Renal/urology Flashcards
What is the function of the urinary tract?
To collect urine produced continuously by the kidneys
To store collected urine safely
To expel urine when socially acceptable
What are the ureters?
25cm – 30cm
Retroperitoneal organs
Run over psoas muscle, cross the iliac vessels at the pelvic brim and insert into trigone of bladder
Urine produced by the kidney enters the renal pelvis and is transported via peristalsis down the ureter into the bladder
Reflux of urine is prevented by a valvular mechanism at the vesicoureteric junction
What is the nervous control of the Bladder and Sphincter?
- Parasympathetic Nerve (pelvic nerve) comes from roots S2-S4, uses acetylcholine neurotransmitter, mediates involuntary control.
- Sympathetic Nerves (hypogastric plexus) comes from roots T11 – L2, uses noradrenaline neurotransmitter, mediated involuntary control.
- Somatic Nerve (pudendal nerve) comes from roots S2-S4, sends info “viaOnuf’s nucleus”, uses acetylcholine neurotransmitter
- Afferent pelvic nerve (sensory nerve), sends signals from detrusor muscle
How are centres/nuclei in the brain involved with micturition?
Cortex: voluntary control
Pontine Micturition Centre/Periaqueductal Grey: Co-ordination of voiding
Sacral Micturition Centre: Micturition reflex
Onuf’s Nucleus: Guarding reflex
What is the storage phase in urophysiology?
Bladder fills continuously as urine is produced by kidney and is passed through the ureters into the bladder
Normal adult bladder capacity 400-500ml with first sensation at 100-200ml
As the volume in the bladder increases the pressure remains low due to “receptive relaxation” and detrusor muscle compliance
What is the filling phase in urophysiology?
At lower volumes the afferent pelvic nerve sends slow firing signals to the pons via the spinal cord Sympathetic nerve (hypogastric plexus) stimulation maintains detrusor muscle relaxation Somatic (Pudendal) nerve stimulation maintains urethral contraction
What happens during the voiding phase (aka Micturition reflex)?
Micturition reflex is an autonomic spinal reflex
Higher volumes stimulate the afferent pelvic nerve to send fast signals to the sacral micturition centre in the sacral spinal cord
Pelvic parasympathetic nerve is stimulated and the detrusor muscle contracts
Pudendal nerve is inhibited and the external sphincter relaxes
How does the bladder empty?
Coordinated detrusor contraction with external sphincter relaxation to expel urine from bladder
A positive feedback loop is generated until all urine is expelled
Detrusor relaxation and external sphincter contraction after complete emptying of bladder
What is the guarding reflex?
Voluntary control of micturition can occur in anatomically and functionally normal adults.
Afferent signals from the pelvic nerve are received by the pontine micturition centre/periaqueductal gray and transmitted to higher cortical centres.
If voiding is inappropriate the guarding reflex occurs.
Sympathetic (hypogastric) nerve stimulation results in detrusor relaxation.
Pudendal nerve stimulation results in contraction of the external urethral sphincter.
What muscular changes occur between storage and micturition?
STORAGE
Receptive Relaxation
Detrusor relaxation (sympathetic stimulation T11-L2)
External Urethral Sphincter contracted (pudendal stimulation S2-4)
MICTURITION
Voluntary control from cortex and pontine micturition centre
Detrusor contraction (parasympathetic stimulation S2-4)
External Urethral Sphincter relaxation (pudendal inhibition S2-4)
What is the normal function of the lower urinary tract?
Convert a continuous process of excretion (urine production) to an intermittent process of elimination.
Store urine insensibly
Void urine when convenient
What muscular systems are involved in the lower urinary tract?
- Detrusor muscle Relaxes during storage (compliant) Contracts during voiding - Distal sphincter mechanism Contracts during storage Relaxes during voiding
What is the neural control of the lower urinary tract?
- Parasympathetic (Cholinergic) S3-5 Drive detrusor contraction - Sympathetic (Noradrenergic) T10-L2 Sphincter/urethral contraction Inhibits detrusor contraction
What are Lower urinary tract symptoms (LUTS)?
STORAGE symptoms Frequency Nocturia Urgency Urgency Incontinence
VOIDING symptoms Hesitancy Straining Poor/intermittent stream Incomplete emptying Post micturition dribbling Haematuria Dysuria
What is BPH, BPE, BOO and LUTS?
