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Posterior lobe prostatic hypertrophy
POSTERIOR LOBE PROSTATIC HYPERTROPHY RAN ABRAHAMY, M . D . HAROLD MITI'Y . M .D . LEONARD BIEL, M . D . From the Department of Urology, The Mount Sinai Hospital, New York, New York
ABSTRACT -A case of asyrnptonratic pelvic miss which was proved to be the . rst confirmed example of true posterior lobe prostatic hypertrophy is presented .
The genesis of benign prostatic hypertrophy is now accepted to originate from proliferation of the periurethral glands, 1-5 and perhaps more accurately termed periurethral adenoma. The following case report represents what we believe to be the first clinical description of true posterior lobe hypertrophy .
trigonal distortion by extrinsic pressure from a rectovesical mass . To clarify the nature of this soft tissue pelvic mass . a retrograde aortogram was performed . This demonstrated superior hemorrhoidal artery branches being stretched over the periphery of
Case Report A seventy-year-old white man was admitted for the w•o rkup of a large pelvic mass which was discovered during routine physical examination . Urologic symptomatology was minimal, consisting of nocturia (x 2) for the last year with mild decrease of the urinary stream . Physical examination disclosed a large suprapuhic mass persistent after urethral catheterization . Rectal examination revealed this mass to be located anteriorly, probably prostate . The base of the mass was beyond finger's reach . Results of complete blood count and blood chemistry were within normal limits . Excretory urogram demonstrated prompt bilateral function with normal upper tracts . The bladder base was not elevated on the cystogram phase of the urogram . Cystograms confirmed the presence of a soft tissue pelvic mass indenting the rectal gas shadow, displacing the bladder anteriorly, and extending superiorly (Fig . 1) . Postvoid residual urine was 10 cc . Cystoscopy revealed mild bladder trabeculation and
UROLOGY
,
MAY 1481
/ VOLUME XVII . NUMBER 5
FIGURE 1 . Lateral cystogram shows soft tissue mass indenting rectal gas shadow (small arrows), displacing bladder anteriorly, and extending superiorly (large arrow) .
473
FIGURE 2 . Flush aortograins show (A) branches of superior hemorrhoidal artery stretched around soft tissue mass (arrows) ; (B) late film shows he,norrhoidal artery branches stretched at periphery of soft tissue mass (arrows), and mass extends above opacfied bladder . Base of bladder not elevated .
an avascular soft tissue pelvic mass (Fig . 2) . The possibility that this mass was related to bowel was considered . Transperitoneal exploration revealed a mass below the pelvic peritoneal reflection located between the bladder and the rectum . After the peritoneum was incised in this area, the mass which was neither attached to the bladder nor to the rectum was enucleated by blunt dissection without entering the urethra and with minimal bleeding . The surgical specimen measured 11 by 11 by 6 cm . and weighed 500 Gin . (Fig . 3) . The Foley catheter which drained clear
FIGURE 3 . Gross specimen shows soft, wellencapsulated mass measuring 11 by 11 by 6 cm . Cut section shows tumor composed of tannish tissue with multiple various sized cysts with smooth lining and some areas of hemorrhage and necrosis .
174
urine was removed on the third postoperative day, and the patient was discharged on the eighth postoperative day . Pathologic report showed a large prostate with fibroadenomatous hypelplasia without evidence of malignancy (Fig . 4) . Comment The prostate is a compound tubuloalveolar gland which on cross section discloses two distinct glandular types : (1) the inner zone consisting of mucosal and submucosal glands, and (2) the outer zone or the prostatic glands proper .
FIGURE 4 . Microscopic examination shows prostate with fibroadenonunous hyperplasia without evidence of malignancy .
