Prostate

classic appearance of prostate cancer US

hypoechoic, peripherally-oriented lesion

PSA velocity can estimate risk for prostate cancer; normal increase with age, but ___ faster if a man has cancer.

increase

Pre exam prep for prostate biopsy

1. cleansing enema 2. pre and post prophylactic antibiotics

The Gleason score is a sum of these 2 grades ___ and ___; each are given a grade between 1-5. (a score of 8, 9, or 10 = high grade prostate cancer)

1. the predominant pattern 2. 2nd MC pattern

Patients with a higher Gleason score have ...

a more aggressive form of prostate cancer and a worse prognosis

Prostate is bordered superiorly by the ___

bladder

prostate-specific antigen (PSA) (single chain glycoprotein)

blood test to screen for prostate cancer - normal upper limits is 4 ng/mL - if elevated, put on antibiotics for 4-6 weeks and PSA rechecked

BPH on US

inner gland enlargement hypoechoic areas, calcifications, and cystic changes within gland diffusely heterogeneous

Prostate is bordered anteriorly by the ___

pubic bone

Prostate is bordered posteriorly by the ___

rectum

The normal prostate has a volume of < 30cc and is located in the ___.

retroperitoneum

Seminal vesicle cysts

s/s - asymptomatic; associated with Zinner syndrome (perineal pain, recurrent prostatitis, painful ejaculation, infertility) S/A - anechoic or complex cystic structures in the area of seminal vesicles

Prostatitis

s/s - hematospermia*, painful ejaculation, perineal pain, dysuria S/A - enlarged hypoechoic prostate, hyperemia

Prostate is bordered inferiorly by the ___

urogenital diaphragm

Incidence of prostate cancer

~ 15% (1 in 6.67) ~ increases with age, family history, race ~ African American ~ brother or father = twice the risk (brother > father, more of a genetic risk)

BPH: (s/s) proliferation of smooth muscle and epithelial cells of ⭐TRANSITIONAL zone in response to hormonal and inflammatory factors

↑ PSA difficult initiation of voiding urinary frequency small stream

Prostate cancer s/s

↑ PSA enlarged prostate hematuria or hematospermia (sperm & blood) pain in back, pelvic, hip, thigh impotence decreased ejaculation fluid

⭐ Seminal vesicles

⭐ 2 sac-like outpouchings of the vas deferens situated adjacent to the superior/posterior aspect of prostate, between bladder and rectum; located posteroinferior to the bladder

⭐ The prostate gland primarily receives arterial blood from the ___ artery.

⭐ Inferior Vesical artery

⭐ Seminal vesicle agenesis, associated with:

⭐ Ipsilateral agenesis - renal & of the vas deferens Ectopic ureter Ejaculatory duct obstruction

⭐ Congenital seminal vesicle cysts, associated with:

⭐ Ipsilateral renal agenesis / dysplasia ADPKD Zinner syndrome - triad of unilateral renal agenesis, ipsilateral seminal vesicle obstruction and ipsilateral ejaculatory duct obstruction

⭐ Methods of prostate biopsy

⭐ Lesion directed ⭐ Systematic sextant ⭐ Parasagittal sextant

⭐ Prostate anomalies

⭐ Seminal vesicle agenesis ⭐ Congenital seminal vesicle cysts

⭐ Median cysts

⭐ Utricle cysts ⭐ Mullerian duct cysts

⭐ Utricle cysts

⭐ a *pear shape* with a *midline* location at level of verumontanum; associated with hypospadias, cryptorchidism, and unilateral renal agenesis. they communicate freely with the prostatic urethra

⭐ Verumontanum

⭐ a long ridge within urethra in which the orifices of the ejaculatory ducts are located on either side

⭐ Müllerian duct cysts

⭐ a tear-drop shaped cyst located in the midline, above prostate posterior to bladder, originating in verumontanum; do NOT communicate with the prostatic urethra

⭐ Fibromuscular stroma

⭐ anterior NON-glandular portion; non-glandular = not affected by cancer, prostatitis, or hyperplasia (BPH)

⭐ Transitional zone

⭐ around urethra ~ 5% ~ location/site of origin of BPH

⭐ Lesion directed biopsy

⭐ biopsy based on a sonographic lesion is infrequently used due to its poor detection rate

⭐ Corpora amylacea

⭐ calcifications commonly seen in the inner gland of the prostate

⭐T1

⭐ clinically inapparent tumor, not palpable or visible by imaging

⭐ Surgical capsule

⭐ demarcation between inner gland (central & transitional zones) and the outer gland (peripheral)

⭐ Ejaculatory ducts

⭐ duct that passes through the central zone and empties into the urethra; originates from the combo of the vas deferens and seminal vesicle.

⭐ Prostate cancer staging; the usual sites of distant mets from prostate cancer are the lymph nodes and bones

⭐ high-res T2-weighted imaging, noninvasive; performed using the TNM (tumor, node, metastasis) staging system ⭐ T0-T4

⭐ Systematic Sextant biopsy

⭐ hodge et al demonstrated that taking systemic biopsies (3 on right and 3 on left) that the cancer detection rate was superior to the lesion-directed method

⭐ Apex of prostate

⭐ inferior portion of the gland; superior to the urogenital diaphragm

⭐ Paramedian cysts = Ejaculatory duct cysts ⭐

⭐ laterally located, occur d/t obstructed ejaculatory ducts (congenital or acquired), resulting in hematospermia, ejaculatory pain, and infertility

⭐T0

⭐ no evidence of tumor

⭐ Peripheral zone

⭐ posterior; extends into apex ~ 70% ~ location of most prostate cancers

⭐ Eiffel tower sign

⭐ shadowing created by edge artifact or calcification of prostatic urethra

⭐ Base of prostate

⭐ superior portion of the gland; below inferior margin of bladder

⭐ Central zone

⭐ superior; ejaculatory ducts pass thru here from seminal vesicles to urethra ~ 25%

⭐T2

⭐ tumor confined within prostate

⭐T3

⭐ tumor extending through the prostatic capsule

⭐T4

⭐ tumor fixed or invading adjacent structures

⭐ Parasagittal Sextant biopsy

⭐to improve on the traditional sextant biopsy method, urologists are including additional biopsy cores in the lateral aspects of the peripheral zone (10-12 cores)