Transrectal Ultrasonography of Prostate 오영택 연세대학교의과대학 영상의학과
Transrectal Ultrasonography (TRUS) of Prostate Anatomy of Prostate Measurement of Prostate volume Benign Prostatic Hyperplasia Prostate Cancer Prostate Biopsy Guiding Inflammatory Disease
Prostate Anatomy McNeal zonal anatomy Glandular zones (70%) Central gland Transitional zone (5%, BPH) Periurethral glandular tissue(1%) Central zone (25%) Peripheral zone (70%) Peripheral gland Central zone (25%) Non-glandular region (30%) Anterior fibromuscular stroma Cancer 20% 10% 70%
McNeal Zonal Anatomy Ref. McNeal JE. Am J Surg Pathol 1988;12:619 633 633
TRUS of Prostate Probe Side-,, end-firing endocavitary probe Axial scan : oriented more coronally at base than apex in end-firing probe 8 12 MHz Rubber cover Position Lateral decubitus Gently insert through sphincter with sufficient lubricant gel
Transrectal Ultrasonography
Transrectal Ultrasonography
BPH TRUS: Normal Appearance Prostate Peripheral zone No clear differentiation from central zone Homogeneous Iso/hyperechoic Transitional zone Coarse & slightly hypoechoic Increasing volume in BPH Surgical capsule Santorini s venous plexus Normal
Transrectal Ultrasonography (TRUS) of Prostate Anatomy of Prostate Measurement of Prostate volume Benign Prostatic Hyperplasia Prostate Cancer Prostate Biopsy Guiding Inflammatory Disease
Volume TRUS: Measurement of Prostate Volumes Normal : 20 g (> 40 g : enlargement) Evaluation of lower urinary tract symptoms Diagnosis Procedure selection Response to treatment Interpretation of serum prostate specific antigen (PSA) levels Determination of PSA density
Method TRUS: Measurement of Prostate Volumes Digital rectal exam (DRE), cystourethrography urethrocystoscopy,, urethral pressure profile inaccurate TRUS, CT, MR more accurate Planimetry volume (PV) calculation Prolate ellipse volume (PEV) calculation Ellipsoid volume measurement technique
TRUS: Measurement of Prostate Volumes Prolate ellipse volume (Width x Height x Length) x 0.523 For three unequal axes Practical for routine clinical application Fast and relatively precise Universal availability H W L
Transrectal Ultrasonography (TRUS) of Prostate Anatomy of Prostate Measurement of Prostate Volume Benign Prostatic Hyperplasia Prostate Cancer Prostate Biopsy Guiding Inflammatory Disease
TRUS: Benign Prostatic Hyperplasia Periurethral & transitional zone Stromal nodule formation Continued growth Compressed peripheral gland Surgical capsule fibrous cleavage plane between two glands bladder-outflow obstruction Compression of urethra or occlusion of bladder neck
TRUS: Benign Prostatic Hyperplasia TRUS finding Diffuse or nodular enlargement of central gland In early, low echoic discrete nodular appearance Progression, nodules increase in size and number mixed variable echogenicity (hypo, iso, hyperechoic) Surgical capsule formation Calcification Increase in frequence with age Usually along the surgical capsule
TRUS: Benign Prostatic Hyperplasia TRUS finding Prostatic or periprostatic cysts Abnormality in digital rectal exam (DRE) Ddx.. from malignancy by TRUS Cancer mimic Contour bulging Peripheral zone Ingrowths to bladder neck (median lobe)
TRUS: Benign Prostatic Hyperplasia
Calcification along Surgical Capsule
BPH Nodule Growing into Bladder Neck
BPH nodule on peripheral zone
Transrectal Ultrasonography (TRUS) of Prostate Anatomy of Prostate Measurement of Prostate Volume Benign Prostatic Hyperplasia Prostate Cancer Prostate Biopsy Guiding Inflammatory Disease
TRUS: Prostate Cancer Prostate Cancer on TRUS Hypoechoic in peripheral zone: 60-70%, typical Overlap with benign lesions prostatitis,, atrophy, infarction positive predictive value (25-30%) Isoechoic : 25-40%, not detected Hyperechoic : 1-2% 1
TRUS: Prostate Cancer Isoecohic cancer
TRUS: Prostate Cancer Prostate cancer in transitional zone Very difficult to detect Underlying heterogeneity of BPH Cancer screening Using only TRUS, not appropriate method Combination with DRE, PSA
TRUS: Prostate Cancer Prostate Cancer Staging Detection of lesion Not accurate Extracapsular extension Sensitivity < 60% Contour bulging Focal area of periprostatic fat plane obliteration Thickening or asymmetricity of seminal vesicle
Extracapsular Extension of Prostate Cancer SV invasion
Benign Lesions mimicking Cancer
TRUS: Prostate Cancer Color/Power Doppler TRUS May improve detection of prostate cancer (10% more) Increased Doppler flow, associated Increased Gleason score Seminal vesicle invasion Higher rate of post-therapy therapy relapse Increased microvessel density, associated Presence of the cancer Metastases Stage of disease Disease specific survival Drawback Increased vascualrity in Inflammation Contrast-enhanced TRUS
