BPH and Carcinoma of Prostate

1. BENIGN PROSTATIC
HYPERPLASIA
Presented by : Adithya S
MBBS , Govt Thiruvarur Medical College

2.  the prostate is an accessory gland of male reproductive system
 The prostate is a pyramidal-shaped, fibromuscular glandular
organ which surrounds the prostatic urethra.
 Its secretions form the bulk of the seminal fluid. Its female
homologue is paraurethral glands
ANATOMY OF PROSTATE

3. The prostate is located in the lesser pelvis below the neck of
the urinary bladder and above the urogenital diaphragm.
It lies behind the lower part of the pubic symphysis and in
front of the rectal ampulla. It is embraced on each side by the
levator ani muscle.
LOCATION

4. DIMENSIONS
• Weight: 7 -16 g.
• Width (at base): 4 cm.
• Length: 3 cm.
• Thickness: 2 cm
GROSS FEATURES
The prostate presents the following external features:
1. Apex.
2. Base.
3. Four surfaces (anterior, posterior and two inferolateral)

5. LOBES
The prostate is divided into five
lobes:
 Anterior lobe (isthmus).
 Posterior lobe.
 Median lobe.
 Two lateral lobes
The median lobe is located
between the urethra and two
ejaculatory duct. The enlargement
of this lobe in BPH is responsible
for urethral obstruction

6. ZONES OF PROSTATE
Histologically, there are two well-defined
concentric zones separated by an ill-defined
irregular fibrous layer. The zones are absent
anteriorly
 Outer zone: The larger outer zone is
composed of long branching glands .
This is a common site for carcinoma
of prostate
 Inner zone: The smaller inner zone is
composed of outer submucosal glands.
The inner zone of prostate is the
common site of benign prostatic
hypertrophy

7. CAPSULES OF PROSTATE
The prostatic capsules are two in number in normal gland
and three in number if gland is affected by benign
hypertrophy of the prostate.
 True capsule: It is formed by the condensation of
peripheral fibrous stroma of the gland,
 False capsule It is derived from the pelvic fascia. It is
outside the true capsule
 Surgical capsule: When the adenoma of the gland
enlarges, the peripheral part of the organ becomes
compressed. This compressed part of the gland is
called surgical or pathological capsule

8. It is a condition of
progressive
enlargement of prostate
gland, resulting from an
increase in number and
size of epithelial and
stromal tissue
Benign prostatic
hyperplasia

9. ETIOLOGY
1. Ageing
2. Excessive accumulation of prostatic
androgen
3. Family history
4. Diet increases animal fat and
saturated fatty acid
5. Reduced exercise
6. alcohol consumption and smoking

10. PATHOPHYSIOLOGY
Age advancement
Decreased androgen
levels
Increased estrogen
Stimulation and
hyperplasia of prostate

11. SECONDARY EFFECTS OF BPH
URETHRAL CHANGES
Urethra gets compressed, elongated and gets converted into a narrow
longitudinal slit
CHANGES IN BLADDER
 Trabeculations
 Sacculations
 Diverticuli
 Stasis , infection and stone formation

12. CHANGES IN URETER AND KIDNEY
 Bilateral hydronephrosis
 Bilateral hydroureter
 Renal failure

13. CLINICAL FEATURES

14. DIAGNOSIS
Digital rectal examination: Enlarged lateral lobes can be easily felt. Rectal mucosa is free
• GRADE I The prostatic lobes protrude minimally into the
rectal lumen by 1-2 cm, the median sulcus is palpable.
• GRADE II Prostatic lobes protrude> 2 cm but < 3 cm into
the rectal lumen and the median sulcus is obliterated.
• GRADE III 3--4 cm protrusion
• GRADE IV > 4 cm protrusion of lobes, most of the rectal
lumen is filled by the projecting prostatic lobes.

