ANATOMY OF PROSTATE

Lobar anatomy

Anterior
Posterior
Median lobes
 ANATOMY OF PROSTATE
Zonal anatomy

Devided in to four glandular zones

surrounding the prostatic urethra:

˜ peripheral zone

˜ transitional zone

˜ central zone &

˜ periurethral glandular area.

 ANATOMY OF PROSTATE

On sonography
Separate the Prostate into :

˜ peripheral zone &

˜ Inner gland

transitional one

central zone

periurethral glandular area.

 ANATOMY OF PROSTATE

A nonglandular region on the anterior anterior surface of the prostate

is termed anterior fibromuscular stroma.

Other fibromuscular structures-

- preprostatic sphincter
- postprostatic sphincter
- longitudinal muscle of the proximal urethra.
 ANATOMY OF PROSTATE

Peripheral zone
70% of prostatic glandular tissue.

Source of most prostatic ca.

Surround the distal urethral segment & separated from transition zone
& central zone by surgical capsule.

Occupies the posterior, lateral and apical regions of the prostate,

extending some what anteriorly.

Ducts of the peripheral zone enter the distal urethra.

ANATOMY OF PROSTATE
 ANATOMY OF PROSTATE

Transition zone
5% of prostatic glandular tissue.

Site of origin of benign prostatic hyperplasia.

Seen as two small glandular areas located adjacent to the proximal

urethral segment.

Ducts of the transition zone end in proximal urethra at the level of

verumontanum.
ANATOMY OF PROSTATE
 ANATOMY OF PROSTATE

Cenral zone
25% of prostatic glandular tissue.

Site of origin of 5% prostatic ca.

Located at the prostatic base.

Ducts of the vas deferens & seminal vesicle enter the central zone & the
ejaculatory ducts pass through it .

Central zone ducts terminate in the proximal urethra near the

verumontanum.
 ANATOMY OF PROSTATE

Periurethral glands

1% of prostatic glandular tissue.

Embedded in the longitudinal smooth muscle of the proximal urethra,

known as internal prostatic sphincter.
 MEASUREMENT OF PROSTATE

Step planimetry method, which calculates volume from the sum of

sequential horizontal areas measured from the base to apex.

Diameter method which comprise measurements of height (H), width

(W) and length (L) and volume is calculated using the formula
½ (H x W x L).
Normal volume : 20gm.
NORMAL PROSTATIC ECHO PATTERNS
Three echo levels are seen on prostatic
Sonographic examinations:
Isoechoic
Hypoechoic and
Hyperechoic
In normal young men, the normal inner gland of the
prostate has generally low echogenicity compared
with the outer gland .As the transition zone enlarges
a distinct demarcation between these regions
become clear. The transition zone produces a
hypoechoic images compared with the generally
isoechoic peripheral zone. Hyperechoic structures
are most common characteristic of fat, corpora
amylacea or calculi.
 TECHNIQUE OF TRANSRECTAL ULTRASOUND
˜ Left lateral decubitus or lithotomy position.
˜ A self-administered enema is routinely used before
scanning.
˜ Rectal examination befor probe insertion.

Transverse or semi coronal plane:

The seminal vesicles are seen at the cephalad portion of

the prostate gland above the prostatic base.
They are hypoechoic & irregular and usually symmetrical.
 TECHNIQUE OF TRANSRECTAL ULTRASOUND

Continuing Transverse or semi coronal plane:

Base of the prostate is examined with demonstration of
Central zone, transition zone & periurethal glandular area.
The anterior fibromuscular area is hypoechoic.

Semi coronal plane:

The periurethal area may be very hypoechoic.

The urethra & ejaculatory duct may be identified.
Near the apex most of the tissue is the peripheral zone
 TECHNIQUE OF TRANSRECTAL ULTRASOUND

In sagital plane :

Rotating from right to left will assess glandular symmetry

& confirm any suspicious abnormalities seen on axial or

Coronal imaging.

