Benign & Malignant Diseases Of The Prostate By:  Dr. Saud Al-Subaie Moderator:   Dr.E.O.Kehinde
Outline <ul><li>Introduction </li></ul><ul><li>BPH </li></ul><ul><li>Prostate cancer </li></ul><ul><li>Prostatitis  </li><...
Introduction  <ul><li>BPH & prostate adenocarcinoma are the 2 major neoplasms affecting the human prostate. </li></ul><ul>...
 
<ul><li>The normal prostate measures between  3-4cm at its widest portion; it is 4-6cm in length & 2-3cm in thickness. </l...
<ul><li>The other 5% is formed by the transition zone which is located just outside the urethra & is composed of the periu...
Benign Prostatic hypertrohy ( BPH )
Incidence & Epidemiology <ul><li>The term BPH is a misnomer because the actual change is a hyperplasia & not hypertrophy. ...
Etiology  <ul><li>The etiology of BPH is unclear. </li></ul><ul><li>Two factors necessary for BPH to occur are: </li></ul>...
 
Pathogenesis <ul><li>Stromal – epithelial interaction  </li></ul><ul><li>normal 2:1, BPH 3 or 4:1 </li></ul><ul><li>major ...
Pathophysiology Of Symptoms <ul><li>Symptoms of BPH: </li></ul><ul><li>1)  obstructive  </li></ul><ul><li>decrease in forc...
Pathophysiology Of Symptoms <ul><li>2) Irritative symptoms: </li></ul><ul><li>Frequency:   </li></ul><ul><li>-  Incomplete...
Pathophysiology Of Symptoms <ul><li>Obstructive symptoms are common with enlarged prostates.  Predominance of irritative s...
Pathophysiology Of Symptoms <ul><li>Systemic symptoms related to the UT: </li></ul><ul><li>- Vesicoureteral reflux </li></...
 
Signs of BPH <ul><li>If the disease is advanced & has resulted in renal failure.  Signs of renal failure include elevated ...
Signs of BPH <ul><li>Rectal examination may reveal an enlarged prostate. </li></ul><ul><li>The distinction between right &...
Laboratory Findings <ul><li>Urinalysis & microscopic examination:  to R/O infection or the presence of hematuria. </li></u...
Imaging <ul><li>Ultrasonography: </li></ul><ul><li>In BPH, it is most useful for measuring bladder & prostate volume as we...
Treatment  <ul><li>Because BPH is not invariably progressive, the timing of intervention for each patient is variable. </l...
Medical Treatment <ul><li>Obstruction secondary to BPH occurs because of 2 factors: </li></ul><ul><li>a. Dynamic component...
Alpha-1 adrenergic antagonists <ul><li>Ideally suited for the treatment of  the dynamic component of BOO because they can ...
5 alpha- reductase inhibitor <ul><li>Agents that selectively blockade androgens at the prostate cellular level are termed ...
5 alpha- reductase inhibitor <ul><li>Another approach to blocking androgen uptake by prostatic cells is to prevent androge...
Conventional Surgical Therapy  <ul><li>1) TURP </li></ul><ul><li>The principles of TURP are to remove the obstructing aden...
Conventional Surgical Therapy <ul><li>TUR syndrome </li></ul><ul><li>Because irrigating fluid under pressure is used durin...
 
 
 
Conventional Surgical Therapy <ul><li>2) TUIP </li></ul><ul><li>It is indicated in patients with obstructive symptoms & no...
Conventional Surgical Therapy <ul><li>3) Open prostatectomy </li></ul><ul><li>Open prostatectomy can be done either  Tranv...
 
Minimally Invasive Therapy <ul><li>1) Laser prostatectomy </li></ul><ul><li>advantages over TURP: technical simplicity, la...
Minimally Invasive Therapy <ul><li>2) Transurethral needle ablation </li></ul><ul><li>High frequency radio waves to cause ...
Minimally Invasive Therapy <ul><li>4) Prostate stents </li></ul><ul><li>In recent years, metallic spirals & stents have be...
Minimally Invasive Therapy <ul><li>5) Transurethral balloon dilatation </li></ul><ul><li>It involves the use of non compli...
Prostate Cancer
Incidence <ul><li>prostate cancers is the 2 nd  most common cause of cancer deaths in USA. </li></ul><ul><li>Autopsy studi...
Etiology <ul><li>*  Genetic predisposition, racial origin. </li></ul><ul><li>Autosomal dominant inheritance of  </li></ul>...
Pathogenesis <ul><li>Most prostate cancers are  adenocarcinomas  arising from prostatic acinar cells. </li></ul><ul><li>Pr...
Grading of Prostatic Cancer <ul><li>Gleason grading system is the most widely used. It’s based on glandular differentiatio...
Stages of Prostatic Cancer
Pattern of Progression <ul><li>Local Metastasis: </li></ul><ul><li>Cancers arising in close proximity are prone to spread ...
Pattern of Progression <ul><li>Distant Metastasis </li></ul><ul><li>Osseous metastases is most common form of hematogenous...
 
Clinical Findings <ul><li>Symptoms </li></ul><ul><li>Most prostate cancers are discovered because of elevated PSA or with ...
Tumor Markers <ul><li>Prostate Specific Antigen (PSA)   </li></ul><ul><ul><li>Glycoprotein secreted in the cytoplasm of th...
Tumor Markers (PSA) <ul><ul><li>PSA rises by 0.04 per year in individual without cancer   upper limit of PSA for </li></u...
Tumor Markers <ul><li>Other Tumor Markers </li></ul><ul><ul><li>DNA ploidy recently reported to be useful in predicting pr...
Prostate Biopsy <ul><li>Diagnosis of prostate cancers  is confirmed by needle and core biopsy. </li></ul><ul><li>Ultrasoun...
Imaging <ul><li>Trans-rectal U/S </li></ul><ul><ul><li>Can identify  60% of cancers even if non-palpable. </li></ul></ul><...
 
