PROSTATE CANCER AND BPH Prostate cancer - PowerPoint Presentation

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PROSTATE CANCER AND BPH

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Prostate cancerThe second most common cancer diagnosed in menThe incidence increase with age very rare before age of 40, more in western countries particularly Scandinavian countries (low light exposure), and black men are at greatest risk

Family history:

ptn

with family history has increase incidence of prostate cancer and earlier onset

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The most common prostatic malignancy is adenocarcinoma of prostate acinar or ductal epithelium

75% are in peripheral zone, and 85% are multifocal

15% in transitional and 5% in central zone

Tumour

may involve nearby structures (urethral sphincter, corpora of penis, trigon, seminal vesicle , unlikely the rectum because

denonvilliers

fascia

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Prostate zones

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GradingIt is graded by gleason

system

Using low power microscope adenocarcinoma is graded into 1-5 according to gland forming differentiation

Because the PC is multiple we add the two dominant grade

2-6 is well differentiated, 7 moderate differentiated, 8-10 poorly differentiated

It correlate well with prognosis

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Cytologic features play no part in this grading system

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StagingTNM

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T stage assessed by DRE, TRUS, and MRIN stage assessed by MRI or during pelvic lymphadenectomyM stage by CT scan and bone scan

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PresentationAsymptomaticLUTS

Hematuria or

hematospermia

Ureteric obstruction

Back pain, anemia,

jundice

in metastatic disease

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Clinical diagnosisIt is usually suspected in the basis of DRE or PSAAbnormal digital examination

isassociate

with higher grade , and indication of

bx

PSA it is organ specific not disease specific, may be elevated in different prostate disease such as BPH, prostatitis, cancer, prostate calculi

There is no agreed standard for measuring PSA, higher level increase the chance of prostate cancer, and the level depend on the age

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PSAPSA density :the level divided by TRUS prostate volume the higher the density more chance of malignancy

Free/total ratio: decrease the ratio increase the

posibility

of prostate cancer, no clinical use if PSA more than 10

PS velocity : absolute annual increase in PSA per year and PSA doubling time: exponential increase in PSA over time, has prognostic role but limited diagnostic role.

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TRUS and

multiparametric

MRI are imaging study that can be used to detect PC

Prostate

bx

: can be done

transrectal

or

transperineal

, at least 8

bx

for prostate 30 cc and 10-12 for larger prostate

Complication include

hematospermia

,

hematurea

, prostatitis , retention, rectal bleeding

-

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ManagementAssessing the risk category into:-1- low risk with PSA< 10,

gleason

score <7 and stage T1-T2a

2- intermediate risk with PSA 10-20,

gleason

7 and T2b-T2c

3-High risk with PSA >20,

gleason

8-10 and T3-T4

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1-Watchful waitingIt is suitable for ptn

with health problem and life expectancy less than 10 years

Ptn

watched if develop local or distant progression

If disease progress

…

palliative treatment for cancer and symptom

Mx

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2-Active surveillanceIn low risk pt to avoid overtreatment

Do serial DRE, PSA and TRUS biopsy, if disease progress aim to cure it

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3- Radical prostatectomyBest option for localized and locally advanced diseaseEither

retropubic

or perineal approaches

…

.

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4- EBRTFor localized and locally advanced diseaseC.I. in :- severe LUTS and IBD

S.E.:-

LUTS, GI symptoms, hematuria and ED

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5- BrachytherapyC.I.:-previous TURP, prostate volume >60 ml and severe LUTS

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6- Hormonal therapyIn metastatic diseaseTypes:- surgical castration

…

medical castration ( LHRH antagonist , LHRH agonist and antiandrogens)

…

..

