Anatomy of Prostate, LUTS, TURP, Prostatic Cancer😍

Prostate

Zones of Prostate

• 5 lobes
• anterior
• posterior
• two lateral
• one middle lobe.

• Transitional zone:
• Most commonly involved in Benign Prostatic Hyperplasia (BPH).

• Peripheral zone:
• Most commonly involved in prostate cancer.

Median lobe of the prostate

• forms the uvula vesicae.

• elevation found in the lower part of the bladder trigone.
• It is the most common site of adenoma.

Corpora Amylacea

• Lamellated eosinophilic stones.

• Precursor for prostatic stones (Calcium Phosphate).

Urethra

Length

• Female: 3-4 cm.

• Male: 18-21 cm.

Parts

• Proximal: Membranous + Prostatic Urethra.

• Distal: Penile + Bulbar Urethra.

Epithelium of Male Urethra

Part	Notes
Pre-prostatic & Prostatic urethra	Transitional epithelium
Membranous urethra	Pseudostratified / Stratified columnar
Bulbar urethra	Most distensible part
Penile (Spongy) urethra	• Proximal → Pseudostratified columnar • Distal → Stratified squamous

---

Transitional epithelium / urothelium lines

• Renal pelvis and calyces,

• ureter

• urinary bladder

• pre-prostatic & prostatic parts of the urethra

---

Lower Urinary Tract Symptoms (LUTS)

• Divided into voiding & storage symptoms.

Voiding Symptoms

• Hesitancy

• Poor flow

• Intermittent stream

• Post-void dribbling

• Sensation of poor bladder emptying

• Episodes of near retention

Storage Symptoms

• Frequency (Earliest & Most common)

• Nocturia

• Nocturnal incontinence (Enuresis)

• Urgency

• Urge incontinence

LUTS Workup

• Digital Rectal Examination (DRE)
• BPH: Rubbery, mobile mucosa.
• Cancer: Hard, fixed mucosa.

• USG KUB (Kidney, Ureter, Bladder)
• Measures prostatic volume.
• Normal: 15-20 cc
• Detects upper urinary tract changes.
• Measures residual urine.

Prostate Specific Antigen (PSA)

• Value (Age 50-69 yrs):
• 0-3 ng/ml:
• Inference: Normal, BPH.
• Management: No biopsy needed, for BPH initiate management.
• >3-4 ng/ml:
• Inference: BPH, Cancer, Prostitis

• Biopsy Options:
• TRUS-guided biopsy (Transrectal Ultrasound):
• Minimum 12 cores.
• Done under local anesthesia (LA).
• Targets posterior lobe.
• When doing anal → apply LA → insert 12 times
• Transperineal biopsy:
• Done under general anesthesia (GA).
• For anterior lobe biopsy.

Whitaker Test – Used to differentiate between obstructive vs non-obstructive hydronephrosis

Principle:

• Measures differential pressure between the renal pelvis and bladder during fluid infusion.

Procedure:

• A percutaneous nephrostomy is created (puncture through loin into the renal pelvis).

• Normal saline or contrast is infused at a constant rate (typically 10 mL/min) into the renal pelvis.

• Simultaneous measurement of pressure in:
• Renal pelvis
• Bladder

Interpretation:

• Normal: Renal pelvic pressure stays <22 cm H₂O.

• Obstruction:
• Renal pelvic pressure >22–25 cm H₂O, or a
• pressure gradient >15 cm H₂O between renal pelvis and bladder.

• While taking water (Whitaker)

Uroflowmetry

• >15 ml/sec: Normal.

• 10-15 ml/sec: Equivocal.

• <10 ml/sec: Low flow.

Christmas or pine or fir tree appearance

• Seen in neurogenic bladder.

• The tone of the bladder is affected, causing a shape change from round to elongated.

• Multiple diverticuli are present.

Teardrop or pear shape or inverted pear shape appearance

• In an IVP image, the bladder appears to have a teardrop shape.

• A normal bladder is compressed by external forces, causing elongation.