Seminal vesicles & periurethral area are better evaluate in

sagital plane.
 NORMAL SEMINAL
VESICLES

Engorged, echogenic seminal

vesicles with a fine vesicular

pattern
 NORMAL SEMINAL
VESICLES

Hypoechoic, featureless
appearance
 NORMAL SEMINAL
VESICLES

Echogenic, small vesicles

 NORMAL SEMINAL
VESICLES & VAS
DEFERENCE

The Rt. vas deferens seen

joining the Rt. seminal
vesicle
 NORMAL SEMINAL
VESICLES

Echogenic, featureless
 NORMAL VAS
DEFERENS

Showing normal anatomy

of vas deferens seen in this
oblique cornonal section on
TRUS imaging.
 INDICATION OF TRANSRECTAL ULTRASOUND
Abnormal digital rectal examination

Abnormal lab test results indicative of prostate cancer

PSA
Acid phosphatase
Other evidence of metastetic disease.

Guidance for directed sonographic biopsy

Monitoring response to treatment for prostate cancer.

 BENIGN PROSTATIC HYPERPLASIA SONOGRAPHIC
APPEARENCE

WT of the gland in young pt is about 20gm.

Beginning at age 50, the doubling time of the wt is aprox

10yrs.

Prostate gland enlarge more than 40gm consider

enlarged in older man.
 BENIGN PROSTATIC HYPERPLASIA SONOGRAPHIC
APPEARENCE
Distinct nodules or diffuse enlargement present in
transition zone, peripheral glandular tissue or both.

Typical feature of BPH is enlargement of inner gland,

which remain relatively hypoechoic to peripheral zone.

The echo pattern depend on the admixture of glandular

and stromal elements as nodules may be fibroblastic,
fibromuscular, muscular & fibroadenomatous.
This combination may result in either an isoechoic or
hyperehoic appearance.
 BENIGN PROSTATIC HYPERPLASIA SONOGRAPHIC
APPEARENCE
With increasing enlargement, the hypoechoic transition
zone compresses the central and peripheral zone

The margin separating the hyperplasia from the

peripheral zone is considered to be the surgical capsule.

Ultrasound can also analyze the effect of the hyperplasia

on the anterior urethra and assess median lobe
enlargement.
Other sonographic appearances of benign prostatic
hyperplasia (BPH) include calcifications and rounded
hypoechoic nodules called BPH nodule.
 Benign prostatic hyperplasia

Transabdominal ultrasound scan images reveal obvious

intravesical enlargement of the enlarged median lobe of the
prostate.
 Benign prostatic hyperplasia

Transabdominal ultrasound scan images reveal obvious

intravesical enlargement of the enlarged median lobeof the
prostate.
 Benign prostatic hyperplasia

Ultrasound showed an enlarged prostate consistent with BPH.

 Benign prostatic hyperplasia

Post-voiding trans-rectal ultrasound scan (TRUS) images reveal-

1) large volume of residual urine (303 cc) (more than 40 cc. is
abnormal). 2) gross enlargement of the prostate mainly involving
the transition zone. 3) intra-vesical enlargement of median lobe. 4)
few small cysts in inner gland 3) there is also evidence of corpora
amylacea and nodularity in the transition zone. 5) the peripheral
zone is compressed by the enlarged transition zone.
 Prostatitis

Bulky prostate of approximately 49m

 Color Doppler imaging of prostatitis

The above TRUS ultrasound and color doppler images in a

young male patient show a) hypoechoic prostate b) gross
augmentation of vascularity in the prostatic tissue. These
ultrasound findings suggest presence of acute prostatitis
 TRUS images of prostatitis:

Note the markedly hypoechoic patches in the inner zone of the

prostate (arrowed), which appear overtly vascular on color doppler
imaging
Transurethral resection
of the prostate (TURP):
In this TRUS sonographic image, the
defect due to a Trans-Urethral
Resection of the Prostate, is
evident. Here, the transition zone of
the prostate has been resected. The
transition zone is the seat of the
benign hyperplasia of the prostate,
and is a part of the ³inner gland´.
 PROSTATIC ABSCESS

TRUS scan shows a

hypoechoic collection of 2.5
cms within the right lobe
of the prostate. The walls of
the lesion are shaggy s/o an
abscess.
 Calculi or calcific foci in prostate:

TRUS images show multiple hyperechoic foci (arrows), each of 4 to 7 mm. in the inner
gland of the prostate and also along the prostatic urethra. Power Doppler image (bottom)
shows normal flow in the prostate. These ultrasound images suggest prostatic
calcification or calculi. Calcific foci in prostate are associated with normal aging process
in the male and may be the result of formation of corpora amylacea. These are formed by
calcification of secretions of the gland. It is also seen in chronic inflammation of the
prostate (chronic prostatitis).
 Seminal vesicle calculi (seminal vesicle calcification)

The ultrasound images show multiple seminal vesical calculi bilaterally, each
measuring 2 to 4 mm. in size. Studies suggest that such stones are related to
inflammation, obstruction or diabetes mellitus. The ultrasound image on bottom right
shows Power Doppler study of the prostate; no abnormal flow was found. Calculi in
this case can cause poor flow of semen during ejaculation, hemospermia and painful
ejaculation.
 Utricle cyst

Transrectal ultrasound of the prostate. Transverse image of the prostate in

a young male demonstrates a small midline cystic structure (arrow),
thought to represent a utricle cyst.
Prostate Carcinoma

Axial transrectal ultrasonographic

(TRUS) scan shows extensive

hypoechoic area (arrows) in the right

peripheral zone. Biopsy revealed

prostatic adenocarcinoma.
 Carcinoma prostate- Ultrasound and Color Doppler imaging:

Ultrasound images (TRUS) reveal a hypoechoic lesion involving much of

the left peripheral zone. Color and Power Doppler images (TRUS) reveal
marked vascularity in the region of the nodule (left peripheral zone). These
ultrasound image findings are typical of carcinoma of prostate. There is
also evidence of benign prostatic hypertrophy.
 Prostate Carcinoma

Axial transrectal ultrasonographic

(TRUS) scan shows a hypoechoic

area in left peripheral zone and a

small hypoechoic area in right

peripheral zone (arrows) .

 Prostate Carcinoma
Image shows extensive bilateral but

predominantly left-sided hypoechoic

areas in the peripheral zone (arrows).

Biopsy confirmed a Gleason grade 8

prostate cancer. Minor capsular

irregularity is present on the left; this is

consistent with a T3 tumor.

 Prostate Carcinoma




  


 
 



  


 

 





 Prostate Carcinoma
Axial transrectal ultrasonographic
(TRUS) scan in a patient with clinical
benign prostatic hyperplasia (BPH) and a
serum prostate-specific antigen (PSA)
level of 11 ng/mL. Enlargement of the
transition zone is present, but no focal
abnormality is observed in the peripheral
zone. Systematic 6-core biopsy revealed
adenocarcinoma from both lobes of the
prostate (ie, this is an isoechoic tumor in
the peripheral zone of both prostatic
lobes).
 Prostate Carcinoma

Sonogram shows an extensive,

hypoechoic T3 tumor (arrowheads).

Capsular irregularity is present,

particularly on the right and

posteriorly, with a suggestion of

infiltration into the rectal wal

 Prostate Carcinoma

On frontal (or transversal)

Scans, a hypoechoic mass is

identified in the posterolateral

aspect of the left peripheral

zone.. Note, also, the invasion

of the capsule.
 Prostate Carcinoma

Increased color flow in a

hypoechoic cancer in the

posterolateral zone on this

transverse view.
PROSTATIC CANCER
 STAGING OF CARCINOMA OF PROSTATE

Stage 1

Tumor not detectable by imaging or clinical exam

Low grade tumor

Less than 5% of tissue specimen

 STAGING OF CARCINOMA OF PROSTATE

Stage 2

Tumor not detectable by imaging or clinical exam.

May be found in one or more lobes by needle
biopsy
Moderate to High grade tumor
Over 5% of tissue specimen
 STAGING OF CARCINOMA OF PROSTATE

Stage 3

Tumor extends beyond prostate capsule. Can

invade seminal vesicles.

Any grade tumor

 STAGING OF CARCINOMA OF PROSTATE

Stage 4

Tumor is fixed or invades adjacent structures other

than seminal vesicles, such as sphincter, bladder
neck, wall of pelvis, and rectum
Tumor spread to lymph nodes or metasteses
Any grade tumor