Referred Pain and Pain location

Difference between Hydrocele and Varicocele

Hydrocele:--Painless enlargement of the Scrotum.
Can be Unilateral or Bilateral.

Diagnosis with Transillumination. However transillumination cannot confirm the diagnosis because it also may indicate hernia.

Ultrasound can be done to confirm the diagnosis.

Varicocele:-Varicocele is a mass of enlarged veins that develops in the spermatic cord.

A varicocele can develop in one testicle or both, but in about 85% of cases it develops in the left
testicle. The left spermatic vein drains into the renal vein .

Highest in men between the ages of 15 and 25.
The sudden appearance of varicocele in an older man
may indicate a renal tumor blocking the spermatic
vein.

S&S:--Asymptomatic or may have:--

• Ache in the testicle
• Feeling of heaviness
• Infertility
• Atrophy of the testicle
• Visible or palpable enlarged vein 

Diagnosis:--Large varicoceles may be seen with the naked eye. Medium-sized varicoceles may be detected during physical examination by palpating--"Bag of Worms

Doppler ultrasonography uses ultrasound echos to detect the characteristic sound of the backflow of
blood through the valve.

Treatment:--Surgical Ligation of the affected Spermatic veins.

Summary :

varicocele is described as a "bag of worms", will not transilluminate
hydrocele is collection of fluid in tunica vaginalis, will feel different depending whether it is communicating or not, will transilluminate

Swellings

Lipoma 

• Benign tumor from adipose tissue
• Commonest benign tumor
• Can be single or multiple(lipomatosis), usually encapsulated, slowly growing, soft swelling
• Usually painless. 
• Types 
• Painful lipomas are called neurolipomas . Dercum’s disease is tender deposition of fat especially on the trunk also known as adiposis dolorosa. It is basically neurolipomatosis.
• Fibrolipoma
• Nevolipoma 

Sites :

• Subcutaneous 
• Subfascial 
• Intramuscular
• Submucosal in GI tract
• Not present in brain

Clinical features

• Usually localized , nontender semifluctuant  mobile mass with edges slipping between palpating fingers 
• It is free from overlying skin
• Differential diagnoses
• Neurofibroma
• Sebaceous cyst
• Dermoid
• Lymph node enlargement

Complications

• Sarcomatous changes
• Saponification 
• Calcification 
• Submucosal lipoma can lead to intussusception

Treatment 

Excision 

Sebaceous cyst

• Retention cyst due to blockage of the duct of sebaceous gland
• Contains yellowish white cheesy material
• Common sites face , scalp and scrotum (not seen in palms and soles)
• Clinical features
• Painless swelling which is smooth, soft, nontender, freely mobile but adherent to skin over the summit, fluctuant, nontransilluminant and punctum over the summit (70%)
• It moulds on finger indentation 

Dermoid

Types :

1.Sequestration dermoid

• Cysts generally develops in line of embryonic fusion. So may be seen anywhere in midline, outer angle of dermoid, behind pinna or root of nose
• Clinical features- painless swelling in the line of embryonic fusion, soft, smooth, fluctuant and nontransillumintating with free skin

2. Implantational dermoid

• Due to minor pricks or trauma, epidermis gets buried into deeper subcutaneous tissue which causes reaction and cyst formation.
• Common in fingers , toes and feet
• Clinical features – swelling is painless , soft , tensely cystic nontransilluminating often adherent to skin

TREATMENT : Excision

Ganglion

• Cystic swelling containing clear gel formed by degeneration of synovial tissue.
• Occur in relation to tendon sheath or joint capsule
• Common sites: dorsum of wrist, flexor aspect of wrist
• Clinical features
• Well localized smooth, soft , cystic, nontender, transilluminant and mobile but mobility restricted when tendon is contracted against resistance

Treatment 
excision but high recurrence rate

Bursa

Bursa is a sac like cavity containing fluid within which prevents friction between tendon and bone

