Rasyid Ridha ButarButar

NARASUMBER :
dr.TITIK YULIASTUTI, Sp.Rad (K)
▪ Prostate
▪ Benign Prostatic Hypertrophy
▪ Prostate cancer
▪ Post Treatment Follow-up
▪ Prostatitis/Prostatic Abscess
▪ Prostatic calcifications
▪ Seminal Vesicles
PROSTATE : ANATOMY
• Walnut-sized gland located
beneath bladder and in front of
rectum lies above superior fascia
of urogenital diaphragm
• Surrounds uppermost part of
urethra
• Normal prostate ~ 3 cm
craniocaudal x 4 cm wide x 2 cm
anteroposteriorly
• Surrounded by fibrous prostatic
capsule
 CT
• Homogeneous density similar
to muscles
• Not used for evaluation of
prostate because of poor
tissue characterization
Benign Prostatic Hypertrophy
 BPH:
• Enlarged prostate secondary to stromal
• smooth muscle and glandular hyperplasia
• associated with bladder outlet obstruction
• Enlargement of transition zone due to
glandular and stromal hyperplasia
Etiology
• Testosterone stimulates prostatic growth as evidenced by the
fact
lncidence
• The prostate gland in adult males younger than 50 years is
about the size of a walnut and weighs 15 to 20 g
• 50% of men have some degree of prostatic hypertrophy.
• The prostate may double in size before the age of 70 years
Radiology
CT
• Enlarged prostate ± calcifications
• Extrinsic impression on bladder base
IVP
• Extrinsic impression on bladder base, "J-hooking" or "fish hooking" of
distal ureters
Trans urethral ultrasound (TRUS)
• Hypoechoic nodular enlargement of transition/periurethral zones
• Isoechoic hyperplastic nodules (10-20%)
• Large residual urine volume post void
MRI
T1WI
• Enlarged prostate
• Some BPH nodules show increased signal intensity (SI)
• T2WI
• Enlarged transition zone with multiple nodules
• SI: Increased glandular BPH, decreased stromal BPH
• Morphology of nodules: Round/oval; usually with capsule
• Compressed and displaced peripheral zone
DWI
BPH nodules may show strong or weak diffusion restriction
CT scan :
• Enlarged prostate
• a portion of the
bladder is seen anterior
to the prostate
Uretroghrapy :
• The enlarged prostate indents
and elevates the bladder floor.
• The ureterovesical junction
are displaced superiorly
• producing a J shape of the
distal ureter
• The bladder is thick-walled due to
chronic outlet obstruction
• smooth walled
• irregular (trabeculated) wall
• BPH commonly extends into
the urinary bladder (UB)
• frequently referred to as the
median lobe
 High-intravesical pressure

Tractus urinarius dilated

bilateral symmetric ureteropyelocalictasis

 Benign Prostatic Hypertrophy

Bilateral symmetric: hydronephrosis

due to bladder outlet obstruction
Treatment of BPH
1. Oral medication
2. TURP
PROSTATE CANCER
Incidence
• a very large public health problem in the United States;
• Nearly a quarter of a million new cases diagnosed this year
with over 30,000 deaths
• the second most common case of death from tumor.
Pathology
• Adenocarcinoma → typical
• Other prostate tumors are rare such as : Squamous cell
carcinomas
• Mesenchymal neoplasms such as rhabdomyosarcoma,
leiomyosarcoma, or fibrosarcoma.
GRADING :
The Gleason system
Histologic evaluation of tissue
1.glandular pattern
2.Size
3.Distribution
• Score ranging from 2 to 10
• The higher the grade the less differentiation is present.
STAGING
The Whitmore-Jewett staging (See on table)
Screening for Prostate Cancer
• Detection of prostate cancer is performed by digital rectal
examination (DRE) and measurement of prostate-specific
antigen (PSA)
• Elevated PSA associated with prostatitis, prostatic infarct, acute
urinary retention and benign hypertrophy of the prostate
• PSA normal between 2.5 and 4.0
• Screening with DRE depends on the skill of the examiner
• No imaging modality is used for screening for prostate cancer.
• Because non spesific and/or too expensive to use for screening.
Dissemination
Spread of prostatic carcinoma occurs by three methods:
1. Direct extension
2. Lymphatic spread
3. Hematogenous spread
Diagnosis
• Once prostate cancer is suspected based on the DRE, PSA
• Biopsy is golden diagnosis
• TRUS is for guided biopsy
• When repeated TRUS-guided biopsy resulted are negatif but
suspected to be false negative, MRI –guided byopsi is
considered to identify foci of tumor
LESION HIPERECHOIC PROSTATE
ON TRUS
Treatment planning
1. Watchful waiting
2. Surgery (usually radical prostatectomy), radiotherapy
(brachytherapy or external beam)
• The combination of biopsy findings tumor volume and Gleason
soore),local staging by DRE and PSA levels permits estimation
of the likelihood of finding metastatic disease
• CT,like ultrasound, is relatively inaccurate in local staging.
Although in the rare cases in which the local tumors are very
large;
• MRI is by far the most accurate method for anatomic staging of
localized prostate cancer.
POST BIOPSY PROSTATE
 MRI PROSTATE
ON T2W SEQUENCE
MRI PROSTATE
T2W SEQUENCE
MRI PROSTATE T2W SEQUENCE
Focal peripheral zone tumor (arrows)
appears as low intensity region.
Prostate cancer most likely transgressing capsule
Prostate cancer with gross tumor
invasion of posterolateral capsule
Normal seminal vesicle and
vassa deferentia on MRI
Vesica seminalis invasion
by tumor
• MRI is used to image the entire abdomen and pelvis and to
search for nodal and skeletal metastasis in these regions.
• MRI is probably more sensitive than bone scanning in searching
for metastases in the lumbar spine,
• But whole-body MRI has not proved to be more accurate than
bone scanning in other anatomic areas and has not replaced it
for standard skeletal evaluation.
Obturator node involvement in
prostate cancer on CT scan
There are enlarged obturator
node bilaterally
• Patient with poorly differentiated cancer (Gleason 8-10) or
markedly elevated PSA

