Surgery Of The Prostate Flashcards
What breeds are predisposed to BPH? (5)
Doberman Pinschers, Bernese Mountain Dogs, German Pointers, Bouvier des Flanders and Scottish Terriers.
What % of dogs (ME) will experience prostatic enlargement by age of 9?
95%
Why is dysuria rare with BPH?
compression of the urethra is rare in this condition
As prostate enlarges; which way does it expand in dogs?
Outwards
What clinical signs are seen with BPH? (6)
no clinical signs,
Dyschezia
Tenesmus
Compressed ribbon like faeces
Haematuria
Urethral bleeding
What is identified on rectal palp with BPH?
symmetrical, non-painful prostatic enlargement being identified.
How is prostate enlargement described on radiographs?
Anything greater than 70% the distance between the pubis and sacral promontory on lateral radiographs
What structures may displace and how on xrays with an enlarged prostate? (2)
Cranial displaced bladder
Dorsal displace/compress of colon
What can be calculated with evaluate if a prostate is enlarged on U/S?
maximum predicted volume
How does BPH appear on U/S?
diffuse symmetrical enlargement, with multiple small parenchymal cysts
How to calculate maximum predicated volume?
(0.867 x body weight) + (1.885 x age) + 15.88
What diagnostic can be performed to differentiate benign vs malignant prostate disease?
FNA (via U/S)
What is the cytology of BPH?
Sheets of uniform, mature, well-differentiated prostatic epithelial cells arranged in a honeycomb pattern.
How should we treat BPH if no clinical signs?
No treatment needed
How can we monitor BPH progression?
Serial U/S measurements
If an animal is clinically effected by BPH , what is the most effective treatment and how long will this take?
Surgical castration which will result in a rapid (1-3 months) and permanent involution of the hypertrophied tissue.
Options for medical management of BPH? (3)
- Delmadinone acetate
- Finasteride
- Deslorelin acetate
How does Deslorelin acetate work medically for BPH?
- what % reduction is seen?
- Drawback?
Potent GnRH agonist
- 60%.
- readministered every 6-12 months.
How does Finasteride work for medical management of BPH?
Enzyme inhibitor that decreases the metabolism of testosterone into a more potent metabolite.
How does Delmadinone acetate work for medical management of BPH?
Progestogen that reduces the production of testosterone through interstitial cell suppression.
What surgery is a procedure that could be used in valuable breeding animals with clinical BPH?
Subtotal prostatectomy
How much prostatic parenchyma can be removed whilst maintaining urinary continence?
85%
What are the 2 potential sequelae to BPH?
2ry bacterial infection
Perineal herniation
2 techniques for subtotal prostatectomy?
- Capsulectomy
- Intercapsular
What are the 2 types of prostatic cysts? Define
Prostatic - develop either in or communicate with the parenchyma
Paraprostatic - developing adjacent to the prostate
What are the clinical signs of prostatic cysts associated with?
Comression of rectum, urethra or bladder
IF clinical signs are present, what might they be if prostatic cysts present? (7)
- Dysuria
- Incontinence
- Haematuria
- Azotemia (2ry to obstruct)
- Dyschezia
- Tenesmus
- Faecal ribboning
Why is a rectal palp not always useful for prostatic cysts?
Per rectum exam is often less useful than in BPH because the prostate may be displaced cranially and in cysts that are pelvic, anatomical landmarks can be difficult to identify.
How can perineal rupture occur with prostatic cyst?
chronic increased pressure on the pelvic diaphragm,
What MAY be palp on abdo palp with prostatic cysts? (2)
- Abdomen distension
- Abdo mass
What may xray identify with prostatic cyst?
a soft tissue opacity in the caudal abdomen or pelvis with mineralised regions present in some cases.
How can you differentiate between prostatic cyst and bladder on xrays?
Contrast studies (cystourethrogram)
What does cytology of prostatic cysts show?
occasional inflammatory and epithelial cells.
How can you differentiate between urine and cystic fluid?
fluid:serum creatinine ratio
Why is surgery recommended for the treatment of prostatic cysts?
As they are predisposed to abscess
How are prostate cysts surgically treated? (3)
- Complete resection
- Omentalisation
- Marsupilisation with concurrent medical/surgical castration
What patient position for prostate resection?
Dorsal recumbency
What must be placed prior to prostate resection?
Urinary catheter
What should be taken upon identifying prostate during resection?
FNA or biopsy
What must be placed when isolating prostate cyst during resection?
Sterile, moistened gauze laparotomy swabs should be used to isolate the cyst from the abdomen before it is incised with a stab incision.
How to complete prostatic excision if there are other vital structures identified?
prostatic urethra and bladder neck are identified, and the cyst capsule is partially excised. Omentum can then be drawn into the cyst remnants and secured with a mattress suture.
