drainage. Fixation of the drainage and suturing of the wound is carried out in the same way as described for epicystostomy.

Some urological surgeons, in addition to drainage in the bladder, insert a rubber catheter into the urethra. Long-term observation of patients operated on without the use of a catheter showed that there were no strictures or obliterations from the bladder neck and posterior urethra. The presence of a permanent catheter in the urethra often causes a temperature reaction and other complications.

During an operation - adenomectomy - the patient is injected intravenously with an anti-shock solution or canned blood, and sometimes both.

After the operation, a day later, the tampon is removed from the bladder, from the paravesical space and from the peritoneum. Extensive bladder rinsing is performed daily. On the 8-10th day after the operation, bougie No. 23-25 ​​is performed, the patency of the urethra and bladder neck is checked.

Closure of a suprapubic fistula should not be routine. If the adenoma is enucleated entirely and there is no bleeding, a permanent catheter is inserted to heal the fistula at an earlier date. If the adenoma was removed by biting or the operation was accompanied by heavy bleeding with the formation of clots, the fistula closes later, when there is confidence in the passage of all blood clots, the absence of necrotic films, loose pieces of tissue, and adenomatous nodes.

We recommend that before closing a suprapubic vesical fistula, the bladder should be inspected using epicystoscopy. A catheter is inserted into the bladder through the urethra, through which a clear liquid flows in a continuous stream. A cystoscope is inserted through the suprapubic fistula and the bladder neck, bottom and side walls are first examined. It must be borne in mind that in the area of ​​the vesical fistula on the anterior wall there is always significant reactive swelling of the mucosa, which gradually disappears after removal of the drainage. After making sure that there are no foreign bodies or other pathological processes in the bladder, the fistula is closed.

Experience shows that it is best to insert a permanent catheter to close the fistula on the 10-15th day after surgery. This makes it possible to quickly close the fistula with minimal stay of an indwelling catheter.

After the operation, intravenous or subcutaneous administration of 1.5-2.0 liters of physiological solution is performed drip-wise, with the addition of multivitamins; Cupping or diathermy on the chest, therapeutic physical exercises, active behavior of the patient in bed (periodic deep breaths and exhalations, turning the body 45° to the right and left) are prescribed. For better outflow of venous blood, the legs are elevated. To prevent the development of infection, patients receive antibiotics. More often

total penicillin along with streptomycin, in some cases oleotetrin, sigmomycin, morphocycline. When the temperature rises of an unknown nature, injections of 40% methenamine 10 ml are given for 4-5 days.

In the postoperative period, the attention of medical personnel is drawn to the general condition of the patient, as postoperative shock or late bleeding may occur. An indispensable condition for monitoring the patient is checking blood pressure and pulse. It is necessary to monitor the condition of the dressing and the function of the drainage. It is important to monitor the electrolyte balance, since disruption of the latter can lead to serious complications.

After surgery, complications in the form of pneumonia, oliguria, anuria, thromboembolic disease, etc. are sometimes observed. The possibility of bleeding from the bed of a removed adenoma makes it necessary to avoid prescribing anticoagulants several days before surgery to prevent thromboembolism, as some urologists do. We prescribe anticoagulants on the 3-4th day after surgery, using data not only from prothrombin and prothrombin time, but also from studies of fibrinolytic activity of blood plasma. For the purpose of prevention, it is recommended to treat patients with thrombophlebitis and varicose veins with great caution, and to avoid prolonged use of a permanent catheter before and after surgery. The upper body should not be raised high because of the resulting angle in the hip joints, which leads to congestion in the femoral veins.

Intestinal atony, which is sometimes possible after surgery, is easily eliminated with proserin or intravenous administration of a 10% sodium chloride solution.

Postoperative complications include a long-healing suprapubic vesical fistula. The reason for this is an incompletely removed adenoma, enucleated but not removed pieces of adenoma, necrotic encrusted tissue, stones, labial fistula, etc. Elimination of the above reasons allows you to quickly close the suprapubic vesical fistula, and only in a very small percentage of cases does it have to be sutured.

Complications of adenomectomy also include the occasional urinary incontinence. It depends either on the stretching of the sphincter by the adenoma, or on its damage during the operation itself. Urinary incontinence disappears quite quickly and only in rare cases remains permanent. Strictures at the bladder neck are not common.

Sexual function after adenomectomy does not change in most patients, only some authors indicate a slight decrease in sexual potency.

In some patients, the bladder infection does not subside immediately. Such patients are prescribed furadonin 0.1 three times a day for 7 days, and sometimes more, bladder lavage, outpatient observation by a urologist.

Long-term results of adenomectomy are good. Patients feel cheerful, the act of urination becomes normal. The average mortality rate during adenomectomy is 3-5%.

According to L. I. Dunaevsky, the mortality rate is 3-5%, according to A. M. Gasparyan, with a one-stage adenomectomy - 2.8%, with a two-stage adenomectomy - 7.1%. According to Salvaris, the mortality rate was 4.2%. A slightly larger percentage is given by other authors (Scorer, Knight). V.V. Goldberg writes that the main cause of death after adenomectomy in 59.0% was damage to the cardiovascular system and only in 35.9% was urinary. In patients who were not radically operated, on the contrary, kidney damage was in first place as the cause of death - 78.8%, and 18.7% died from diseases of the cardiovascular system.

All urological surgeons have encountered relapses of prostate adenoma. Relapses can be true or false. True ones include relapses after complete removal at a relatively young age (50-55 years) with the elimination of all symptoms of the disease. Many years later, dysuria occurs again and the adenoma is palpated rectally or is identified from the bladder. False relapses are more common; they occur if the adenoma is not completely removed. With false relapses, clinical manifestations of prostate adenoma occur faster than with true relapses.

Simultaneous transvesical adenomectomy with a blind suture. In 1927, Harris reported a method of adenomectomy with a primary suture of the bladder.

Operation technique. A transverse incision is made slightly above the pubis to dissect the skin and subcutaneous tissue, and the bladder is opened. The adenoma is removed. To produce hemostasis and restore the bladder neck, the bottom of the bladder is punctured immediately behind the interureteral ligament and a needle is inserted into the bed of the removed adenoma, trying to pull the triangle to the bed of the adenoma. Above the inserted catheter into the bladder, two deep sutures are placed through the tissue of the bed to the right and left of the catheter. To fix and adjust the permanent catheter, a thread is sewn to the end of the catheter located in the bladder, which is brought to the surface of the abdominal wall. Stitches on the wound. Thus, there was no complete blind suture in the Harris operation - thanks to the withdrawn thread fixing the catheter.

