Prostate Gland

ANATOMY OF PROSTATE ANATOMY OF PROSTATE

Lobar anatomyLobar anatomy

Median lobes

Zonal anatomyZonal anatomy

Devided in to four glandular zones

surrounding the prostatic urethra:

• peripheral zone

• transitional zone

• central zone &

• periurethral glandular area.

Devided in to four glandular zones

surrounding the prostatic urethra:

• peripheral zone

• transitional zone

• central zone &

• periurethral glandular area.

On sonographyOn sonography

Separate the Prostate into :

• peripheral zone &

• Inner gland

transitional one

central zone

periurethral glandular area.

Separate the Prostate into :

• peripheral zone &

• Inner gland

transitional one

central zone

periurethral glandular area.

A nonglandular region on the anterior anterior surface of the prostate

is termed anterior fibromuscular stroma.

Other fibromuscular structures-

- preprostatic sphincter

- postprostatic sphincter

- longitudinal muscle of the proximal urethra.

A nonglandular region on the anterior anterior surface of the prostate

is termed anterior fibromuscular stroma.

Other fibromuscular structures-

- preprostatic sphincter

- postprostatic sphincter

- longitudinal muscle of the proximal urethra.

Peripheral zonePeripheral zone

70% of prostatic glandular tissue.

Source of most prostatic ca.

Surround the distal urethral segment & separated from transition zone

& central zone by surgical capsule.

Occupies the posterior, lateral and apical regions of the prostate,

extending some what anteriorly.

Ducts of the peripheral zone enter the distal urethra.

Source of most prostatic ca.

Surround the distal urethral segment & separated from transition zone

& central zone by surgical capsule.

Occupies the posterior, lateral and apical regions of the prostate,

extending some what anteriorly.

Ducts of the peripheral zone enter the distal urethra.

Transition zoneTransition zone

Site of origin of benign prostatic hyperplasia.

Seen as two small glandular areas located adjacent to the proximal

urethral segment.

Ducts of the transition zone end in proximal urethra at the level of

verumontanum.

Site of origin of benign prostatic hyperplasia.

Seen as two small glandular areas located adjacent to the proximal

urethral segment.

Ducts of the transition zone end in proximal urethra at the level of

verumontanum.

Cenral zoneCenral zone

Site of origin of 5% prostatic ca.

Located at the prostatic base.

Ducts of the vas deferens & seminal vesicle enter the central zone & the

ejaculatory ducts pass through it .

Central zone ducts terminate in the proximal urethra near the

verumontanum.

Site of origin of 5% prostatic ca.

Located at the prostatic base.

Ducts of the vas deferens & seminal vesicle enter the central zone & the

ejaculatory ducts pass through it .

Central zone ducts terminate in the proximal urethra near the

verumontanum.

Periurethral glandsPeriurethral glands

Embedded in the longitudinal smooth muscle of the proximal urethra,

known as internal prostatic sphincter.

Embedded in the longitudinal smooth muscle of the proximal urethra,

known as internal prostatic sphincter.

MEASUREMENT OF PROSTATE MEASUREMENT OF PROSTATE

Step planimetry method, which calculates volume from the sum of

sequential horizontal areas measured from the base to apex.

Diameter method which comprise measurements of height (H), width

(W) and length (L) and volume is calculated using the formula

½ (H x W x L).

Normal volume : 20gm.

Step planimetry method, which calculates volume from the sum of

sequential horizontal areas measured from the base to apex.

Diameter method which comprise measurements of height (H), width

(W) and length (L) and volume is calculated using the formula

½ (H x W x L).

Normal volume : 20gm.

NORMAL PROSTATIC ECHO PATTERNS NORMAL PROSTATIC ECHO PATTERNS

Three echo levels are seen on prostatic Sonographic examinations:IsoechoicHypoechoic andHyperechoic

In normal young men, the normal inner gland of the prostate has generally low echogenicity compared with the outer gland .As the transition zone enlarges a distinct demarcation between these regions become clear. The transition zone produces a hypoechoic images compared with the generally isoechoic peripheral zone. Hyperechoic structures are most common characteristic of fat, corpora amylacea or calculi.

TECHNIQUE OF TRANSRECTAL ULTRASOUND TECHNIQUE OF TRANSRECTAL ULTRASOUND

• Left lateral decubitus or lithotomy position.• A self-administered enema is routinely used before scanning.• Rectal examination befor probe insertion.