Imaging <ul><li>2) CT: </li></ul><ul><li>used only when extensive L.N. disease is suspected and it is based only on the si...
 
Management of Localized Disease <ul><li>The current therapy of patients with low stage disease (stage T1 and T2) is radica...
 
Radical Prostatectomy <ul><li>Retropubic approach  allow simultaneous access to the prostate and the pelvic LN, but it is ...
 
Complication of Surgical Therapy <ul><li>Intra-operatively: </li></ul><ul><ul><li>bleeding and injury to the obturator ner...
Radiation Therapy <ul><li>All modern techniques use CT scans for accurate localization of the prostate. </li></ul><ul><li>...
 
Complication of Radiation Therapy <ul><li>Intestinal sequelae: </li></ul><ul><ul><li>Rectal bleeding, tenesmus, mucous dis...
Neoadjuvant Hormonal Therapy <ul><li>LHRH agonists and antiandrogens </li></ul><ul><li>Studies showed that hormonal therap...
Manegment of patients with Margin-Positive Disease / Extracapsular Extension <ul><li>60% of positive margins are at postla...
Management of locally extensive disease <ul><li>Stage T3,T4 or C prostate cancer are advised to have radiation therapy. Su...
 
Management of  distant metastatic disease <ul><li>The standard treatment is androgen ablation therapy  to lower serum test...
Prognostic Factors in Ca prostate <ul><li>Stage   1&2     65 - 98%  5-yrs survival rate </li></ul><ul><li>3     60% 5-yr...
Prostatitis
NIH Consensus Conference on Prostatitis  (1995) <ul><li>Category I : Acute Bacterial Prostatitis = Acute infection of the ...
Acute bacterial prostatitis <ul><li>Etiology </li></ul><ul><li>Is mainly caused by aerobic gram negative rods.  </li></ul>...
Leukocytic infiltration of stroma and glandular lumina during acute bacterial prostatitis
Acute bacterial prostatitis <ul><li>Clinical Findings </li></ul><ul><li>A.  Symptoms </li></ul><ul><li>Acute febrile illne...
Acute bacterial prostatitis <ul><li>C. Laboratory Findings </li></ul><ul><li>Voided urine usually shows significant pyuria...
Acute bacterial prostatitis   <ul><li>Complications </li></ul><ul><li>Acute urinary retention. </li></ul><ul><li>Acute bac...
Acute bacterial prostatitis <ul><li>Prostatic Abscess </li></ul><ul><li>More recently, about 70% of prostatic abscesses ha...
Acute bacterial prostatitis <ul><li>Treatment </li></ul><ul><li>Fluoroquinolone  </li></ul><ul><li>Ciprofloxacin  </li></u...
Acute bacterial prostatitis <ul><ul><li>Prognosis </li></ul></ul><ul><ul><li>Unless the patient develops septicemia and se...
Chronic Bacterial Prostatitis <ul><li>Etiology: </li></ul><ul><li>Is a non acute infection of the prostate caused by one o...
Chronic Bacterial Prostatitis <ul><li>Clinical Findings </li></ul><ul><li>A. Symptoms </li></ul><ul><li>Asymptomatic; most...
Chronic Bacterial Prostatitis <ul><li>C. Laboratory findings </li></ul><ul><li>The Prostatic secretions obtained by prosta...
Chronic Bacterial Prostatitis <ul><li>Complications </li></ul><ul><li>Relapsing recurrent UTI. </li></ul><ul><li>Ascending...
Chronic Bacterial Prostatitis <ul><li>Treatment </li></ul><ul><li>General Measures </li></ul><ul><li>Symptoms can be relie...
Chronic Bacterial Prostatitis <ul><li>Treatment </li></ul><ul><li>Surgical Measures </li></ul><ul><li>Radical prostatovesi...
Chronic Bacterial Prostatitis <ul><li>Prognosis </li></ul><ul><li>Chronic bacterial prostatitis is difficult to cure perma...
Chronic Abacterial Prostatitis  <ul><li>Etiology   </li></ul><ul><li>Is the most common of the prostatitis syndromes; its ...
Chronic Abacterial Prostatitis <ul><li>Pathogenesis and Pathology </li></ul><ul><li>The cause of the pathogenesis of nonba...
Chronic Abacterial Prostatitis <ul><li>Clinical Findings </li></ul><ul><li>The signs and symptoms are similar except that ...
Chronic Abacterial Prostatitis <ul><li>Treatment </li></ul><ul><li>Antimicrobial therapy should be tried for at least 4 we...
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Benign & Malignant Diseases Of The Prostate Saud

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Benign & Malignant Diseases Of The Prostate Saud

