1. WELCOME

2. Fayzun Nahar (86) Rumana Saireen(87) Anika Anjum Haque(88)
Case Presentation
Group 7
Surgery Unit I
Ward no 24
Presented by-
Fayzun Nahar (86) Rumana Saireen(87) Anika Anjum Haque(88)

3. Particulars of the patient:
Name : Mr. Mohammad Hossain
Age : 70 years
Sex :Male
Father’s name : Late Sabor Mulok
Mother’s name : Late Aleya Khatun
Present address : B.M. Char, Chokoria, Cox’s Bazar
Contact number :
Occupation : Retired school teacher
Religion : Islam
Marital status : Married
Date & time of admission : at 10.00am
Date & time of examination : at 7.30 pm
Bed number : 13
Ward number : 24 ( surgery unit- I)

4. The presenting complaints:
Frequency of micturition for 2 months.
Urgency for 2months.
Sensation of poor bladder emptying for 1.5 months.

5. The history of present illness:
According to patient’s statement, he was relatively well 2 months back, then he gradually develop frequency and urgency of micturition. He gave history of micturition 7-8 times in day and 4-5 times in night. He woke up from sleep for frequency of micturition .He also gave history of sensation of incomplete bladder emptying. Sometimes, he would strain for emptying the bladder . He gave history of weight loss, the loss being 15% of his previous body weight for last 6 months. He gave no history of cough, chest pain, haemoptysis,jaundice, ascites, hematemesis, melaena ,haematuria or bone pain. His bowel habit is normal.

6. The history of past illness:
He is hypertensive ,non diabetic and gave no history of tuberculosis, asthma.
He gave no history of previous hospitalization and blood transfusion.
Personal history:
He was a ex-smoker
He was non alcoholic.
His diet was normal.
Personal hygiene was satisfactory.

7. Socio-economic history:
Family history:
His brother has been suffering from such disease for last 5 years.
Drug history:
He used to take antihypertensive drugs for 7 years. No history of drug allergy.
Socio-economic history:
He came from middle class family.

8. General examination Appearance : Anxious Pulse : 60 bpm
Body built :Average
Nutrition : Nourished
Co-operation : Co-operative
Decubitus : On choice
Anemia : Absent
Jaundice : Absent
Edema : Absent
Dehydration : Absent
Pulse : 60 bpm
Blood pressure : 160/80 mm Hg
Temperature : 98◦F
Respiratory rate : 22 breaths/min
Ascites :Absent
Neck vein : Not engorged
Neck gland :Not enlarged
Lymph node : Not palpable
Hernial orifice : Intact

9. Systemic examination Genitourinary system: Abdomen Examination:
External genitalia: Normal
Kidneys: not ballotable.
Abdomen Examination:
Inspection:
Abdomen was scaphoid in shape
Umbilicus was centrally placed and inverted
No engorged vein, no visible peristalsis, no scar mark were present
Palpation:
Temperature was normal, tenderness was absent.
No mass was palpable
Liver, spleen were not palpable, kidney s were not ballotable.

10. Other systemic examination:
Percussion:
Percussion note was tympanitic
Shifting dullness and fluid thrill absent
Auscultation:
Bowel sound was present and normal
Other systemic examination:
Other systemic examination reveals no abnormality.

11. Digital rectal examination
Inspection:
Perianal skin was normal
A skin tag was present in the right side of anus.
Anal mucosa was normal and regular.
Palpation:
Anal tone: Normal.
Prostate was enlarged
Consistency-hard
Surface-irregular
Median sulcus-obliterated
Overlying rectal mucosa-fixed to prostate.
Upper limit could not be reached
Finger stain-not blood stained

12. Salient Feature
Mr. Muhammad Hossain, 70 years old, retired school teacher, son of late Md.Sabor Mulok hailing from B.M.Char, Chokoria, Cox’s Bazar, presented with the complaints of frequency and urgency in micturition for 2 months and sensation of poor bladder emptying for 1.5 month.
According to patient’s statement, he was relatively well 2 months back, then he gradually develop frequency and urgency of micturition. He gave history of micturition 7-8 times in day and 4-5 times in night. He woke up from sleep for frequency of micturition .He also gave history of sensation of incomplete poor bladder emptying. Sometimes, he would strain for emptying the bladder . He gave history of weight loss, the loss being 15% of his previous body weight for last 6 months.
He gave no history of cough, chest pain, haemoptysis, jaundice, ascites, hematemesis, melaena ,haematuria or bone pain. His bowel habit was normal.