Hryntschak, following the basic principles of Operation Harris, made his own modifications. Hryntschak makes an incision above the pubis longitudinally along the midline. The muscles are moved to the side, the peritoneal fold is moved to the top of the bladder. The bubble opens stupidly. Through a tube inserted into the bladder, urine is sucked out of the bladder and the tube is removed. The bladder wound expands. Its side walls are taken on holders, after which the bladder is opened with dilators and examined. The adenoma is enucleated. To stop bleeding, catgut sutures are placed on the edge of the adenoma bed. Bleeding areas are stitched twice on both sides of the vessel. Hryntschak performs longitudinal dissection of the sphincter or wedge-shaped excision of the fundus

bladder from the interureteric ligament to the sphincter. The author believes that after removal of the adenoma, the protrusion of the bottom of the bladder hangs over the bed and interferes with the passage of the catheter. The bed is sutured with several deep sutures, a rubber catheter is inserted, which is sewn with one suture to the wall of the adenoma bed. A purse-string suture is applied to the wall of the bladder, without puncturing the bladder mucosa, and a second submersible purse-string or zeta-shaped suture is applied.

After suturing, the bladder is checked for leaks. A disinfectant liquid is injected into the bladder under pressure and the strength of the sutures is monitored. Sutures on the aponeurosis and skin.

V.V. Goldberg, starting in 1953, developed a method of adenomectomy with a primary blind suture. The author believes that what is common to the operations of Harris, Grinchak and the one he proposes is hemostasis of the bed and suturing of the bladder wound. Only technical details of execution distinguish these operations from each other,

V.V. Goldberg makes a median incision between the navel and the pubis, dissects the skin, subcutaneous tissue, aponeurosis, the muscles are retracted to the side, the peritoneal fold is moved upward. The bladder is opened bluntly, as far as possible from the symphysis. Urine is removed from the bladder using a slope through a tube. The walls of the bladder are stretched in the transverse direction and hemmed to the track. A special wound retractor is inserted into the bladder cavity, and the mucous membrane over the adenoma is dissected with an electric knife or scalpel. The adenoma is removed under eye control. The bladder cavity and bed are freed from blood clots. If there are large, heavily bleeding vessels, they are punctured and the edges of the bed are sutured on both sides. After this, transverse sutures are applied to the bed. Drainage is carried out into the bladder through the urethra. Purse-string suture on the wall of the bladder, without piercing the mucous membrane, the second immersion suture is z-shaped. The tightness of the sutures is then checked by filling the bladder with aseptic liquid. The liquid is injected under pressure with a Janet syringe. After making sure of the tightness, layer-by-layer sutures are applied to the wound. Unlike Hryntschak, V.V. Goldberg does not dissect the bottom of the bladder. Instead of a catheter, a drain is inserted into the bladder, which provides better drainage of urine from the bladder. To more effectively remove blood clots from the bladder, the author uses the aspiration irrigator he proposed.

V.V. Goldberg also uses a blind suture for two-stage adenomectomy. By the way, the latter amounted to about two percent.

Conditions for the healing of a bladder wound after the application of a blind suture during a two-stage adenomectomy are less favorable, and wetting occurs more often than after a one-stage operation. However, this does not affect the results of final wound healing, which occurred in all patients. With two-stage adenomectomy using a blind suture, the postoperative period was significantly shorter compared to bed tamponade and suprapubic drainage.

It seems to us that the success of an operation with a blind suture, developed in detail and carefully by V.V. Goldberg, largely depends on postoperative care for patients. Despite hemostasis and suturing of the bed, there is a high possibility of clots forming and blocking the urethral drainage, resulting in urine leakage through the sutures. To avoid side complications, it is necessary to rinse the bladder every 1-2 hours or use the author’s aspiration irrigator. Without personal experience, we still believe that this method should find wider application and distribution. It's simple

every 1-2 hours or use the author’s aspiration irrigator. Without personal experience, we still believe that this method should find wider application and distribution. It is simple, easily accessible, not dangerous, has few complications and a low mortality rate. The mortality rate with this method was 3.9% per 1000 operations, and with a two-stage operation - 5.5%.

A new extravesical adenomectomy was performed behind the forehead. The idea of ​​approaching the prostate gland through the extravesical route belongs to Van Stockum. A. T. Lidsky (1923) developed this operation in detail. MiShp in 1945 began to widely promote this method of treatment. Retropubic adenomectomy has become quite widespread in America and Europe. In the Soviet Union, this operation did not find wide distribution and was used in three or four urological departments by several authors (L. Ya-Schnitser, C. A. Sinkevichus, I. I. Sabelnikov, A. A. Avdeev, etc.).

This operation is used mainly for rectal forms and moderate sizes of viutripesical adenomas.

Operation technique. A rubber catheter is inserted, through which the bladder is washed with a disinfectant solution. The patient is placed on the table with the pelvis slightly elevated. A transverse or midline incision exposes the paravesical space. The transversalis fascia is incised at the pubis. Paravesical tissue, together with the peritoneum, moves posteriorly and upward. At the junction of the bladder and the urethra, the prostatic capsule is freed from fiber, taken with ligatures and dissected. The capsule is dissected to the adenoma with a transverse (Lenco and Ciesllnski), longitudinal or arcuate (C. A. Sinkevichus) incision. The adenoma is isolated bluntly. The prostatic part of the urethra is dissected transversely and removed along with the adenoma. Extraurethral removal of an adenoma is quite rare; as a rule, the urethra is damaged. The bleeding stops, the capsule is sutured with a two-story suture. A rubber catheter is connected to the capsule. A permanent rubber catheter is fixed to the penis.

Macroscopic hematuria usually lasts 3-4 days, and microscopic hematuria lasts about a week. According to Lenco and Cieslinski, hematuria resolved after 3 days in 73%, in 24% after 4-6 days, and in the rest after 6-7 days. The permanent catheter is removed on the 7-8th day.

The operation may be accompanied by complications. These include symptoms of cardiac weakness, shock, injury and late bleeding, tamponade of the bladder with blood clots, leakage of urine through the wound after removal of the catheter.

Quite often, the operation is complicated by osteitis of the pubic bones, which develops 2-5 weeks after the operation. The first symptom of the disease is pain in the suprapubic region, in the perineum and on the inner thighs. On the 3-5th day after the onset of the disease, tension in the thigh muscles appears, movement of the legs, and an attempt to take a sitting position increases the pain. The temperature of most people is normal, but it may increase

13 Ed. M. N. Zhukova

swing up to 38°. At the same time, hemoglobin decreases sharply, the number of red blood cells decreases, and ROE accelerates.

X-ray of the pelvic bones in the first days of the disease does not show any changes. Only in the second or third week are socket discharges and osteoporosis of the pubic and ischial bones noted on the x-ray.

Treatment of osteitis consists of rest, the use of x-ray therapy, UHF, cortisone, etc.