Transverse or semi coronal plane:Transverse or semi coronal plane:

The seminal vesicles are seen at the cephalad portion of

the prostate gland above the prostatic base.

They are hypoechoic & irregular and usually symmetrical.

The seminal vesicles are seen at the cephalad portion of

the prostate gland above the prostatic base.

They are hypoechoic & irregular and usually symmetrical.

Base of the prostate is examined with demonstration of

Central zone, transition zone & periurethal glandular area.

The anterior fibromuscular area is hypoechoic.

Base of the prostate is examined with demonstration of

Central zone, transition zone & periurethal glandular area.

The anterior fibromuscular area is hypoechoic.

The periurethal area may be very hypoechoic.

The urethra & ejaculatory duct may be identified.

Near the apex most of the tissue is the peripheral zone

The periurethal area may be very hypoechoic.

The urethra & ejaculatory duct may be identified.

Near the apex most of the tissue is the peripheral zone

Continuing Transverse or semi coronal plane:Continuing Transverse or semi coronal plane:

Semi coronal plane:Semi coronal plane:

Rotating from right to left will assess glandular symmetry

& confirm any suspicious abnormalities seen on axial or

Coronal imaging.

Seminal vesicles & periurethral area are better evaluate in

sagital plane.

Rotating from right to left will assess glandular symmetry

& confirm any suspicious abnormalities seen on axial or

Coronal imaging.

Seminal vesicles & periurethral area are better evaluate in

sagital plane.

In sagital plane :In sagital plane :

NORMAL SEMINAL VESICLES

Engorged, echogenic seminal

vesicles with a fine vesicular

pattern

Engorged, echogenic seminal

vesicles with a fine vesicular

pattern

Hypoechoic, featureless

appearance

Hypoechoic, featureless

appearance

Echogenic, small vesicles Echogenic, small vesicles

NORMAL SEMINAL VESICLES & VAS

DEFERENCE

NORMAL SEMINAL VESICLES & VAS

DEFERENCE

The Rt. vas deferens seen

joining the Rt. seminal

vesicle

The Rt. vas deferens seen

joining the Rt. seminal

vesicle

Echogenic, featureless Echogenic, featureless

NORMAL VAS DEFERENS

Showing normal anatomy

of vas deferens seen in this

oblique cornonal section on

TRUS imaging.

Showing normal anatomy

of vas deferens seen in this

oblique cornonal section on

TRUS imaging.

INDICATION OF TRANSRECTAL ULTRASOUND INDICATION OF TRANSRECTAL ULTRASOUND

Abnormal digital rectal examinationAbnormal digital rectal examination

Abnormal lab test results indicative of prostate cancer PSA Acid phosphatase Other evidence of metastetic disease.

Guidance for directed sonographic biopsyGuidance for directed sonographic biopsy

Monitoring response to treatment for prostate cancer.Monitoring response to treatment for prostate cancer.

BENIGN PROSTATIC HYPERPLASIA SONOGRAPHIC APPEARENCE

WT of the gland in young pt is about 20gm.WT of the gland in young pt is about 20gm.

Beginning at age 50, the doubling time of the wt is aprox 10yrs.Beginning at age 50, the doubling time of the wt is aprox 10yrs.

Prostate gland enlarge more than 40gm consider enlarged in older man. Prostate gland enlarge more than 40gm consider enlarged in older man.

Distinct nodules or diffuse enlargement present in transition zone, peripheral glandular tissue or both.Distinct nodules or diffuse enlargement present in transition zone, peripheral glandular tissue or both.

Typical feature of BPH is enlargement of inner gland, which remain relatively hypoechoic to peripheral zone.Typical feature of BPH is enlargement of inner gland, which remain relatively hypoechoic to peripheral zone.

The echo pattern depend on the admixture of glandular and stromal elements as nodules may be fibroblastic, fibromuscular, muscular & fibroadenomatous. This combination may result in either an isoechoic or hyperehoic appearance.

With increasing enlargement, the hypoechoic transition zone compresses the central and peripheral zone With increasing enlargement, the hypoechoic transition zone compresses the central and peripheral zone

The margin separating the hyperplasia from the peripheral zone is considered to be the surgical capsule. The margin separating the hyperplasia from the peripheral zone is considered to be the surgical capsule.

Ultrasound can also analyze the effect of the hyperplasia on the anterior urethra and assess median lobe enlargement. Other sonographic appearances of benign prostatic hyperplasia (BPH) include calcifications and rounded hypoechoic nodules called BPH nodule.

