1. General surgery and perioperative care
   Fluid/electrolyte balance, shock, sepsis, wounds, burns, nutrition, surgical infections, preoperative and postoperative care.
2. Trauma and emergency surgery
   ATLS assessment, head/chest/abdominal trauma, fractures, hemorrhage control, damage-control surgery.
3. Gastrointestinal and hepatopancreatobiliary surgery
   Esophagus, stomach, small bowel, appendix, colorectal disease, hernias, liver, biliary tract, pancreas, spleen.
4. Breast, endocrine, vascular, and urology
   Breast lumps/cancer, thyroid/parathyroid, arterial and venous disorders, urinary tract and prostate conditions.
5. Procedures, exam practice, and revision tools
   Operations, instruments, clinical cases, long and short questions, viva, MCQs, flowcharts, and mnemonics.

1. General surgery and perioperative care
   Fluid/electrolyte balance, shock, sepsis, wounds, burns, nutrition, surgical infections, preoperative and postoperative care.
2. Trauma and emergency surgery
   ATLS assessment, head/chest/abdominal trauma, fractures, hemorrhage control, damage-control surgery.
3. Gastrointestinal and hepatopancreatobiliary surgery
   Esophagus, stomach, small bowel, appendix, colorectal disease, hernias, liver, biliary tract, pancreas, spleen.
4. Breast, endocrine, vascular, and urology
   Breast lumps/cancer, thyroid/parathyroid, arterial and venous disorders, urinary tract and prostate conditions.
5. Procedures, exam practice, and revision tools
   Operations, instruments, clinical cases, long and short questions, viva, MCQs, flowcharts, and mnemonics.

• Acute appendicitis
• Intestinal obstruction
• Inguinal hernia
• Acute cholecystitis
• Shock
• Burns
• Breast carcinoma
• Thyroid swelling
• Head injury
• Perforated peptic ulcer

Enlarged Prostate: BPH, IPSS, Watchful Waiting, Medical Therapy, TURP and Open Prostatectomy

1. Core definition and terminology

• Benign prostatic enlargement (BPE): anatomical enlargement
• Benign prostatic obstruction (BPO): bladder outlet obstruction due to the enlarged prostate
• LUTS: lower urinary tract symptoms

Not every enlarged prostate causes LUTS, and not every man with LUTS has BPH or obstruction.

Pathology and mechanism

1. Ageing and androgenic stimulation, especially dihydrotestosterone (DHT), promote stromal and glandular hyperplasia.
2. Nodules arise in the transition/periurethral zone.
3. Enlarging lateral lobes and sometimes a median lobe compress or distort the prostatic urethra.
4. This causes increased bladder outlet resistance.
5. The detrusor initially hypertrophies, giving a trabeculated bladder.
6. Later, the bladder decompensates, producing residual urine, recurrent UTI, stones, chronic retention, hydroureteronephrosis, and renal impairment.

2. Clinical features: LUTS

A. Voiding or obstructive symptoms

• Hesitancy
• Poor urinary stream
• Intermittency
• Straining to void
• Terminal dribbling
• Sensation of incomplete emptying
• Acute or chronic urinary retention

B. Storage or irritative symptoms

• Frequency
• Urgency
• Nocturia
• Urge incontinence

3. IPSS: International Prostate Symptom Score

• Quantify symptom severity
• Assess the degree of bother
• Monitor response to watchful waiting, drug treatment, or surgery

Seven IPSS questions

1. Incomplete emptying
   “How often have you had the sensation of not emptying the bladder completely?”
2. Frequency
   “How often have you had to pass urine again within 2 hours?”
3. Intermittency
   “How often have you found that you stopped and started again while passing urine?”
4. Urgency
   “How often have you found it difficult to postpone urination?”
5. Weak stream
   “How often have you had a weak urinary stream?”
6. Straining
   “How often have you had to push or strain to begin urination?”
7. Nocturia
   “How many times do you usually get up at night to pass urine?”

Scoring

Interpretation

• 0: Delighted
• 6: Terrible

Viva pearl

IPSS measures symptom severity, but it does not prove bladder outlet obstruction. Definitive assessment of obstruction, when necessary, is by pressure-flow urodynamic studies.

