Diagnosis dan Tata Laksana

Hyperthropi Prostat
dan
Kanker Prostat Masa Kini

Dr. Rochani
Prostate anatomy – urethral division of gland

Edwin M. Meares Jr, MD, Differential Diagnosis of Prostate Disorders, 1993

Clinical importance of prostatic zonal anatomy

Edwin M. Meares Jr, MD, Differential Diagnosis of Prostate Disorders, 1993

Functions of prostatic gland and fluid

Reproduction

Antibacterial

Edwin M. Meares Jr, MD, Differential Diagnosis of Prostate Disorders, 1993

Composition of normal ejaculate

Total volume 3 - 3.5 mls

Semifinal vesicles 50% volume

Prostate 15 - 30% volume
Cowper’s glands and 5% volume
urethral glands

Edwin M. Meares Jr, MD, Differential Diagnosis of Prostate Disorders, 1993

 Constituents of prostatic fluid
Polyamines (spermine)
Plasminogen activator
Citrate
Seminal neutral protease (seminin)
Cholesterol, lipids
Lactate dehydrogenase
Prostatic acid phosphatase (PAP)
Prostatic - specific antigen (PSA)
Electrolytes (K+, Na+, etc.)
Zinc (prostatic antibacterial factor)
Glucose

Edwin M. Meares Jr, MD, Differential Diagnosis of Prostate Disorders, 1993

Prostatic secretory products - actions

 Zinc Antibacterial factor

 Citrate Sperm transport
 Spermine Cell proliferation
Odor of semen
 Cholesterol / lipids Sperm protection
 Plasminogen activator Semen liquefaction
 Seminin Semen liquefaction
 Prostate weight versus age

Edwin M. Meares Jr, MD, Differential Diagnosis of Prostate Disorders, 1993

Edwin M. Meares Jr, MD, Differential Diagnosis of Prostate Disorders, 1993
 Etiological factors in BPH

C Lee et All, 5th International Consultation on BPH, Paris 2000

 Role of androgens in BPH

• Castration or antiandrogen drugs cause

shrinkage of prostate
• Castration before puberty prevents BPH
• Genetic diseases, e.g., 5α – reductase
deficiency, are associated with nonpalpable
prostates
• Androgen levels (T, DHT) in prostate are
high in elderly men
 The hypothalamus – pituitary – testes –
prostate hormonal axis

T = testosterone
LH = luteinizing hormone
LH – RH = luteinizing
hormone – releasing
hormone
DHT = dihydrotestosterone

Edwin M. Meares Jr, MD, Differential Diagnosis of Prostate Disorders, 1993

Conversion of testosterone to dihydrotestosterone by
the enzyme 5α – reductase in the prostatic epithelial cell

Edwin M. Meares Jr, MD, Differential Diagnosis of Prostate Disorders, 1993

Prostatic growth factors – Putative roles in BPH

Periurethral stromal cells

Basic fibroblast growth factor (bFGF)

Transforming growth
? ß1 (TGF ß-1)

Stromal hyperplasia Epithelial hyperplasia

Edwin M. Meares Jr, MD, Differential Diagnosis of Prostate Disorders, 1993

The growth factors EGF and FGF activate proto-
oncogenes and thus stimulate cell growth

C. Lee et All, 5th International Consultation on BPH, Paris 2000

The role of estrogen in prostatic growth

C. Lee et All, 5th International Consultation on BPH, Paris 2000

A Simple summary of the influence
of the extrinsic factors

C. Lee et All, 5th International Consultation on BPH, Paris 2000

BPH – hyperplastic tissue surrounds urethra, forming
“pseudo” or “surgical” capsule

Edwin M. Meares Jr, MD, Differential Diagnosis of Prostate Disorders, 1993

 BPH – Mechanism of Obstruction

o Dynamic – Determined primarily by the tone of

the prostate smooth muscle

o Static / mechanical – Related to the obstruction

caused by the enlarging prostate adenoma
Andersson K.E et All, 5th International Consultation on BPH, Paris 2000
Andersson K.E et All, 5th International Consultation on BPH, Paris 2000
Determinants of symptoms in BPH

Smooth
Prostate Bladder
muscle

Histologic BPH Muscle tone Prostate

Size Muscle contractility Bladder neck

Symptomatic BPH
Edwin M. Meares Jr, MD, Differential Diagnosis of Prostate Disorders, 1993
Pathophysiology of the urinary bladder
in obstruction

J. Nordling et All, 5th International Consultation on BPH, Paris 2000

Effects of BPH – trabuculated bladder with multiple
diverticula and dilated ureters

Edwin M. Meares Jr, MD, Differential Diagnosis of Prostate Disorders, 1993

 Effects of bladder outlet obstruction
Infection
Large post-void residual volumes
Calculi
Bladder trabeculation
and diverticula