UROLOGY
/ MAY 1981
/
VOLUME XVII, NUMBER 5
\1cNeal' demonstrated the existence of three component glands : (1) central zone, (2) peripheral zone, and (3) periurethral organ or periurethral glands . The outer zone according to Franks'- or the central and peripheral zones according to McNeal undergoes progressive atrophy with aging . This external or prostatic glands proper, of which the posterior lobe (lying behind the plane defined by the ejaculatory ducts) is an integral part, is believed to he the development site of prostatic adenocarcinoma . The inner zone or periurethral glands is now accepted as the }listogenesis site of benign prostatic hvperplasia . :1- s In our case we have no anatomic or err hrvologic explanation for the presence of this 500-Gin . prostatic mass, showing fibroadenomatous hvperplasia without evidence of malignancy, unless it represents true prostatic hypertrophy (hypertrophy of the outer zone or prostatic glands proper) involving the posterior lobe alone without involvement of the middle or lateral lobes (inner zone) . In only one instance of 700 postmortem prostatic examinations performed by Moore' has a benign nodule been demonstrated in the posterior lobe . The possi-
UROLOGY
MAY 1981
/
VOLUME
x`yll . NUMBER
5
hility of this benign tuluor originating from the seminal vesicle was considered : however, the slides were reviewed bN- Mostoli, 7 who confirmed the histologic diagnosis . Alter review of the literature . the case reported herein appears to represent the first confirmed example of benign hvperplasia of the posterior lobe of the prostate . University Medical Center 7710 N W . 71st Ct . . Florida 33321 Tamara (DR . ABBAHAMY) References I . McNeal J : In . Goland N1 ',Ed) : Normal and Abnormal Growth of the Prostate, Spnigheld . Illinois, Charles C : Thomas, 1974 . 2 . Fmuks I .N1 : Benign nodular hvperplasia of the prostate, a review . Ann . 11 . Coll . Sun;. Engl . 14 : 92 ;19541 . 3 . LeDne JF: The auutomv of the prostate and the patholw4v of early benign hypertrophy. , J . Urol . 42 : 1217 :1939) . 4 . Deming C, and Neumann C : Early phases of prostatic hvperplasia, Surg- Gvnecol . Obstet . 68 : 155 ..1939) . 5 . Mostofi FK, and Thomson RV : Benigm hypeiplasia of the prosute gland, in Campbell MF (Ed) : Urology_ Philadelphia. W.B Sanders Co ., 1963, pp . 1101-1157 . 6 . Moore R4. Benign hypertrophy of the prostate, J . l rol . 50 : MO ;19431 . Vlostofi FK . Personal communication, December. 1778 .
47 5
ABSTRACT -A case of asyrnptonratic pelvic miss which was proved to be the . rst confirmed example of true posterior lobe prostatic hypertrophy is presented .
The genesis of benign prostatic hypertrophy is now accepted to originate from proliferation of the periurethral glands, 1-5 and perhaps more accurately termed periurethral adenoma. The following case report represents what we believe to be the first clinical description of true posterior lobe hypertrophy .
trigonal distortion by extrinsic pressure from a rectovesical mass . To clarify the nature of this soft tissue pelvic mass . a retrograde aortogram was performed . This demonstrated superior hemorrhoidal artery branches being stretched over the periphery of
Case Report A seventy-year-old white man was admitted for the w•o rkup of a large pelvic mass which was discovered during routine physical examination . Urologic symptomatology was minimal, consisting of nocturia (x 2) for the last year with mild decrease of the urinary stream . Physical examination disclosed a large suprapuhic mass persistent after urethral catheterization . Rectal examination revealed this mass to be located anteriorly, probably prostate . The base of the mass was beyond finger's reach . Results of complete blood count and blood chemistry were within normal limits . Excretory urogram demonstrated prompt bilateral function with normal upper tracts . The bladder base was not elevated on the cystogram phase of the urogram . Cystograms confirmed the presence of a soft tissue pelvic mass indenting the rectal gas shadow, displacing the bladder anteriorly, and extending superiorly (Fig . 1) . Postvoid residual urine was 10 cc . Cystoscopy revealed mild bladder trabeculation and
UROLOGY
,
MAY 1481
/ VOLUME XVII . NUMBER 5
FIGURE 1 . Lateral cystogram shows soft tissue mass indenting rectal gas shadow (small arrows), displacing bladder anteriorly, and extending superiorly (large arrow) .
