“ ANATOMY AND

PATHOPHYSIOLOGY OF
PROSTRATE”

DILEEP SINGH THAKUR

 INTRODUCTION
 Pyramidal fibromuscular gland
 Weight 20 gms + 6 gms
 Location
 Extend from bladder to urogenital diaphragm
 Has base an apex
 Pierced by urethra, ejaculatory ducts and prostatic
utricle
 Produces thin milky fluid
 Embryologically derived from urogenital sinus
 Female counter part are SKENE TUBULES
 RELATIONS
• Anteriorly
• Posteriorly
• Superiorly
• Inferiorly
• Laterally
 CAPSULE
TRUE FALSE
- Anatomical capsule - Surgical capsule
- Formed of endopelvic fascia- Formed due to compression
of peripheral zone by
enlarging adenoma

False capsule provides plane of clavage for surgical enucleation of

hyper plastic tissue leaving behind prostatic plexus of veins
 STRUCTURE OF PROSTRATE
Composition

70% glandular element 30% fibromuscula

stroma made up of
collagen and smooth
muscle cells

Traversed by urethra at junction of anterior and middle 1/3rd

 LOBES
 Anatomically 5 in number
 Distinguished in fetal gland < 20 weeks of gestation
 Anterior
– Devoid of glandular tissue
 Posterior
 Middle or median
– Wedge between urethra and ejaculated ducts
– related superiorly to trigon
– Reach in glandular element
– Affected in BPH
 Lateral
– Two in number
– Separated by a shallow vertical groove
– Rich in glandular tissue
– Affected in BPH
 LOBES cont..
 JE McNeal (1988) divided into zones
 Can be demonstrated by TRUS
 Zones are distinguished by the location of
ducts in prostatic urethra
TRANSITION CENTRAL PERIPERAL

5% of glandular tissue 25% 70%

Ducts arise and pass beneath Ducts arise Ducts drain into prostatic
pre prostatic sphincter circumpherencially around sinus in post sphincteric
opening of ejaculatory ducts urethra

Commonly give rise o BPH Commonly give rise to

carcinoma and chronic
prostatitis
Sampled in most random
biopsy of prostrates
 PROSTATIC URETHRA
•3 cm long
•Most dilatable part of urethra
•Posteriorly there is elevation known as
URETHRAL CREST
•On either side prostratic sinus opens
•At mid point of urethral crest it turns anteriorly
by 350 (urethral angle)
 PROSTATIC URETHRA cont…
Pre prostatic urethra Pro prostatic urethra
Proximal Distal part
Made up of smooth muscle Major glandular element open here
Forms involuntary sphincter

Beyond urethral angle crest widens and protrudes VERUMONTANUM

At summit is opening of prostatic utricle
On either side or opening of ejaculatory ducts
 ARTERIAL SUPPLY

• Inferior vesicle artery

• Divides into two branch
• Urethral artery Capsular artery
• Approaches at bladder Runs posterolaterally
neck at 1 to 5 O’clock along with
and 7 to 11 O’clock neurovascular
• On resection of gland bundle
• These vessels bleed
significantly specially
those at 4 and 8 O’clock
position
 VENOUS DRAINAGE

•Prostatic venous plexus which lies

between true capsule and fibrous sheath
•Finally drains into internal iliac veins
•BATSON showed existence of valve less
connections prostatic plexus and vertebral
veins
 LYMPHATIC DRAINAGE
• Primarily into obturator and internal iliac
lymph nodes
• Small portion into presacral and external
iliac
 NERVE SUPPLY
• From inferior hypogastric plexus
• Neurovascular bundle containing nerves which
supply prostate, penis and seminal vesciles are
closely applied to postero lateral margins which
may be damaged during radicle prostatectomy and
cause impotance
• Alpha-1 A adrenergic receptor are in a abundance
in prostrate
 MICRO STRUCTURE
 Compound tubulo alveolar organ
 Function unit are lobules
 Large glandular spaces lined by epithelium
 Glandular tissue consists of follicles
 Colloid amyloid bodies (corpora amylacea
are frequent in follicles
 AGE CHANGES
 Before birth
– Hyperplasia and squamous metaplasia ductal epithelium
– Due to metarnal estrogen
 At puberty (14-18 yrs)
– Maturation phase starts
– Increase in size
– Growth entirely due to follicular development
 30-35 yrs
– Size remains unaltered
 45-50 yrs (involution starts)
– Epithelial foldings disappears
– Follicular outline become irregular
– Amyloid body increase
 > 45-50 yrs
– BPH tends to develops
 PHYSIOLOGY

•Continuous presence of testerosterone stimulate and maintain

growth and secretary function
(-) FINASTERIDE
5 α reductase Type II
Testosterone ======================> DHT
(Testis) in prostate
 HYPOTHALAMUS
GnRH analogue (+) Gn RH (-) Gn RH antagonist
(luperolide) LH RH (Ganirelix)