4. Basic assessment before treatment

History

• LUTS and IPSS
• Duration and impact on quality of life
• Hematuria, dysuria, fever, UTI
• Retention episodes
• Drug history: anticholinergics, sympathomimetics, opioids, diuretics
• Diabetes, Parkinson disease, stroke, spinal disease
• Fluid, caffeine, alcohol intake
• Sexual function and erectile dysfunction

Examination

• Abdomen: palpable distended bladder
• External genitalia and meatus
• Neurological examination where indicated
• Digital rectal examination (DRE):
  • BPH: smooth, enlarged, firm-rubbery, non-tender prostate with obliterated median sulcus
  • Carcinoma: hard, irregular, nodular, asymmetrical prostate

Investigations

Uroflowmetry values

5. Watchful waiting

Definition

Suitable patient

• IPSS usually 0-7, or selected men with moderate symptoms
• Symptoms do not significantly impair quality of life
• No retention, recurrent UTI, bladder stones, renal impairment, or recurrent significant hematuria
• Low residual urine and no high-pressure chronic retention
• Patient understands when to return urgently

Measures

• Explain the benign nature after appropriate assessment
• Avoid excessive fluids and “fluid binges”
• Reduce evening fluid intake, especially if nocturia
• Reduce caffeine and alcohol
• Timed voiding and bladder training
• Review drugs that worsen voiding
• Treat constipation
• Manage diabetes, heart failure, sleep apnea, and other causes of nocturia
• Repeat IPSS, DRE, PVR, renal function, and PSA when indicated

Do not choose watchful waiting if there is:

• Refractory or recurrent retention
• Renal impairment due to obstruction
• Hydroureteronephrosis
• Recurrent UTI
• Recurrent gross hematuria due to BPH
• Bladder stones or diverticulum
• Severe bothersome symptoms despite conservative measures

6. Medical management

A. Alpha-1 blockers

Examples

• Tamsulosin
• Alfuzosin
• Silodosin
• Doxazosin
• Terazosin

Mechanism

• Prostate
• Prostatic urethra
• Bladder neck

Clinical use

• First-line drug for moderate-to-severe bothersome LUTS
• Particularly useful when rapid improvement is desired
• Benefit begins within days to weeks
• They improve symptoms but do not shrink the prostate or substantially prevent long-term progression.

Adverse effects

• Postural hypotension
• Dizziness and fatigue
• Headache
• Nasal congestion
• Retrograde ejaculation or reduced ejaculation
• Intraoperative floppy iris syndrome, especially with tamsulosin, relevant before cataract surgery

B. 5-alpha reductase inhibitors, 5-ARIs

Examples

• Finasteride
• Dutasteride

Mechanism

Effects

• Prostate shrinks by roughly 20-25%
• Reduces risk of acute urinary retention
• Reduces future need for surgery
• Onset is slow: meaningful benefit requires 4-6 months, often longer
• Serum PSA falls by approximately 50% after adequate treatment. Interpret PSA accordingly.

Indications

• Moderate-to-severe LUTS
• Enlarged prostate, generally >40 mL
• PSA suggestive of increased prostate volume/progression
• Concern about disease progression, retention, or surgery

Adverse effects

• Reduced libido
• Erectile dysfunction
• Ejaculatory dysfunction
• Reduced semen volume
• Gynecomastia or breast tenderness, less common

C. Combination therapy: alpha-blocker + 5-ARI

Indication

Rationale

• Alpha-blocker gives rapid symptom relief.
• 5-ARI reduces prostate size and long-term risk of retention/surgery.

D. Other useful drugs

7. Indications for surgery in BPH

Absolute or strong indications

• R: Refractory or recurrent urinary retention
• U: Upper tract dilatation, hydroureter/hydronephrosis
• S: Stones in the bladder
• H: Hematuria, recurrent and attributable to BPH after exclusion of other causes
• S: Sepsis or recurrent UTI due to obstruction

• Renal impairment due to obstruction
• Large bladder diverticulum with obstruction
• Severe symptoms affecting quality of life despite conservative/medical therapy

8. TURP: Transurethral resection of prostate

Definition

TURP removes the obstructing transition-zone adenoma. It is not a radical prostatectomy and does not remove the entire prostate.

