HISTORY:

A 69 yo gentleman with a past medical history of coronary artery disease, aortic insufficiency, hyperlipidemia, gout and melanoma who presented with enlarged prostate, elevated PSA of 8.6 and lower urinary tract symptoms of weak stream and mild nocturia.

Patient had been followed by urologists for his prostate enlargement since 2011 when he had negative prostate biopsies. His PSA was trended and followed carefully with repeatedly negative prostate biopsies.

PSA History (ng/mL)

• 10/03/17 - PSA 8.60, TRUS biopsy negative for prostate cancer, other positive pathologic diagnosis is identified
• 12/27/16 - PSA 12.9
• 06/02/15 - PSA 15.1
• 11/13/13 - PSA 7.13 TRUS biopsy negative

Due to elevated PSA of 8.6, MRI prostate was obtained 10/03/17 which showed a large prostate (130mL) with two PI-RADS 4 lesions on the right and left transitional zones and a substantial periurethral mass of 7-8 cm.

Sagittal T2 weighted MRI showed non uniform periurethral mass between the posterior vesicle and compressing rectosigmoid junction. Overall, well circumscribed 7 cm mass with possible bladder invasion.

After review of the pelvic MRI and concern for periurethral mass and enlarged prostate, a cystoscopy was performed, MRI guided TRUS prostate biopsies and periurethral mass biopsy was also indicated.

Cystourethroscopy showed no urethral stenosis or stones, prostatic enlargement of bilateral lobes and median lobe. No lesions or neoplasms were identified within the bladder.

GROSS:

Three irregular, pale tan to purple-tan soft tissue fragments measuring 1.2 x 0.5 x 0.4 cm, 2.1 x 1.0 x 0.9 cm, and 2.3 x 2.2 x 0.6 cm. The smaller tissues were somewhat ragged and partially disrupted. The larger tissue was sectioned to reveal tan-white, homogeneous, semi-translucent cut surfaces. There is no gross evidence of necrosis or calcification, and there is some focal hemorrhage.