Tumours & Stones Flashcards
Describe the basic anatomy of the kidneys
- location? [3]
- what is the Gerota’s fascia? [1]
- paired retroperitoneal organs located between T12-L3 with the right kidney lying lower than the left
- Gerota’s fascia is a collagen-filled, fibrous connective tissue that encapsulates the kidneys and adrenal glands (except doesn’t cover inferiorly)
Describe the anatomy of the ureters:
- what are the 3 segments? [3]
- what are the layers of the ureters? [4]
- where are the physiological narrowings of the ureter and what is the clinical significance of this? [4]
- 3 segments
- proximal: PUJ-pelvic brim
- mid: segment over sacral bone
- distal: lower sacral border to UO
- 4 layers which vary depending on site:
- urothelial mucosa
- lamina propria
- muscular layer
- adventitial layer
- Physiological narrowings → where calculi likely to obstruct
-
pelvic ureteric junction (PUJ)
- the connection between the renal pelvis and the ureter (tube running from the kidney to the bladder)
- crossing iliacs at pelvic brim
-
vesicoureteric junction (VUJ)
- also known as the ureterovesicular junction (UVJ)
- the most distal portion of the ureter, at the point where it connects to the urinary bladder
-
pelvic ureteric junction (PUJ)
List the risk factors for kidney stones [9]
- Intrinsic factors
- sex (more common in older men)
- age (peak 20-50yrs)
- family history (familial renal tubular acidosis/cystinuria)
- comorbid conditions
- Extrinsic factors
- fluid intake
- diet
- lifestyle
- climate (generally more in hot climates)
- country of residence (more common in Caucasian/Asian)
Describe the different compositions of renal stones and state whether each is radio-opaque or radiolucent [6]
- calcium oxalate → radio-opaque
- uric acid → radiolucent
- calcium phosphate and calcium oxalate → radio-opaque
- pure calcium phosphate → radio-opaque
- struvite (infection stones) → relatively radiolucent
- Mg-ammounium-phosphate stones
- cysteine → relatively radiolucent
Describe the mechanisms of renal stone formation [3]
crystals form in urine that is supersaturated with particular compounds, either due to too much of the solutes (e.g. high levels of calcium oxalate) or not enough solvent (e.g. in dehydration)
What factors affect stone formation? [7]
- low volume
- low pH (acidic urine)
- low citric
- low magnesium
- high uric acid
- high calcium
- high oxalate
How do renal stones present clinically? [4]
- incidental - picked up on imaging
- colic pain, that radiates from loin to groin, doesn’t settle and is unable to stay still
- haematuria - visible or non-visible
- sepsis/infection
- of unknown cause until imaged
What investigations should you carry out on a patient with suspected renal stones? [3]
- bloods
- U&Es
- calcium
- urate
- venous bicarbonate (if recurrent)
- urine
- urine dip
- 24hr urine analysis (if recurrent)
- imaging
- CT KUB (gold standard)
- ultrasound
- X-ray KUB
What medical therapy should you administer to a patient with renal stones? [3]
- analgesia
- NSAIDs or opiates
- NSAIDs reduce pain due to reduced glomerular filtration, renal pressure and ureteric peristalsis
What are the surgical options for renal stones?
- ureteroscopy and basket
- ureteroscopy and fragmentation
- FURS – flexible ureteroscopy
- ESWL – extracorporeal shockwave lithotripsy
- PCNL – percutaneous nephrolithotomy
- Emergency stent or nephrostomy
What are the differentials for emergency presentations of renal stones? [5]
- testicular pain
- penile pain
- abdominal aortic aneurysm
- appendicitis
- gynae pathology
What is the SEPSIS SIX? [6]
- Give O2 to keep sats above 94%
- take blood cultures
- give IV antibiotics
- give a fluid challenge
- measure lactate
- measure urine output
What are Staghorn calculi and what are they composed of? [2]
- Staghorn calculi refer to branched stones that fill all or part of the renal pelvis and branch into several or all of the calyces
- most often composed of struvite (magnesium ammonium phosphate)
What are the risk factors for prostate cancer? [7]
- age >65yrs
- genetics
- HPC1 (hereditary prostate cancer)
- BRCA2 gene mutations
- PTEN & TP53 tumour suppressor gene mutations
- race
- more common in African American men
- environment/occupation
- hormones
- possibly elevated 5α-reductase levels
- sexual behavoiur
- early age of sex or history of STDs
- diet
What are the signs & symptoms of prostate cancer?