In the clinic of A.P. Frumkin, 12 patients with osteitis were observed. Of the 35 patients operated on with the retropubic method, osteitis was observed in 8, and of the 358 patients operated on transvesically, osteitis was observed in 4. Thus, osteitis occurs much more often after the use of the retropubic method of surgical treatment of prostate adenoma. Other authors have not seen such a high percentage of complications from retropubic adenomectomy.

Perineal adenomectomy began to be used much earlier than transvesical adenomectomy, but at first it did not become widespread due to the frequency of serious postoperative complications in the form of urinary incontinence, rectal perineal fistulas, etc. The development and study of topographic and anatomical data of the perineum and pelvis made it possible to gradually improve the results of surgical intervention. This operation has become widespread in America, as well as in some other countries. In the Soviet Union it is rarely used.

Indications for perineal adenomectomy are considered to be more favorable rectal forms, as well as obese patients with suspected prostate cancer.

Contraindications to surgery are a very narrow pelvis, ankylosis in the hip joint, large intravesical adenoma and large bladder stones.

Operation technique. The patient is placed on the operating table in the gynecological position with the pelvis elevated and legs bent at the hip joints.

A metal bougie is inserted into the urethra. An arcuate incision is made in the perineum above the ischial tuberosities through the skin and subcutaneous tissue. First, the muscle running between the anus and the bulbar part of the urethra is cut, then the muscle running from the urethra to the rectum is cut. Muscle dissection should not damage the rectum and bulbar urethra. The wound is spread wide with hooks, and the surface of the prostate gland becomes clearly visible. The prostatic capsule is incised transversely 1 cm below the apex of the prostate. The adenoma is peeled off using sharp or blunt means; The urethra is divided at the point where the urethra enters the prostate. Using a special instrument, a spoon, the bladder cavity is examined for the presence of stones. Some authors use a Jung tractor when removing an adenoma.

After revision of the adenoma bed, a rubber catheter is passed through the urethra into the bladder. The urethra and bladder neck are sutured with four interrupted sutures. A tampon or rubber strip is inserted into the bed. Stitches on the wound. The tampon is removed from the adenoma bed on the 3-4th day. The bladder is washed daily with saline solution. The catheter is removed after the wound on the perineum has healed.

M. N. Enfendzhiev, using perineal adenomectomy, did not see complications in 93% of patients. There were no postoperative fistulas, urinary incontinence, or strictures observed. Complete healing of the wound occurred in 8-15 days. Turner and Belt, in 6% of operated patients, temporary urinary incontinence was observed, in 2% - permanent incontinence, in 9% - epididymitis, 5% of patients received epididymitis after bilateral ligation of the vas deferens. Many patients develop impotence. Perineal adenomectomy has many different modifications.

Ischeo-rectal adenomectomy. The method of ischeorectal adenomectomy is not used in urological clinics of the Soviet Union. This method is rarely used abroad.

Operation technique. The patient is placed on the operating table on his stomach, with his legs lowered and bent at the knees. A cushion is placed under the basin. The anus is closed. The incision starts from the base of the coccyx and continues to the right or left of the anus and slightly lower. The gluteal and levator muscles are incised and moved to the side. The rectum is moved to the side and held in place. The prostate capsule is opened; Through an incision, a Young's “tractor” is inserted into the urethra, which tightens the adenoma, and enucleation occurs. After revision of the adenoma bed, a rubber catheter is passed through the urethra into the bladder. A suture is placed above the catheter between the urethra and the neck of the bladder. Through a wound in the perineum next to the catheter, drainage is inserted into the bladder. The drainage tube is removed 8 days after surgery, and the catheter is removed 10 days later.

Long-term debridement of adenomectomy. Long-term complications of all methods of adenomectomy include: urinary incontinence, bladder stones, chronic cystitis, non-healing suprapubic fistula, strictures, osteitis, impotence.

Urinary incontinence is often caused by atony of the sphincter or its significant destruction at the time of surgery. Most authors note that this is more often observed with perineal than with suprapubic adenomectomy.

Bladder stones or encrustation of pieces of tissue with salts occur more often in patients where the adenoma was difficult to bulge and necrotic tissue was slowly rejected; With infected urine and an abundance of salts, the possibility of stone formation is greater.

Chronic cystitis is most often supported by encrusted tissue debris. In some patients, suprapubic vesical fistulas do not close for a long time or do not close at all. This happens due to cystitis or labial fistula. Strictures are sometimes observed. Careful bougienage and the use of lidase can quickly restore the patency of the urethra.

Osteitis occurs rarely, and, as we mentioned, they most often occur in patients after retropubic adenomectomy.

After suprapubic adenomectomy, according to various authors, the average mortality rate ranges from 6.4% to 2%; with retropubic adenomectomy, the percentage of deaths is approximately the same - it is equal to 6.3-1.8%; after perineal adenomectomy - 11-1.6%.

It is difficult to say which method of surgical intervention is better. For the authors who have developed this or that method of adenomectomy, who have great skill, experience, and good postoperative results, it is the best. And it can be very difficult to give up, perhaps in favor of a better way. Wanting to be objective in choosing the method of adenomectomy, we would give preference to simultaneous adenomectomy with a blind suture. Of course, guided by the developed indications for this operation. The great advantage of this method is that the entire operation is carried out under visual control; in addition, the shape of the adenoma does not matter here (whether we are dealing with intravesical or rectal forms, whether there are stones in the bladder, large or small). A detailed examination of the bladder with retropubic, perineal, and ischiorectal methods is impossible.”

• stones were found in the urinary system;
• the patient cannot go to the toilet independently;
• there were problems with the functioning of the kidneys.

Surgery will also be prescribed if taking medications does not produce the expected effect.

Causes of mucus and squamous epithelium in prostatic secretions

When collected under a microscope, no more than two epithelial cells should be detected.

Exceeding the norm is a sign of inflammation of organ tissue. High values ​​indicate that the man has desquamatous inflammation, that is, the epithelial linings are peeling.

The appearance of mucus signals that the ducts of the gland are swollen, and the lumen is clogged with secretions, sometimes with pus.

Video on the topic

About prostate adenoma in the video:

If a violation is suspected, it is important to determine its size and volume. These parameters are very important when making a diagnosis. The size of the prostate changes with benign enlargement of the organ - hyperplasia (adenoma).

Size matters when prescribing medications and indications for surgery. Ultrasound and TRUS allows not only to determine the size, but also to study the structure of the organ.

If you suspect a prostate adenoma, especially if a man has trouble urinating, he should consult a urologist. Early diagnosis of the disease allows drug therapy without surgical intervention.

- this is prostate adenoma grows from the rudiments of the paraurethral glands and is located in the submucosal layer of the urethra.

Etiology and pathogenesis.