473
FIGURE 2 . Flush aortograins show (A) branches of superior hemorrhoidal artery stretched around soft tissue mass (arrows) ; (B) late film shows he,norrhoidal artery branches stretched at periphery of soft tissue mass (arrows), and mass extends above opacfied bladder . Base of bladder not elevated .
an avascular soft tissue pelvic mass (Fig . 2) . The possibility that this mass was related to bowel was considered . Transperitoneal exploration revealed a mass below the pelvic peritoneal reflection located between the bladder and the rectum . After the peritoneum was incised in this area, the mass which was neither attached to the bladder nor to the rectum was enucleated by blunt dissection without entering the urethra and with minimal bleeding . The surgical specimen measured 11 by 11 by 6 cm . and weighed 500 Gin . (Fig . 3) . The Foley catheter which drained clear
FIGURE 3 . Gross specimen shows soft, wellencapsulated mass measuring 11 by 11 by 6 cm . Cut section shows tumor composed of tannish tissue with multiple various sized cysts with smooth lining and some areas of hemorrhage and necrosis .
174
urine was removed on the third postoperative day, and the patient was discharged on the eighth postoperative day . Pathologic report showed a large prostate with fibroadenomatous hypelplasia without evidence of malignancy (Fig . 4) . Comment The prostate is a compound tubuloalveolar gland which on cross section discloses two distinct glandular types : (1) the inner zone consisting of mucosal and submucosal glands, and (2) the outer zone or the prostatic glands proper .
FIGURE 4 . Microscopic examination shows prostate with fibroadenonunous hyperplasia without evidence of malignancy .
UROLOGY
/ MAY 1981
/
VOLUME XVII, NUMBER 5
\1cNeal' demonstrated the existence of three component glands : (1) central zone, (2) peripheral zone, and (3) periurethral organ or periurethral glands . The outer zone according to Franks'- or the central and peripheral zones according to McNeal undergoes progressive atrophy with aging . This external or prostatic glands proper, of which the posterior lobe (lying behind the plane defined by the ejaculatory ducts) is an integral part, is believed to he the development site of prostatic adenocarcinoma . The inner zone or periurethral glands is now accepted as the }listogenesis site of benign prostatic hvperplasia . :1- s In our case we have no anatomic or err hrvologic explanation for the presence of this 500-Gin . prostatic mass, showing fibroadenomatous hvperplasia without evidence of malignancy, unless it represents true prostatic hypertrophy (hypertrophy of the outer zone or prostatic glands proper) involving the posterior lobe alone without involvement of the middle or lateral lobes (inner zone) . In only one instance of 700 postmortem prostatic examinations performed by Moore' has a benign nodule been demonstrated in the posterior lobe . The possi-
UROLOGY
MAY 1981
/
VOLUME
x`yll . NUMBER
5
hility of this benign tuluor originating from the seminal vesicle was considered : however, the slides were reviewed bN- Mostoli, 7 who confirmed the histologic diagnosis . Alter review of the literature . the case reported herein appears to represent the first confirmed example of benign hvperplasia of the posterior lobe of the prostate . University Medical Center 7710 N W . 71st Ct . . Florida 33321 Tamara (DR . ABBAHAMY) References I . McNeal J : In . Goland N1 ',Ed) : Normal and Abnormal Growth of the Prostate, Spnigheld . Illinois, Charles C : Thomas, 1974 . 2 . Fmuks I .N1 : Benign nodular hvperplasia of the prostate, a review . Ann . 11 . Coll . Sun;. Engl . 14 : 92 ;19541 . 3 . LeDne JF: The auutomv of the prostate and the patholw4v of early benign hypertrophy. , J . Urol . 42 : 1217 :1939) . 4 . Deming C, and Neumann C : Early phases of prostatic hvperplasia, Surg- Gvnecol . Obstet . 68 : 155 ..1939) . 5 . Mostofi FK, and Thomson RV : Benigm hypeiplasia of the prosute gland, in Campbell MF (Ed) : Urology_ Philadelphia. W.B Sanders Co ., 1963, pp . 1101-1157 . 6 . Moore R4. Benign hypertrophy of the prostate, J . l rol . 50 : MO ;19431 . Vlostofi FK . Personal communication, December. 1778 .
47 5