  1. 1. Benign & Malignant Diseases Of The Prostate By: Dr. Saud Al-Subaie Moderator: Dr.E.O.Kehinde
  2. 2. Outline <ul><li>Introduction </li></ul><ul><li>BPH </li></ul><ul><li>Prostate cancer </li></ul><ul><li>Prostatitis </li></ul><ul><li>Acute bacterial prostatitis </li></ul><ul><li>Chronic bacterial prostatitis </li></ul><ul><li>Chronic pelvic pain (CPP) syndrome ( inflammatory/non-inflammatory) </li></ul>
  3. 3. Introduction <ul><li>BPH & prostate adenocarcinoma are the 2 major neoplasms affecting the human prostate. </li></ul><ul><li>The prostate is a complex organ consisting of epithelial, stromal, & muscular element. </li></ul><ul><li>Anatomically the prostate gland is the shape of a compressed inverted cone, residing in the true pelvis. </li></ul><ul><li>Arterial blood supply: inferior vesical+ middle rectal a. </li></ul><ul><li>Venous drainage: Dorsal venous plexes </li></ul>
  4. 5. <ul><li>The normal prostate measures between 3-4cm at its widest portion; it is 4-6cm in length & 2-3cm in thickness. </li></ul><ul><li>Weight 17-25 gm </li></ul><ul><li>In the early 1970’s McNeal proposed a concept of zonal anatomy. </li></ul><ul><li>According to this concept, the glandular portion of the prostate is composed of a large peripheral & a small central zone, which together constitute about 95% of the gland. </li></ul>
  5. 6. <ul><li>The other 5% is formed by the transition zone which is located just outside the urethra & is composed of the periurethral glands, which presumably are responsible for all of the BPH. </li></ul><ul><li>60-70% of prostatic CA occurs in the peripheral zone, 10-20% in the transition zone, & 5-10% in the central zone. </li></ul>
  6. 7. Benign Prostatic hypertrohy ( BPH )
  7. 8. Incidence & Epidemiology <ul><li>The term BPH is a misnomer because the actual change is a hyperplasia & not hypertrophy. </li></ul><ul><li>The initiation of BPH may not be environmental or genetically influenced. </li></ul><ul><li>It is also suggested that the prevalence of BPH increases with age in all male populations. </li></ul>
  8. 9. Etiology <ul><li>The etiology of BPH is unclear. </li></ul><ul><li>Two factors necessary for BPH to occur are: </li></ul><ul><li>(1) endocrine control (DHT) </li></ul><ul><li>(2) aging </li></ul><ul><li>The relative roles of androgen & estrogen in inducing BPH, however , are complex & not completely understood. </li></ul>
  9. 11. Pathogenesis <ul><li>Stromal – epithelial interaction </li></ul><ul><li>normal 2:1, BPH 3 or 4:1 </li></ul><ul><li>major change is connective tissue </li></ul><ul><li>The differential representation of the histologic components of BPH explains the potential responseviness to medical therapy </li></ul>
  10. 12. Pathophysiology Of Symptoms <ul><li>Symptoms of BPH: </li></ul><ul><li>1) obstructive </li></ul><ul><li>decrease in force & caliber of the stream: due to urethral compression is one of the early & constant features of BPH. </li></ul><ul><li>Hesitancy: occurs because the detrusor takes a longer time to generate the initial increased pressure to overcome the urethral resistance. </li></ul><ul><li>Intermittency: occurs because the detrusor is unable to sustain the increased pressure until the end of voiding. </li></ul><ul><li>Terminal dribbling of urine & incomplete sense of bladder emptying </li></ul>
  11. 13. Pathophysiology Of Symptoms <ul><li>2) Irritative symptoms: </li></ul><ul><li>Frequency: </li></ul><ul><li>- Incomplete emptying during each void results in shorter intervals between voids. </li></ul><ul><li>- The presence of enlarged prostate provokes the bladder to trigger a voiding response more frequently than in normal individuals, especially if the prostate is growing intravesically. </li></ul><ul><li>Nocturia: normal cortical inhibitors are lessened and also because the normal urethral and sphincteric tone is reduced during sleep. </li></ul><ul><li>urgency & dysuria: uncommon. </li></ul>
  12. 14. Pathophysiology Of Symptoms <ul><li>Obstructive symptoms are common with enlarged prostates. Predominance of irritative should suggest voiding dysfunction. </li></ul>
  13. 15. Pathophysiology Of Symptoms <ul><li>Systemic symptoms related to the UT: </li></ul><ul><li>- Vesicoureteral reflux </li></ul><ul><li>- Dilatation & hydronephrosis </li></ul><ul><li>- Renal failure & symptoms of uremia </li></ul><ul><li>Symptoms unrelated to the UT: </li></ul><ul><li>- hernias, hemorrhoids and vesical calculus </li></ul><ul><li>- change in the caliber of bowl movements </li></ul><ul><li>Symptoms related to complications: </li></ul><ul><li>- cystitis </li></ul><ul><li>- pyelonephritis </li></ul><ul><li>- bladder calculi </li></ul><ul><li>- micro or gross hematuria. </li></ul>
  14. 17. Signs of BPH <ul><li>If the disease is advanced & has resulted in renal failure. Signs of renal failure include elevated BP, rapid pulse & respiration, uremic fetor, pericarditis & pallor of nail beds. </li></ul><ul><li>Abdominal examination may reveal palpable kidney or flank tenderness if there is hydronephrosis or pyelonephritis. </li></ul><ul><li>A distended bladder may be noted on palpation or percussion. </li></ul>
  15. 18. Signs of BPH <ul><li>Rectal examination may reveal an enlarged prostate. </li></ul><ul><li>The distinction between right & left lobes of the prostate </li></ul><ul><li>is usually lost in BPH. </li></ul><ul><li>Median sulcus always present. </li></ul>
