Prostate Adenocarcinoma – 4

PHYSICAL EXAMINATION: Patient is a 46-year-old white male seen for annual physical exam and had an incidental PSA elevation of 4.0. All other systems were normal.

PROCEDURES:
Sextant biopsy of the prostate.
Radical prostatectomy: Excised prostate including capsule, pelvic lymph nodes, seminal vesicles, and small portion of bladder neck.

PATHOLOGY:
Prostate biopsy: Right lobe, negative. Left lobe, small focus of adenocarcinoma, Gleason’s 3 + 3 in approximately 5% of the tissue.
Radical prostatectomy: Negative lymph nodes. Prostate gland showing moderately differentiated infiltrating adenocarcinoma, Gleason 3 + 2 extending to the apex involving both lobes of the prostate, mainly right. Tumor overall involved less than 5% of the tissue. Surgical margin was reported and involved at the apex. The capsule and seminal vesicles were free.

DISCHARGE NOTE: Patient has made good post-op recovery other than mild urgency incontinence. His post-op PSA is 0.1 mg/ml.