BLADDER & PROSTATE

CT ANATOMY
MRI ANATOMY
BLADDER
 Bladder Carcinoma
• Primary bladder cancer : 95 % originate from transitional
epithelium
• Secondary bladder cancer : arise from sigmoid, rectum,
prostate, uterus, ovaries.
• Classic clinical presentation is painless, gross hematuria,
age >50 years old, chemical and radiation exposure
• Diagnosis
– Cystoscopy and biopsy
– Gold standard for diagnosis
• Urinary cytology
• Imaging
– CT scan – contrast and non contrast
– MRI scan
– IVU (intravenous urogram)
– Ultrasound
ULTRASOUND

A sessile or pedunculated mixed

echogenicity mass projecting
into bladder lumen
CT
MRI BLADDER CANCER
• Help to reveal cancer growth that is overlooked or difficult to characterise by
conventional CT, X-RAY or MRI.
PROSTATE
 Plain Radiograph
• Cannot be used to demonstrate
localized disease in the prostate
• They are generally only needed in the
first line evaluation of metastatic
disease. (most skeletal metastases from
prostate cancer – about 85% are
osteoblastic and are visible as an area of
abnormal tracer activity on a X ray of the pelvis shows
radionuclide bone scan. prostatic calcification with
areas of sclerosis in the pelvis
• Imaging with skeletal radiographs can and proximal femur on both
help distinguish metastatic areas from sides
degenerative disease.
 CT Scan
• Has little value in demonstrating
intraprostatic pathology and in local
staging
• However it may be helpful in detecting
metastatic disease (such as LN
involvement or bone metastases)
• It also helpful in detecting invasive
progression of prostate carcinoma
• Nodal staging is indicated in
– pt with a PSA value of 20 ng/ml or higher
– Clinical stage T2b or higher
– Gleason score of 7 or higher
 Ultrasound Prostate

• Approach of ultrasound can be divided into :

– TRUS (Transrectal Ultrasound)
– TRAS (Transabdominal Ultrasound)
• Objective of Prostate Ultrasound
– Size of gland
– Overall echotexture
– Focal lesion
– Seminal vesicles
– Vasa deferentia
– Ejaculatory ducts
– Periprostatic fat
 1) Prostate Volume

• Size of glands :
– Sagittal image
– Transverse image
• V : (0.52) x L x W x H
• Weight = Volume
• Normal : 7-16 grams
• Volume < 30 ml (NORMAL)
2) Echotexture of prostate
• Outer gland :
– Iso-hyper echoic
• Inner gland :
– Hypoechoic
Hyperechoic : (white on screen)
Hypoechoic : (gray on screen)
Anechoic : (black on screen)
Isoechoic : (same relatively)
 MRI Anatomy of prostate
•The best anatomic detail is on T2WI.
•Below an example of a prostate with minimal BPH (<30 mL entire gland).
•From superior to inferior, the gland is commonly divided into 3 levels
(approximate thirds)
 Base (incudes parts of peripheral zone, central zone and transition zone)
 Mid Gland (includes mostly peripheral and transition zones)
 Apex (includes mostly peripheral zone, some transition zone)

Sagitt Coro
al nal
BPH
 Approach to Benign Prostate
Hyperplasia

• Benign prostatic hyperplasia is due to a combination of stromal and

glandular hyperplasia, predominantly of the transition zone (as opposed
to prostate cancer which typically originates in the peripheral zone).
• Androgens (DHT and testosterone) are necessary for the development
of BPH, but are not the direct cause for the hyperplasia.
• C/P : asymptomatic or with lower urinary tract symptoms (LUTS)
• Clinically use International Prostate Symptom Score (IPSS) for plan of Mx
• P/E : DRE -> enlarged prostate
• Markers : Prostate Specific Antigen (PSA) : elevated but non-specific
 Ultrasound in BPH
• Ultrasound has become the standard first
line investigation after the urologist's finger.
– there is an increase in volume of the prostate
with a calculated volume exceeding 30 mL (width
x height x length x 0.52)
– the central gland is enlarged, and is hypoechoic
or of mixed echogenicity
– calcification may be seen both within the
enlarged gland as well as in the pseudocapsule
(representing compressed peripheral zone)
– post-micturition residual volume is typically
elevated
– associated bladder wall hypertrophy and Ultrasound of the bladder and
trabeculation due to chronically elevated filling prostate demonstrates and
enlarged prostate (consistent with
pressures benign prostatic hypertrophy)
resulting in a high post micturition
volume
 MRI of Prostate (BPH)