13. The patient is hypertensive, non diabetic. He is ex-smoker
The patient is hypertensive, non diabetic. He is ex-smoker. He came from middle socio-economic status. His brother is suffering from such disease for 5 years.
On general examination, the patient was anxious, of average body built and nutrition, co-operative and decubitus on choice. He was not anemic, non-dehydrated, not icteric, not edematous. His pulse rate was 60 bpm, blood pressure was 160/80 mmHg, temperature was 98◦F
and respiratory rate was 22 breaths per min. Neck vein was not engorged, neck gland was not enlarged,, hernial orifices were intact, peripheral lymph nodes were not palpable. On abdominal examination, no abnormality was found. No organomegaly was found.

14. On digital rectal examination, on inspection ,perianal skin was normal, a skin tag was present in the right side of anus, rectal mucosa was normal and regular.
. On palpation, anal tone was normal. It was hard in consistency, surface was irregular and fixed with overlying rectal mucosa s. Upper limit could not be reached. On withdrawal , the finger was not blood stained. Other systemic examination revealed no abnormality.

15. Provisional diagnosis:
Carcinoma prostate
Differential diagnosis:
Benign enlargement of prostate(BEP)
Chronic prostatitis

16. Difference between BEP &Ca prostate by DRE
Trait
BEP
Ca prostate
1.Symmetry of enlargement
Symmetrically enlarged
Asymmetrically enlarged
2.Surface
Smooth
Irregular
3.Consistency
Firm
Hard
4.Medial sulcus
Prominent
Obliterated
5.Rectal mucosa
Free
May be fixed
6.Examining finger
Not blood stained
May be blood stained

17. Investigation For diagnosis: For metastasis: For prognosis:
1.Prostatic biopsy
2.USG of KUB region and prostate
For metastasis:
1.Bone scan
2. CXR
3.USG of whole abdomen
4.General blood test
For prognosis:
Serum PSA

18. Routine investigation:
CBC
Urine R/M/E
Serum electrolyte
Random blood glucose
Serum creatinine
Chest X-ray P/A view
ECG

19. Bone scan

20. Management A. Counseling. B. Preoperative preparation: C. Surgery:
Cross matching of blood
Anti-hypertensive: To control blood pressure
Anxiolytic.
C. Surgery:
Radical prostatectomy

21. Preoperative counseling
Men undergoing prostatectomy need to be advised about the following: 1.Incontinence 2.Erectile impotence 3.Success rate-90% 4.Morbidity rate- Severe haematuria , Severe sepsis 5.Death

24. THEORITICAL BASIS FOR CARCINOMA PROSTATE

25. Surgical anatomy
Prostate is a fibro-musculo-glandular organ which situated at the bladder neck around the proximal part of the male urethra.

26. Lobes in prostate: 5 Lobes
1 anterior
2 Lateral
1 posterior
1 Medial
Zones of prostate:
1.Peripherial (most carcinoma arise from this zone)
2.Transitional zone(most benign hyperplasia arises)
3.Central zone
Gland:
1.Urethral gland
2.Submucosal gland
3.Prostatic gland proper

28. Carcinoma prostate It is the second most common cause of death.
Carcinoma of the prostate is the most common malignant tumors in men.
It is the second most common cause of death.
Incidence-
Most commonly occurs at age >65 years
-25%-50 to 65 years
-70%-over 80 years
About 10-15% younger men who develop prostate cancer have a
family history of disease.

29. Pathology A. It arises from three zones: 1.Peripheral zone-70%
2.Central zone-5%
3.Transitional zone-25%
B. Histological:
1.Primary
-Adenocarcinoma-95%
-Transitional cell carcinoma-4%
-Neuro endocrine Ca Figure:Adenocarcinoma
-Sarcoma of prostate
2.Secondary
-From adjacent organ-Bladder, rectum

30. Risk factors Dietary factor: Age:>50 years Family history:
Men who have a first-degree relative (father or brother) with
prostate cancer have twice the risk of developing prostate cancer.
Racial factor
Endocrine cause: Testosterone
Genetic factor
Dietary factor:
High calorie diet,saturated fat,red meat
Environmental factor:
Textile, fertilizer,rubber industry