The proliferation of paraurethral glands is accompanied by compression and atrophy of the prostate parenchyma.
Under the influence of the adenoma, the shape of the gland changes: it becomes round, pear-shaped, consists of 3 lobes that cover the urethra and deform its lumen, the adenoma is surrounded by connective tissue.
The lobe of the gland can, like a valve, block the internal opening of the urethra and cause stagnation of urine in the bladder, upper urinary tract, and kidneys.
The lumen of the ureter with prostate adenoma is expanded up to the pelvis. The disease ends with the development of bilateral pyelonephritis and chronic renal failure.
Circulatory disorders in the bladder neck and prostate gland and hypoxia lead to a decrease in the level of tissue metabolism with a decrease in detrusor contractility.

Clinic.

Symptoms of the disease depend on the degree of impairment of the contractile function of the bladder; therefore, three stages are distinguished.

In the first stage, the adenoma is manifested by frequent urination, especially at night. The first stage lasts 1–3 years, there is no residual urine, the gland is enlarged, has a dense elastic consistency, its boundaries are clearly defined, the median sulcus is well palpated, palpation of the gland is painless.

In the second stage, residual urine appears; sometimes the urine is cloudy or mixed with blood, acute urinary retention is observed, and symptoms of chronic renal failure are added.

In the third stage, the bladder is greatly distended, cloudy or blood-tainted urine is released drop by drop; weakness, weight loss, poor appetite, anemia, dry mouth, constipation are observed

Diagnostics.

On palpation, the gland is enlarged, densely elastic, hemispherical. Cystoscopy reveals bladder diverticula and trabecularity, which makes the ureteric orifices sometimes difficult to detect. Excretory urography reveals functional and morphological changes in the kidneys and ureters. Radionuclide methods are used to study kidney function and determine the amount of residual urine. Informative echography.

Treatment.

TYPES OF SURGICAL TREATMENT OF PROSTATE ADENOMA

Surgery makes it possible to free the urethra from prostate pressure. In this case, the overgrown organ is not completely removed, but only partially. This leads to normalization of the process of urine outflow, eliminating the occurrence of stagnation.

In the surgical treatment of prostate adenoma, two methods are used:

1. Transvesical adenomectomy

TOUR - TRANSURETHRAL RESECTION OF THE PROSTATE

in a supine position. His legs are bent at the knees and spread wide apart. The doctor inserts a resectoscope into the urethra. This is a special instrument equipped with a microscopic camera. The image is transferred to the monitor. This allows the specialist to constantly monitor his actions. The resectoscope cuts off the gland tissue that is compressing the urethra. Cauterization of the circumcised vessels helps prevent bleeding.

The removed pieces of tissue are sent for examination to determine the nature of the formation and ensure the absence of cancer cells.
After the operation of the prostate adenoma itself is completed, a tube made of latex or silicone is installed in the urethra. At its end there is a urinal.

TRANSVESICAL (TRANSVESICAL) ADENOMECTOMY

Transvesical adenomectomy is a more traumatic method of surgical treatment of prostate adenoma. To remove tissue that puts pressure on the urethra, in the area of ​​the abdominal cavity between the pubis and the navel, the surgeon cuts the skin, subcutaneous fat, muscles and bladder wall. Then the existing adenoma nodes are removed using fingers. In addition to the catheter, which is installed in the urethra, sometimes a drainage cystostomy tube is inserted into the surgical incision.
This removal of prostate adenoma requires a longer hospital stay than after a TURP.

Pathological anatomy. PDA, which arises from the paraurethral glands located in the circumference of the prostatic urethra, can have a different configuration. It consists of 2 or 3 lobes, which have nothing in common with the lobes of the prostate gland itself. By this time, the prostate gland itself is pushed by the adenoma under great pressure to the periphery and atrophies. Basically, it turns into a surgical capsule, at the border with the rectum - into a thin plate, where elements of parenchymal tissue are preserved to a small extent. According to the configuration, several variants of the APL are possible. It can consist of two lateral lobes, one middle lobe, three lobes, or be grape-shaped.

The lateral lobes are characterized by asymmetry in size and configuration. However, the surface of the adenoma is smooth, the consistency is elastic, homogeneous. The configuration of the internal opening of the urethra is characteristic, where the internal sphincter of the bladder is stretched; it looks crater-shaped and at the same time in the form of a gap, sometimes forked.

Its dimensions correlate with mass. An adenoma up to 30 g is considered small, a medium - up to 70 g, a large - up to 250 g. Giant PCA are also possible. Depending on the topography, intravesical, rectal and mixed forms are distinguished. Clinical manifestations also depend on this.

About the rectal form already mentioned. Bladderwort is characterized primarily by a disorder of urination. In such patients, only the middle lobe may be adenomatous, but its effect on the internal sphincter of the bladder is quite pronounced.

The prostatic part of the urethra is compressed, the mucous membrane is swollen. This leads to pollakiuria, nocturia, stranguria and dysuria, and acute and chronic urinary retention is possible. Often the growth of adenoma is uniformly diffuse and intermediate in relation to the two extreme forms. The so-called cystic symptoms also occur, but they can be mild, even with a large adenoma.

ADENOMA

an excerpt from the book was provided by the Kron Press publishing house; the copyright for these texts belongs to the publishing house

Prostate adenoma

Prostate adenoma - a benign tumor of the prostate gland - has many synonyms that are widespread among doctors: dishormonal adenomatous prostatopathy, adenoma of the cranial part of the prostate gland, periurethral adenoma, nodular hyperplasia of the prostate gland, adenoma of the paraurethral glands (Borisovsky N.M., 1936; Dunaevsky L. I., 1959; Tiktinsky O.L., 1990; etc.).

EPIDEMIOLOGY, ETIOLOGY AND PATHOGENESIS OF PROSTATE ADENOMA

Prostate adenoma is one of the most common diseases among men over five decades old. Only according to official statistics, enlargement of the prostate gland in residents of large Russian cities who have reached the age of 50 is observed in 15-20% of subjects. In this regard, it would be legitimate to talk about<пандемии>of this disease. Prostate adenoma is certainly not a new disease, although in ancient times no one called it that, but many described the symptoms. So, Avicenna in<Каноне врачебной науки>not only describes the symptoms of the disease, but also gives very instructive methods of treatment:<Вот полезное лекарство для стариков, страдающих мочеиспусканием по каплям: если ввести в задний проход мумие, разведенное в масле жасмина, или капать им в мочевой канал, то больной будет способен удерживать мочу; так же действует прием в пищу инжира с оливковым маслом>. Today, our Russian scientists, using the gifts of nature, also focus on natural preparations containing biologically active natural components. Thus, produced by the Volgograd NPO<Европа-Биофарм>pumpkin preparations (<Тыквеол>And<Простабин>) are not only accumulators of biologically active substances, including saturated and polyunsaturated fatty acids, but also contain vegetable oils.