- local S&S? [6]
- metastastic S&S? [2]
- local S&S
- often asymptomatic w/raised PSA level
- painful or slow micturition
- urinary retention (may cause anuria/uraemia)
- urinary tract infection
- haematuria
- lymphoedema
- metastastic S&S:
- bone pain
- renal failure due to ureteric obstruction
What investigations should be carried out on a patient with suspected prostate cancer for diagnosis and screening? [4]
- DRE - digital rectal examination
- PSA - prostate-specific antigen
- PIRADS - Prostate MRI
- TRUS - guided needle biopsy
What is the common type of prostate cancer and where does it usually arise? [2]
- adenocarcinoma
- usually arise in the peripheral zone of prostate
Prostate Specific Antigen:
- what is it and where is it secreted into? [2]
- function? [1]
- what factors influence PSA levels? [4]
- serine protease (33kD) secreted into seminal fluid
- responsible for liquefaction of seminal coagulation
- tends to rise with age, depends on prostate size and influenced by inflammation/infection
What are the treatment options for localised prostate cancer? [6]
- watchful waiting
- active Surveillance
- radiotherapy (with or without LHRH analogue)
- external beam
- brachytherapy
- radical prostatectomy
- cryotherapy/HIFU
- TURP if symptomatic
Metastatic complications of prostate cancer:
- what are they? [2]
- presentation of each? [2]
- management? [2]
-
Spinal cord compression
- urological emergency
- presentation:
- evere pain
- off legs
- retention
- constipation
- urgent MRI
- radiotherapy vs spinal decompression surgery
-
Ureteric obstruction
- presentation:
- anorexia
- weight loss
- raised creatinine
- to nephrostomize or not and then to stent or not
- temporary measure will not improve cancer progression
- presentation:
What are the treatment options for advanced prostate cancer? [6]
- androgen ablation therapy
- medical castration (LHRH analogue) or
- surgical castration (orchidectomy)
- chemotherapy
- TURP for relief of symptoms
- radiotherapy
Describe the hypothalamic pituitary-testicular axis [5]
- Luteinising hormone-releasing hormone (LHRH) is secreted from the hypothalamus
- LHRH then stimulates the pituitary gland to produce luteinising hormone (LH) and follicle-stimulating hormone (FSH)
- In turn, LH and FSH stimulate the testes to secrete testosterone
- Adrenocorticotrophic hormone (ACTH) is released from the pituitary gland after stimulation by corticotrophin-releasing hormone (CRH) which is secreted from the hypothalamus
- ACTH regulates secretion of adrenal androgens, some of which are converted to testosterone
List the risk factors for bladder cancer [8]
- age >80yrs
- male
- race - Caucasians
- chronic inflammation
- stones
- infection (schistosomiasis)
- long term catheters
- drugs
- cyclophosphamide
- pioglitzone
- pelvic radiotherapy
- occupation
- smoking
Clinical Features of Bladder Cancer:
- classical presentation? [1]
- what are the types? [3]
- what are the staging types? [2]
- classically painless frank haematuria
- types:
- transitional cell carcinoma
- squamous carcinoma
- adenocarcinoma
- staging:
- non-muscle invasive bladder cancer (NMIBC)
- muscle invasive bladder cancer (MIBC)
Treatment of Bladder Cancer:
- initial treatment? [4]
- follow-up treatment? [2]
- Initial Treatment:
- diagnosed at flexible cystoscopy
- urgent TURBT (trans-urethral resection of bladder tumour)
- CT IVU (5% chance upper tract involvement)
- bimanual examination carried out at TURBT
- Follow-up Treatment:
- mitomycin C
- chemotherapy that targets DNA synthesis
- BCG therapy
- immunotherapy that targets cell mediated immune response
- mitomycin C
What are the risk factors of renal cell carcinoma? [8]
- age (peak of 40-70yrs old)
- males
- smoking
- obesity
- hypertension
- acquired renal cystic disease
- haemodialysis
- genetics
What is the typical presentation of renal carcinoma? [10]
- systemic symptoms:
- night sweats
- fever
- fatigue
- weight loss
- classic triad:
- mass
- pain
- haematuria
- varicocele
- lower limb oedema
- paraneoplastic syndromes
What are the types of paraneoplastic syndromes? [8]
- polycythaemia
- hypercalcaemia
- either from a PTH-like substance or from oestolytic hypercalcaemia
- hypertension
- from renin secretion
- deranged LFTs
- Stauffer’s syndrome, from hepatotoxic tumour products
- rare:
- ACTH (Cushing’s syndrome)
- enteroglucagon (protein enteropathy)
- prolactin (galactorrhoea)
- insulin (hypoglycaemia)
What investigations should you carry out on a patient with renal carcinoma [4] and what are the treatment options? [2]
- investigations:
- ultrasound for initial diagnosis
- CT kidneys +/- MRI RV
- renal biopsy
- CT chest
- histology - conventional or clear cell
- treatment:
- tyrosine kinase inhibitors
- surgery
What are the risk factors for testicular cancer? [4]
- age 20-45yrs
- cryptorchidism
- HIV
- Caucasian population
What investigations should you carry out on a patient with suspected testicular cancer? [3]
- scrotal ultrasound
- tumour markers
- alpha-fetoprotein
- beta hCG
- LDH
- CT staging if advanced
What are the classifications of testicular cancer types? [8]
- germ cell tumours (most common)
- seminoma
- teratoma
- mixed
- yolk sac
- stromal tumours
- leydig
- sertoli
- other
- lymphoma
- metastasis
What are the treatment options for testicular cancer? [4]
- radical orchidectomy
- chemotherapy
- para-aortic nodal radiotherapy
- retroperitoneal lymph node dissection
Penile Cancer:
- risk factors? [2]
- treatment? [5]
- risk factors:
- HPV infection
- smoking
- treatment:
- circumcision
- topical treatment CO2/5FU
- penectomy +/- reconstruction
- lymphadenectomy
- chemo-radiotherapy