15. INVESTIGATIONS
 Blood urine
 Creatinine
 Uroflowmetry
• Normal peak flow rate: 20 ml/sec.
• Doubtful peak obstruction: 10 to 15 ml/sec.
• Definite peak obstruction: Less than 10 ml/sec
 USG
 Cystometrogram

16. TREATMENT
The treatment plan depends on the cause of BPH , severity of the obstruction and patients
general health condition
DRUGS
Finasteride acetate : It helps in prevention of hyperplasia: of the prostate. It is given for large
prostates.
α-adrenergic blockers: It is supposed to relax the internal sphincter for better drainage of the
bladder (tamsulosin , terazosin, alfazocin)
MEDICAL MANAGEMENT

17. TREATMENT
INDICATIONS FOR SURGERY
o Urinary retention
o Frequency of micturition disturbs normal daily activities
o Complications like haematuria ,hydronephrosis , prostatic diverticulosis
SURGICAL MANAGEMENT

18. SURGICAL METHODS
Transurethral resection of the prostate (TURP)
 This is gold standard method.
 A resectoscope is passed through the urethra and
under vision with constant irrigation with water or
glycine, the prostate is resected into multiple pieces
and removed.
 Haemostasis is obtained with the help of a cautery
COMPLICATIONS
 Incontinence
 Retrograde ejaculation
 Impotence
 Bladder neck contracture

19. Transvesical suprapubic prostatectomy
 This method is now restricted to glands more than 100 g in
weight and associated with calculus
 Through an extraperitoneal approach the bladder is
opened, prostate is enucleated with finger, bleeding is
controlled by inflating the Foley bulb with about 30 50 ml of
air and by ligatures.
 During the process, the prostatic urethra is also avulsed.
 After about 7-10 days, a tract develops along the length of
Foley catheter which heals by granulation, fibrosis and
forms the future prostatic urethra.

20. Retropubic prostatectomy
Done by extraperitoneal approach without opening the bladder,
pushing the bladder to one side and excision of the prostate.
Not done nowadays
Perineal prostatectomy
Newer treatments
•Holmium: YAG laser.
• Intraurethral stents- in men who are grossly unfit

21. CARCINOMA
OF
PROSTATE

22. INTRODUCTION
 Carcinoma of the prostate is common after the age of 65
years.
 The incidence increases with age.
 In Western countries, it is the second most common type
of carcinoma in males after 65 years, first being
bronchogenic carcinoma.
 Prostatectomy done for BPH does not give protection
against development of carcinoma of prostate because
during prostatectomy the outer zone is left undisturbed

23. CLINICAL
FEATURES
 Multiple bone pains
 Acute retention of urine
 Difficulty in passing urine
 Painful micturition

24. • Hematogenous spread- occurs through prostatic venous plexus
which communicates through the emissary veins with the bones
• Bones affected in carcinoma prostate are
METASTASIS
1.Thoracolumbar vertebrae
2. Pelvic bone, iliac crest
3. Femur
4. Scalp
5. Ribs

25. •Local spread
Medial side spread – prostatic urethra affected
Upward spread- bladder & seminal vesicle affected
• Lymphatic spread - Prostatic chain of lymphatics drain into internal
iliac nodes . From this group of nodes, para-aortic nodes, mediastinal
nodes, followed by left supraclavicular nodes get involved.

26. TNM STAGING OF CARCINOMA PROSTATE

27. INVESTIGATIONS
a) Transrectal ultrasound guided trucut biopsy
b) X-ray of bones
c) Prostatic acid phosphatase
d) Serum alkaline phosphatase
e) Prostate specific antigen
f) Abdominal and transrectal USG
g) CT / MRI
h) Bone scan
i) Gallium – 68 PSMA PET

28. TREATMENT
Early malignancy (T1 or T2 , M0 ,N0)
Radical prostatectomy - Radical prostatectomy involves pelvic lymphadenectomy
and removal of the prostate, seminal vesicle including the distal urethral sphincter
followed by anastomosis of urethra to the bladder neck.
Radical radiotherapy - for prostate and pelvic nodes is given postoperatively
Early prostatic malignancy with PSA > 20 nmol/ml or more and the patient is
already beyond 65 to 70 years of age, surgery is not favoured. Radical
radiotherapy is given

29. Late malignancy – T3
Androgen ablation- in the form of bilateral orchidectomy is done as the tumour is
androgen-dependent followed by anti-androgenic measures like
 Estrogens - oral Diethylstilboestrol
 LHRH agonist – Leuprolide
Chemotherapy
 Docetaxel
 Cabazitaxel
Radiotherapy

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