31. Clinical features 1.Early prostatic Ca Asymptomatic
Incidentally following TURP for a clinically
benign disease T1
As a nodule on rectal examination
2.Advanced prostate Ca
Bladder outflow obstruction (BOO)
Pelvic pain and haematuria
Bone pain,malaise,arthritis,anaemia
Renal failure
Locally advanced disease or even asymptomatic

32. Spread 1.Local spread: 2.Spread by bloodstream: 3Lymphatic spread:
Involves seminal vesicle,bladder neck trigone, distal sphincter
mechanism, both end of ureter,rectum.
2.Spread by bloodstream:
Bones-most common site,
sequely-pelvic bone,lower lumber vertebra,femoral
head,ribs,skull.
Lung
Liver
3Lymphatic spread:
Obturator and hypogastric nodes
Internal iliac LN
External iliac LN
Retroperitoneal,mediastinal,supraclavicular LN

33. TNM Staging clinically benign T2-clinically palpable tumour
T1-incidental diagnosis after histopathology of
clinically benign
T1a-involves <5% of resected specimen -well differentiated
T1b-involves >5% of resected specimen
T1c-impalpable tumour following screening with raised PSA
T2-clinically palpable tumour
T2a-<1.5cm tumour involves one lobe in D/R/E
T2b->1.5 cm involving both lobe
T3-tumour extends through the capsule
T3a-unilateral/bilateral extension
T3b-involves seminal vesicles
T4-Tumour is fixed or involve adjacent structure other than T3
T4a-bladder neck, regional LN
T4b-metastasis to bone and viscera

34. N M N1-single node 2cm or less
N2-single node 2-5cm or multiple nodes<5 cm
N3-one or more nodes >5 cm M
Mo-no distal metastasis
M1-distal metastasis

36. White More-Jewelt-system
Stage A
Microscopic disease found incidentally
Stage B
Gross disease confined to prostate and palpable on DRE
Stage C
Tumors Extend beyond capsule without metastasis
Stage D
Metastatic disease

38. Grading Gleason grading system
Grade Score Well differentiated
Grade Score Moderately differentiated
Grade Score Poorly differentiated

40. Investigation For diagnosis: For metastasis: For prognosis:
1.Prostatic biopsy
2.USG of KUB region and prostate
3. TRUS
4.Urodynamic study
For metastasis:
1.Bone scan
2. CXR
3.USG of whole abdomen
4.General blood test
5.IVU
6.CT scan &.MRI
For prognosis:
Serum PSA
Routine investigation:
1.CBC
2.Urine R/M/E
3.Serum electrolyte
4.Random blood glucose
5. Serum creatinine
6. Chest X-ray P/A view
7. ECG

41. Screening for Ca Prostate
Screening tool:
PSA

42. Prostatic biopsy
Transrectal biopsy
TURP

43. Management Depends on- Age of patient Staging Grading Symptom
CVS status

44. Treatment according to staging
1.T1a and T1b-
If pt age >70 years-Conservative treatment
If pt age <70 years-Radical prostatectomy after counseling and Pt’s benefit
2.T1c and T2-
Options-
a. Radical prostatectomy/Radical radiotherapy-if pt <70 years
b. Watchful waiting-Elderly patient
c. TURP with or without hormone therapy –Elderly pt with outflow
obstruction .
3.T3 and T4-
Palliative treatment by androgen ablation
a. Surgical Castration- Orchidectomy
b. Medical castration-Drugs
(Reduction of LH production, antiandrogen,combined)
c. General radio therapy

46. Radical prostatectomy
Surgical removal of prostate.
May be done with a retropubic, perineal, laporoscopic or robotic approach
Removal of prostate down to distal sphincter,seminal vesical,bladder neck,pelvic lymph node and reconstruction of bladder neck & urethra.

51. External Beam Radiotherapy

54. Complication of Prostatectomy
1.Peroperative:
a. Haemorrhage
b.Injury to bladder,urethra,sphincter & nerves
Cardiac arrest,MI,aspiration,water intoxication.
2.Early postoperative:
Reactionary haemorrhage,clot retention,2ndary haemorrhage,wound infection,sepsis,incontinence
3.Late postoperative:
Retrograde ejaculation, Erectile dysfunction, urethral stricture, bladder neck contracture
DVT, Pulmonary atelectasis,pneumonia,MI,CCF.

55. THANK YOU