  16. 19. Laboratory Findings <ul><li>Urinalysis & microscopic examination: to R/O infection or the presence of hematuria. </li></ul><ul><li>serum U/E & creatinine: to provide baseline information on renal function & metabolic status. </li></ul><ul><li>Uroflowmetry: At a volume of 125-150ml, normal individuals have average flow rates of 12ml/sec & peak flow close to 20ml/sec. </li></ul><ul><li>Mild 11-15 ml/sec </li></ul><ul><li>Moderate  7 and  10 ml/sec </li></ul><ul><li>Severe  7ml/sec </li></ul><ul><li>Residual Urine: estimated by U/S or catheterizations. Volumes >150 ml are considered significant since they constitute approximately one-third of normal bladder volume. </li></ul>
  17. 20. Imaging <ul><li>Ultrasonography: </li></ul><ul><li>In BPH, it is most useful for measuring bladder & prostate volume as well as residual urine. </li></ul><ul><li>Estimation of prostatic size is important because most urologists prefer to perform TURP for glands under 100g. </li></ul><ul><li>TRUS must be used as it is more accurate. </li></ul><ul><li>IVP: </li></ul><ul><li>For UTI & complications of BPH </li></ul>
  18. 21. Treatment <ul><li>Because BPH is not invariably progressive, the timing of intervention for each patient is variable. </li></ul><ul><li>Absolute indications for treatment include severe obstructive symptoms & renal insufficiency. </li></ul><ul><li>Relative indications include moderate symptoms of prostatism, recurrent UTI and hematuria. </li></ul><ul><li>Until recently, surgery was the mainstay of therapy for BPH. In the last decade or so , there has been a tremendous resurgence of interest in non surgical therapies. </li></ul>
  19. 22. Medical Treatment <ul><li>Obstruction secondary to BPH occurs because of 2 factors: </li></ul><ul><li>a. Dynamic component: a result of contraction of smooth muscles of the prostate & prostatic urethra mediated mostly by adrenergic receptors. </li></ul><ul><li>b. Mechanical component: related to the presence of a mass which compresses & narrows the urethral lumen. </li></ul>
  20. 23. Alpha-1 adrenergic antagonists <ul><li>Ideally suited for the treatment of the dynamic component of BOO because they can selectively reduce resistance along the bladder outlet without impairing detrusor contractility. </li></ul><ul><li>Example: </li></ul><ul><li>- Tamsulosin 0.4mg OD </li></ul><ul><li>- Alfuzosin XL 10mg OD </li></ul><ul><li>- Doxazosin 4mg TID </li></ul><ul><li>Indication: Prostate size < 40 gm </li></ul><ul><li>S/E are related to their antihypertensive effects and include dizziness and lightheadedness, Tachycardia, palpitation, tiredness, weakness & nasal congestion. </li></ul><ul><li>Retrograde ejaculation may occur due to relaxation of the bladder neck. </li></ul><ul><li>Alpha blockers also have beneficial S/E including lowering of serum cholesterol & triglycerides. </li></ul>
  21. 24. 5 alpha- reductase inhibitor <ul><li>Agents that selectively blockade androgens at the prostate cellular level are termed anti-androgens. </li></ul><ul><li>the prostate normally requires conversion of testosterone to dihydrotestosterone by the enzyme 5 alpha-reductase. </li></ul><ul><li>Proscar is an anti-androgen that blocks this enzyme. </li></ul><ul><li>In long term clinical trials, proscar has been shown to decrease prostatic size & improve urine flow rates & symptoms of BPH. </li></ul>
  22. 25. 5 alpha- reductase inhibitor <ul><li>Another approach to blocking androgen uptake by prostatic cells is to prevent androgen binding to nuclear androgen receptors ( e.g. Flutamide). </li></ul><ul><li>There are also anti-androgens that block both LH and nuclear androgen uptake. </li></ul><ul><li>In BPH patients, this has been demonstrated to improve flow rates & voiding symptoms. </li></ul><ul><li>Indication: Prostate size > 40 gm </li></ul><ul><li>S/E include impotence, decreased libido & lowers serum PSA by approximately 50% within 6 months of use. </li></ul>
  23. 26. Conventional Surgical Therapy <ul><li>1) TURP </li></ul><ul><li>The principles of TURP are to remove the obstructing adenomatous portion of the prostate via the urethra. </li></ul><ul><li>Overall morbidity: 18%. </li></ul><ul><li>Current mortality: 0.2%. </li></ul><ul><li>One preventable complication is TUR syndrome </li></ul><ul><li>Immediate complications: failure to void, post op. haemorrhage, clot retention, & UTI. </li></ul><ul><li>Late complications: impotence, incontinence, uretheral stricture and retrograde ejaculation. </li></ul>
  24. 27. Conventional Surgical Therapy <ul><li>TUR syndrome </li></ul><ul><li>Because irrigating fluid under pressure is used during resection, there is a certain amount of absorption via the venous sinuses. </li></ul><ul><li>It results in hypervolemia & hyponatremia which leads to cerebral oedema & seizures. </li></ul><ul><li>Other S/E include visual disturbance & hyperammonemia or hemolysis. </li></ul><ul><li>The incidence is approximately 2%. </li></ul><ul><li>Preventive measures include suprapubic drainage during TURP, continuous flow resectoscopes & diuretics. </li></ul>
  25. 31. Conventional Surgical Therapy <ul><li>2) TUIP </li></ul><ul><li>It is indicated in patients with obstructive symptoms & normal or small prostates in whom TURP is considered excessive surgery to obtain relief of symptoms. </li></ul>
  26. 32. Conventional Surgical Therapy <ul><li>3) Open prostatectomy </li></ul><ul><li>Open prostatectomy can be done either Tranvesical , perineal or Retropupic prostatectomy. </li></ul><ul><li>In recent years the suprapubic & retropubic approaches for BPH have been limited to approximately 10% of patients. </li></ul><ul><li>Indications for suprapubic prostatectomy are a gland size greater than 100g, cystolithotomy or diverticulum excision. </li></ul><ul><li>Most post op complications are similar to TURP, however, wound infection & thromboembolism are additional complications. </li></ul>