Doppler US: Prostate Cancer
Transrectal Ultrasonography (TRUS) of Prostate Anatomy of Prostate Measurement of Prostate Volume Benign Prostatic Hyperplasia Prostate Cancer Prostate Biopsy Guiding Inflammatory Disease
TRUS guided Biopsy Advantage More accurate than DRE Distributed throughout prostate in standard geometric pattern Minimize risk of damage to midline structure and bladder Positioning along peripheral zone without damage to neurovascular bundle Detect more abnormality than DRE
TRUS guided Biopsy Indication Elevated prostate specific antigen (PSA) > 4.0 ng/ml : PPV 17 ~ 28% > 10 ng/ml : PPV 42 ~ 64% Age-adjusted PSA, PSA density, free PSA ratio, PSA velocity ( > 0.75 ng/ml/year) Abnormal Digital Rectal Examination (DRE) Abnormal TRUS findings Evaluation treatment result or recurrence
TRUS guided Biopsy Preparation Stop some medications Anticoagulation, aspirin, NSAID, herbal medication Cleansing enema Antiobiotic prophylaxis Complication Hematuria (23.6%), hematospermia (45.3%) Fever (5%), voiding difficulty(13%) Severe hemorrage or sepsis (<1%): life- threatening
TRUS guided Biopsy Local anesthesia The more number of biopsies the better chance of diagnosing prostate cancer the more pain induced Local anesthesia makes it possible to obtain many tissues with acceptable range of pain Nerve blockade before prostatic biopsy results in a more comfortable procedure for the patient Nash, P.A. J Urol 1996;155:607 Periprostatic infiltration of lidocaine,, injection into Denonviller s fascia, lidocaine gel infusion into rectum
TRUS guided Biopsy Strategy (I) Directed biopsy TRUS and/or DRE Sextant biopsy technique Hodge KK et al, J Uro 1989. Three core ( base, mid, apex) on both side Improve detection of prostate cancer than targeted biopsy Significant minority of cancers were not detected by sextant biopsy
TRUS guided Biopsy Strategy (II) Modified sextant biopsy Laterally directed sextant 8, 10, 12 biopsy cores, even more Optimal number and location Need extensive research Transitional zone biopsy Routine biopsy is controversy Recommended : >10ng/ml with previous negative biopsy
TRUS guided Biopsy
Transrectal Ultrasonography (TRUS) of Prostate Anatomy of Prostate Measurement of Prostate Volume Benign Prostatic Hyperplasia Prostate Cancer Prostate Biopsy Guiding Inflammatory Disease
TRUS: Inflammatory Disease Acute bacterial prostatitis/abscess Diagnosed clinically & treated without need for imaging Indication Unresponsive to Tx., abscess drainage Risk for sepsis E coli : usual infecting agent TRUS Generalized enlargement and more rounded symmetrical contour Decreased echogenicity Multifocal hypoechoic area Fluid-filled abscess cavity Extension of abscess to seminal vesicle & extracapsule
TRUS: Inflammatory Disease Chronic bacterial/nonbacterial prostatitis Symptomatic/asymmtomatic asymmtomatic Abnormal DRE, elevated PSA with fluctuation Granulomatous Prostatitis Malakoplakia TRUS finding Hypoechoic change of PZ (focal, multifocal,, diffuse) mimic cancer, need biopsy Increased vascularity Calcification Periprostatic venous engorgement Seminal vesicle abnormality dilatation, loculation, septal thickening
TRUS: Chronic Prostatitis
TRUS: Seminal Tracts Seminal vesicle (SV) Length : 3.6 7.6cm (TRUS : 1.9 4.1 cm) Width : 1.2 2.4 (TRUS: 0.4 1.4 cm) Mucoid,, alkaline secretion help activate spermatozoa 70% of male ejaculate vas deference Continuation of tail of epididymis Ampullary segment join with excretory duct of SV -> ejaculatory duct -> > open into the prostatic urethra on either side of verumontanum TRUS Symmetrically hypoechogenicity Fine internal echoes or septation by convolution
TRUS: Seminal Tracts Ejaculatory duct VD VD SV SV
TRUS: Seminal Tracts Congenital anomaly Agenesis Seminal vesicle cyst Combined renal anomaly Mid line cyst Utricular cyst, mullerian duct cyst, ejaculatory duct cyst May cause obtruction of ejaculatory duct
Mid Line Cyst
TRUS: Seminal Tracts Acquired disease Inflammation Neoplasms Adenocarcinoma,, sarcoma, seminoma, leiomyoma, Metastasis from malignancy of prostate, rectum, bladder Infertility & hematospermia evaluation Ejaculatory duct obstruction, anomaly Inflammation, stone, prostate cancer
Ejaculatory Duct Obstruction with Seminal Vesicle dilatation Ejaculatory duct
Acquired Disease Chronic inflammation Invasion of prostate cancer