Indications

• Bothersome moderate-to-severe LUTS refractory to medical therapy
• Recurrent/refractory urinary retention
• Recurrent UTI, bladder stones, hematuria, diverticulum, renal impairment from BPO
• Usually preferred for prostate size approximately 30-80 mL, depending on surgeon skill, anatomy, and available technology

Contraindications or situations requiring caution

• Untreated UTI
• Uncorrected coagulopathy
• Unfit for anesthesia
• Very large prostate, where open simple prostatectomy or enucleation may be preferable
• Suspected untreated prostate cancer requires appropriate evaluation first

Preoperative preparation

• History, IPSS, DRE
• Urine culture and treat infection
• CBC, renal function, electrolytes, coagulation screen
• Ultrasound for prostate size, PVR, upper tract if indicated
• PSA and prostate cancer assessment when appropriate
• Stop/adjust anticoagulants where safe
• Informed consent: bleeding, infection, TUR syndrome, retrograde ejaculation, erectile dysfunction, incontinence, stricture, bladder-neck contracture, reoperation

Basic operative principle

1. Spinal or general anesthesia.
2. Resectoscope introduced per urethra.
3. Cystoscopy is performed to assess urethra, prostate, bladder, stones, and tumors.
4. Resection begins with obstructing tissue, commonly median lobe if present.
5. Prostatic tissue is resected in chips while preserving:
   • Ureteric orifices
   • External urethral sphincter, distal to verumontanum
   • Prostatic capsule
6. Hemostasis is achieved.
7. Chips are evacuated and sent for histopathology.
8. A three-way Foley catheter is inserted for continuous bladder irrigation.

Postoperative care

• Continuous bladder irrigation until urine clears
• Monitor catheter patency, urine color, clots, input-output
• Check hemoglobin and electrolytes if significant bleeding or prolonged procedure
• Analgesia and antibiotics according to local protocol
• Catheter generally removed after 1-3 days when hematuria settles
• Trial of void and measurement of PVR
• Warn about temporary dysuria, frequency, urgency, and hematuria during healing

Complications of TURP

Early

• Hemorrhage and clot retention
• UTI/sepsis
• Bladder perforation
• Capsular perforation and extravasation
• Failure to void
• DVT/PE, anesthetic complications
• TUR syndrome

TUR syndrome

• Nausea/vomiting
• Restlessness, confusion, seizures
• Bradycardia
• Hypertension initially
• Pulmonary edema
• Hyponatremia

1. Stop surgery and irrigation.
2. ABC resuscitation and oxygen.
3. Check electrolytes and ECG.
4. Restrict fluid and give loop diuretic if fluid overloaded.
5. Severe symptomatic hyponatremia requires carefully monitored hypertonic saline in a high-dependency/ICU setting.
6. Bipolar TURP uses normal saline irrigation and markedly reduces this risk.

Late

• Retrograde ejaculation: common
• Erectile dysfunction
• Urethral stricture
• Bladder-neck contracture
• Persistent storage symptoms/urge incontinence
• Rare stress urinary incontinence due to sphincter injury
• Recurrent adenoma and need for re-treatment

9. Open simple prostatectomy

Definition

It is different from radical prostatectomy, which removes the whole prostate, seminal vesicles, and often pelvic lymph nodes for prostate cancer.

Indications

• Very large gland, commonly >80-100 mL
• Large median lobe/large intravesical protrusion
• Coexisting bladder stone requiring open cystolithotomy
• Large bladder diverticulum requiring diverticulectomy
• Inability to perform or lack of availability of endoscopic enucleation
• Failed prior endoscopic procedure in selected cases

Types

A. Freyer's transvesical prostatectomy

Main steps

1. Lower midline or Pfannenstiel incision.
2. Open the bladder.
3. Inspect bladder, ureteric orifices, median lobe, stones, and diverticula.
4. Circumferential mucosal incision at the bladder neck around the adenoma.
5. Finger enucleation of adenoma along the surgical capsule.
6. Achieve hemostasis by suturing or packing.
7. Insert urethral Foley catheter, usually with suprapubic drainage depending on local practice.
8. Close bladder and provide drainage.