  27. 34. Minimally Invasive Therapy <ul><li>1) Laser prostatectomy </li></ul><ul><li>advantages over TURP: technical simplicity, lack of complications & shorter hospital stay. </li></ul><ul><li>Laser energy works by thermal destruction of tissue. </li></ul><ul><li>disadvantages: lack of tissue availability for pathologic examination, longer postop cathitarization time, more irritative voiding complain, & high costs </li></ul>
  28. 35. Minimally Invasive Therapy <ul><li>2) Transurethral needle ablation </li></ul><ul><li>High frequency radio waves to cause thermal injury to the prostate. </li></ul><ul><li>3) High-intensity focused Ultrasound </li></ul>
  29. 36. Minimally Invasive Therapy <ul><li>4) Prostate stents </li></ul><ul><li>In recent years, metallic spirals & stents have been used as permanent indwelling prostheses . </li></ul><ul><li>These stents may be placed endoscopically & under radiologic guidance. </li></ul>
  30. 37. Minimally Invasive Therapy <ul><li>5) Transurethral balloon dilatation </li></ul><ul><li>It involves the use of non compliant balloons to dilate the prostate under pressure. </li></ul><ul><li>This pressure is maintained for 15 min. </li></ul><ul><li>The exact mechanism is unclear. </li></ul><ul><li>6) Thermotherapy </li></ul>
  31. 38. Prostate Cancer
  32. 39. Incidence <ul><li>prostate cancers is the 2 nd most common cause of cancer deaths in USA. </li></ul><ul><li>Autopsy studies demonstrate that there is an increasing incidence starting around 30% in men at 50 increasing to 75% in men at 75 years. </li></ul><ul><li>USA (blacks) 137/100,000 per year </li></ul><ul><li>Germany 45/100,000 per year </li></ul><ul><li>Kuwait 6.5/100,000 per year (1998-2002) </li></ul><ul><li>Kuwait 12.8/100,000 per year (2002-2005) </li></ul><ul><li>China  1/100,000 per year </li></ul>
  33. 40. Etiology <ul><li>* Genetic predisposition, racial origin. </li></ul><ul><li>Autosomal dominant inheritance of </li></ul><ul><li>rarely yet highly penetrant gene. </li></ul><ul><li>* Hormonal influences. </li></ul><ul><li>* Dietary & environmental factors. </li></ul><ul><li>* Infectious agents. </li></ul><ul><li>* Sexual habits, multiple sexual partner. </li></ul><ul><li>* Idiopathic </li></ul>
  34. 41. Pathogenesis <ul><li>Most prostate cancers are adenocarcinomas arising from prostatic acinar cells. </li></ul><ul><li>Prostate normally atrophies between the 5 th & 7 th decades of life with some atypical and hyperplastic changes. </li></ul><ul><li>Among dysplastic changes, prostatic intraepithelial neoplasia (PIN) considered premalignant lesion found in 30% of patients with prostate cancers. </li></ul><ul><li>70% of prostate cancers arise in the peripheral zone of the prostate; 15-20% arise in the central zone; 10-15% arise in the transition zone. </li></ul><ul><li>Most prostate cancers are multicentric . </li></ul>
  35. 42. Grading of Prostatic Cancer <ul><li>Gleason grading system is the most widely used. It’s based on glandular differentiation: </li></ul><ul><li>* Gleason Score 2-4  well differentiated </li></ul><ul><li> 5-7  moderately differentiated </li></ul><ul><li> 8-10  poorly differentiated </li></ul>
  36. 43. Stages of Prostatic Cancer
  37. 44. Pattern of Progression <ul><li>Local Metastasis: </li></ul><ul><li>Cancers arising in close proximity are prone to spread early to the urethra, periprostatic tissues, bladder and seminal vesicles. </li></ul><ul><li>Spread to seminal vesicles indicates ominous prognosis with 50% of patients developing distant metastasis. </li></ul><ul><li>Rectal invasion is rare, ? Due to the tough Denonvilliers’ fascia in between. </li></ul><ul><li>Ureteral invasion by direct extension can occur but late, usually lymph node and distant metastasis present at this time. </li></ul>
  38. 45. Pattern of Progression <ul><li>Distant Metastasis </li></ul><ul><li>Osseous metastases is most common form of hematogenous metastases and occur in 85% of patients dying from prostate cancer </li></ul><ul><li>Frequent sites: lumbar spines, pelvis, proximal femur, thoracic spines, ribs, sternum and skull. </li></ul><ul><li>Extension to the axial skeleton vai the Batson’s plexus of presacral veins which communicate with the pre & periprostatic venous complex. </li></ul>
  39. 47. Clinical Findings <ul><li>Symptoms </li></ul><ul><li>Most prostate cancers are discovered because of elevated PSA or with incidental finding on rectal examination. </li></ul><ul><li>prostate cancers rarely cause symptoms but may present with bladder outlet obstruction, acute urinary retention, hematuria or incontinence </li></ul><ul><li>Signs </li></ul><ul><li>irregular firm or hard prostatic nodule during rectal examination. </li></ul><ul><li>Median sulcus is absent </li></ul>
  40. 48. Tumor Markers <ul><li>Prostate Specific Antigen (PSA) </li></ul><ul><ul><li>Glycoprotein secreted in the cytoplasm of the prostatic cells and function normally in liquefaction of the semen, normal value in young adult 0-4 ng/dL. </li></ul></ul><ul><ul><li>PSA elevation is proportional to the size of the transitional zone. 1g of prostate cancer will ↑PSA by 0.3 ng/dL. </li></ul></ul><ul><ul><li>PSA production by the malignant cell depends on the degree of differentiation, well diff. gland will give more </li></ul></ul><ul><ul><li>Prostate cancer with poor differentiation have normal PSA </li></ul></ul>