• Causes include:
• Extrinsic compression of the bladder.
• Any pelvic cause.
• e.g., pelvic lipomatosis, pelvic abscess, pelvic hematoma, pelvic lymphadenopathy, pelvic vessel aneurysm.

Fetal skull calcification of the urinary bladder

• Seen in schistosomiasis.

• Bladder wall calcification

• Schistosoma haematobium resides in the vesical venous plexus of the bladder.

Benign Prostatic Hyperplasia (BPH)

Components

• In transitional zone of prostate

• Dynamic: Increased smooth muscle tone.
• α adrenergic receptors

• Static: Stromal hyperplasia.
• 5 DHT

BPH Management

Surgical Management

• TURP (Transurethral Resection of Prostate).

• TULIP (Transurethral Laser Incision of Prostate).

• Nd:YAG laser (Most common).

• KTPA (Best laser).

Indications for Surgical Management

• Hydronephrosis/upper urinary tract changes.

• Recurrent UTI

• Urinary retention.

• Uroflowmetry <15 ml/sec.

• Complications:
• Hematuria.
• Stones.
• Bladder diverticulae.

TURP (Transurethral Resection of Prostate)

Irrigation Fluid

• 5% Dextrose.

• Distilled water.

• Isotonic glycine (Most common).

• Normal saline (Used only with bipolar cautery).

TURP Complications

• Retrograde ejaculation (Most common): Due to bladder neck injury.

• Hemorrhage: Due to Badenoch arteries.

• Clot retention: Prevented by 3-way Foley’s catheter.

• Incontinence: 
• Due to resection beyond verumontanum or bladder injury.

Water intoxication/dilutional hyponatremia/TURP syndrome:

• Most common with distilled water/5% dextrose.

• Isotonic glycine reduces incidence.

Mechanism:

• Urethra → Water diffusion → Blood vessels → Hyponatremia.

Clinical features:

• Altered sensorium + Headache (few hours post-op).

Management:

• Mild (120-130 mEq/L):
• Water restriction.

• Severe (<120 mEq/L):
• 3% hypertonic saline
• ≤8-10 mEq/L/day gradually
• Rapid correction (>8-10 mEq/day) can lead to Central Pontine Demyelination.

Acute urinary retention

• Foleys Catheter

• Coude tip catheter
• More rigid and angulated
• Can use large Fr size

• Suprapubic aspiration
• If both fails

Prostatic Cancer

Risk Factors

• ↑↑ age (Most common >5th decade).

• ↑↑ testosterone.

• African American ethnicity.

• BRCA2 > BRCA1 gene mutation.

• Obesity.

Spread of Prostatic Cancer

• Local.

• Lymphatic: 
• First node affected is Obturator Lymph Node (Pelvic LN)

• Distant Mets: 
• Bones (Lumbar vertebrae).
• Osteoblastic > Osteolytic lesions.
• Travels via Batson’s plexus.
• Breast and Prostate → Both Batson → Bone
• Breast → Lytic
• Prostate → Blastic

• Not metastasised to liver

Investigations

• PMSA (Prostate Membrane specific antigen) PET
• For mets

• IOC (Investigation of Choice): 
• TRUS-guided biopsy
• SEXTANT APPROACH
• 12 CORES

• Indication for bone scan



1. PSA >10 ng/ml
2. Gleason >7
3. Symptomatic

• Serum acid phosphate is raised

Prostatic Cancer Management

T1, T2a Stages:

• Observation/Surveillance:
• Indications: 
• >70 years old, life expectancy <10 years, Grade 1-2 tumors.

• Radical Prostatectomy:
• Indications: 
• <70 years old, life expectancy >10 years, Grade 3-4 tumors.
• Structures removed: 
• Prostate, iliac + obturator lymph nodes, seminal vesicles.
• Approches
• Transurethral (m/c)
• Retropubic
• Transvesical
• (NOT Transrectal)

T2b, T3, T4 Stages:

• Brachytherapy (I 125, Pd 103, Gold, Cs):



• <70 years old, >10 years life expectancy, Grade 3-4 tumors.
• If no residual disease:
• Surveillance.
• If residual disease +:
• Radical prostatectomy.