Minor injuries and pressure lead to bursitis which will present as swelling and  pain

Treatment excision if necessary

Neurofibroma 

• Tumor arising from connective tissue of the nerve.
• Can be single or multiple
• Types :
• Nodular neurofibroma – single, smooth, firm, often tender swelling which moves perpendicular to direction of nerve but not in the direction of nerve
• Plexiform neurofibroma – commonly occurs in the direction of Vth cranial nerve in skin of face . It attains enormous size with thickening of skin which hangs downwards.
• Generalised neurofibromatosis (von Recklinghausen’s disease) – it is inherited as autosomal dominant disease. Multiple neurofibromas associated with pigmented spots in skin (café au lait spots) . Associated with MEN type IIb   

Complications 

• Sarcomatous change – rapid enlargement, warm and vascular with dilated veins
• Cystic degeneration
• Hemorrhage into tissues
• Erosion of deeper structures
• Neurological deficits may occur

Treatment : excision for symptomatic , cosmetically problematic or malignant changes

Callosity and corn 

Callosity 

• raised thickened patch of hyperkeratosis common in areas which undergoes excessive wear and tear.
• Histologically there is increased thickening of epidermis particularly the stratum corneum and granular layer 

Corn 

• Circumscribed horny thickening cone-like in shape with its apex pointing inwards and base at surface.
• Occurs at the site of friction and often disappears spontaneously when causing factor is removed
• Histologically composed of keratin masses with intact basal layer
• Often caused by ill-fitting and tight shoes chiefly affecting feet and toes. 

Wart 

• Patches of overgrown skin with hyperkeratosis
• Usually occur in children and adolescents and young adults
• Growth occurs due to stimulation by HPV
• Main complaint is disfiguring 
• Frequently affects hands, face, knees, and sole (plantar warts) .
• Warts are usually firm and covered with rough surface and filifom excrescences.

NUTRITION

Caloric requirement in adults – 40kcal/kg/day

Carbohydrates 50% , fat  30-40% and protein 10-15%

Caloric value- carbohydrate and protein - 4kcal/g and fat – 9kcal/g

Indications of nutritional supplementation

• Preoperative nutritional depletion
• Burns
• Trauma
• Anorexia nervosa and intractable vomiting
• Pancreatitis, malabsorption, ulcerative colitis, pyloric stenosis
• High output intestinal fistulas
• Postoperative complications like sepsis, ileus and fistula
• Malignant disease

Methods of feeding

Enteral feeding

• GI tract is the best route to provide nutrition.
• Can be done 

i.Orally

ii.By nasogastric tube

iii.By enterostomy e.g. gastrostomy and jejunostomy in severe malnutrition, major surgeries, severe sepsis

Total parenteral nutrition (TPN)

Indications:

• Failure or contraindication for any enteral nutrition
• High output intestinal fistulas
• Major abdominal surgery of liver, pancreas, biliary tract, colon
• Septicemia
• Multiple trauma
• Short bowel syndrome
• TPN is given through central vein and not through peripheral vein
• Components used in TPN – carbohydrates, fat, aminoacids, vitamins and trace elements
• Contraindications :
• Cardiac failure
• Blood dyscrasias
• Altered fat metabolism

Complications of TPN 

1.Due to placement of CVP

• Air embolism
• Pneumothorax
• Bleeding
• Infection 
• Catheter displacement, sepsis, blockage, thrombosis

2. Biochemical

• Electrolyte imbalance
• Hyperglycemia
• Hyperosmolarity
• Dehydration
• Azotemia 
• Altered immunological function

3. Others

• Dermatitis
• Anemia 
• Cholestatic jaundice.

PRINCIPLES OF SKIN COVER - GRAFTS AND FLAPS

Characteristics

• Largest organ of the human body- surface area 1.5-2.0 sq.m,  2-3mm thick
• 15% of body weight
• Epidermis- Corneum, Lucidum, Granulosum, Spinosum, Basale,
• Dermis- papillary and reticular, made of collagen, 

Functions of skin

• Protective layer - Langhan’s cells of adaptive immune system
• Sensation
• Heat regulation
• Control evaporation
• Aesthetics 
• Makes vitamins D

When is skin required?