  41. 49. Tumor Markers (PSA) <ul><ul><li>PSA rises by 0.04 per year in individual without cancer  upper limit of PSA for </li></ul></ul><ul><ul><li>- 40-49 yrs is 2.5 ng/dL </li></ul></ul><ul><ul><li>- 50-59 yrs is 3.5 ng/dL </li></ul></ul><ul><ul><li>- 60-69 yrs is 4.5 ng/dL </li></ul></ul><ul><ul><li>- 70-79 yrs is 6.5 ng/dL. </li></ul></ul><ul><ul><li>PSA density (PSA level/prostate volume) level between 0.1-0.15 associated with 15% incidence of cancer, level above 0.15 associated with 60%. </li></ul></ul><ul><ul><li>New studies showed two types of PSA, </li></ul></ul><ul><ul><li>a. complex PSA associated with cancer </li></ul></ul><ul><ul><li>b. free PSA goes with BPH. </li></ul></ul>
  42. 50. Tumor Markers <ul><li>Other Tumor Markers </li></ul><ul><ul><li>DNA ploidy recently reported to be useful in predicting prognosis in prostate cancer. </li></ul></ul><ul><ul><li>Low grade tumors associated with diploidy and high grade tumors with aneuploidy. </li></ul></ul><ul><ul><li>Patients with deploid tumors do well with expectant therapy while those with aneuploidy do poorly. </li></ul></ul>
  43. 51. Prostate Biopsy <ul><li>Diagnosis of prostate cancers is confirmed by needle and core biopsy. </li></ul><ul><li>Ultrasound guided systematic sampling of the prostate in 4 quadrants provides the most accurate information for staging and grading the cancer. </li></ul>
  44. 52. Imaging <ul><li>Trans-rectal U/S </li></ul><ul><ul><li>Can identify 60% of cancers even if non-palpable. </li></ul></ul><ul><ul><li>By allowing precise placement of biopsy needle in various quadrants, adequate sampling achieved. </li></ul></ul><ul><ul><li>More accurate than DRE at detecting extra-capsular extension. </li></ul></ul><ul><ul><li>Allow biopsy of seminal vesicles which improve staging accuracy. </li></ul></ul><ul><ul><li>Disadvantage of TRUS include the inability to look at the pelvic lymph nodes. </li></ul></ul>
  45. 54. Imaging <ul><li>2) CT: </li></ul><ul><li>used only when extensive L.N. disease is suspected and it is based only on the size of the nodes thus false +ve and –ve are common. </li></ul><ul><li>3) MRI: </li></ul><ul><li>not useful because of the cost and the overlap in the appearance of benign & malignant processes, but its more accurate than TRUS for staging extracapsular extension and seminal vesicle involvement. </li></ul><ul><li>4) Bone scanning: </li></ul><ul><ul><li>most common way to assess systemic metastasis. </li></ul></ul><ul><ul><li>False +ve rate is less than 2%. </li></ul></ul><ul><ul><li>Diagnosis is confirmed by plain radiographs, thin section CT or MRI and bone biopsy </li></ul></ul>
  46. 56. Management of Localized Disease <ul><li>The current therapy of patients with low stage disease (stage T1 and T2) is radical prostatectomy & radiotherapy to the prostate. </li></ul><ul><li>Treatment mortality is under 1%. </li></ul><ul><li>For patients  75 years of age, treatment is “watchful waiting” </li></ul>
  47. 58. Radical Prostatectomy <ul><li>Retropubic approach allow simultaneous access to the prostate and the pelvic LN, but it is often associated with a greater amount of blood loss from the dorsal vein complex. </li></ul><ul><li>Perineal approach requires separate incision for pelvic LN, associated with minimal blood loss and it is preferred for obese individuals. </li></ul><ul><li>5 yrs disease free survival for Stage T1 is 92% and for stage T2 is 86% </li></ul>
  48. 60. Complication of Surgical Therapy <ul><li>Intra-operatively: </li></ul><ul><ul><li>bleeding and injury to the obturator nerve, ureter or rectum </li></ul></ul><ul><li>Post-operatively: </li></ul><ul><ul><li>DVT & PE. </li></ul></ul><ul><ul><li>Symptomatic pelvic lymphadenocele. </li></ul></ul><ul><ul><li>Wound infections & UTI </li></ul></ul><ul><li>The long term : </li></ul><ul><ul><li>Incontinence and impotence. </li></ul></ul>
  49. 61. Radiation Therapy <ul><li>All modern techniques use CT scans for accurate localization of the prostate. </li></ul><ul><li>Generally, prostate is subjected to 6800-7000 rads and the pelvic LNs are subjected to 4500-5000 rads. </li></ul><ul><li>Total treatment duration is 6-7 weeks. </li></ul><ul><li>5 yrs disease free survival rate for Stage T1 is 83% and for Stage T2 is 72%. </li></ul><ul><li>PSA level is useful for assessing the response to RT </li></ul><ul><li>Rising PSA or PSA level persistently more than 30 ng/dL indicate poor response to RT. </li></ul>
  50. 63. Complication of Radiation Therapy <ul><li>Intestinal sequelae: </li></ul><ul><ul><li>Rectal bleeding, tenesmus, mucous discharge, diarrhea, fecal incontinence, intestinal obstruction and rectal strictures. </li></ul></ul><ul><li>Urological sequelae: </li></ul><ul><ul><li>Frequency, dysurea, cystitis, hematuria and urethral stricture </li></ul></ul><ul><li>Edema of the extremities and impotence </li></ul><ul><li>Majority of these complications are minor and persist less than 6 months </li></ul>
  51. 64. Neoadjuvant Hormonal Therapy <ul><li>LHRH agonists and antiandrogens </li></ul><ul><li>Studies showed that hormonal therapy will not down-stage the cancer in patient with stage T3, however, in patient with stage T2 the hormonal therapy will reduce the size and the incidence of positive margins </li></ul>
  52. 65. Manegment of patients with Margin-Positive Disease / Extracapsular Extension <ul><li>60% of positive margins are at postlateral areas, 30% are posterior </li></ul><ul><li>In stage T1 cancers, 40% of positive margins are anterior. </li></ul><ul><li>Adjuvant radiation in these patients controls local recurrence but whether it reduces systemic recurrences is unclear. </li></ul><ul><li>Adjuvant hormones & more recently intermittent adjuvant hormones appears to reduce PSA. </li></ul>