The nutritional characteristics of the rural population, as well as the population of Asian and African countries, and their especially widespread use in nutrition of vegetable oils containing polyunsaturated fatty acids, are accompanied by a significantly lower level of patients with prostate adenoma and force us to pay some attention to this.

Of course, the age factor in the development of prostate adenoma is cumulative, including a number of changes that occur in the body and are usually accompanied by hormonal disorders, atherosclerosis, and a significant increase in body weight. Apparently, it is impossible not to take into account the influence of accompanying factors, which include: environmental factors, stress, age-related lifestyle changes.

We must not, of course, forget that a fifty-year-old patient’s history of previous or existing prostatitis of any etiology should also serve as a warning factor in terms of the development of prostate adenoma.

Currently, there is no unified theory of the etiology and pathogenesis of the development of prostate adenoma. However, if we combine the works of domestic and foreign scientists, we can state that the theory should have received the greatest distribution<гормонального дисбаланса>, directly related to age-related changes occurring in the body of men who have stepped beyond the fifth decade. According to this theory of estrogen-androgen imbalance, a prostate tumor should develop gradually from the periurethral (paraprostate) glands and lead to enlargement of the prostate gland and hyperplasia of the glandular epithelium. However, the harmony of this theory is very contradictory, since some authors speak more in favor of the importance of estrogens in the development of adenoma, others - androgens; There are also opinions that hyperplasia begins from the cranial zone of the prostate gland itself and only then affects the periurethral glands (Klyucharev B.V., 1947; Shabad L.M., 1949; Konoplev V.P., 1953; Dunaevsky L.I. ., 1959, etc.). The role of pituitary gonadotropins and autonomic centers of the hypothalamus cannot be considered fully studied in the pathogenesis of the development of prostate adenoma.

The role of the biomicroelement zinc in the possible development of prostate adenoma due to its participation in the regulation of testosterone metabolism is very interesting and poorly studied today (J.Larul et al., 1985).

Of no less interest in the pathogenesis of the development of prostate adenoma is the recently studied prostate specific antigen (Murphy I.P., 1995). The bulk of this antigen is synthesized in the cells of the glandular epithelium of the prostate and is then excreted through the ducts into the prostatic part of the urethra, mixing with the components of seminal fluid during ejaculation or secretion. Currently, differences have been discovered in the structure of RNA transcripts and prostate specific antigen in normal and pathologically altered prostate tissue. The probable biological significance of prostate specific antigen production in the prostate may be as follows. Firstly, the high proteolytic activity of prostate juice and mixed seminal fluid, caused mainly by this antigen, ensures the breakdown of the high molecular weight protein of seminal fluid - seminogelin - after ejaculation. This reduces the viscosity of seminal fluid and possibly increases sperm motility, although the latter has not been proven. Secondly, proteolysis occurs of fibronectin, which is part of the seminal fluid and, possibly, is an inhibitor of prostate cell growth factors. Thirdly, it is known that insulin-like growth factors (IGFs) are formed in prostate stromal cells, which act paracrinely on neighboring epithelial cells that have corresponding receptors and stimulate their reproduction. The mitogenic effect of IPFR is limited by special proteins that bind IPFR. Several such proteins have been found in human seminal fluid. These proteins, located in stromal cells, probably reduce the mitogenic activity of IGF towards prostate epithelial cells. Active prostate specific antigen in prostate tissue catalyzes the proteolysis of the above specific proteins and thus enhances the proliferation of these cells. Therefore, prostate specific antigen, by indirectly activating IPFR, can regulate and accelerate the proliferation of epithelial cells in both healthy and pathologically altered prostate glands. The question of the relationship between prostate specific antigen, androgens, peptide growth factors, as well as androgen and growth factor receptors, in normal conditions and in pathology, is very important and has not been fully clarified. In this regard, it is advisable to obtain comparative data on changes in the content of these components in prostate tissue or in its secretion in normal conditions and at the stages of development of prostate adenoma.

It has now also been established that in the stromal cells of the prostate, dihydrotestosterone is synthesized from testosterone - DTS (enzyme - 5-alpha reductase type 2), which, enhancing transcription in these same cells, induces in them the synthesis of various peptide growth factors (PGFs), including (IPFR), their receptors and 5-alpha reductase. The resulting PFR and DTS act autocrinely on the stromal cell, and also reach the prostate epithelial cells in a paracrine way, enhancing the synthesis of RNA and proteins in them, including PGF and prostate-specific antigen. All this together leads to accelerated proliferation of epithelial cells. As men age, the production of DTS in the prostate gland increases, which has not yet received a convincing explanation. An increased content of DTS in the prostate, caused by age-related or other factors, may be one of the triggers for benign or malignant hyperplastic processes (Zezerov E.G., 1998).

PATHOLOGICAL ANATOMY OF PROSTATE ADENOMA

Adenoma is a benign tumor arising from the glandular epithelium. Macroscopically, it is a clearly defined node, delimited by a capsule, located in the thickness of the organ. Microscopically, the adenoma consists of epithelial parenchyma and connective tissue stroma. The epithelium in an adenoma often retains the ability to produce secretions, as a result of the accumulation of which cystic cavities can form in the adenoma.

Histological examination of prostate adenoma often shows, along with the proliferation of glandular tissue, the presence of fibroadenoma (fibrous growth) and ademioma (proliferation of muscle fibers). In weight terms, this is accompanied by an increase in the mass of the adenoma from 30 to 200 or more grams.

Prostate adenoma consists of 2 or 3 lobes (middle and two lateral), which have nothing in common with the atrophied prostate itself. Prostate adenoma arises from the paraurethral glands. Depending on the nature of the growth of the adenoma, the following 3 forms are distinguished:

1) intravesical form, when growth is directed into the lumen of the bladder;

2) subvesical form (most common) - the growth of the adenoma is directed towards the rectum;

3) retrotrigonal form (rare), when growth is directed under the bladder triangle.

Growing adenomatous nodes cause compression of the prostatic part of the urethra, difficulty in the outflow of urine, accompanied first by hypertrophy of the muscular wall of the bladder, and then by its atony.

Acute and chronic urinary retention contributes to the ascending penetration of infection into the kidneys (due to vesicoureteral reflux), which often leads to the development of latent or chronic pyelonephritis. Pathological changes in the kidneys are characterized by an infiltrative or productive process in the interstitial substance of the medulla with damage to the renal tubules.

PROSTATE ADENOMA CLINIC

In the clinical course of prostate adenoma, three stages are distinguished:

Stage I - compensated, or the stage of precursors;

Stage II - subcompensated;

Stage III - decompensated.

In general, the clinical course of prostate adenoma depends primarily on the degree of bladder emptying and mainly comes down to urination disorders.