BPH – benign prostatic hyperplasia (histological)
BPE – benign prostatic enlargement (DRE findings)
BOO – bladder outflow obstruction (urodynamic proven obstruction)
LUTS - Lower urinary tract symptoms, a constellation of symptoms, neither gender nor disease specific
What is benign prostatic hyperplasia?
Increase in epithelial and stromal cell numbers in the periurethral area of the prostate.
May be due to increase in cell number
Or due to decrease apoptosis
Or due to combination of the two
What are the two aspects that lead to benign prostatic obstruction?
Alpha1 adrenoceptor mediated prostatic smooth muscle contraction (dynamic). Smooth muscle accounts for 40% of the area density of the hyperplastic prostate
Volume effect of BPE (static)
What is the link between Androgens and BPH?
Androgens do not cause BPE, but are a requirement for BPH
Castration prior to puberty or genetic diseases that inhibit androgen action or production, men do not develop BPH
Androgen withdrawal leads to partial involution of established BPH
How take a history for LUTS?
What symptoms? storage, voiding or mixture Duration of symptoms Past medical history Past surgical history Drug history Allergies Symptom scoring e.g. IPSS Bother (often incorporated as part of symptom score) -establish symptoms that are most bothersome to the patient
What is the IPSS?
International Prostate Symptom Score (IPSS)
Used to assess severity of symptoms in benign prostatic hypertrophy
What examinations might you do for LUTS?
General examination i.e fitness for surgery Abdominal examination External genitalia Digital rectal examination (DRE) Focussed neurological examination Urinalysis
What investigations might you do for LUTS?
Renal biochemistry Imaging PSA? Flow rates and residual volume Frequency volume chart TRUSS – trans-rectal ultrasound scan (for size) Flexible cystoscopy (if infection, stones, haematuria or recent onset storage symptoms) Urodynamics
What are normal flow rates for men?
Men < 40 >= 21 ml/s
Men 40-60 >= 18 ml/s
Men > 60 >= 13 ml/s
Need to void at least 125mls of urine for representative flow
When might flow rates be reduced?
Flow rates can be reduced due to obstruction within the lower urinary tract
They can also be reduced due to detrusor underactivity (pump failure)
What is Post Void Residual (PVR)?
The amount of urine retained in the bladder after a voluntary void and functions as a diagnostic tool.
Typically performed using ultrasound, a bladder scanner, or with a urinary catheter.
100% normal men have PVR < 12 ml
Consider detrusor underactivity as cause of high PVR
How does the flow rate indicate obstruction?
Qmax >15ml/s - 24% obstructed
Qmax 10-15ml/s - 54% obstructed
Qmax <10ml/s - 88% obstructed
What are the complications of benign prostatic enlargement?
Symptom progression (17-40%) Infections (0.1-12%) Stones (0.3-3.4%) Haematuria Acute retention (1-2% per year) Chronic retention Interactive obstructive uropathy (<2.5%)
What is Acute retention of urine (AUR)?
Painful
Typically 600-1L residual urine
Normal U&E’s
Pain relieved by catheterisation
Precipitated retention – often does not recur
Spontaneous retention – 50% recur very early, 70% within a year
Treatment:
Alpha-blockers have a role in trial without catheterisation (TWOC)
Intermittent self-catheterisation
Bladder outflow surgery
What is chronic retention of urine?
More difficult to define
Incomplete bladder emptying
Increased risk of infections and stones
Can be low pressure with detrusor failure
Can be high pressure, with risk of interactive obstructive uropathy
What is Interactive obstructive uropathy?
A structural or functional hindrance of normal urine flow, sometimes leading to renal dysfunction.
Nocturnal enuresis should be warning sign
Residual volume can be up to 4L
Check U&Es and monitor daily if creatinine raised, check BP
Observe for a diuresis (excessive production of urine)
Long term options:
Transurethral resection of the prostate (TURP) or indwelling catheter
What is nocturnal enuresis?
Nocturnal enuresis is involuntary urination that happens at night while sleeping, after the age when a person should be able to control his or her bladder. (Involuntary urination that happens during the day is known as diurnal enuresis.)
What are the treatment aims for LUTS?
Improve urinary symptoms
Improve quality of life
Reduce complications of bladder outflow obstruction
When might you suggest watchful waiting for men with LUTS?
Suitable for men with mild symptoms
Over 5 years 25% progress, just under half remain static and 30% improve, 2% experience acute retention
Lifestyle changes may be useful
What’s the treatment for BPE?