Ureteral dilatation

Obstructive uropathy
Azotemia
Renal damage
Renal failure
Edwin M. Meares Jr, MD, Differential Diagnosis of Prostate Disorders, 1993
 DIAGNOSIS
PEMBESARAN PROSTAT JINAK
 ANAMNESIS
 ANAMNESA
• PROSES & LAMANYA GGN BERKEMIH

• RIWAYAT OPERASI SEBELUMNYA

• KESEHATAN UMUM & FUNGSI SEKS

• TOLERANSI PADA TERAPI

• OBAT-OBATAN YANG DIMINUM

 Anticholinergic ( mengurangi kontraksi buli-

buli)
  simpatomimetik ( meningkatkan resistensi
outflow)

(Cockett et all 1993, McConnell et all 1994)

 ANAMNESIS
 SISTIM SKORING
 I-PSS (International Prostat Symtom Score)

• Menilai sendiri

• Ringan = 0–7
• Sedang = 8 – 19
• Berat = 20 - 35

 BS (Bother Score)
• Lebih mudah, pilihan terapi & follow up

• 0 – 6

• Seandainya anda harus menghabiskan sisa hidup anda

dengan kondisi berkemih seperti saat ini bagaimana
perasaan anda ?
SELAMA 1BULAN TERAHIR SEBERAPA SERING
Tidak Kurang dari Kurang Kadang Lebih Hampir
pernah sekali dari 5 dari kadang dari selalu
kali berkemih setengah (50%) setengah
1.Tidak lampias saat 0 1 2 3 4 5
selesai berkemih ?
2. Harus kembali 0 1 2 3 4 5
kencing dalam waktu
< 2jam
3. Kencing terputus 0 1 2 3 4 5
putus
4. Sulir menahan 0 1 2 3 4 5
kencing
5. Pancaran kencing 0 1 2 3 4 5
lemah
6. Mengedan untuk 0 1 2 3 4 5
mulai berkemih

7.Bangun untuk Tidak 1 kali 2 kali 3 kali 4 kali 5 kali /

berkemih malam hari ada lebih
0 1 2 3 4 5
 PEMERIKSAAN FISIK
UMUM o SUPRA SIMPISIS
–MOTORIK & SENSORIK RETENSIO URIN

o COLOK DUBUR
TONUS SFINGTER ANI 
PROSTAT
 UKURAN ( obstruksi) 
 KONSISTENSI
 NODUL
 NYERI TEKAN
Masa di rectum

 (Cockett et all 1993, McConnell et all 1994)

 (Donkervoort dkk 1975, Bissada dkk 1976, Roehrborn dkk 1986, Meyhoff dkk 1981)
 LABORATORIUM
 URINALISA
• HEMATURI,

• PYURI,

• PROTEINURI (?),

• GLUKOSURIA.
(Cockett et all 1993, McConnell et all 1994)

 UREUM / KREATININ
• 13,6% (0,3 – 30%) BPH + insufisiensi renal
(McConnell et all 1994)
 LABORATORIUM

o PSA
• Dihasilkan oleh Jaringan Prostat Jinak
dan Ganas.
• Terdapat False (+) / (-).
• Nilai normal (< 4 ng/dl).
• Biopsi :
1. > 4ng/dl
2. 4 – 10 ng/dl bila PSAD (PSA/Vol prostat) > 0,15
UROFLOWMETRI
UROFLOWMETRI

 Tidak infasif (nyaman)

 Q MAX  (MAX. FLOW RATE)
 NORMAL ( 15 – 25 CC/DET)
 Ringan (12 – 14 cc/det)
 Sedang    ( 8 – 12cc/det)
 Buruk ( <8 cc/det)

 Jumlah kencing
 >150cc
 UROFLOWMETRI
Studi Adam - Griffith dari 180 kasus

Q max > 10 ml Qmax 10-15 ml Qmax >15 ml

Obstruksi 88% 45% 24%

Tidak 12% 46% 76%

obstruksi
 RESIDU URIN
 RESIDU URIN (USG trans abdominal)
 Normal (78% < 5cc)  

(100% < 12 cc)
 Minimal     (< 50cc) (Di Mare et all 1963)
 Sedang (50 – 100cc)

 Banyak      (>100cc)
TRUS (Trans Rectal Ultrasound)
 BENTUK & UKURAN PROSTAT
 Rekomendasi Terapi :

 Hipertermi

 Stents

 TUIP

 GUIDE NEEDLE BIOPSY

 BIOPSI SEXTAN ( 6 TEMPAT)

