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ANATOMY OF PROSTATE ANATOMY OF PROSTATE
Lobar anatomyLobar anatomy
Anterior
Posterior
Median lobes
Anterior
Posterior
Median lobes
ANATOMY OF PROSTATE ANATOMY OF PROSTATE
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.
ANATOMY OF PROSTATE ANATOMY OF PROSTATE
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.
ANATOMY OF PROSTATE ANATOMY OF PROSTATE
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.
ANATOMY OF PROSTATE ANATOMY OF PROSTATE
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.
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.
ANATOMY OF PROSTATE ANATOMY OF PROSTATE
ANATOMY OF PROSTATE ANATOMY OF PROSTATE
Transition zoneTransition zone
5% of prostatic glandular tissue.
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.
5% of prostatic glandular tissue.
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.
ANATOMY OF PROSTATE ANATOMY OF PROSTATE
ANATOMY OF PROSTATE ANATOMY OF PROSTATE
Cenral zoneCenral zone
25% of prostatic glandular tissue.
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.
25% of prostatic glandular tissue.
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.
ANATOMY OF PROSTATE ANATOMY OF PROSTATE
Periurethral glandsPeriurethral glands
1% of prostatic glandular tissue.
Embedded in the longitudinal smooth muscle of the proximal urethra,
known as internal prostatic sphincter.
1% of prostatic glandular tissue.
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
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.
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.
• 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.
TECHNIQUE OF TRANSRECTAL ULTRASOUND TECHNIQUE OF TRANSRECTAL ULTRASOUND
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:
TECHNIQUE OF TRANSRECTAL ULTRASOUND TECHNIQUE OF TRANSRECTAL ULTRASOUND
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
NORMAL SEMINAL VESICLES
Engorged, echogenic seminal
vesicles with a fine vesicular
pattern
Engorged, echogenic seminal
vesicles with a fine vesicular
pattern
NORMAL SEMINAL VESICLES
NORMAL SEMINAL VESICLES
Hypoechoic, featureless
appearance
Hypoechoic, featureless
appearance
NORMAL SEMINAL VESICLES
NORMAL SEMINAL VESICLES
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
NORMAL SEMINAL VESICLES
NORMAL SEMINAL VESICLES
Echogenic, featureless Echogenic, featureless
NORMAL VAS DEFERENS
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.
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
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.
BENIGN PROSTATIC HYPERPLASIA SONOGRAPHIC APPEARENCE
BENIGN PROSTATIC HYPERPLASIA SONOGRAPHIC APPEARENCE
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.
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.
BENIGN PROSTATIC HYPERPLASIA SONOGRAPHIC APPEARENCE
BENIGN PROSTATIC HYPERPLASIA SONOGRAPHIC APPEARENCE
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.
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.
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.
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
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
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).
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.
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.
Axial transrectal ultrasonographic
(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.
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.
Prostate CarcinomaProstate Carcinoma
Axial transrectal ultrasonographic
(TRUS) scan shows a hypoechoic
area in left peripheral zone and a
small hypoechoic area in right
peripheral zone (arrows) .
Axial transrectal ultrasonographic
(TRUS) scan shows a hypoechoic
area in left peripheral zone and a
small hypoechoic area in right
peripheral zone (arrows) .
Prostate CarcinomaProstate Carcinoma
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.
Prostate CarcinomaProstate Carcinoma
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).
Prostate CarcinomaProstate Carcinoma
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).
Prostate CarcinomaProstate Carcinoma
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
Prostate CarcinomaProstate Carcinoma
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.
Prostate CarcinomaProstate Carcinoma
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
STAGING OF CARCINOMA OF PROSTATE STAGING OF CARCINOMA OF PROSTATE
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
STAGING OF CARCINOMA OF PROSTATE STAGING OF CARCINOMA OF PROSTATE
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
STAGING OF CARCINOMA OF PROSTATE STAGING OF CARCINOMA OF PROSTATE
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