Benign prostatic hyperplasiaBenign prostatic hyperplasia

Transabdominal ultrasound scan images reveal obvious intravesical enlargement of the enlarged median lobeof the prostate.

Benign prostatic hyperplasiaBenign prostatic hyperplasia

Transabdominal ultrasound scan images reveal obvious intravesical enlargement of the enlarged median lobeof the prostate.

Post-voiding trans-rectal ultrasound scan (TRUS) images reveal- 1) large volume of residual urine (303 cc) (more than 40 cc. is abnormal). 2) gross enlargement of the prostate mainly involving the transition zone. 3) intra-vesical enlargement of median lobe. 4) few small cysts in inner gland 3) there is also evidence of corpora amylacea and nodularity in the transition zone. 5) the peripheral zone is compressed by the enlarged transition zone.

Benign prostatic hyperplasia

Prostatitis Prostatitis

Bulky prostate of approximately 49m Bulky prostate of approximately 49m

Color Doppler imaging of prostatitisColor Doppler imaging of prostatitis

The above TRUS ultrasound and color doppler images in a young male patient show a) hypoechoic prostate b) gross augmentation of vascularity in the prostatic tissue. These ultrasound findings suggest presence of acute prostatitis

TRUS images of prostatitis: TRUS images of prostatitis:

Note the markedly hypoechoic patches in the inner zone of the prostate (arrowed), which appear overtly vascular on color doppler imaging

Transurethral resection of the prostate (TURP): Transurethral resection of the prostate (TURP):

In this TRUS sonographic image, the

defect due to a Trans-Urethral

Resection of the Prostate, is evident.

Here, the transition zone of the

prostate has been resected. The

transition zone is the seat of the

benign hyperplasia of the prostate,

and is a part of the “inner gland”.

In this TRUS sonographic image, the

defect due to a Trans-Urethral

Resection of the Prostate, is evident.

Here, the transition zone of the

prostate has been resected. The

transition zone is the seat of the

benign hyperplasia of the prostate,

and is a part of the “inner gland”.

PROSTATIC ABSCESS PROSTATIC ABSCESS

TRUS scan shows a

hypoechoic collection of 2.5

cms within the right lobe

of the prostate. The walls of

the lesion are shaggy s/o an

abscess.

TRUS scan shows a

hypoechoic collection of 2.5

cms within the right lobe

of the prostate. The walls of

the lesion are shaggy s/o an

abscess.

Calculi or calcific foci in prostate: Calculi or calcific foci in prostate:

TRUS images show multiple hyperechoic foci (arrows), each of 4 to 7 mm. in the inner gland of the prostate and also along the prostatic urethra. Power Doppler image (bottom) shows normal flow in the prostate. These ultrasound images suggest prostatic calcification or calculi. Calcific foci in prostate are associated with normal aging process in the male and may be the result of formation of corpora amylacea. These are formed by calcification of secretions of the gland. It is also seen in chronic inflammation of the prostate (chronic prostatitis).

Seminal vesicle calculi (seminal vesicle calcification)Seminal vesicle calculi (seminal vesicle calcification)

The ultrasound images show multiple seminal vesical calculi bilaterally, each measuring 2 to 4 mm. in size. Studies suggest that such stones are related to inflammation, obstruction or diabetes mellitus. The ultrasound image on bottom right shows Power Doppler study of the prostate; no abnormal flow was found. Calculi in this case can cause poor flow of semen during ejaculation, hemospermia and painful ejaculation.

Transrectal ultrasound of the prostate. Transverse image of the prostate in

a young male demonstrates a small midline cystic structure (arrow),

thought to represent a utricle cyst.

Transrectal ultrasound of the prostate. Transverse image of the prostate in

a young male demonstrates a small midline cystic structure (arrow),

thought to represent a utricle cyst.

Utricle cystUtricle cyst

Prostate CarcinomaProstate Carcinoma

Axial transrectal ultrasonographic

(TRUS) scan shows extensive

hypoechoic area (arrows) in the right

peripheral zone. Biopsy revealed

prostatic adenocarcinoma.

(TRUS) scan shows extensive

hypoechoic area (arrows) in the right

peripheral zone. Biopsy revealed

prostatic adenocarcinoma.

Carcinoma prostate- Ultrasound and Color Doppler imaging:Carcinoma prostate- Ultrasound and Color Doppler imaging:

Ultrasound images (TRUS) reveal a hypoechoic lesion involving much of the left peripheral zone. Color and Power Doppler images (TRUS) reveal marked vascularity in the region of the nodule (left peripheral zone). These ultrasound image findings are typical of carcinoma of prostate. There is also evidence of benign prostatic hypertrophy.

