What goes wrong with the Prostate? Prof. Dr. H. Van Poppel Chair Urology KULeuven Adjunct Secretary General EAU Chair Sc. Comm. EUomo 19-9-2012 Brussels 25-09-2013 Leonardo da Vinci 1452-1519 Why no prostate? D.Schultheiss The Role of Testosterone Skin Hair growth, sebum production Brain Libido, Mood Liver Synthesis of serum proteins Muscle Increase in strength and volume Bone Accelerated linear growth, closure of epiphyses Male sexual organs Penile growth, spermatogenesis, prostate growth and function Kidney Stimulation of erythropoietin production Bone marrow Stimulation of stem cells Andreas Vesalius 1514-1564 First illustration of the prostate (1538) D.Schultheiss Normal Anatomy Bladder neck Ejacul. duct Prostate ducts PSA Prostate Specific Antigen Prostate specific ≠ tumor specific - inceased values: age related and prostate volume related - (role = liquefaction of the ejaculate) What goes wrong with the Prostate ? • Enlarges: Benign Prostate Enlargement • (Inflames: Prostatitis) • Develops cancer: Prostate Carcinoma Normal Anatomy Zonal Anatomy Benign Prostate Enlargement BPE • Nearly all men → in fact no ‘disease’ • Occurs in transition zone (TZ) → peripheral zone is compressed → urethra can be narrowed • Can remain asymptomatic, even in very large glands, or be pretty symptomatic in small ones BPE Symptoms : Poor stream Normal voiding Obstructive voiding Symptoms : Prostatism OAB Overactive Bladder Urgency-Frequency Diagnosis of BPE Digital Rectal Examination Transrectal Ultrasound PSA Flowmetry BPE TZ PZ Treatment of BPE Indications 1. Patient- Indication: Complaints 2. Doctor’s-Indication: Acute or chronic retention Infection Bladder stones Bleeding First Medical treatment, is highly effective Surgery if drugs not efficient Medical treatment of BPE = Highly effective and well tolerated 1. Phyto-therapy - good symptomatic relief 2. Alpha-blockers - bladder neck relaxation 3. 5α α reductase inhibitors - volume decrease 4. Combinations 5. PD-5 Inhibitors And,…when drugs fail? Surgical Treatment of BPE Trans-urethral resection = “TURP” What goes wrong with the Prostate ? • Enlarges: Benign Prostate Enlargement • (Inflames: Prostatitis) • Develops cancer: Prostate Carcinoma Natural History of PrCa Normal HG PIN Latent PrCa Localised PrCa Metastatic PrCa (Bone) Death Where does one develop PrCa? Urethra (Transition zone) Peripheral Zone 85% Incidence of PrCa PIN and Occult Carcinoma in younger male 10-19 y 20-29 y 30-39 y 40-49 y PIN 0% 9% 20% 44% Occult Ca 0% 0% 27% 34% Risk Factors of PrCa • Age (> 50 y) • Genetic (+ familial) factors • Race and geographic factors • Obesity • Nutrition PrCaProstaatkanker Mortality Animal Fat AUA Update Series, Lesson 38, Volume XVIII Tracy Bocchicchio, William R. Fair Prostate Cancer Mortality Switzerland Norwa Sweden y Denmark New Zealand Australia Netherlands Ireland Finland USA Austria England Germany Canada France Spain Israel Italy Mexico Greece Russia Japan 0 5 10 15 20 Mortality per 100,000 men 25 Prostate Cancer Symptoms • Early PrCa is asymptomatic ! • Presence of symptoms suggest – Locally advanced disease – Metastases : bone pain, spinal cord compression PrCa Diagnosis • • • • Digital Rectal Examination Transrectal Ultra-Sound Prostate Specific Antigen Prostate Puncture Biopsy • Microscopic Findings DRE TRUS PSA PPB = Pathology DRE TRUS TRUS Transition Zone? Cancer MRI Magnetic Resonance Imaging Stage T2a Stage T3a Today: Multiparametric MRI ….. PSA for Early Detection? PSA Screening • More tumors detected ! - risk of overtreatment • Stage migration ! • Mortality decrease … Rate/100.000 PrCa incidence and Mortality PSA www.cdc.gov/cancer/prostate Changes in Relative 5-Year Survival Rates 50 45 40 35 30 25 20 15 10 5 0 Bladder Melanoma Breast Lymphoma Colorectal Lung Pancreas Leukemia Ovary Prostate % Change W.Catalona Prostate Puncture Biopsy PPB Gleason Grade Gleason Score = Sum of the 2 most common Gleason Grades Gl.Score 3+3= 6 = good Gl.Score 10 = very bad Prostate Cancer Mortality Management Options ? • Active Surveillance : wait and eventually treat • Rad.Prostatectomy : open, laparoscopic or robot • Irradiation: - external ( EBRT, IMRT, IGRT…) - interstitial ( brachy - implant…) • Other : - Cryotherapie - HIFU ? Our Life on Earth A sexually transmitted condition with 100% mortality in a clever way !