• Loss of large area of skin
• Large wound 
• Post burn raw area
• Release of contracture

Reconstructive Ladder

Graft and Flap

• Graft is free tissue without its vascular supply- skin, bone, tendon, nerve, vessels, muscle, fascia, mucosa
• Flap is tissue with its original blood supply
• Areas where we cannot put graft will need a flap-Flaps for bone devoid of periosteum, cartilage devoid of perichondrium, tendon devoid of paratenon

Grafting 

• Skin graft is essentially dead with no circulation. Under favourable conditions obtain new blood supply from recepient wound or defect. This is known as graft take
• Infection, pressure, hematoma or shear forces can result in graft failure
• Meshing – increase surface area and prevention of collections
• Immobilisation with Sutures / plaster slab
• Prevention of hematoma / seroma
• Dressing of recipient wound
• Donor site management

Process of graft take

1. Imbibition

2. Inosculation

3. Vascularization

Conditions affecting graft take

• Malnutrition- hypoproteinemia, vitamin deficiency
• Presence of hypertension, diabetes
• Compromised immune status
• Collagen vascular disease
• Constant pressure on the area

When to graft?

• Wound flat and red / can see the imprint of gauge piece
• No unhealthy granulation tissue or necrotic tissue
• Margins are healing and spreading
• Not much bleeding on touch
• dressing peels  with difficulty
• Bacterial count less than 105 
• No evidence of beta hemolytic streptococci

Types of skin graft:

Partial thickness- thin intermediate thick

Full thickness

Composite graft- More than one tissue type required to perform reconstruction

Split thickness skin grafting (Thiersch graft)

• Donor site heals spontaneously as part of dermis is left behind
• Contracture may occur
• Sensation function of hair sebaceous gland not present
• Donor area is dressed and dressing is removed after 10 days and after 5 days in recepient area

Skin graft harvesting

Instruments  -  Humby’s knife

Donor sites:

Thigh , legs, arm, forearm, body

Taking split skin graft with a Humby’s knife holder

Differences

Split thickness Skin graft:

• Epidermis and part of dermis
• Donor sites heal spontaneously 
• Extensive defects
• Graft take – good
• More contraction later
• Less stable
• Less colour and texture matching

Full thickness graft:

• Epidermis and whole dermis
• Donor site needs to be closed – direct or SSG
• Small defects
• Graft take – less readily- needs optimal condition
• Secondary contraction less
• More stable
• Good colour and texture matching

Full thickness skin grafting (Wolfe’s graft)

• Harvested with surgical blade
• Accurately fitted to the defect and sutured
• Donor sites – postauricular, upper eyelid, supraclavicular, flexural, abdomen
• Donor site closure
• Recipient site – dressing / immobilisation
• Whole thickness of skin is excised
• Defatting is done to improve graft take
• Blood supply must be restablished
• Where cosmesis is important (face) or flexibility is important (over joint)

Flaps

• Flap is tissue with its original blood supply

Classification:

1. Based on blood supply – 

• Random pattern (dermal and subdermal plexus)

Rotation flap / transposition flap / advancement flap

• Axial pattern (named vessel) e.g. groin flap (lat. Circumflex artery)

Peninsular flap / island / free flap

Free tissue transfer

• Most technically demanding
• Single stage wound closure
• Wide variety of flaps- tailored to coverage needs
• More acceptable aesthetic outcome

2. Classification based on tissue type
1. Cutaneous flap
2.Faciocutaneous flap
3.Muscle flap
4.Musculocutaneous flap
5.Osteocuaneous flap