  53. 66. Management of locally extensive disease <ul><li>Stage T3,T4 or C prostate cancer are advised to have radiation therapy. Surgery is not recommended. </li></ul>
  54. 68. Management of distant metastatic disease <ul><li>The standard treatment is androgen ablation therapy to lower serum testosterone. </li></ul><ul><li>Methods of lowering testosterone include: </li></ul><ul><li>(1) Bilateral subcapsular orchiectomy </li></ul><ul><li>(2) LHRH agonist By downregulating pituitary LH production. </li></ul><ul><li>(3) Estrogen e.g. diethylstilbestrol which create negative feedback to the pituitary. </li></ul><ul><li>S/E include impotence, breast tenderness, & hot flushes </li></ul>
  55. 69. Prognostic Factors in Ca prostate <ul><li>Stage 1&2  65 - 98% 5-yrs survival rate </li></ul><ul><li>3  60% 5-yrs survival rate </li></ul><ul><li>4  30% 5yrs survival rate </li></ul><ul><li>Grade </li></ul><ul><li>Tumor Volume </li></ul><ul><ul><li>< 0.5 ml -> no capsular penetration </li></ul></ul><ul><ul><li>< 4 ml -> less SV invasion & LN metastasis </li></ul></ul>
  56. 70. Prostatitis
  57. 71. NIH Consensus Conference on Prostatitis (1995) <ul><li>Category I : Acute Bacterial Prostatitis = Acute infection of the prostate gland </li></ul><ul><li>Category II : Chronic Bacterial Prostatitis = Recurrent infection of the prostate. </li></ul><ul><li>Category III : Chronic Abacterial Prostatitis/CPPS: No demonstrable infection </li></ul><ul><ul><li>Category IIIA : Inflammatory CPPS = WBCs in semen/EPS/VB3 </li></ul></ul><ul><ul><li>Category IIIB : Noninflammatory CPPS = No WBCs in semen/EPS/VB3 </li></ul></ul><ul><li>Category IV : Asymptomatic Inflammatory Prostatitis </li></ul>
  58. 72. Acute bacterial prostatitis <ul><li>Etiology </li></ul><ul><li>Is mainly caused by aerobic gram negative rods. </li></ul><ul><li>(E-coli and Pseudomonas aerigenosa) </li></ul><ul><li>Common in people with “uptight personality” </li></ul><ul><li>The possible routes of infection include: </li></ul><ul><li>Ascent from the urethra. </li></ul><ul><li>Reflux of infected urine into prostatic ducts that empty into the posterior urethra. </li></ul><ul><li>Direct extension (lymphatogenous spread): from the rectum. </li></ul><ul><li>Ascending infection and reflux of infected urine into prostatic ducts are probably the most common routes of prostatic infection. </li></ul>
  59. 73. Leukocytic infiltration of stroma and glandular lumina during acute bacterial prostatitis
  60. 74. Acute bacterial prostatitis <ul><li>Clinical Findings </li></ul><ul><li>A. Symptoms </li></ul><ul><li>Acute febrile illness characterized by chills, low back and perineal pain, urinary urgency and frequency, nocturia, dysuria, and varying degrees of bladder outlet obstruction. </li></ul><ul><li>Both myalgia and arthralgia are common. </li></ul><ul><li>B. Signs </li></ul><ul><li>Moderate or high grade fever. </li></ul><ul><li>Rectal palpation: tender, swollen, indurated, boggy and warm to be touched. </li></ul><ul><li>Since acute cystitis often accompanies acute bacterial prostatitis, the urine may be cloudy. </li></ul><ul><li>Initial, terminal, or even total gross hematuria may be observed occasionally. </li></ul>
  61. 75. Acute bacterial prostatitis <ul><li>C. Laboratory Findings </li></ul><ul><li>Voided urine usually shows significant pyuria, microscopic hematuria, and bacilluria. </li></ul><ul><li>The prostatic expressate is purulent and yields the infecting pathogen in heavy growth on culture plates. </li></ul><ul><li>Because massage of an acutely infected prostate is painful for the patient and can produce bactermia, prostatic massage is generally contraindicated. Except under anaesthesia and antibiotic cover. </li></ul><ul><li>D. Instrumental Examination </li></ul><ul><li>Transurethral instrumentation should be avoided during the acute stage of bacterial prostatitis. </li></ul>
  62. 76. Acute bacterial prostatitis <ul><li>Complications </li></ul><ul><li>Acute urinary retention. </li></ul><ul><li>Acute bacterial cystitis. </li></ul><ul><li>Acute pyelonephritis. </li></ul><ul><li>Unilateral or bilateral acute bacterial epididymitis. </li></ul><ul><li>bactermia with possible septic shock. </li></ul><ul><li>Rarely meningitis, spread of infection via Batesan’s veinous plexus </li></ul><ul><li>Prostate abcess </li></ul>
  63. 77. Acute bacterial prostatitis <ul><li>Prostatic Abscess </li></ul><ul><li>More recently, about 70% of prostatic abscesses have been caused by coliform bacteria, mostly E-coli. </li></ul><ul><li>Although the pathogenesis remains unclear, most cases of prostatic abscesses are probably complications of acute bacterial prostatitis. </li></ul><ul><li>The signs and symptoms of prostatic abscess can mimic those of bacterial prostatitis; Fluctuation is an important diagnostic clue. </li></ul><ul><li>Once the diagnosis of prostatic abscess is made preferred treatment consists of surgical drainage combined with appropriate antimicrobial therapy. </li></ul><ul><li>With proper diagnosis and therapy, the overall prognosis is good. </li></ul>