Advantages

• Direct access to bladder
• Easy removal of concomitant large bladder stones
• Useful for very large median lobe and huge adenoma

Disadvantages

• More invasive
• Greater blood loss
• Longer admission and catheter duration
• Wound-related complications

B. Millin's retropubic prostatectomy

Main principle

Advantages

• Avoids cystotomy
• Useful for large prostate when bladder surgery is not needed

Disadvantages

• Less suitable if large bladder stones/diverticulum need simultaneous treatment
• Risks include bleeding, urinary leak, and injury to surrounding structures

10. TURP versus open simple prostatectomy

11. High-yield management flowchart

Male with LUTS
       ↓
History + IPSS + DRE + urinalysis/culture
Creatinine, PVR, uroflowmetry ± PSA/ultrasound
       ↓
Exclude: UTI, cancer, stricture, stones, neurogenic bladder,
diabetes, overactive bladder, drugs
       ↓
Mild symptoms, not bothered, no complication?
       ↓
Yes → Watchful waiting + lifestyle modification + follow-up
       ↓
No / bothersome moderate-severe symptoms
       ↓
Alpha-1 blocker
       ↓
Large prostate (>40 mL) or high progression risk?
       ↓
Add 5-alpha reductase inhibitor
       ↓
Persistent symptoms or complication of BPO?
       ↓
Surgery
       ↓
30-80 mL → TURP / bipolar TURP / suitable endoscopic option
>80-100 mL → HoLEP if available, or open/robotic simple prostatectomy

12. Important viva questions

1. What is BPH?
   Histological hyperplasia of stromal and epithelial elements in the transition zone of the prostate.
2. Where does BPH occur?
   Transition zone/periurethral region.
3. Where does prostate carcinoma commonly arise?
   Peripheral zone.
4. What is the IPSS range?
   0 to 35.
5. Interpret IPSS.
   Mild 0-7, moderate 8-19, severe 20-35.
6. Does a high IPSS prove obstruction?
   No. It quantifies symptoms; obstruction is confirmed by pressure-flow studies when required.
7. How do alpha-blockers work?
   Relax smooth muscle at prostate and bladder neck, reducing dynamic obstruction.
8. How do 5-ARIs work?
   Inhibit conversion of testosterone to DHT, shrinking prostate and reducing progression.
9. Which drug class lowers PSA by about 50%?
   5-alpha reductase inhibitors.
10. What is the gold-standard operation for BPH?
    TURP for appropriately sized prostates.
11. What is TUR syndrome?
    Dilutional hyponatremia and fluid overload due to absorption of hypotonic irrigating fluid during monopolar TURP.
12. Name indications for surgery in BPH.
    Retention, renal impairment/hydronephrosis, recurrent UTI, recurrent hematuria, stones, diverticulum, and failed medical therapy with severe bothersome symptoms.
13. What is the difference between simple and radical prostatectomy?
    Simple prostatectomy removes/enucleates adenoma for BPH. Radical prostatectomy removes the entire prostate for cancer.

One-minute revision

• BPH = transition-zone stromal + glandular hyperplasia.
• IPSS = 7 urinary symptoms, total 0-35; mild 0-7, moderate 8-19, severe 20-35.
• Watchful waiting = mild/non-bothersome uncomplicated LUTS.
• Alpha-blocker = rapid symptom relief; relaxes prostate/bladder-neck smooth muscle.
• 5-ARI = slow action, reduces prostate volume and progression; PSA falls about 50%.
• TURP = standard operation for moderate-sized glands.
• Open simple prostatectomy = large prostate, generally >80-100 mL, or associated large bladder stone/diverticulum.
• TUR syndrome = water intoxication/dilutional hyponatremia from hypotonic irrigation.

Carcinoma of Prostate: Clinical Presentation and Management

Definition

• Bailey & Love's Short Practice of Surgery, p. 1553
• Robbins & Kumar Basic Pathology, pp. 661-662

Clinical presentation

1. Early localized prostate cancer

• Raised PSA on risk-based testing
• Abnormal DRE: hard nodule, induration, asymmetry, or irregularity
• Incidental carcinoma in TURP tissue for presumed BPH:
  • T1a: tumor in ≤5% of resected tissue
  • T1b: tumor in >5% of resected tissue
• MRI followed by targeted/systematic biopsy

Early prostate cancer does not usually cause LUTS because it arises peripherally, away from the urethra.