• Low PSA (<10) do not need bone scans.

• Bone scan reveal metastatic disease as regions of increased

activity like degenerative arthritis and Paget disease

• The tumor burden as reflected by bone scans can be used

prognostically to estimate patient survival
Metastatic prostate
cancer
Extensive skeletal metastases
from prostate cancer.
Metastatic prostate cancer producing
multiple enlarged periaortic nodes
POST TREATMENT FOLLOW-UP
• The treatment of ca prostate may produce characteristic finding

• This finding is patognomonic for treatment choice

• Skeletal scintigraphy CT and/or MRI of abdominal, pelvic,

and thoracic can help imaging following up after treatment
• After treatment for localized prostate cancer, surveillance for recurrence is
primarily performed by serial PSA determinations.
• selection of treatment depends to a great degree
• In the former case, treatment may constitute a second attempt at local tumor
eradication (so-called salvage therapy).
• If the original treatment was resection, salvage radiotherapy may be employed;
• salvage therapy is not without its side effects and is ineffective if distant disease
is present.
PROSTATITIS/PROSTATIC ABSCESS
• Collections of pus that develop as the result of acute bacterial
prostatitis.
• Etiology : bacterial infection
• Prostatitis is clinical diagnosis
• Imaging generally used to evaluate for abscess formation
Radiology
• Most imaging modalities yield nonspecific findings in prostatitis
• TRUS altered echogenicity similar to the findings in prostatic
hypertrophy
 Abscess prostate
on the CT examination
Abscess prostate On uretrography
PROSTATIC CALCIFICATIONS
• The peripheral zone of the prostate gland is the seat of the
corpora amylacea, where calcifications with no known etiology
and without pathologic effects tend to occur.
• These calcifications are discrete, vary in size from 1 to 5 mm,
and are usually multiple
SEMINAL VESICLES
• Sac-like structures located
superolaterally to prostat
between fundus of urinary
bladder and rectum
• Secrete fructose-rich, alkaline
fluid, which is major component
of semen
• Secretions are energy
source for sperm
• Do not store sperm
• Symptoms caused by seminal vesicle disease are often difficult
to differentiate from those related to prostatic abnormalities.
• Patients frequently complain of painful ejaculation, bloody
semen (hematospermia), perineal or suprapubic pain, and
infertility
• Conditions affecting the seminal vesicles include calculi, cysts,
inflammation, infection, and neoplasms.
Radiology
• Best imaged by TRUS, CT or MRl
• Ultrasound shows typical acoustic shadowing and stones are
easily identified on CT by their high density.
• Seminal vesicle calcifications should not be confused with the
calcification that can be found in the vasa deferentia in diabetic
men
1. SEMINAL VESICLES CYST

2. SEMINAL VESICLES ABSCESS

3. CA SEMINAL VESICLES
• two-thirds of patients with a congenital seminal vesicle cyst.
• Associated ipsilateral renal agenesis
• Acquired cysts can occur in the seminal vesicles secondary to
obstruction or inflammation.
• Congenital or acquired cysts may become quite large and
indent the bladder posteriorly
• No one image differentiate congenital from acquired exccept
that congenital may be accompanied by ipsilateral renal
agenesis.
A mass is seen indenting the bladder on this
excretory urogram, which also revealed
absence of the left kidney

The seminal vesicle cyst is opacified after

injection of the left vas deferens.
Ultrasound demonstrate. A cystic mass
protruding into the bladder lumen.
Seminal vesicle abscess
CT shows the left seminal vesicle
to be enlarged; the abscess (arrow)
has a pus-filled center and faintly
enhancing walls.
• Extremely rare
• The most common cause of is
• direct invasion of the seminal
vesicles by prostate cancer.