  64. 78. Acute bacterial prostatitis <ul><li>Treatment </li></ul><ul><li>Fluoroquinolone </li></ul><ul><li>Ciprofloxacin </li></ul><ul><li>Trimethoprim-sulfamethoxazole </li></ul><ul><li>Alternatively, initial therapy with Gentamicin or Amikacin or Tobraminycin, 3-5 mg/kg/d divided into 3 intravenous or intramuscular doses, plus ampicillen, 2 g intravenously every 6 hours, is recommended until the results of culture and sensitivity tests are known. </li></ul><ul><li>Transurethral instrumentation is contraindicated during acute infection. </li></ul>
  65. 79. Acute bacterial prostatitis <ul><ul><li>Prognosis </li></ul></ul><ul><ul><li>Unless the patient develops septicemia and septic shock, the prognosis generally is good with prompt and appropriate therapy. </li></ul></ul>
  66. 80. Chronic Bacterial Prostatitis <ul><li>Etiology: </li></ul><ul><li>Is a non acute infection of the prostate caused by one or more specific bacteria. </li></ul><ul><li>The possible routes of infection are the same in acute and chronic bacterial prostatitis. </li></ul>
  67. 81. Chronic Bacterial Prostatitis <ul><li>Clinical Findings </li></ul><ul><li>A. Symptoms </li></ul><ul><li>Asymptomatic; most have varying degrees of irritative voiding dysfunction and low back or perineal pain and discomfort. </li></ul><ul><li>Occasionally, myalgia and arthralgia accompany the other symptoms. </li></ul><ul><li>B. Signs </li></ul><ul><li>On rectal examination, the prostate may feel normal (rarely), boggy, or very tender focally indurated. </li></ul><ul><li>Crepitation may be felt when large prostatic stones are present or if infection is due to gas forming organisms commenly seen in diabetic patients. </li></ul><ul><li>Secondary epididymitis sometimes is associated with chronic bacterial prostatitis. </li></ul>
  68. 82. Chronic Bacterial Prostatitis <ul><li>C. Laboratory findings </li></ul><ul><li>The Prostatic secretions obtained by prostatic massage typically show excessive numbers of inflammatory cells. </li></ul><ul><li>The presence of large numbers of lipid laden macrophages in prostatic fluid correlates particularly well with the presence of prostatic inflammation. </li></ul><ul><li>D. X-Ray findings </li></ul><ul><li>normal unless there are complications (eg, prostatic calculi, prostatic enlargement, urethral stricture, renal infection). </li></ul><ul><li>E. Instrumental Examination </li></ul><ul><li>Cystoscopy and urethroscopy may reveal normal findings or erythema and edema of the prostatic urethra, with or without inflammatory polyps. </li></ul>
  69. 83. Chronic Bacterial Prostatitis <ul><li>Complications </li></ul><ul><li>Relapsing recurrent UTI. </li></ul><ul><li>Ascending bacterial infection of the upper urinary tract and bacterial epididymitis. </li></ul><ul><li>Bladder outlet obstruction. </li></ul>
  70. 84. Chronic Bacterial Prostatitis <ul><li>Treatment </li></ul><ul><li>General Measures </li></ul><ul><li>Symptoms can be relieved by the liberal use of hot sits baths. </li></ul><ul><li>Irritative voiding discomfort and pain often respond to the use of anti-inflammatory agents ( eg, indomethacin, ibuprofen) and anticholinergic drugs. </li></ul>
  71. 85. Chronic Bacterial Prostatitis <ul><li>Treatment </li></ul><ul><li>Surgical Measures </li></ul><ul><li>Radical prostatovesiculectomy is curative; unfortunately, the sequels of this operation ( sexual impotence and possible urinary incontinence) seldom make this a desirable choice. </li></ul><ul><li>Transurethral prostatectomy can be curative provided all infective stones and tissues are successfully removed; unfortunately, this may be difficult to achieve, especially since the peripheral zone of the prostate usually contains the most foci of the infection. </li></ul>
  72. 86. Chronic Bacterial Prostatitis <ul><li>Prognosis </li></ul><ul><li>Chronic bacterial prostatitis is difficult to cure permanently, but its symptoms and tendency to cause recurrent UTIs generally can be controlled by suppressive antimicrobial therapy. </li></ul>
  73. 87. Chronic Abacterial Prostatitis <ul><li>Etiology </li></ul><ul><li>Is the most common of the prostatitis syndromes; its cause is unknown. </li></ul><ul><li>There has been much speculations but little proof that chlamydial infection is responsible for many cases of apparent nonbacterial prostatitis. </li></ul><ul><li>Like wise, there is little evidence that infection due to U urealyticum plays an important role in this prostatitis. </li></ul><ul><li>Some researchers believe that non bacterial prostatitis is an autoimmune disease of the prostate. </li></ul>
  74. 88. Chronic Abacterial Prostatitis <ul><li>Pathogenesis and Pathology </li></ul><ul><li>The cause of the pathogenesis of nonbacterial prostatitis are unknown. </li></ul><ul><li>The histopathologic findings are non specific and resemble those seen in chronic bacterial prostatitis. </li></ul>
  75. 89. Chronic Abacterial Prostatitis <ul><li>Clinical Findings </li></ul><ul><li>The signs and symptoms are similar except that documented UTI almost never occurs in former. </li></ul><ul><li>Complications </li></ul><ul><li>Non bacterial prostatitis causes no known organic complications </li></ul>
  76. 90. Chronic Abacterial Prostatitis <ul><li>Treatment </li></ul><ul><li>Antimicrobial therapy should be tried for at least 4 weeks. </li></ul><ul><li>Therapy must be directed toward control of the symptoms. </li></ul><ul><li>Symptomatic flare ups often respond to anti-inflammatory agents. </li></ul><ul><li>Like most patients with prostatodynia, most patients with non bacterial prostatitis respond favorably to therapy using an alpha blocking agent. </li></ul><ul><li>Most authorities agree that prostatectomy is not indicated. </li></ul>
  77. 91. THANK YOU 
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