 AREA TERTENTU
TRUS (Trans Rectal Ultrasound)
 TRUS
•USG TRANSREKTAL

•BIOPSI PROSTAT
 URODINAMIK

• Menilaiproses fisiologi berkemih

• Tekanan intra vesika
• Kontraksi otot abdomen
• Pancaran urin
• Residu urin
Suteja PMK, Rochani, 2000, Riwayat retensio urin, setelah Aff catheter dapat BAK
spontan, pada evaluasi urodinamik 90% (44 dari 49 kasus ) tekanan intra vesika
>55cm H2O (OBSTRUKSI) dilakukan TUR Prostat.
URODINAMIK
 Tata Laksana Hypothropi Prostat
 1. Alfa adrenergic receptor blockers
 A. Hytrin
 B. Cardura
 C. Tamsulosin (harnal)
 D. Xatral
 E. Silodosin
 Tata Laksana Hypothropi Prostat
2. 5α – reductase inhibitor
a.Proscar

b.Dustaterit (Avodat)
 Indikasi operasi / Tur prostat

1. Retensi urine berulang

2. ISK berulang karena PPJ
3. batu kandung kemih karena PPJ
4. Divertikel kandung kemih karena PPJ
5. Fungsi ginjal menurun karena PPJ
6. Hematuri berulang karena PPJ

WHO consultaion on BPH – Paris 2002

 TUR Prostat

Indikasi
1. Prostat kurang dari 60 gram

2. Toleransi untuk operasi cukup baik

3. Tidak memakai obat-obat pengencer darah

 TUR Prostat
Keuntungan TUR prostat dibandingkan operasi
1. Tidak ada luka operasi

2. Lama perawatan lebih pendek (5 hari)

3. Dianggap masih merupakan golden standard untuk

terapi pengangkatan prostat

4. Terjangkau oleh masyarakat luas (ASKES,

ASKESKIN, JAMKESMAS)
 TUR Prostat
Komplikasi TUR prostat
1. Perdarahan yang memerlukan
transfusi
2. Perforasi kandung kemih

3. TUR syndrome

4. Retrograde ejakulasi

5. Striktura uretra (1%)

6. Incontinensia urine (1-2%)

7. Impotensia (?)
 TUR Prostat

Audit medic (morbiditas max 10%)

1. Perawatan lebih 5 hari

2. Perdarahan perlu transfusi

3. Konversi ke operasi terbuka

4. Masuk ICU yang tidak direncanakan

TUR PROSTAT
TUR PROSTAT
TUR PROSTAT
TUR PROSTAT
TUR PROSTAT
Prostate Cancer : Natural 
History & Treatment 
Timeline
Presentasi Klinik dan 
Diagnosis
Kanker Prostat
Signs and Symptoms

American Cancer Society 2010
Signs and Symptoms –
Advanced Disease
 Signs and symptoms of advanced prostate cancer
include:
• Fatigue

• Loss of appetite

 Bone metastases can cause:

• Pain in the hips

• Pain in the spine

• Increased susceptibility to fractures

 Prostate cancer that has spread to the spine and is

compressing spinal nerves can lead to:
• Weakness or numbness in the legs or feet

• Loss of bladder or bowel control

Diagnosing Prostate Cancer
 Diagnostic work-up for prostate cancer
involves:
• Digital rectal examination (DRE) -> nodule (+)
• Serum PSA testing (biopsy if > 4ng/ml)
• Transrectal ultrasonography (TRUS)
• Prostate biopsyAdditional tests may also be
carried out to help stage the tumour more
accurately:
• Pelvic CT
• MRI scan
• Radionuclide bone scan
 Physical Examination and Digital Rectal
Exam

o A focused physical examination 
to assess : 
 the suprapubic area for bladder 
distention
 motor and sensory function of the 
perineum and lower limbs. 
o A digital rectal exam (DRE) 
 evaluate anal sphincter tone and the 
prostate gland :
 approximate size, 
consistency, shape and 
abnormalities suggestive of 
prostate cancer.
Prostate Imaging & Biopsy with Transrectal
Ultrasound

Biopsi prostat dengan cara mengambil jaring
Dengan jarum besar sebanyak 10‐12 core
 Increased PSA levels equate to 
increased prostate cancer risk

The chance of having prostate cancer increases with increasing 
PSA:
• About 15% of men with PSA<4 will have prostate cancer on 
biopsy
• Men with a PSA in the borderline range (4‐10 ng/ml) have a 
25% chance of having prostate cancer
• PSA >10 ng/ml is associated with a 50% likelihood of 
prostate cancer 

