Case Presentation: Mr. Mohammad Hossain - Urinary Frequency and Urgency

1. WELCOME

2. Case Presentation Group 7 Surgery Unit I Ward no 24 Presented by- FayzunNahar (86) RumanaSaireen(87) AnikaAnjumHaque(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 : 01676847914 Occupation : Retired school teacher Religion : Islam Marital status : Married Date & time of admission : 05.11.13 at 10.00am Date & time of examination : 05.11.13 at 7.30 pm Bed number : 13 Ward number : 24 ( surgery unit- I)

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. 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 • 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 • Appearance : Anxious • Body built :Average • Nutrition : Nourished • Co-operation : Co-operative • Decubitus : On choice • Anemia : Absent • Jaundice : Absent • Edema : Absent • Dehydration : Absent

9. Systemic examination Genitourinary system: 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. 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.SaborMulok 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. 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

17. Investigation For diagnosis: 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: • 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 • 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 CaFigure:Adenocarcinoma -Sarcoma of prostate 2.Secondary -From adjacent organ-Bladder, rectum

30. Risk factors 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,saturatedfat,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: 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

36. White More-Jewelt-system

38. GradingGleason grading system

40. Investigation For diagnosis: 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

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,seminalvesical,bladderneck,pelvic lymph node and reconstruction of bladder neck & urethra.