Patok 2021 Flashcards
Best intravesical therapy for NMIBC
BCG
Most commonly used agents are BCG, mitomycin, and gemcitabine.
Other options include: sequential gemcitabine/docetaxel, epirubicin, valrubicin, docetaxel, or sequential gemcitabine/mitomycin.
If feasible, the dose of BCG may be split (1/3 or 1/2 dose) so that multiple patients may be treated with a single vial in the event of a shortage.
3-4 weeks after TURBT w/ or w/o maintenance; weekly instillations x 6 weeks
MAX 2 consecutive cycles
Withhold if traumatic catheterization, bacteriuria, persistent gross hematuria, persistent severe local symptoms, or systemic symptoms.
Immunotherapy agents for prostate CA
Sipuleucel-T: dendritic cell vaccine: adverse effects: chills, fever, fatigue, nausea, headache
Ipilimumab: Monoclonal antibody (CTLA-6): Fatigue, diarrhea, pruritus, rash, colitis, severe immune mediated adverse reactions
Tasquinimod: Novel small molecule inhibitor: GI disroders, fatigue, MSK pain
Prostvac-VF: Recomibinant viral vaccine targeting PSA; Injection site reactions, fatigue
Classification of ED
Campbell Table 69.4 PSYCHOGENIC Sudden onset Complete immediate loss Situational dysfunction Waking erections present
ORGANIC
Gradual onset
Incremental progression
Global dysfunction
Types of URINARY RETENTION
EAU 2021
Acute retention of urine is defined as a painful, palpable or percussible bladder, when the patient is
unable to pass any urine
Chronic retention of urine is defined as a non-painful bladder, which remains palpable or percussible after
the patient has passed urine. Such patients may be incontinent
Management of Post-RP incontinence
Urodynamics Imaging of urinary tract Urethrocystoscopy (if indicated) ⬇️ IF STRESS UI: - Due to sphincteric incompetence - If initial therapy fails: AUS, male sling
IF MIXED UI:
- Treat major component first
- If with coexisting BOO:
- Alpha-blockers
- Correct anatomic BOO
- Antimuscarinics/beta-3 agonists
IF URGENCY UI:
- Due to detrusor OA (during filling)
- if with coexisiting DU (during voiding)
- Intermittent catheterization
- Antimuscarinics/beta-3 agonists
Trauma: URETHRA
- Bulbar: most common affected by blunt - compressed against pubic symphysis
Iatrogenic anterior urethra: STC or IFC
Partial blunt anterior urethra: STC or IFC
Complete blunt anterior urethra: immediate urethroplasty (if surgical expertise available), otherwise suprapubic diversion with delayed urethroplasty
PFUI with hemodynamic instability: IFC or STC
PFUI male: early endoscopic realignment when feasible
DO NOT repeat endoscopic treatments after failed re-alignment for male PFUI
Partial posterior urethra: STC or IFC
DO NOT perform immediate urethroplasty (<48h) in male PFUIs
Male PFUIs with complete disruption, stable, short gap, soft perineum, lithotomy possible: Early urethroplasty (2-6 weeks)
Complete posterior urethral disruption: SP diversion and at wait at least 3 months before urethroplasty
Female PFUIs: Early repair (within 7 days) (NOT delayed repair or early realignment)
Anterior urethral injury: immediate repair
Penetrating stable patients
Penile fracture
with IFC or STC x 2-3 weeks then RUG
Anterior urethral trauma: STC or IFC
Iatrogenic
Blunt: partial or complete
Penetrating UNSTABLE
IFC or STC x
1-2 weeks for partial
3 weeks for complete
Then RUG
Male posterior urethral injury:
RUG/urethroscopy – PARTIAL injury
Early endoscopic realignment - STC if failed
If short flimsy non-obliterative stricture: DVIU
Otherwise: delayed urethroplasty (>3 months)
Male posterior urethral injury:
RUG/urethroscopy – COMPLETE injury + BLADDER NECK and/or PROSTATE injury
EARLY REPAIR
Male posterior urethral injury:
RUG/urethroscopy – COMPLETE injury, no bladder or prostate
Surgery for associated injuries – YES – early endoscopic realignment – if failed, STC
Assess 2days-6 weeks
IF short distraction defect, soft perineum, lithotomy possible – early urethroplasty
IF not: delayed urethroplasty (> 3 months)
IMMEDIATE INTRAVESICAL
• A single instillation of chemotherapy is administered within 24 hours of surgery (ideally within 6 hours).
• Gemcitabine (preferred) (category 1)1 and mitomycin (category 1)2 are the most commonly used agents in the United States for intravesical
chemotherapy. Thiotepa does not appear to be effective.3
• Immediate postoperative intravesical chemotherapy reduces the 5-year recurrence rate by approximately 35% and has a number needed to
treat to prevent a recurrence of 7. However, it does not reduce the risk of progression or the risk of cancer mortality.3
• It is not effective in patients with an elevated EORTC recurrence risk score (≥5). This includes patients with ≥8 tumors and those with
≥1 recurrence per year.
• Contraindications include: bladder perforation, known drug allergy
INDUCTION INTRAVESICAL
• Treatment option for NMIBC.
• The most commonly used agents are BCG, mitomycin, and gemcitabine.
• In the event of a BCG shortage, BCG should be prioritized for induction of high-risk patients (eg, high-grade T1 and CIS). Preferable
alternatives to BCG include mitomycin or gemcitabine.
Other options include: sequential gemcitabine/docetaxel, epirubicin, valrubicin, docetaxel, or sequential gemcitabine/mitomycin.
If feasible, the dose of BCG may be split (1/3 or 1/2 dose) so that multiple patients may be treated with a single vial in the event of a shortage.
• Initiated 3–4 weeks after TURBT with or without maintenance.
• Weekly instillations during induction are given for approximately 6 weeks.
• Maximum of 2 consecutive cycle inductions without complete response.
• Withhold if traumatic catheterization, bacteriuria, persistent gross hematuria, persistent severe local symptoms, or systemic symptoms.
MAINTENANCE INTRAVESICAL
• Although there is no standard regimen for maintenance BCG, many NCCN Member Institutions follow the SWOG regimen consisting of a 6-week induction course of BCG followed by maintenance with 3 weekly instillations at months 3, 6, 12, 18, 24, 30, and 36.4 • In the event of a BCG shortage, BCG should be prioritized for high-risk patients (eg, high-grade T1 and CIS), especially in the early maintenance period (ie, 3 and 6 months post-induction). If feasible, the dose of BCG may be split (1/3 or 1/2 dose) so that multiple patients may be treated with a single vial in the event of a shortage. • Ideally maintenance should be given for 1 year for intermediate-risk and 3 years for high-risk NMIBC. • BCG would be withheld if traumatic catheterization, bacteriuria, persistent gross hematuria, persistent severe local symptoms, or systemic symptoms. • Dose reduction is encouraged if there are substantial local symptoms during maintenance therapy. 4 • Data suggest the benefit of maintenance BCG therapy through a decreased rate of recurrence for NMIBC
CAH
- Low cortisol production caused by a metabolic enzymatic abnormality in the cholesterol-steroid biosynthesis pathway
- ACTH production by the pituitary gland is increased, resulting in hyperplasia of the adrenal cortex and overproduction of adrenal androgens
Deficiency of aldosterone in the salt-wasting form results in renal sodium losses (HYPONATREMIA), hypovolemia, and HYPERKALEMIA. Cortisol deficiency results in poor cardiac contractility with decreases in vascular tone