Aimed at either reducing the prostatic smooth muscle tone or reducing size of the prostate
Alpha – adrenergic antagonists, (e.g. Alfuzasin XL, Tamsulosin), improves flow average 3ml/s
5-alpha-reductase inhibitors, (e.g. Finasteride, dutasteride) inhibit the conversion of testosterone to the more active, dihydrotestosterone, reduces size 20-30%
Combination therapy better than either singly
Anti-cholinergics for overactivity
When would a patient with LUTS need surgery?
RUSHES Retention UTI’s Stones Haematuria (that isn't responding to 5-ARI) Elevated creatinine due to BOO Symptom deterioration
What are the surgical treatment options for BPE?
Bladder neck incision Trans-urethral resection of prostate (TURP) Bipolar Greenlight laser Thullium laser Holmium enucleation Millins retro-pubic prostatectomy
What are the potential complications of TURP?
Immediate – Sepsis, haemorrhage, TUR syndrome
Early – Sepsis, haemorrhage and clot retention
Late - Retrograde ejaculation, erectile dysfunction, urethral stricture, bladder neck stenosis, urinary incontinence
Why are the symptoms of LUTS different between the genders?
Women have a very weak sphincter mechanism, especially after childbirth. Get stress incontinence more commonly, less problems with passing urine.
Men have quite tight sphincter mechanisms, more problems with passing urine.
What are the basic centres involved in neuro-urology?
- Cortex - in control of sensation and voluntary initiation
- PMC/PAG - involved in coordination and completion of voiding
- Spinal reflexes - involved in reflex bladder contraction (sacral micturition centre), guarding reflex (Onaf’s nucleus), receptive relaxation (sympathetic)
How is the lower urinary tract controlled by the nervous system?
During the storage phase the internal urethral sphincter remains tense and the detrusor muscle relaxed by sympathetic stimulation. During micturition, parasympathetic stimulation causes the detrusor muscle to contract and the internal urethral sphincter to relax. The external urethral sphincter (sphincter urethrae) is under somatic control and is consciously relaxed during micturition.
Central coordination from the pontine micturition centre
What happens in normal bladder function?
Storage (99%)
Sympathetic causes detrusor relaxation and sphincter contraction.
Bladder fullness increases, messages to the pons and higher centres to consider voiding.
Can be postponed until it is convenient.
Voiding (1%)
PMC co-ordinates voiding via parasympathetic, causes detrusor contraction and sphincter relaxation at the same time.
How are LUTS classified?
Storage - frequency, urgency, nocturia (waking up to urinate with the intention of going back to sleep), incontinence
Voiding - slow stream, splitting or spraying, intermittency (some flow, no flow), hesitancy (takes a while to get started), straining, terminal dribble
Post-micturition - post-micturition dribble, feeling of incomplete emptying
What are the parameters used in a bladder diary?
Parameters - frequency per day (2-8) and per night (0-1), volume per day (2L) and per night (900ml), nocturnal volume (20% young, 33% elderly), functional capacity (>400ml) and incontinence per day (0)
Normals in brackets.
What are the different types of incontinence?
Urgency incontinence - associated with an urgent desire to void which is difficult to defer
Stress incontinence - associated with increase in abdominal pressure due to coughing/straining
Mixed incontinence - combination of stress and urgency
Continuous incontinence - due to a fistula
Overflow incontinence - occurs in the presence of a full bladder
Social incontinence - occurs in those with dementia
What is an overactive bladder?
OAB is defined as urgency with frequency with or without nocturia when appearing in the absence of local pathology.
Can be wet or dry
Detrusor overactivity may be seen on urodynamics (measures bladder pressure)
How is an overactive bladder managed?
Behavioural therapy - frequency volume chart, caffeine, alcohol, bladder drill
Antimuscarinic agents - decrease parasympathetic activity by blocking M2/M3 receptors but have side-effects of a dry mouth
B3 agonist - increase sympathetic activity at B3 receptor in bladder
Botox - blocks neuromuscular junction for ACh release, side effects of incomplete bladder emptying (need to catheterise in 15%)
Sacral neuromodulation - insertion of electrode to S3 nerve root to modulate afferent signals from bladder (pacemaker battery tells it to relax)
Surgery - augmentation cystoplasty, involves major surgery
What causes stress incontinence in females?
Usually secondary to birth trauma
- denervation of the pelvic floor and urethral sphincter
- weakening of fascial support of bladder and urethra
Neurogenic
Congenital
How do you treat stress incontinence in females?