The compensated stage of adenoma is clinically characterized by the patient's complaints of frequent urge to urinate, especially at night, a delayed onset of urination, and a sluggish stream of urine. However, at this stage the patient’s bladder is still completely emptied, and there are no significant changes in the upper urinary tract.

In the second subcompensated stage, as a result of increasing difficulty in the outflow of urine from the bladder, compensatory hypertrophy of its muscular wall (detrusor) gradually develops, which is accompanied by the presence of residual urine after natural urination in an amount of 100 ml or more. The patient at this stage of the disease begins to feel a feeling of incomplete emptying of the bladder; he urinates in several stages with a sluggish thin stream.

In the first and second stages of the disease, cases of acute urinary retention, provoked by alcohol intake or hypothermia, are sometimes observed. However, catheterization leads to the restoration of urination.

The third, decompensated, stage of prostate adenoma is characterized by loss of tone of both the detrusor and the internal sphincter of the bladder. Clinically, this is manifested by the patient’s complaints of both urinary retention and urinary incontinence, expressed in the form of involuntary release of urine drop by drop when the bladder is full. This phenomenon has been defined<парадоксального мочеиспускания>.

DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS OF PROSTATE ADENOMA

Timely diagnosis of prostate adenoma is of great importance in terms of proper subsequent treatment of this disease. The examination of the patient begins with a thorough history taking. Particular attention is paid to complaints related to the nature of urination. An objective examination (examination, palpation, percussion) of the patient allows, with urinary retention, to identify a full bladder bulging above the symphysis pubis. A digital rectal examination performed by an experienced urologist reveals enlarged paraurethral glands, usually their two lobes, and not the prostate gland itself. The adenoma has clear boundaries, dimensions 4-6 _ 6-8 cm, a smooth, round, somewhat convex shape, a smoothed median interlobar groove, and a homogeneous dense-elastic surface. The rectal mucosa above the adenoma is freely mobile.

In the rectal form of prostate adenoma, the prostate protrudes significantly into the lumen of the rectum. With the cystic form, rectal digital examination is of little help.

Laboratory tests of urine and blood for uncomplicated prostate adenoma have no changes in clinical tests. According to Mrczinsk A. (1983) and Tiktinsky T.L. (1990), when patients have a combination of prostate adenoma and prostatitis, there is a significant increase in the blood serum of immunoglobulins of classes A, M, G, which is very important, since the secretion of the prostate gland with a tumor, as a rule, cannot be extracted.

Currently, very promising in the diagnosis of adenoma and prostate cancer is the determination of the concentration of total and free prostate-specific antigen in blood serum using a heterogeneous two-step enzyme immunoassay (Enzymun-Test PSA, , Germany). Research in this direction is just beginning, but few data indicate its promise. Kushlinsky N.E. et al. (1998) showed that the study of total and free prostate-specific antigen with subsequent analysis of the concentration of total and the ratio of free to total antigen makes it possible to use this method with greater accuracy in the differential diagnosis of adenoma and prostate cancer in the concentration range of total prostate-specific antigen up to 10 ng /ml.

Other methods for diagnosing prostate adenoma include the following: ultrasound (US), x-ray, cystoscopy, sphincterometry, radionuclide urofluometry, pneumocystotomography and some others.

It should be noted that due to disturbances in the outflow of urine in prostate adenoma, instrumental research methods, due to their traumatic nature, should be carried out only when indicated. Thus, the indication for cystoscopy is hematuria or suspicion of concomitant neoplasms of the bladder, identified after studies using ultrasound and x-ray.

The functions of the detrusor, urethra, vesicourethral segment and intravesical pressure can be characterized in a comprehensive study using cystomanometry, radionuclide uroflowmetry (Portnoy A.S., 1979), sphincterometry (Karpenko V.S., 1981).

Ultrasound examination is very important in modern diagnosis and differential diagnosis of prostate adenoma. Using ultrasound, it is possible to determine the size of the prostate gland, its structure, the presence of stones, as well as the amount of residual urine in the bladder. Currently, new generation ultrasound devices have appeared that allow transrectal ultrasound, which has improved the differential diagnosis of prostate adenoma complicated by cancer, prostatitis, etc.

In the X-ray diagnosis of prostate adenoma, a targeted radiograph of the bladder projection and pneumocystography are used. On a cystogram performed after urination, or a pneumocystogram (after catheterization of the bladder and administration of oxygen), it is possible to detect not only the presence of residual urine and calculate its amount, but also to detect a characteristic oval filling defect corresponding to prostate adenoma and calculi.

Using excretory urograms, the anatomical and functional state of the kidneys and upper urinary tract is assessed separately.

Of particular importance in the differential diagnosis of adenoma and prostate cancer is computed tomography performed in large clinics and diagnostic centers, which makes it possible to identify the contours, boundaries and homogeneity of a prostate tumor.

Radionuclide studies help determine kidney function, urodynamic status, and the amount of residual urine.

In order to exclude prostate cancer, when carrying out differential diagnosis with inflammatory nodes and areas of calcification in the adenoma, transperineal or transrectal biopsy is used.

Differential diagnosis is carried out mainly with diseases accompanied by similar urination disorders. Among these diseases, it is necessary to highlight the following: sclerosis of the prostate gland and bladder neck, chronic prostatitis, urethral stricture, prostate cancer, neoplasms of the urethra and bladder, bladder stones.

TREATMENT OF PROSTATE ADENOMA. CONSERVATIVE TREATMENT

Treatment of prostate adenoma can be conservative or surgical. The initial stages of the disease, especially the 1st, are treated conservatively. Conservative treatment is aimed at improving trophism and blood circulation in the pelvic organs, eliminating inflammation and reducing the size of prostate adenoma.

When carrying out conservative treatment, patients with prostate adenoma are recommended to: avoid hypothermia, prolonged sitting, eating spicy food, alcohol and significant amounts of liquid, especially at night. Patients are advised to take walks in the fresh air, exercise therapy with an emphasis on exercises for the muscles and organs of the pelvic floor and hips. Sexual life in such patients should continue and be rhythmic. Patients with concomitant cardiovascular diseases and edema need to be prescribed drugs that normalize the water-salt balance.

Among the drugs that normalize the act of urination and emptying the bladder, we can highlight androgens that increase the functional ability of the detrusor.

The most widely used androgens in domestic practice are testosterone propionate, methyltestosterone, sustanon and others.

A 5% oil solution of testosterone propionate is prescribed intramuscularly, 1 ml (50 mg) 2-3 times a week, a course of 6-8 injections.

Methyltestosterone, available in tablets of 0.005 g, is prescribed 1 tablet under the tongue 3 times a day. Course 1 month. If necessary, the course is repeated after a month.

Sustanon is a long-acting drug. It is administered intramuscularly at 0.5 ml (20% solution) once a month, for a course of up to 3 injections.