(TRUS) scan shows a hypoechoic

area in left peripheral zone and a

small hypoechoic area in right

peripheral zone (arrows) .

(TRUS) scan shows a hypoechoic

area in left peripheral zone and a

small hypoechoic area in right

peripheral zone (arrows) .

Image shows extensive bilateral but

predominantly left-sided hypoechoic

areas in the peripheral zone (arrows).

Biopsy confirmed a Gleason grade 8

prostate cancer. Minor capsular

irregularity is present on the left; this is

consistent with a T3 tumor.

Image shows extensive bilateral but

predominantly left-sided hypoechoic

areas in the peripheral zone (arrows).

Biopsy confirmed a Gleason grade 8

prostate cancer. Minor capsular

irregularity is present on the left; this is

consistent with a T3 tumor.

A generalized increase in vascularity

was noted in the posterior aspect of the

prostate (arrows).

A generalized increase in vascularity

was noted in the posterior aspect of the

prostate (arrows).

Axial transrectal ultrasonographic (TRUS)

scan in a patient with clinical benign

prostatic hyperplasia (BPH) and a serum

prostate-specific antigen (PSA) level of 11

ng/mL. Enlargement of the transition zone

is present, but no focal abnormality is

observed in the peripheral zone.

Systematic 6-core biopsy revealed

adenocarcinoma from both lobes of the

prostate (ie, this is an isoechoic tumor in

the peripheral zone of both prostatic

lobes).

Axial transrectal ultrasonographic (TRUS)

scan in a patient with clinical benign

prostatic hyperplasia (BPH) and a serum

prostate-specific antigen (PSA) level of 11

ng/mL. Enlargement of the transition zone

is present, but no focal abnormality is

observed in the peripheral zone.

Systematic 6-core biopsy revealed

adenocarcinoma from both lobes of the

prostate (ie, this is an isoechoic tumor in

the peripheral zone of both prostatic

lobes).

Sonogram shows an extensive,

hypoechoic T3 tumor (arrowheads).

Capsular irregularity is present,

particularly on the right and

posteriorly, with a suggestion of

infiltration into the rectal wal

Sonogram shows an extensive,

hypoechoic T3 tumor (arrowheads).

Capsular irregularity is present,

particularly on the right and

posteriorly, with a suggestion of

infiltration into the rectal wal

On frontal (or transversal)

Scans, a hypoechoic mass is

identified in the posterolateral

aspect of the left peripheral

zone.. Note, also, the invasion

of the capsule.

On frontal (or transversal)

Scans, a hypoechoic mass is

identified in the posterolateral

aspect of the left peripheral

zone.. Note, also, the invasion

of the capsule.

Increased color flow in a

hypoechoic cancer in the

posterolateral zone on this

transverse view.

Increased color flow in a

hypoechoic cancer in the

posterolateral zone on this

transverse view.

PROSTATIC CANCER

STAGING OF CARCINOMA OF PROSTATE STAGING OF CARCINOMA OF PROSTATE

Stage 1 Stage 1

Tumor not detectable by imaging or clinical exam

Low grade tumor

Less than 5% of tissue specimen

Tumor not detectable by imaging or clinical exam

Low grade tumor

Less than 5% of tissue specimen

Stage 2 Stage 2

Tumor not detectable by imaging or clinical exam.

May be found in one or more lobes by needle

biopsy

Moderate to High grade tumor

Over 5% of tissue specimen

Tumor not detectable by imaging or clinical exam.

May be found in one or more lobes by needle

biopsy

Moderate to High grade tumor

Over 5% of tissue specimen

Stage 3 Stage 3

Tumor extends beyond prostate capsule. Can

invade seminal vesicles.

Any grade tumor

Tumor extends beyond prostate capsule. Can

invade seminal vesicles.

Any grade tumor

Stage 4 Stage 4

Tumor is fixed or invades adjacent structures other

than seminal vesicles, such as sphincter, bladder

neck, wall of pelvis, and rectum

Tumor spread to lymph nodes or metasteses

Any grade tumor

Tumor is fixed or invades adjacent structures other

than seminal vesicles, such as sphincter, bladder

neck, wall of pelvis, and rectum

Tumor spread to lymph nodes or metasteses

Any grade tumor

Prostate Gland

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