3. Specialized flaps
1. Fascial flap
2. Vascularized bone flap
3. Functional muscle flap

The Gallbladder and bile ducts

Gallbladder

• The gallbladder is a pear-shaped reservoir in continuity with the common hepatic and common bile ducts through the cystic duct.
•  It is usually 7.5 to 12cm in length, is 3 to 5 cm in diameter, and has a capacity of 35 to 50 mL.
•  The gallbladder lies on the inferior surface of the liver partially enveloped in a layer of peritoneum.
•  The gallbladder is anatomically divided into the fundus, body, infundibulum, and neck, which empties into the cystic duct.
•  Both the gallbladder neck and the cystic duct contain spirally oriented mucosal folds known as the valves of Heister. 
• The valves prevent the passage of gallstones and excessive distention or collapse of the cystic duct, despite variations in ductal pressure. 

The Hepatic Duct (ductus hepaticus)

• Two main trunks of nearly equal size. Arising from the liver at the porta. one from the right, the other from the left lobe.
• The common hepatic duct is less than 2.5cm long  and is formed by the union of the right  and left hepatic ducts.
• It passes downward and to the right for about 4 cm.
• Joined at an acute angle by the cystic duct to form the common bile duct. Lies between  the layers of the lesser omentum.
• Is accompanied by the hepatic artery and portal vein. 

Cystic duct

The cystic duct varies in length from 1 to 5 cm and in diameter from 1 to 3 mm; it usually joins the common hepatic duct at an acute angle.

The Common Bile Duct 

The common bile duct is formed by the junction of the cystic and hepatic ducts.

• Length: It is about 7.5 cm. long.
• Diameter: That of a  goose-quill.

• Course and extent : It descends along the right free margin  of the lesser omentum along with   portal vein ( which is behind it ) , and to the right of the hepatic artery. 
• Then behind the superior portion of the duodenum,
• After crossing the duodenum, it runs on the posterior surface of the head of the pancreas, and in front of IVC. 
• Occasionally completely imbedded in the pancreatic substance. 
• At its termination it lies for a short distance along the right side of the terminal part of the pancreatic duct and passes with it obliquely between the mucous and muscular coats. 
• The two ducts unite and open by a common orifice upon the summit of the duodenal papilla, situated at the medial side of the descending portion of the duodenum, a little below its middle and about 7 to 10 cm. from the pylorus. The short tube formed by the union of the two ducts is dilated into an ampulla, the ampulla of Vater. 

Blood supply

• Gall bladder is supplied by Cystic artery, a branch of right hepatic artery.
• The blood supply to the common hepatic duct, cystic duct and common bile duct comes from the gastroduodenal, retroduodenal, postero-superior pacreatico duodenal arteries. 

Lymphatics

• The lymphatics of gallbladder (subserosal and submucosal) drain into the cystic L/N of Lund.
• Small veins and lymphatics course between the gallbladder fossa and the gallbladder wall, connecting the lymphatic and venous drainage of the liver and gallbladder. These connections are the cause of the direct inflammatory and carcinomatous spread from the gallbladder into the liver.

Calot’s triangle

Formed by:

• Common hepatic duct to the left
• Cystic duct below and 
• inferior surface of the liver above.

Content:

• the cystic artery, 
• the right hepatic artery, and
• the cystic duct lymph node.

Functions of gall bladder

• Stores bile
• Concentrates bile
• Secretion of mucus

Embryology

• The hepatic diverticulum arises from the ventral wall of the foregut and elongates into a stalk to form the choledochous.
• A lateral bud is given off, which becomes the gall bladder and the cystic duct.

Congenital abnormalities

• Absence of the gall bladder
• The Phrygian cap
• Floating gall bladder
• Double gall bladder
• Absence of the cystic duct
• Low insertion of the cystic duct
• An accessory cholecystohepatic duct

Biliary atresia

It may be due to viral infection or defective embryogenesis resulting in the inflammatory destruction of extra- and intrahepatic biliary tree.
Incidence 1 in 12000 live births
Male and female equally affected.
It may be associated with: cardiac lesions, polysplenia, situs inversus, absent vena cava and a preduodenal portal vein.