Pelvic floor physiotherapy
Can use Duloxetine to increase contraction of urinary sphincter (but does have side effects)
Surgery
What causes stress incontinence in males?
Neurogenic
Iatrogenic (prostatectomy)
How would you treat stress incontinence in males?
Treat with artificial urinary sphincter or male sling
What causes voiding problems and how would you treat them?
Obstructive - BPE, urethral stricture, prolapse/mass
If BPE - give alpha blockers with or without 5alpha reductase inhibitor. Another option is PDE5i with erectile dysfunction. If the above fails then use TURP.
Non-obstructive - detrusor underactivity
Long term catheterisation to empty - ISC/LTC/SPC
Sacral neuromodulation in trial phase-works in Fowlers syndrome
What are the features of a Spastic spinal cord injury (supra-conal lesion)?
If there is a lesion above the cauda equina, the brain is no longer connected to the lower body (upper motor neuron lesion). Bladder over-contracting. Loss of coordination and completion of voiding. Features: - Reflex bladder contractions - Detrusor sphincter dyssynergia - Poorly sustained bladder contraction - Potentially unsafe bladder
What are the features of a Flaccid Spinal cord injury (conus lesion, decentralised bladder)?
Lesion at the level of the cauda equina. Bladder never contracts. Features: - Areflexic bladder - Stress incontinence - Risk of poor compliance - Loss of Guarding reflex - Loss of Receptive relaxation
What is an unsafe bladder?
One that puts the kidneys at risk due to raised bladder pressure
Causes: prolonged detrusor contraction or loss of compliance
Result: problems with drainage of urine from the kidneys and ultimately hydronephrosis and renal failure
What is Autonomic Dysreflexia?
Occurs lesions above T6
Overstimulation of sympathetic nervous system below level of lesion in response to a noxious stimulus.
Symptoms: Headache, severe hypertension, flushing.
What are the aims for managing a neurogenic bladder?
Bladder safety
Continence/symptom control
Prevent autonomic dysreflexia
How to treat an unsafe bladder?
Harness reflexes to empty bladder into incontinence device (may not keep bladder safe)
OR
Suppress reflexes converting bladder to flacid type and then empty regularly
How to manage the bladder in a paraplegic?
Suprapubic catheter
Convene drainage
OR
Suppress reflexes or poorly compliant bladder converting bladder to safe type and then emptying regularly using ISC
What is convene drainage?
A sheath that allows for urine to be funnelled away from your body and stored in a discreet bag secured comfortably to your leg.
No indwelling catheter
Needs monitoring
Develop incomplete bladder emptying long term
What is a supra-pubic catheter?
An SPC is inserted a couple of inches below your navel, , directly into your bladder, just above your pubic bone. This allows urine to be drained without having a tube going through your genital area.
Inserted under anaesthetic
Risk of infections, stones and autonomic Dysreflexia if blocked
How would you treat Neurogenic stress incontinence in men and women?
Ensure that bladder is safe before treating
Men: artificial sphincter
Women: autologous sling, artificial sphincter, synthetic tapes (TVT/TOE) - not recommended by NICE
What bladder problems are frequently found in patients with MS?
Overactive bladder syndrome - urinary urgency and frequency, caused by neurogenic detrusor overactivity
Incomplete bladder emptying
What are the risk factors for prostate cancer?
Age - 100% of prostates at 80 years old
Family history - 2-3x increased risk if first degree relative is affected
Ethnicity - 50% more PC in afro-carribean patients
Genetic - more common in younger patients
What are the different areas that prostate cancer can occur?
Majority is adenocarcinoma Site: Peripheral zone (70%) Transitional zone (20%) Central zone (10% Cases in the transitional and central zone are difficult to palpate in a digital rectal exam.
How are prostate cancers graded?
Gleason grading system used. Correlation between Gleason grade and biological behaviour of the tumour.
Gleason established five grades of glandular morphology. The two most prominent glandular patterns are graded from 1 to 5. The sum of these two grades will range from 2-10, with 2 representing the most differentiated, and 10 the most undifferentiated.
Take 2 most common patterns in the biopsy, added together and then calculate the gleason score.
Where can the prostate cancer spread to?
Lymphatics - to the external iliac )obturator group), internal iliac and presacral node. Occasionally , the supraclavicular nodes are involved via the thoracic duct.
Blood vessels
Directly into the bladder, seminal vesicles
Lung, thyroid, kidney, breast and prostate most commonly metastasise to the bone.
How might you stage a prostate cancer using TNM?