Catalona W et al. JAMA 1998; 279(19):1542
Heidenreich A  et al. EAU Guidelines 2009 available at: www.uroweb.org accessed Sept 2010
Schröder FH, ECCO‐ESMO 2009; Educational Book p402
American Urological Association 2009. Prostate Specific Antigen Best Practice Statement
American Cancer Society 2010
STAGING, GRADING 
AND 
MANAGEMENT
 Gleason Score
o Most common grading 
system for prostate cancer
• Two grades (1‐5) are added to 
define the score
• Numbering each type from 1 for 
the least affected up to 5 for the 
most affected
o Histopathological grade
o Gives a measure of tumour 
aggressiveness
o Based microscopic 
Gleason score Aggressiveness of Prostate 
examination Cancer
2‐4 Low
• pattern of infiltration
5‐6 Moderate
• degree of differentiation
7 Intermediate
• 5 cellular patterns recognised
8‐10 High
American Urological Association 2007
STAGE – How far the cancer has developed
 Stage 1 - the cancer is small and
contained within the prostate.
 Stage 2 - the cancer is larger and may be

in both lobes of the prostate, but is still

confined to the organ.
 Stage 3 - the cancer has spread beyond

the prostate and may have invaded the

adjacent lymph glands or seminal
vesicles.
 Stage 4 - the cancer has spread to other

organs, or to bone.
Staging
Staging
Staging
 Disease Management: Prostate Cancer

Potential Treatable Population
60-70% 10-20%
20%

Local tumor Locally advanced Metastatic disease

(organ‐confined disease) (spread‐outside prostate) (lymph nodes, bones)
15-33% 60%

Watchful 
waiting Surgery RXT Hormonal 
Ablation 
therapy
RXT 95%

Hormonal 
Surgery therapy
60%
RXT
Chemotherapy
 IUA Guidelines on Prostate Cancer
RISK Age

> 80 yo 71‐80 yo ≤ 70 yo

Low Active  1. Active  1. Radical 
T: 1a or 1c and monitoring monitoring Prostatectomy
Gleason: 2‐5 and 2. EBRRT,  2. EBRT or 
PSA: <10 and permanent  permanent 
Biopsy: Unilateral  Brachytherapy Brachytherapy
<50% 3. Investigational  3. Active 
therapy Monitoring
4. Investigational 
Therapy
 IUA Guidelines on Prostate Cancer
RISK Age

> 80 yo 71‐80 yo ≤ 70 yo

Moderate: 1. Active  1. EBRT,  1. Radical 

T: 1b, 2a or monitoring Brachytherapy Prostatectomy
Gleason: 6, or 3+4  2. EBRT,  , Permanent or  2. EBRT, 
or Brachytherap Combination Brachytherapy
PSA: <10 or y, Permanent  2. Radical  , Permanent or 
Biopsy: Bilateral  or  Prostatectomy Combination
<50% Combination 3. Investigational  3. Investigational 
3. Investigation Therapy Therapy
al Therapy
 IUA Guidelines on Prostate Cancer
RISK Age
> 80 yo 71‐80 yo ≤ 70 yo
HIGH 1. Hormonal  1. EBRT + Hormonal  1. EBRT + 
T: 2b, 3a, 3b or Therapy Therapy (2‐3y) Hormonal 
Gleason: ≥ 4+3  2. EBRT+Thorm 2. Hormonal  Therapy (2‐3y)
or onal Therapy Therapy 2. Radical 
PSA: 10‐20 or 3. Investigation 3. Radical  Prostatectomy + 
Biopsy: > 50%  al Therapy Prostatectomy +  Pelvic Lymp 
Perineural,  Pelvic Lymph  Node Dissection
ductal Node Dissection 3. Investigational 
4. Investigational  Therapy
Therapy 4. Hormonal 
Therapy
 IUA Guidelines on Prostate Cancer
RISK Age
> 80 yo 71‐80 yo ≤ 70 yo

VERY HIGH: 1. Hormonal  1. Hormonal  1. EBRT + 

T: 4 or Therapy Therapy Hormonal 
Gleason: ≥8 or 2. EBRT +  2. EBRT + Hormonal  Therapy
PSA: >20 or Thormonal  Therapy 2. Hormonal 
Biopsy:  Therapy 3. Nonhormonal  Therapy
Limphovascula 3. Investigation Systemic Therapy  3. Systemic 
r,  al Therapy (Chemotherapy Therapy + 
Neuroendocrin Hormonal 
Therapy
4. Multimodal 
investigational 
Therapy
 Summary
1. Pembesaran prostat jinak merupakan
penyakit yang sering dijumpai laki-laki di
atas 50 tahun.
2. Diagnosi ditegakkan dengan IPSS,
Uroflometri, USG prostat dan Residu Urine
3. Therapy yg terdiri dari terapi medik dan
terapi minimaly invasif
 Summary

4. Pemeriksaan serum PSA dan colok dubur

secara berkala merupakan cara terbaik
untuk deteksi dini kanker prostat
5. Tatalaksana kanker prostat tergantung pada
umur penderita, staging klinik dan grading
histopatology
Terima Kasih