Classification

Type I: atresia restricted to the common bile duct
Type II: atresia of the common hepatic duct
Type III: atresia of the right and left hepatic ducts

Clinical features

• Progressive jaundice in a new born.
• Steatorrhea
• Osteomalacia
• Biliary rickets
• Severe pruritus
• Clubbing and skin xanthomas

D/D

• Alpha 1-AT deficiency
• Cholestasis associated with i.v feeding
• Choledochal cyst
• Inspissated bile syndrome
• Neonatal hepatitis

Treatment
In correctable cases:
Roux-en-Y hepaticojejunostomy
In noncorrectable cases:
Hepaticoportojejunostomy (Kasai’s operation)
Radical excision of all bile duct tissue up to the liver capsule is performed.
A roux-en-Y loop of jejunum is anastomosed to the exposed area of liver capsule above the bifurcation of the portal vein creating a portoenterostomy

Liver transplantation: in case of unsuccessful

Caroli’s disease

It is a congenital, multiple, irregular dilatations of the intrahepatic ducts with stenotic segments in between.
Extrahepatic biliary system is normal.

Types :

Simple type
Presents later with episodes of aqbdominal pain and biliary sepsis

Associated with:
Congenital hepatic fibrosis
Polycystic liver
Cholangiocarcinoma
Periportal fibrotic type
Presents in childhood

Periportal fibrotic type is associated with:
Biliary stasis
Stone formation and
Cholangitis

T/T

• Antibiotics for chalangitis and removal of calculi.
• If limited to one lobe of liver- lobectomy

Choledochal cyst

Choledochal cysts are congenital dilations of the intra- and/or extrahepatic biliary system.

Classification (Todani)

Type Ia and b: diffuse cystic
Type II: diverticulum of the common bile duct
Type III: diverticulum within the pancreas
Type IV: extension into the liver
Type V: cystic dilatation only of the intrahepatic ducts

Clinical features

• Can occur in any age.
• Patients may present with jaundice, fever, abdominal pain.
• O/E right upper quadrant mass which is smooth, soft, not moving with respiration, not mobile and resonant.

Ix

Ultrasonography abdomen:
Confirms the presence of  abnormal cyst

MRI/MRCP:  
reveals anatomy. Esp. relationship between the lower end of the bile duct and the pancreatic duct.

CT: 
show the extent of intra- and extrahepatic dilatation.

Treatment
Radical excision of the cyst is the t/t of choice with reconstruction of the biliary tree using a RouX-en-Y loop of jejunum.

Prostate Anatomy

Location and Description

• The prostate is a fibromuscular glandular organ that surrounds the prostatic urethra . It is about 1.25 in. (3 cm) long and lies between the neck of the bladder above and the urogenital diaphragm below.
• The prostate is surrounded by a fibrous capsule. The prostate has a base, which lies  against the bladder neck above, and an apex, which lies against the urogenital diaphragm below. The two ejaculatory ducts pierce the upper part of the posterior surface of the prostate to open into the prostatic urethra at the lateral margins of the prostatic utricle.

Relations

• Superiorly: The base of the prostate is continuous with the neck of the bladder, the smooth muscle passing without interruption from one organ to the other. The urethra enters the center of the base of the prostate.
• Inferiorly: The apex of the prostate lies on the upper surface of the urogenital diaphragm. The urethra leaves the prostate just above the apex on the anterior surface.
• Anteriorly: The prostate is related to the symphysis pubis, separated from it by the extraperitoneal fat in the retropubic space (cave of Retzius). The prostate is connected to the posterior aspect of the pubic bones by the fascial puboprostatic ligaments.