• Brachytherapy ± Androgen Deprivation Therapy (ADT):
• > 70 years old, <10 years life expectancy, Grade 1-2 tumors.

Metastasis:

• First-line:
• ADT (Androgen Deprivation Therapy):
• Medical:
• LHRH agonists (Zoladex: Goserelin, buserelin),
• Antiandrogens (Flutamide, Abiraterone: Zytiga).
• Surgical: 
• Bilateral Orchidectomy.

• Hormone Resistant Disease:
• Chemotherapy: 
• Cabazitaxel, Paclitaxel.
• Radiotherapy.
• Sipuleucel-T: 
• T-cell vaccine (Provenge).

• Hormone Resistant Bony Mets: 
• Radium 233 (α rays)

• Remember → I 125, Pd 103, Radium 233

• Mnemonic:
• Prostate cancer → BR doctor → So Wife’s Bra (Brachytherapy) removd → by Aditi (ADT) - Abi
• Both Go (Goserilin) on bus (Buserilin) for solo (Zoladex) trip
• Sit (Zytiga) → Flut (Flutamide) for Abi (Abiraterone)
• To avoid tax (Paclitaxel, Cabazitaxal)
• BR doctor took Revenge (Provenge)

Gleason Method of Scoring

• Mnemonic: PSG (Pattern, Score, Grade)

A. Gleason Patterns (1-5)

• Pattern 1 → Crowded but
• Glands are closely packed/stuck to each other.

• Pattern 2 → Crowded but
• Glands have little space between them (moved slightly away).

• Pattern 3 → Crowded but
• Glands are distinctly separate, with more space.

• Pattern 4
• Hypernephroid pattern 
• (HypernephFOURoid to remember it's pattern 4).

• Pattern 5:
• Single cells:
• No glands seen; cells are separate.
• Comedonecrosis:
• "Dirty" necrotic material inside the gland.

B. Gleason Score

• If only one pattern mentioned (100% of slide):
• Double that pattern.
• Example: Only pattern 4 (100%) = Score of 8 (4+4).

• If two patterns mentioned:
• Add primary pattern (most prevalent) + secondary pattern.
• Example: Primary pattern 4 (80%) + Secondary pattern 5 (20%) = Score of 9 (4+5).

• If three patterns mentioned:
• Take the primary pattern.
• Take the higher number from the secondary and tertiary patterns.
• Add these two numbers for the score
• Example:
• Primary pattern 4 (90%), Secondary pattern 3 (9%), Tertiary pattern 5 (1%)
• 4 (primary) + 5 (higher of 3 and 5) = Score of 9.

C. Gleason Grade

• ISUP Grade Group & Gleason Score Correlation:

Correlation	Score	Grade
Low Risk	Score 6	Grade 1
Intermediate	Score 7 (Favourable) = 3 + 4	Grade 2
Intermediate	Score 7 (Unfavourable) = 4 + 3	Grade 3
High Risk	Score 8	Grade 4
High Risk	Score 9 and 10	Grade 5

Gleason Scoring Examples

• Example 1:
• Query: Biopsy shows tumor cells without any glandular formation (single cells) and 10% showing cribriform pattern.
• Pattern: Single cells → Primary Pattern 5. Cribriform → Secondary Pattern 4.
• Score: 5 + 4 = 9.
• Grade: Score 9 = Grade 5.

• Example 2 (AIIMS Question):
• Query: Prostate biopsy shows adenocarcinoma. Predominantly cribriform pattern, followed by crowded pattern but separate glands, and minor single cell infiltration.
• Pattern: Predominantly cribriform → Primary Pattern 4. Crowded but separate glands → Secondary Pattern 2. Single cell infiltration → Tertiary Pattern 5.
• Score: Primary (4) + Higher of secondary/tertiary (higher of 2 and 5 is 5) = 4 + 5 = 9.
• Grade: Score 9 = Grade 5.