T1 Clinically inapparent tumour neither palpable or visible by staging
T2 Tumour confined within the prostate
T3 Tumour extends through the prostate capsule
T4 Tumour is fixed or has invaded adjacent structures
N1 Metastasis in regional lymph nodes
M1 Distant metastasis - can split into categories depending on where it has spread
How might prostate cancer present?
Weight loss
Fatigue
Loss of appetite
Night sweats
Difficulty urinating - hestinancy, slow stream, post-micturition dribble
Bone pain
Neurological deficits from spinal cord compression
Lower extremity pain and oedema
Uremic symptoms can occur from ureteric obstruction
What would you expect in an examination for potential prostate exam?
DRE: a nodule, asymmetry, difference in texture and bogginess
Neurologic examination, including determination of external anal sphincter tone, should be performed to help detect possible spinal cord compression.
Overdistended bladder due to outlet obstruction
Bony tenderness
What is the PSA test?
PSA
A glycoprotein produced only by prostate cells. Thus it is specific to the prostate but not to prostate cancer.
Can be used as a screening test - high sensitivity, but low specificity
Normal level less than 3ng/ml. Elevated level suggesting prostate cancer.
What are the investigations you can use to assess whether it is prostate cancer or not?
- PSA test
- MRI Prostate: Most centres perform this prior to a biopsy to identify lesions to target with biopsy. Also aids in local staging.
- Prostate biopsy: Indications - a palpably suspicious DRE regardless of PSA level, PSA >3.0ng/mL, suspicious lesion on MRI, TRUE or transperineal
- Staging imaging: Use in higher risk patients based on PSA, clinical stage and Gleason grade
- To look for evidence of nodes or metastatic disease use a bone scan orCT abdomen
What are the treatment options for prostate cancer?
Treatment depends on grade, stage, patient comorbidities, life expectancy and preference.
- Active surveillance: aims to minimize treatment related toxicity without compromising survival, Can only use in low risk patients.Curative treatment prompted by rising PSA.
- Radical prostatectomy: used in fit patients with localised cancer. Complication include urinary incontinence and impotence.
- Radiotherapy: used in localized and locally advanced cancer. Can cause impotence and urinary problems.
What are the treatment options for metastatic prostate cancer?
Hormone therapy Chemotherapy Bisphosphonates Radiotherapy for bone pain TURP to relieve symptoms of bladder outflow obstruction Nephrostomies for ureteric obstruction
How can hormone therapy be used to treat prostate cancer?
Used in locally advanced or metastatic disease
Prostate cancer is androgen sensitive
May take the form of:
- Orchiectomy: a surgical procedure to remove both testicles, the main source of testerone
- LH-releasing hormone agonist e.g. leuprolide, goserelin, buserelin
- Antiandrogens block the action of testosterone e.g. flutamide, bicalutamide
Important to counsel patients on side effects - impotence, depression, hot flushes, lethargy etc
Hormone resistance can occur quickly or after a few years.
What is the prognosis of prostate cancer?
Localized prostate cancer - excellent prognosis with 70-90% 10 year disease-specific survival figures
Locally advanced, non-metastatic disease - median survival of 7 year
Metastatic disease - median survival of 2-3 years
Once the state of hormone-resistant disease has been reached, the median survival is 6-12 months
What are the risk factors for renal cancer?
Smoking - 2 fold increased risk
Environmental - petroleum, phenacetin, cadmium
Occupational - leather tanners, shoe workers, asbestos
Hormonal - obesity, diethylstilbestrol
Genetic - VHL, BHD etc
How might renal cancer present?
Classic triad - mass haematuria and pain (<10%)
Incidental (>50%)
Haematuria
Symptoms of metastatic disease
Paraneoplastic syndrome symptoms - PTH, erythropoietin, prolactin
Varicocele rare but do worry if it’s on the right side
How are renal cancers classified?
Bosniak classification
I - Benign simple cyst with thin wall without septa, calcifications, or solid component
II - Benign cyst with a few thin septa, which may contain fine calcifications or a small segment of mildly thickened calcification.
IIF - Renal cysts with multiple thin septa, a septum thicker than hairline, slightly thick wall, or with calcification, which may be thick
III - Indeterminate cystic masses with thickened irregular septa with enhancement.
IV - Malignant cystic masses with all the characteristics of category III lesions but also with enhancing soft tissue components.
Where might renal cancer spread?
Local Nodal Renal vein Lungs Bone Brain Pancreas Liver Skin
What are some of the genetic causes of renal cancer?