• Posteriorly: The prostate is closely related to the anterior surface of the rectal ampulla and is  separated from it by the rectovesical septum (fascia of Denonvilliers). This septum is formed in fetal life by the fusion of the walls of the lower end of the rectovesical pouch of peritoneum, which originally extended down to the perineal body.
• Laterally: The prostate is embraced by the anterior fibers of the levator ani as they run posteriorly from the pubis.

Structure of the Prostate

• The numerous glands of the prostate are embedded in a mixture of smooth muscle and connective tissue, and their ducts open into the prostatic urethra.
• The prostate is incompletely divided into five lobes. 
• The anterior lobe lies in front of the urethra and is devoid of glandular tissue. 
• The median, or middle, lobe is the wedge of gland situated between the urethra and the ejaculatory ducts. Its upper surface is related to the trigone of the bladder; it is rich in glands. 
• The posterior lobe is situated behind the urethra and below the ejaculatory ducts and also contains glandular tissue. 
• The right and left lateral lobes lie on either side of the urethra and are separated from one another by a shallow vertical groove on the posterior surface of the prostate. The lateral lobes contain many glands.

Function of the Prostate

• The prostate produces a thin, milky fluid containing citric acid and acid phosphatase that is added to the seminal fluid at the time of ejaculation. 
• The smooth muscle, which surrounds the glands, squeezes the secretion into the prostatic urethra. 

Blood Supply

Arteries

• Branches of the inferior vesical and middle rectal arteries.

Veins

• The veins form the prostatic venous plexus, which lies outside the capsule of the prostate. The prostatic plexus receives the deep dorsal vein of the penis and numerous vesical veins and drains into the internal iliac veins.

Lymph Drainage

• Internal iliac nodes.

Nerve Supply

• Inferior hypogastric plexuses. The sympathetic nerves stimulate the smooth muscle of the prostate during ejaculation.

Benign Prostatic Hyperplasia

It is a benign enlargement of prostate which occurs after about 50 years (usually between 60-70 years)
Theories
It is involuntary hyperplasia due to disturbance of the ratio and quantity of circulating androgens and estrogens.
BPH is a benign neoplasm, also called as fibromyoadenoma.

Pathology

• BPH usually involves median and lateral lobes or one of them.
• It involves adenomatous zone of prostate, i.e. submucosal glands.
• Median lobe enlarges into the bladder.
• Lateral lobes narrow the urethra causing obstruction.
• Urethra gets elongated and narrowed.
• Bladder initially takes the pressure burden causing trabeculations, sacculations and later diverticula formation.
• Enlarged prostate compresses the prostatic venous plexus causing congestion, called as vesical piles leading to haematuria.
• Incrimination of BPH as the source of haematuria before excluding other causes is termed as “Decoy prostate”
• Kidney and ureter
• Back pressure causes hydroureter and hydronephrosis.
• Secondary ascending infection can cause acute or chronic pyelonephritis.
• Often severe obstruction can lead to obstructive uropathy with renal failure.
• BPH causes impotence.

Clinical Features

• Frequency occurs due to introversion of sensitive urethral mucosa into the bladder or due to cystitis and urethritis.
• Urgency
• Overflow and terminal driblling.
• Difficulty in micturation with weak stream and dribble.
• Pain in suprapubic region and in loin due to cystitis and hydronephrosis respectively.
• Acute retention of urine
• Retention with overflow
• Haematuria
• Renal failure
• Prostatism is a combination of symptoms like frequency both at day and night, poor stream, delay in starting and difficulty in micturation.
• Tenderness in suprapubic region, with palpable enlarged bladder due to chronic retention. Hydronephrotic kidney may be palpable.
• P/R examination shows enlarged prostate. It should be done when bladder is empty.
• Features of urinary infection like fever, chills, burning micturation.

Investigations

• Urine for microscopy and C/S
• Blood urea and serum creatinine
• USG abdomen- look for presence of residual urine
• Urodynamics
• Cystoscopy
• Acid phosphatase
• Prostate specific antigen (PSA)
• IVU
• Serum electrolytes

Management

• Patient with acute retention of urine requires urethral catheterization.
• If urethral catheterization fails, then suprapubic cystostomy is done.
• If patient presents with uraemia, then urethral catheterization is a must. That allows the kidney to function adequately and further obstructive damage is prevented.
• Serum electrolyte should be corrected properly in these patients.