2. Locally advanced disease

Symptoms

• Lower urinary tract obstruction:
  • Poor stream, hesitancy, intermittency
  • Incomplete emptying
  • Acute or chronic retention
• Hematuria
• Pelvic or perineal pain
• Ureteric obstruction causing hydronephrosis and renal failure
• Rarely rectal symptoms: tenesmus or constipation due to rectal compression

3. Metastatic disease

Features of metastases

• Persistent lower back, pelvic, hip, rib, or bone pain
• Pathological fracture
• Spinal metastasis with cord compression:
  • Severe back pain
  • Limb weakness
  • Sensory loss
  • Bladder/bowel dysfunction
• Malaise, anorexia, weight loss
• Anemia or pancytopenia due to marrow infiltration
• Lower-limb edema from pelvic lymph-node obstruction
• Renal failure from bilateral ureteric obstruction

• Bailey & Love's Short Practice of Surgery, pp. 1553-1555

Examination

General examination

• Pallor and weight loss
• Bony tenderness
• Leg edema
• Neurological deficit or signs of spinal cord compression
• Palpable distended bladder in obstruction/retention
• Supraclavicular lymphadenopathy in advanced disease

DRE findings

• Hard or stony hard
• Irregular or nodular
• Asymmetrical
• May have obliteration of median sulcus
• May be fixed in locally advanced disease

Investigations

Initial tests

PSA: high-yield points

• PSA is prostate-specific, not cancer-specific.
• PSA rises in cancer, BPH, prostatitis, urinary retention, recent instrumentation, and after ejaculation.
• PSA must be interpreted with age, DRE, prostate volume, MRI, and clinical risk.
• It is particularly useful for post-treatment monitoring:
  • After radical prostatectomy, PSA should become very low/undetectable.
  • Rising PSA after treatment may indicate biochemical recurrence.

Confirming diagnosis

Multiparametric MRI, mpMRI

• Identify suspicious lesions
• Assign PI-RADS score
• Guide targeted biopsy
• Assess local extension

Biopsy: diagnostic gold standard

• Transperineal MRI-targeted biopsy plus systematic regional cores, or
• Transrectal ultrasound-guided biopsy where appropriate

Staging investigations

Histology and grading

Gleason score

Primary pattern + Secondary pattern = Gleason score
Example: 3 + 4 = 7

ISUP Grade Groups

TNM staging: simplified MBBS version

Management principles

1. Stage: localized, locally advanced, nodal, metastatic
2. PSA
3. Gleason score/ISUP grade
4. Life expectancy, age, comorbidities, and performance status
5. Patient preference
6. Urinary, erectile, and bowel function

Confirmed prostate cancer
        ↓
Stage + PSA + ISUP grade + life expectancy
        ↓
Localized low risk → Active surveillance or curative treatment
Localized intermediate/high risk → Radical treatment
Locally advanced/N1 → Radiotherapy + long-term hormonal therapy
Metastatic disease → Systemic hormonal treatment ± intensified therapy

1. Localized low-risk cancer

Active surveillance

Follow-up includes

• Serial PSA
• Periodic DRE
• Repeat MRI when indicated
• Repeat biopsy according to protocol
• Curative treatment if grade, volume, PSA, MRI, or biopsy indicates progression

Suitable patients

• Low-risk localized cancer
• Long enough life expectancy for monitoring to matter
• Reliable for follow-up

2. Localized cancer suitable for curative treatment

A. Radical prostatectomy

Definition

• Entire prostate
• Prostatic capsule
• Seminal vesicles
• Usually vas deferens segments

• Open retropubic surgery
• Laparoscopic surgery
• Robot-assisted laparoscopic surgery

Indications

• Localized disease in a fit patient
• Usually life expectancy >10 years
• Selected locally advanced disease as part of multimodal therapy

Major complications

• Erectile dysfunction
• Incontinence, especially stress urinary incontinence
• Retrograde ejaculation/infertility, although ejaculation is absent after removal of seminal vesicles

• Bleeding
• Lymphocele after lymph-node dissection
• Urethrovesical anastomotic stricture
• Rectal injury, rare
• DVT/PE

B. Radical radiotherapy

• External beam radiotherapy, EBRT
• Brachytherapy in selected localized cases
• Hypofractionated schedules are increasingly used

Often combined with androgen-deprivation therapy, ADT

• Intermediate-risk: short course ADT may be used with radiotherapy.
• High-risk or locally advanced disease: long-term ADT with radiotherapy.