How is marsupialisation performed for prostatic cyst?
cysts wall or capsule is incised and then sutured to an incision through the fascia of the external rectus in the ventrolateral abdominal muscle creating a continuation with cavity of the cyst.
What may marsupilisation lead to over time for treatment of prostate cyst?
permanent fistula and can predispose to infection
What is the signalment for prostatitis?
middle aged and older, entire dogs
What is the most common bacteria associated with prostatitis?
E.Coli
What may indicate prostatitis based on clinical history?
Recurrent non responsive UTI
How can prostatitis –> septic peritonitis?
multiple sites of infection and microabscessation are present which then coalesce to form discrete larger abscesses which can rupture contaminating the peritoneal cavity (leading to septic peritonitis) or retroperitoneal space
Clinical signs of prostatitis/abscess? (7)
Pain urination, pain defecate, dyschezia, tenesmus, pyrexia, pelvic limb stiffness/lameness and sometimes a purulent penile discharge
What is found on rectal palp with prostatitis?
painful and rectal palpation will often be resented along with findings of lumbar or caudal abdominal pain.
What is found on xray/ultrasounf with prostatitis?
prostatomegaly with mineralisation occasionally seen. The appearance on ultrasound is of a multi-lobulated prostate with flocculent material bordered by irregularly defined capsular tissue.
Prostatitis:
A) what may yield on wash?
B) What is seen on urinalysis?
A) High numbers of neutrohpils
B) Haematuria and pyuria
Haematology findings of prostatitis?
Neutophilic leukocytosis with left shift
What antibiotic type are good for prostatits?
Highly lipid soluble antibiotics are good choices such as fluroquinolones and trimethoprim sulphonamides
Various techniques have been described for provision of drainage and resolution in prostatic abscesses. Name (5)
Ventral drainage
Omentalisation
Marsupialisation
Subtotal and total prostatectomy
Placement of percutaneous drains.
Why should the dorsal aspect of the prostate be avoided in surgery?
To minimise damage to the hypogastric and pelvic nerves as well as the vascular supply.
Which aspect of the prostate are incised with suction to remove purulent contents?
Lateral aspects
How to flush prostatic abscess cavities?
Warm sterile saline
How are abscess cavities explored and adhesions/loculations broken down?
Digitally
True or false
Prostatic abscesses are not painful.
False
True or false:
Acute bacterial prostatitis and prostatic abscesses can be life threatening.
True
True or false:
Abscess capsules can rupture secondary to aspiration leading to contamination and peritonitis.
True
How common is prostatic neoplasia in dogs?
Uncommon
How common is prostatic neoplasia in cats?
Rare
What is the most common prostatic tumour?
carcinomas such as adenocarcinoma, transitional cell carcinoma, squamous cell carcinoma and undifferentiated carcinoma
How many prostatic nesoplasms have metastasised at the point of diagnosis?
70-80%
Other than carcinomas; what other prostate neoplasia is seen?
smooth muscle (leiomyosarcoma) and vascular tissue (hemangiosarcoma) as well as fibrosarcoma and osteosarcoma
Prostate neoplasia rectal palp
A prostatic mass may be palpable on examination as may enlarged sublumbar lymph nodes. Whilst it is not always enlarged, the prostate can be asymmetrical, firm, painful and/or nodular.
What is seen on xrays/ultrasound with prostate neoplasia?
prostatomegaly with mineralisation, lymphadomegaly and ostyeolytic or proliferative lesions in the vertebra or pelvis. Thoracic radiographs or CT should be evaluated for signs of metastasis.
What can be useful for assessing urethral invasion or compression, particularly as most tumours will involve the urethra or bladder trigone?
Urethrocystography
What may cytology show in prostate neoplasia?
abnormal epithelial cells with large prominent multiple nuclei. Prostatic washes can be used to harvest cytological samples, but they are less reliable.
What is the main complication of prostatectomy when trigone is involved?
Incontinence
When is surgery appropriate in prostate neoplasia?
transitional cell carcinoma involved the prostate gland only and not the trigone
Steps for prostatectomy
- The prostate is isolated and Penrose drains are placed proximally and distally. The urethra is catheterised, and a stay suture is placed at the apex of the bladder.
- The prostate is removed by incising the urethra proximal and distal to it. The urethral catheter is used as a guide.
- Final anastomosis.
What medical treatment may improve survival times in prostate neoplasia?
Cyclooxygenase inhibitors (piroxicam/carprofen)
What is often one of the most debilitating sequelae to prostatic neoplasia?
Dysuria
What has been described to treat 2ry dysuria in prostate neoplasia? (2)
Tube cystostomy and urethral stenting
What is the drawback of tube cystotomy in prostate neoplasia? (2)
UTI
Neoplasia seeding
Drawbacks of urethral stenting in prostate neoplasia? (2)
Cost (specialist equipment too)
Incontinence