Indications for surgery

• Prostatism (frequency, dysuria, urgency)
• Acute retention of urine.
• Chronic retention of urine with residual urine more than 200 ml.
• Complications like hydroureter, hydronephrosis, stone formation, recurrent infection, bladder changes.
• Haematuria

Surgeries

• Transurethral resection of prostate (TURP)

Using cystoscope with fluid like glycine irrigating continuously, enlarged prostate is identified and resected using a loop with a hand control. Resection is done using high frequency diathermy current.
After surgery, continuous bladder irrigation using NS is done using three way Foley’s catheter. Antibiotics should be given. Catheter is removed within 72 hours.

• Freyer’s suprapubic transvesical prostatectomy.Before TURP this was procedure of choice.

• Millin’s retropubic prostatectomy
• It is done without opening the bladder ( not commonly practiced)
• Young’s perineal prostatectomy through perineal approach.
• Laser treatment using holmium laser.
• High energy electromagnetic treatment.
• Placement of intraurethral stents at prostatic urethra.
• Placement of extraurethral stents which are inert.
• Transurethral balloon dilatation of the prostate.

Drugs used for BPH

1)Alpha 1 adrenergic blocking agents- which inhibit smooth muscle contraction of prostate. They reduce the bladder neck resistance so as to improve the urine flow

• Short acting drugs are prazocin and indoramin.
• Long acting drugs are terazocin and doxazosin.
• Selective alpha1A- adrenoceptor blocking agent: tamsulosin

2)5-alpha reductase inhibitor inhibits conversion of testosterone to dihydrotestosterone.

• It is effective in palpably enlarged prostate.
• Drug used is finasteride 5mg daily for 6-8 months.
• It is contraindicated in obstructive uropathy or carcinoma prostate.

Carcinoma of Prostate

 Epidemiology

•  Most common cancer in men
•  Second most common cause of cancer death in men
•  Incidence increases with age
•  Highest rate in African Americans

Gross

• ill-defined, firm, yellow mass
• Commonly arises in the posterior aspect of the peripheral zone

Micro

• Adenocarcinoma
• Gleason grading system

Spread

1.Local spread

• Tends to grow upwards to involve seminal vesicles, bladder neck, trigone, lower end of ureter.

2. Hematogenous

• Bone esp, pelvic bone and lower lumber vertebrae.( osteoblastic)
• Femoral head, rib cage and skull are other common sites.

3. Lymphatic

• Commonly goes to the obturator and pelvic lymph nodes

TNM Staging

1. T1a, T1b, T1c: incidentally found tumor.

T1a : tumor involving less than 5% of the resected specimen

T1b: Tm involving greater than 5% of the resected specimen

        T1c: impalpable tumor found following a raised PSA.

2. T2a: suspicious nodule on rectal examination confined within prostate capsule involving one lobe.

T2b: involves both lobes

3. T3: extends beyond the capsule

T3a: U/L or B/L extension

T3b: seminal vesicle extension

4. T4: tm which is fixed or invading adjacent structures other than seminal vesicles- rectum or pelvic side wall

Clinical Presentation

• Often clinically silent
• May present with lower back pain secondary to metastasis
• Advanced localized disease may present with urinary tract obstruction or UTIs

Investigations

• Digital rectal exam (induration)
• Serum PSA levels
• Transrectal U/S and biopsy
• Alkaline phosphatase elevated with metastasis
• Bone scan

Treatment

Local disease (T1 and T2):
 prostatectomy and/or external beam radiation

• Metastatic disease (T3 and T4): B/L Orchidectomy

• Estrogens or androgen receptor blockade (flutamide or leuprolide)
• Monitor with PSA levels