Among the drugs that cause disturbances in androgen metabolism in the prostate gland are progesterone and oxyprogesterone.

Progesterone is available in the form of ampoules containing a 1% oil solution. Intended for intramuscular administration of 2 ml 3 times a week for a monthly course.

Oxyprogesterone capronate is also an ampoule preparation containing a 12.5% ​​oil solution. It is administered in the same way, but 1 ml 3 times a week for 2 months.

Depostat is a long-acting drug. One milliliter of depostate contains 100 mg of gestonorone capronate in an oil solution. Depostat, like all oil solutions, is administered intramuscularly. Injections should be made very slowly, 1 ampoule (2 ml) once a week, course 2-3 months.

In the presence of prostate adenoma and prostatitis, patients are prescribed Raveron. Raverone is obtained from bovine prostate gland extract. One 1 ml ampoule contains 16 mg of prostate extract. Raverone is prescribed deep intramuscularly. On the first day, the injection dose is 0.3 ml, on the second day - 0.5 ml, then 1 ml per day or 2 ml every other day for 4 weeks.

The tableted analogue of Raverone is Robaverone, obtained from an extract of the pig prostate gland. Robaverone is prescribed 2 tablets 6 times a day, course 3 weeks.

The first in a new class of drugs that specifically inhibit the action of 5-alpha reductase, an intracellular enzyme that prevents the conversion of testosterone into the more active androgen dihydrotestosterone (DHT), was a drug marketed in the United States under the name Proscar. Proscar (finasteride, MSD) is a synthetic 4-azasteroid compound. Finasteride has no affinity for androgen receptors.

Prostate growth and subsequent adenoma development depend on the conversion of testosterone to DHT within the prostate. As with other androgen-stimulated processes, prostate adenoma develops slowly, and therefore a decrease in the clinical manifestations of the disease may require several months of treatment.

Proscar is indicated for the treatment and control of prostate adenoma. Proscar reduces DHT levels in the circulatory system and within the prostate. Within 24 hours of ingestion of this drug, there is a marked decrease in DHT levels in the circulatory system as a result of inhibition of 5-alpha reductase.

In long-term clinical trials in patients taking the drug at 5 mg per day, suppression of DHT was accompanied by a marked decrease in gland volume, an increase in maximum urinary flow rate, and a decrease in both general symptoms and symptoms of urinary tract obstruction. Control over the growth of the adenoma was maintained over the next two years, which indicates that treatment with Proscar can lead to a reversal of the disease.

Compared with baseline, patients showed improvement in all three primary efficacy measures at three months. Compared with patients taking placebo, after 3 months, patients had a statistically significant decrease in prostate volume and prostate-specific antigen levels of approximately 45%. Statistically significant changes compared to placebo were also observed in peak urinary flow rate at 4 months and in reductions in overall and urinary tract obstruction symptoms at 7 months.

Thus, Proscar is indicated for the treatment of prostate adenoma and control of its development. The drug causes a reduction in the size of the enlarged gland, improves urine flow and reduces symptoms associated with the adenoma.

The recommended dosage of the drug is 5 mg in one tablet per day with or without food. It is possible to achieve rapid improvement, but it may take at least 6 months for the doctor to assess the presence or absence of a beneficial effect. One of the positive aspects of using Proscar is that the same dose of the drug is used for both the elderly and patients with kidney failure.

In the treatment of prostate adenoma today, herbal preparations are also widely used, such as: permixon, trianol, prostagute, prostabin, pumpkinol.

Permixon is a lipid-sterol extract from the dwarf American palm Serenoa repens. The drug is an inhibitor of the metabolism of dihydrotestosterone, the main growth factor of adenoma, by blocking 5-alpha reductase and the binding of DHT to cytoplasmic receptors. These properties manifest themselves exclusively at the level of the target organ, without leading to shifts in hormonal homeostasis and without interacting with the hypothalamic-pituitary system. In addition, this extract has a clear anti-edematous effect, affecting the vascular phase of inflammation and capillary permeability.

Permixon contains 80 mg of extract in 1 tablet. Take the drug orally, 2 tablets 2 times a day with meals. Permixon is produced by a French company

Trianol is a natural extract of the bark of the Pygeum africanum tree, which does not have hormonal properties. One capsule of trianol contains 25 mg of biologically active lipidosterol complex.

Trianol reduces inflammatory reactions in prostate tissue, stimulates the regeneration of its epithelium and promotes the secretory activity of glandular tissue. Trianol quickly relieves pain, soothes urinary disorders and reduces the residual volume of urine in diseases of the prostate gland, especially in the case of prostate adenoma. Trianol does not have androgenic or extragenic properties.

Trianol is used in doses of 4 capsules per day or 2 capsules twice a day before meals for four to six weeks. The drug is produced in Slovenia.

Prostagut (prostoplant) is a herbal preparation created (manufacturer - company ) based on natural components (sabal palm fruit extract and stinging nettle root), intended for the treatment of the initial stage of prostate adenoma, disruption of the bladder emptying process, as well as irritation and weakness of the bladder sphincter without organic changes. The mechanism of action is associated with the suppression of aromatase and 5-alpha reductase.

Prostagute is produced in the form of capsules (mono and forte) and drops. Prostoplant only in capsule form.

Prostagut-mono contains 160 mg of lipophilic extract of sabal fruits in one capsule. Prostagute (Forte) in one capsule 160 mg of standardized extract from sabal fruits and 120 mg of standardized dry extract from stinging nettle. Prostagute (drops) - 30 drops contain 80 mg of standardized extract from sabal fruits and 60 mg of standardized dry extract from stinging nettle roots. Prostaplant - one capsule contains 320 units of lipophilic extract from sabal fruits.

Directions for use and dosage. Prostagute capsules - one 2 times a day, swallowing, without chewing, with a small amount of water. Prostaplant capsules - the same, but one capsule once a day. Prostagute drops - 20-40 drops 3 times a day, diluted in a small amount of water.

Russian industry (JSC NPO<Европа-Биофарм>, Volgograd) also produces herbal preparations for the treatment of prostate adenoma - prostabin and pumpkinol.

Prostabin is a protein-vitamin complex obtained from pumpkin seeds. The unique chemical composition of the drug determines the wide range of its effects on the body.

The specific effect of prostabin, associated with the normalization of prostate function, is explained by the presence of the microelement zinc in the composition of the drug. Under the influence of zinc, sperm motility improves, and the secretion of the gland acquires the viscosity necessary for the implementation of reproductive function. This has a beneficial effect on a man’s general well-being and his sexuality increases.

