Surgical Aspects of urological cancer

Question 1

RF of renal cell cancer

Answer 1

• renal failure and dialysis
• men>women
• smoking
• hypertension
• obesity

Question 2

Genetic factors of renal cell cancer

Answer 2

• VHL syndrome (von Hippel Lindau, 50% develop RCC)

Question 3

5 histological subtypes of renal tumours

Answer 3

• clear cell carcinoma (VHL mutation)
• papillary type 1 and 2
• chromophobe
• collecting duct (rare)
• medullary cell (rare)

Question 4

Clinical Presentation of renal cell cancer

Answer 4

• 50% asymptomatic
• CLASSIC TRIAD = macroscopic haematuria, palpable mass, flank pain <10%
• haematuria
• flank pain
• mass
• signs of metastases = bone pain, anorexia, pyrexia of unknown origin
• acute varicocele
• lower limb oedema
• paraneoplastic syndromes

Question 5

Investigations for renal cell cancer

Answer 5

• US
• CT of abdomen with contrast
• CT chest
• bone scan
• US renal tract
• Bloods = FBC, U&E, calcium, LFT

Question 6

Management of renal cell cancer

Answer 6

LOCALISED
- radical or partial nephrectomy (open or laparoscopic)
LOCALLY ADVANCED
- radial nephrectomy & adjuvant treatment
METASTATIC
- immunotherapy

Question 7

Prognosis of renal cell cancer

Answer 7

depends on staging

• T1 organ confined = 70-94%
• T2 organ confined = 65-75%
• T3 locally advanced = 40-70%
• N1 = 40-70%
• locally advanced T4, N2 or M1 = 10-40%

Question 8

Bladder cancer RF

Answer 8

• men>women
• age
• smoking
• occupation (rubber, paint, dye manufacture)
• chronic inflammation of bladder mucosa
• schistosomiasis (squamous cell carcinoma)

Question 9

Malignant bladder tumours

Answer 9

• transitional cell carcinoma (90%)
• squamous cell carcinoma (1-7%)
• adenocarcinoma (2%)

Question 10

Clinical Presentation of bladder cancer

Answer 10

• painless macroscopic haematuria
• microscopic haematuria
• LUTS
• Recurrent UTIs
• Pain
• lower limb swelling

Question 11

Investigations for haematuria

Answer 11

Need to investigate persistent microscopic haematuria (2/3 dipstick) or macroscopic haematuria

• IV urogram
• renal function, urine microscopy and culture
• glomerulonephritis screen?
• US renal tract
• flexible cystoscopy
• urine cytology
• CT urogram

Question 12

Types of bladder cancer

Answer 12

• papillary (70%)
• mixed papillary and solid (10%)
• solid (10%)
• carcinoma in sit (10%)

Question 13

Staging of bladder cancer

Answer 13

• CXR
• bone scan
• CT/MRI of pelvis
• TURBT (histology following transurethral resection of bladder tumour)

Question 14

Management of bladder cancer

Answer 14

• initial TURBT (70% curative)

- adjuvant treatment (MMC = intravesical mitomycin C, intravesical BCG)

Question 15

Intravesical BCG

Answer 15

• bladder cancer
• adjuvant treatment
• stimulates immune system in bladder wall to attack cancer cells

Question 16

MMC

Answer 16

• intravesical mitomycin C
• reduces recurrent rate
• prevents implantation
• cytotoxic and regress small tumours

Question 17

Muscle Invasive TCC

Answer 17

• radical cystectomy + urinary diversion
• radical external beam radiotherapy
• metastatic disease = chemo, radiotherapy

Question 18

Prostate cancer RF

Answer 18

• high fat diets
• smoking
• most commonly diagnosed male cancer

Question 19

Types of prostate cancer

Answer 19

• adenocarcinoma 95%(peripheral zone>, also can be in transitional or central)
• prostatic sarcoma (rare)

Question 20

Presentation of prostate cancer

Answer 20

• majority asymptomatic (PSA testing)
• LUTS
• haematospermia/haematuria
• perineal discomfort
• lower limb swelling
• anorexia and weight loss
• bone pain/pathological fractures

Question 21

PSA

Answer 21

• glycoprotein enzyme produced by prostatic epithelial cells
• function unclear
• normal range varies with age <4ng/ml normally

Question 22

Increased PSA causes

Answer 22

• BPH
• prostatitis
• DRE
• urethral catheterisation
• UTI
• prostatic biopsy

Question 23

Investigations for prostate cancer

Answer 23

• transrectal US guided biopsy

- gleason score

Question 24

Gleason Score

Answer 24

• grade 1-5 according to gland forming differentiation
• most multi focal and heterogenous
• well diff = 2-4
• mod diff = 5-7
• poorly diff = 8-10

Question 25

Management of localised prostate cancer

Answer 25

• radical prostatectomy = open, laparoscopic, robot-assisted laparoscopic
• radical external beam radiotherapy
• brachytherapy (implanting radioactive seeds into prostate)
• cryotherapy

Question 26

Management of advanced prostate cancer

Answer 26

Androgen deprivation therapy

• surgical castration (bilateral orchidectomy)
• medical castration (LH-RH agonist -> goserelin)
• anti-androgen monotherapy

Question 27

Testicular Cancer RF

Answer 27

• Caucasian >
• un-descended testes
• HIV infection
• 1st degree relative

Question 28

Types of testicular cancer

Answer 28

• germ cell tumours (seminoma, non-seminoma)
• non germ cell tumours (sex cord stromal tumours -> Leydig, Sertoli)
• lymphoma
• adenomatoid

Question 29

Presentation of testicular cancer

Answer 29

• painless scrotal lump
• acute scrotal pain (intra-tumoural haemorrhage)
• metastases = weight loss, lymphadenopathy, bone pain

Question 30

Investigations for testicular cancer

Answer 30

• US (hypoechoic region distorting normal architecture, microlithiasis)
• CT abdomen and chest (staging)
• serum tumour markers (AFP, B-HCG, LDH)

Question 31

Staging of testicular cancer

Answer 31

TNM

• tumour stage Tx-T4
• nodes Nx-N3
• metastasis Mx-M1

Question 32

Management of NSGST

Answer 32

Non metastatic disease

• surveillance
• adjuvant chemotherapy if RF relapse (T2-T4, lymphatic or vascular invasion)

Metastatic disease
- chemo (bleomycin, etoposide, cisplatin)

Question 33

Management of SGST

Answer 33

Non metastatic disease

• para aortic nodal spread risk
• adjuvant = chemo, radio

Metastatic

• radio or chemo
• retroperitoneal lymph node dissection