Von Hippel Lindau (VHL) - VHL mutation
Tuberous sclerosis - TSC 1/2 mutation
Birt Hogg Dube (BHD) - BHD mutation
Hereditary papillary RCC - C-MET mutation
What are the treatment options for renal cancer?
Surveillance (good for eldery patients with polypharmacy and comorbidities) Radical nephrectomy (remove the entire kidney) Partial nephrectomy Radiofrequency ablation Cryotherapy Tyrosine kinase inhibitors Cytoreductive nephrectomy Palliative care
What are the risk factors for bladder cancer?
Smoking - 40% reduced risk after 4 year if stopped
4-aminobiphenyl broken down by N-acetyltransferase 2-polymorphic
Occupation (aromatic amines, aniline dyes and aldehydes) - tanner, rubber industry, painter, autoworker, dye worker, hairdresser, dry cleaner
Phenacetin (similar chemical structure to aniline dye)
Chronic cystitis/infection - linked with squamous cancer
LT catheter - around 10% in 10 years
Chronic HPV in immunocompromised
Pelvic irradiation - around 2-4 fold increased risk
Cyclophosphamide - due to acrolein (metabolite)
How might bladder cancer present?
Painless haematuria (no insult) Irritative LUTS but not so specific when without haematuria Flank pain, lower limb oedema, pelvic mass, weight loss and bone pain are uncommon but do worry if there is presentation.
What type of cancer is bladder cancer and what does it look like under a microscope?
Transitional cell carcinoma
Microscopy - increased number of epithelial cell layers, abnormal
What are the risk categories for bladder cancer?
Low risk - single solitary tumour that is superficial
High risk - high grade, intermediate, and invasive and non-invasive
What are the investigations for potential bladder cancer?
CT
Cystoscopy (flexible under LA usually)
What are the treatment options for bladder cancer?
TURBT +/- 2nd TURBT
Intravesical chemotherapy (MMC) - inhibits DNA synthesis
Intravesical immunotherapy (BCG) - immune stimulant, upregulates cytokines
Cystectomy
Radiotherapy - high risk bladder cancer who can’t have cystectomy
Chemotherapy - cisplatin
Combination of the above
Palliative care
What are the risk factors for testicular cancer?
Previous TC (12 times)
Cryptorchidism
Intratubular germ cell neoplasia/testicular intraepithelial neoplasia (TIN)
Risk factors of TIN
HIV
Genetic - first degree relative (9 fold increased risk)
Maternal oestrogen exposure
What is the pathology of testicular cancer?
Most are germ cell tumours, divided into seminomatous and nonseminomatous
Bilateral TC are rare
Usually spread locally first into the epididymis, spermatic cord and rarely scrotal wall
How might testicular cancer present?
Scrotal lump - painless
Delayed presentation is not uncommon
Scrotal pain - intratumoral haemorrhage
What are the differential diagnosis for testicular cancer?
Hydrocele Epididymal cyst Indirect inguinal hernia Varicocele Testicular torsion Acute epididymo-orchitis
How would you investigate potential testicular cancer?
Ultrasound testes - very high sensitivity
CT CAP for staging
CT brain/spine if clinically indicated
Tumour markers - AFP, LDH, hC
What are the treatment options for testicular cancer?
Radical inguinal orchiectomy - most definitive and diagnostic - curactive in approx 75%
Sperm banking in those without a normal contralateral testis
Biopsy of contralateral testis in those with risk factors for testicular intraepithelial neoplasia.
Others: Retroperitoneal Lymph Node Dissection (RLND), radiotherapy and chemotherapy in certain specific settings e.g. metastatic and residual tumour
What is Testicular intraepithelial neoplasia?
The uniform precursor of testicular germ cell tumors. … The most common clinical situation is the case of contralateral TIN in the presence of unilateral testicular cancer.
What are the tumour markers for testicular cancer?
AFP - trophoblastic elements, suggestive of non-seminomatous tumour
HCG - syncytiotrophoblast elements
LDH - cellular enzymes so not overly specific but useful in follow up setting
Marks measured at presentation - good for follow up
Should be measured again at 1-2 weeks post radical inguinal orchiectomy and during follow up
What is Glomerulonephritis?
a group of diseases that injure the part of the kidney that filters blood (called glomeruli). Other terms you may hear used are nephritis and nephrotic syndrome. If the illness continues, the kidneys may stop working completely, resulting in kidney failure.