However, it should be noted that the unique chemical composition of prostabin determines a wide range of its effects on the body, including a possible indirect effect on the prostate. Thus, due to the presence in the preparation of essential amino acids necessary for the biosynthesis of proteins, hormones, and neurotransmitters in the body, it has a general strengthening effect, promotes better functioning of the central nervous system, and increases the overall defenses of the body. The vegetable protein included in prostabin, a characteristic feature of which is high bioavailability, has an anabolic effect, i.e. promotes complete biosynthesis of new proteins in the body. This increases muscle mass, increases the level of mental and physical performance, and optimizes energy processes in the body.

Vitamins C, B2 and B5, present in prostabin, determine its pronounced stimulating effect on the processes of tissue respiration in all organs, helping to increase the body's immune reactivity, improve the biosynthesis of hormones and neurotransmitters, and optimal hematopoiesis. Under the influence of vitamins, the biosynthesis of collagen, the main protein of connective tissue, improves.

For the treatment of prostate adenoma, the drug is recommended to be used 2-3 capsules 3 times a day before meals, long-term, for at least 3 months.

The effect of prostabin treatment increases with simultaneous use of the drug pumpkinol.

Pumpkin is an accumulator of biologically active substances contained in pumpkin - carotenoids, tocopherols, phospholipids, flavonoids, vitamins B1, B2, B6, C, P, PP, saturated, unsaturated and polyunsaturated fatty acids - palmitic, stearic, oleic, linoleic, arachidonic , linolenic.

Due to the anti-inflammatory and reparative properties of pumpkinol, inflammation of the prostate gland is relieved. Tykveol tones the bladder muscle, improves blood supply and oxygen supply. Increases the slipperiness of the inner walls of the urinary and seminal ducts.

In the combined (together with prostabin) treatment of prostate adenoma with pumpkinol, the latter is recommended to be used in microenemas (using the manufacturer's reusable plastic pipettes of 20 ml) 5-10 ml 1-2 times a day - morning and evening after bowel movements, for a course of at least 3 months.

In recent years, conservative treatment of prostate adenoma has been found in urology hospitals with complaints of acute urinary retention. The doctor must decide the question: to perform emergency (emergency) adenomectomy or catheterization of the bladder, followed by conservative, urgent (when the operation is delayed up to 24 hours) or delayed surgical treatment.

Failure to perform catheterization during emergency surgery is associated with the prevention of possible infection of the urethra by bacterial microflora.

In case of urgent surgical intervention, it is necessary to minimize possible complications associated with preliminary catheterization.

Contraindications to emergency and urgent adenomectomy are:

Bilateral acute pyelonephritis;

Suspicions or diagnosed bladder or prostate cancer;

Catheterization carried out over 3-4 days;

Cardiovascular and pulmonary failure;

Uncompensated diabetes mellitus;

Tuberculosis in the active stage;

Senile insanity and psychosis.

If it is necessary to stabilize the patient's condition, especially the functions of the bladder and kidneys, the first stage in the operation is epicystostomy, and only then, 1-2 months after it, radical therapy is carried out. In the interval between operations, additional clinical and urological examinations are carried out, and anti-inflammatory and antibacterial therapy is prescribed.

Currently, various options for surgical interventions for prostate adenoma are performed: one-stage adenomectomy with a blind suture and the application of removable sutures, one-stage retropubic adenomectomy according to Lidsky-Millin, a low-traumatic adenomectomy method based on physiological contraction of the prostate bed and the creation of hydrostatic hemostasis, two-stage adenomectomy according to Holtsov, transurethral resection of prostate adenoma, etc.

In case of early detection of prostate adenoma and the presence of its nodes with a volume of up to 60 cm2, transurethral electroresection is indicated.

If the adenoma is large or has a retrotrigonal shape, a so-called transvesical adenomectomy is indicated.

One of the common complications of transvesical adenomectomy of the prostate is stricture of the prostatic urethra, reaching 2-3.5%. The cause of this complication is rough manipulations during enucleation of the adenoma with damage to the posterior urethra, especially when removing the adenoma in one block, excessive suturing of the bladder neck and prolonged stay of the drainage in the urethra.

To prevent narrowing of the prostatic urethra, it is necessary to maintain the continuity of the urethra, which is possible in cases where the prostate adenoma appears as separate nodes (62%) with clear folds between them (commissures). For this purpose, Gamzatov A.G. et al. (1998) recommend the following: penetrating under the capsule of each lobe at the fold on both sides, peeling them separately, towards each other. The folds that remain will form part of the future urethra. To prevent bleeding during surgery and in the postoperative period, it is advisable to preliminary suturing the prostatic branches of the vesical arteries (according to Pytel Yu.A. et al., 1985), suturing bleeding vessels and suturing the adenoma bed to the catheter according to indications.

It should be noted that adenomectomy is often accompanied by a significant number of complications from 15 to 42% (Panteleev V.S., 1973; Bykov V.M. et al., 1973). Severe complications include: bleeding, prevesicle, cystitis, pyelonephritis, thromboembolism, cystic fistulas, strictures and obliteration of the urethra. All of the above dictates the need to find more gentle and effective methods for enucleation of adenomatous nodes, as well as reliable methods of hemostasis. In this regard, urologists are constantly improving their skills, offering new methods of performing adenomectomy. So, Golubchikov V.A. et al. (1998), using the Deschamps needle principle, developed a special needle for suturing the bed during transvesical adenomectomy. The use of a needle simplifies the technique of applying interrupted transverse catgut sutures, stitching the anterior segment of the capsule from the outside in, and reduces the risk of postoperative complications. This technique eliminates the need to tamponade the bed, and its stitching is carried out under strict visual control.

Dubrovin V.N. (1998) proposed a method for definitively stopping bleeding after prostate adenomectomy by urethrocystoscopy during surgery and transurethral electrocoagulation of bleeding vessels of the prostate bed, also under optical control.

The combination of laser technology and transurethral resection in the treatment of benign prostatic hyperplasia was proposed by V.A. Spirin. and Lipsky V.S. et al (1998). The advantages of the combined technique are the absence of intraoperative bleeding, rapid recovery dynamics and the possibility of radical treatment of patients with a large mass of prostate adenoma nodes.

Relatively new operations on the prostate gland include radical prostatectomy from the retropubic approach with preservation of the nerve bundle. This modification of radical prostatectomy has become more widespread in the United States than in European countries (Lepor, 1997).

Surgical interventions for prostate adenoma should be performed under general or epidural anesthesia.

COMPLICATIONS OF PROSTATE ADENOMA

The mechanism of development of inflammatory complications in prostate adenoma is closely related to the presence of stagnant (congestive) processes and activation of saprophytic microflora, provoked by frequent catheterization of the bladder.

The most common complications of prostate adenoma include: urethritis, cystitis, prostatitis, vesiculitis, epididymitis, acute and chronic pyelonephritis, renal failure.

Long-term, frequent urinary retention leads to overstretching and degeneration of the bladder walls, gaping of the ureteric orifice and, as a consequence, to anatomical changes.