PITUTARY
(-) Ketoconazole
M
LH/FSH Prolactin I ACTH
N
O
R
M
A
(TESTIS) Testesterone PROSTATE Anderoste ADRENAL
J
O
r

Estrogen
 PROSTATIC SECRETORY
PROTEINS
• PSA
• PAP
• PSP 94
 PROSTATE SPECIFIC ANTIGEN
• Gama semino protein
• Glyco protein
• Molecular weight 33,000
• Found exclusively in prostatic epithelial cells
• Cleave and liquefy seminal coagulum
• Serine protease (estrase) circulate in serum complexed
with alpha-1 antichymotripsin and beta-2 macroglobulins
• Increased in BPH, CA prostate, prostatitis, prostatic
instrumentation, injury, ejaculation
• Normal range 0-4 ng/ml
• 15 ng/ml disease confined to prostrate
• > 30 metastatic prostatic carcinoma
• GRAY ZONE 4-10 ng/ml
 PSA
FREE COMPLEXED

With alpha-1 antichymotripsin

When free PSA is > 25%, low risk, for CA prostate, >
10 % high risk
PSAD
•< 0.1 consistent with BPH > 0.15 suggestive of
carcinoma
PSA VELOCITY
•> 0.75 ng/ml/yr suggestive of carcinoma
 PATHOLOGY
Inflammatory Non inflammatory
Acute bacterial prostatitis BPH
Chronic bacterial prostatitis Carcinoma prostate (CaP)

Chronic non bacterial prostatitis

Granulomatous prostatitis
Prostato dynia
 BPH
•Truly a hyperplasia
•Occurs first in peri urethral transient zone
•Prostatic capsule transmits pressure of tissue expansion on
urethra and leads to ↑ in urethral resistance
•So, TUIP improves outflow obstruction
•Smooth muscles or prostate a richly supplied by
adrenargic nerves which increase urethral resistance
 BLADDER RESPONSE TO OBSTRUCTION

Detrusor instability Impaired detrusor

↓ Compliance contractivity

Frequency Hesistancy increased

Urgency residual urine
↓ force of urinary
stream
 BLADDER OBSTRUCTION
Detrusor smooth muscle hypertrophy

↑ Detrusor collagen

Trabeculation
Diverticulae ↑ residual urine Backpressure changes

Hydroureters
Hydronephrosis
Azotemia
 CHANGES IN PROSTATIC
URETHRA
• Lenthening
• Exaggeration of normal posterior curve
• Distortion of prostatic urethra – When only 1
lateral lobe enlarge
 HISTOLOGY
• Hallmark is nodularity due to glandular and
fibromuscular proliferation
• Epithelium is thrown into numerous papillary
buds
• There may be presence of foci of squamous
meta plesia and small areas of infarction
 PROSTATIC TUMOURS
PRIMARY SECONDARY

ADENOCARCINOMA COLLOID SMALL CELLS SARCOMAS

90%

ACINAR DUCTAL
 CARCINOMA PROSTATE
• ORIGIN
CaP
70% 10-20% 5-10%
Peripheral zone Transitional zone Central zone

=> Multifocal in > 85% cases

HISTOLOGIC HALLMARK is absence of basal cell
layer of glandular architecture
Immuno staining with high molecular weight keratin
which stains basal cell layer is absence in CaP
 PIN
• Architectural benign prostatic acinilined with
atypical cells
• Precursor to invasive carcinoma
• Basal cell layer is preserved

• HGPIN LGPIN
• Associated with * Only in 20%
• invasive CaP in
• 50-80% cases
Show if prostatic needle biopsy shows HGPIN a
repeat biopsy is required.
 GRADING
• GLEASON GRADING SYSTEM
• Gleason grading is most accepted due to good interobserver
and intra observer reproducibility
• On basis of glandular pattern and degree of differentiation
observed under low magnification
• Primary (dominant) and secondary architectural patterns are
identified
• Given grade 1 to grade 5
• Grade 1 is most differentiated and grade 5 is least
• Gleason SUM – by addition of primary and secondary grade
• 2-10
 GRADING
• GLEASON GRADING SYSTEM
• Gleason pattern
• 1-2 => Circumscribed nodules closely packed
also k/a clear cell carcinoma
• 3 => Tumour infiltrates in and among non
neoplastic prostate
• 4 => Large irregular cribriforms glands, poor
prognosis
• 5 => No glandular differentiation with central
comedonecrosis also k/a comedocarcinoma
 GRADING
• GLEASON SUM
• 2-4 => well differentiated
• 5-6 => moderately differentiated
• 7 => moderately to poorly differentiated
• 8-10 => poorly differentiated
 SPREAD
• Capsular penetration via perineural space
• Perineural invasion does not worsen prognosis as it is
plane of least resistance
• Most frequent are nodal metastasis especially to
obturatory and internal iliac
• May spread to seminal vesciles, bladder
• Bony metastasis
Lumbar vertebrae > femur > pelvis
• Also to lung, adrenal, skull
• Rectal involvement is rare due to strong denonviller’s
fascia