Central
zone
Peripher
al zone

Magnetic resonance imaging T2- Coronal image of a normal

weighted axial image of the prostate, prostate. Note the
showing normal prostate anatomy. 
hyperintensity of the CZ
compared to the PZ.
 MRI of Prostate (BPH)

T
Z

P
Z

Enlarged transition zone with Enlarged

heterogeneous signal intensity on prostate with heteroge
an Axial T2 image nous signal on Axial T2
 Prostate Hyperplasia
• Benign prostate hyperplasia (BPH) typically arises in
the transition zone, distorts zonal anatomy, and can
get very large (over 200 mL).
• BPH has glandular components (T2 light) as well as
stromal components (T2 dark), usually with multiple
encapsulated appearing nodules.
UB

BPH less commonly

BPH commonly extends
occurs
into the urinary bladder
outside of the
(UB), frequently referred
transition zone.
to as the “median lobe,”
• Small BPH nodule
worth mentioning as
at R base at the
there can be treatment
central/peripheral
implications
zone border
PROSTATE CA
 Approach to Prostate Cancer
• Prostatic carcinoma ranks as the most common malignant
tumor in men and the second most common cause of
cancer-related deaths in men.
• Prostatic adenocarcinoma is by far the most common
histological type
• C/P : LUTS symptoms, hematuria, back pain
• Clinically use International Prostate Symptom Score (IPSS)
to assess symptoms severity.
• Pathophysiology :
– 95% prostatic adenocarcinoma
– spread
• local invasion
• lymphatic spread
• haematogenous spread
– bone (90%)
– use Gleason score
Approach to Prostate Cancer

• Investigations :
– assisted prostatic biopsy (ultrasound/MRI)
– local and whole-body staging
• Role of imaging :
– assist in a successful biopsy
(ultrasound/MRI)
– MRI for local staging, e.g. is there
extracapsular spread?
– whole-body staging (Bone Scan/CT Scan)
 Ultrasound in Prostate
Cancer
• a hypoechoic region in the periphery of the gland
• ultrasound-guided transrectal biopsy
CT Scan
• Not accurate at detecting in situ prostate
cancer.
• Scans of the abdomen and pelvis are
commonly obtained before the onset of
radiation therapy to identify bony landmarks
for planning.
• In advanced disease, CT scan is the test of
choice to detect enlarged pelvic and
retroperitoneal lymph nodes, hydronephrosis
and osteoblastic metastases
CT SCAN PROSTATE CA
 MRI in Prostate CA
• The primary indication for MRI of the prostate is in the
evaluation of prostate cancer after an ultrasound guided
prostate biopsy has confirmed cancer in order to determine
if there is extracapsular extension
• MRI is also being used to detect and localize cancer when the
PSA is persistently elevated, but routine TRUS biopsy is
negative. 
• MRI-guided prostate biopsy is also being used, particularly in
those cases where TRUS biopsy is negative but clinical and
PSA suspicion remains high
• Following radical prostatectomy, patients with elevated PSA
should also be examined using MRI.
• Often a PI-RADS score is given to assess the probability of the
lesion being malignant.
 Axial view sagittal view

Ill-defined hypointense lesions in the peripheral zone of the

prostate gland. This appearance is suggestive of prostate
carcinoma.
T2 hypointense
nodule at the base of
the left prostate side
lobe extending
beyond the capsule.
Involvement of left
seminal bladder can't
be excluded.
Disseminated
osteoblastic skeletal
metastases.

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