Complications

• Urinary frequency, urgency, dysuria
• Radiation cystitis and hematuria
• Radiation proctitis, diarrhea, rectal bleeding
• Erectile dysfunction
• Urethral stricture, less common

3. Locally advanced disease: T3/T4, M0

Common treatment

Manage complications

• Urinary retention: catheterization, suprapubic catheter if needed, selected palliative TURP
• Ureteric obstruction: ureteric stent or percutaneous nephrostomy
• Hematuria: bladder irrigation, endoscopic control, radiotherapy/embolization in selected cases
• Spinal cord compression: emergency corticosteroids, urgent MRI, radiation oncology/neurosurgical referral

4. Node-positive disease: N1, M0

• Radiotherapy to the prostate and pelvic nodes
• Long-term ADT
• In selected high-risk cases, treatment intensification with an androgen receptor pathway inhibitor may be considered under oncology guidance.

5. Metastatic prostate cancer

A. Metastatic hormone-sensitive prostate cancer, mHSPC

Methods of ADT

LHRH agonists

LHRH antagonists

Treatment intensification

• Androgen receptor pathway inhibitor:
  • Abiraterone plus steroid
  • Enzalutamide
  • Apalutamide
  • Darolutamide
• Docetaxel chemotherapy in appropriate patients, particularly with high-volume disease

B. Metastatic castration-resistant prostate cancer, mCRPC

• Continue ADT
• Androgen receptor pathway inhibitors
• Docetaxel or cabazitaxel
• PARP inhibitor therapy for eligible tumors with homologous-recombination repair mutations, such as BRCA alterations
• PSMA-targeted radioligand therapy in eligible settings
• Radium-223 for selected symptomatic bone-predominant disease without visceral metastases
• Palliative radiotherapy for painful bone metastases

Management of bone metastases

• Analgesia using the WHO pain ladder
• Palliative external beam radiotherapy for painful focal lesions
• Urgent management of impending fracture or spinal cord compression
• Orthopedic stabilization where needed
• Bone-protective agents in suitable patients:
  • Denosumab
  • Zoledronic acid
• Calcium/vitamin D assessment and dental review before antiresorptive therapy because of the risk of osteonecrosis of the jaw

High-yield viva questions

1. What is the commonest histological type?
   Adenocarcinoma.
2. Which zone is commonly affected?
   Peripheral zone, usually posteriorly.
3. Why does early carcinoma often not cause LUTS?
   It arises in the peripheral zone and does not initially compress the prostatic urethra.
4. What is the commonest site of distant metastasis?
   Bone, especially axial skeleton.
5. Are bone metastases lytic or blastic?
   Typically osteoblastic/sclerotic.
6. What is the gold standard for diagnosis?
   Histopathology from prostate biopsy.
7. Is PSA diagnostic of prostate cancer?
   No. It is prostate-specific, not cancer-specific.
8. What are the three major factors for risk stratification?
   PSA, clinical TNM stage, and Gleason score/ISUP Grade Group.
9. What is the treatment for low-risk localized disease?
   Active surveillance is often preferred; radical prostatectomy or radiotherapy are alternatives in selected patients.
10. What are definitive curative treatments?
    Radical prostatectomy and radical radiotherapy.
11. What is the first-line foundation for metastatic disease?
    Androgen-deprivation therapy.
12. What is the difference between simple and radical prostatectomy?
    Simple prostatectomy enucleates adenoma for BPH. Radical prostatectomy removes the whole prostate and seminal vesicles for cancer.

One-minute exam summary

Prostate carcinoma:
- Usually adenocarcinoma in peripheral zone.
- Early disease: asymptomatic, raised PSA, abnormal DRE, or incidental TURP finding.
- Advanced disease: BOO, hematuria, pelvic pain, renal failure.
- Metastases: osteoblastic bone lesions → back/bone pain, fracture, cord compression, anemia.
- Diagnosis: PSA + DRE + mpMRI, confirmed by targeted/systematic biopsy.
- Staging: TNM, PSA, Gleason/ISUP, PSMA PET/CT or CT plus bone scan in higher-risk disease.
- Low-risk: active surveillance.
- Localized curable disease: radical prostatectomy or radiotherapy.
- Locally advanced/N1: radiotherapy + long-term ADT.
- Metastatic: ADT plus systemic intensification when appropriate.