S.E.:- ED, hot flushes, weight gain, depression, gynecomastia, osteoporosis (

andropause

)

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BPHProstate is one of sex accessory gland that derived from urogenital sinus

Swelling of terminal part of hindgut result in formation of

cloaca,which

later on divided by urogenital septum into

anorectal

sinus and urogenital sinus

The urogenital sinus is differentiated into bladder ,urethra ,and prostate

Prostate development from urogenital sinus is under

dihydrotestosteron

stimulation

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Function of prostateProstate with other sex accessory gland secrete seminal plasma which provide suitable environment for survival and function of sperm.

SAG include seminal

vesicle,prostate,epididymis,cowper

gland

Prostate form 1\6 of seminal fluid volume while the sperm only 1% of seminal

fluid,the

majority comes from seminal vesicle

Prostate

seretes

zinc,citric

acid ,and

psa

Psa

is important for

liquifaction

of semen

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Prostate zones

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EtiologyBPH is characterized by increase in the number of epithelial and stromal cell

The development of BPH requires androgen

In prostate the testosterone is converted into DHT by 5 alpha

reductase

, which is 5 times more potent than testosterone

There are two types of this enzyme ,type 1 which is

extraprostatic

and type 2 which found in prostate

The process of BPH suggests reawakening of embryonic process of prostate development

Familial factors of BPH

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pathophisiologyBPH develpes in transitional zone

Prostate hyperplasia-BOO-

detruser

response-LUTS

The size of prostate

doesnot

correlate with degree of obstruction

Static

vs

dynamic obstruction

Adrenergic nervous system –alpha 1

receipter

-smooth muscle contraction-increase prostatic urethral resistance

Bladder response to obstruction includes hypertrophy (

detrusal

instability) by modulation of neural

detrusal

response

Deposition of collagen which affect the compliance

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Symptoms of BPH Symptoms can be obstructive or

irritative

symptoms or hematuria

Complication includes bladder stones ,infections ,

hematurea,urinary

retention,

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assesmentHistory and physical examinationSerum creatinine and urine test

psa

Uroflowmetry

and PVR

Renal / TRUS

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ManagementBPH vs

BPE

vs

clinical BPH(LUTS)

Watchful waiting(simple measures such as decrease fluid intake ,moderate intake of

caffiene,time

voiding,avoide

constipation)

Medical management symptoms that cause bothering to the patient

Or patient with moderate to severe IPSS score

Surgical option if failed medical management or complication

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IPSS score

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Mild (symptom score less than of equal to 7) Moderate (symptom score range 8-19

)

Severe (symptom score range 20-35)

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Medical management includes alpha adrenergic blockerLike tamsulosin

alfuzosin

doxazosin

terazosin

Side effect include dizziness ,postural

hypotension,retrograde

ejaculation,intraoperative

floppy iris syndrome(

tamsulosin

impaire

iris dilatation which is important for safe cataract surgery

5 alpha

reductase

inhibiters such as

finasteride

and

dutasteride

If prostate size more than 40 ml ,<decrease the size by 20 %,the effect appear after 3-6

monthes

Mainly sexual side effect ED decrease libido

Anticholinergic.PDEI

good option in

ptn

of ED and LUTS

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Combination treatement of alpha 1 blocker and anti muscarinic in

ptn

with significant

irritative

symptom.

No anti muscarinic if PVR

more than 150 ml

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Surgical like TURP (electrified wire loop, TUIP,laser prostatectomy or open prostatectomy

Indications:-

Failure of medical

Tx

Recurrent UTI

Renal impairment

Recurrent hematuria

Bladder stones

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TURP

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Indications for open rather than endoscopic procedure:-Large prostate size (>80 g) severe Urethral stricture

Difficult lithotomy position

Large bladder stones

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TUR syndrome: fluid absorption of hypotonic fluid which lead to dilutional hypernatremia with resulting neurologic change ,

bradycardia

,and hypertension.

Early

vs

late complication of TURP

Early like infection, hemorrhage, TUR syndrome, or bladder perforation

Late like retrograde ejaculation ,

incontinence,failure

of surgery