Urinary System - Level 2.2 Flashcards
Pathology of bladder cancer?
o Calyces, renal pelvis, ureter, bladder and urethras lined by transitional epithelium
o 50% in bladder
Spread of bladder cancer?
o Local – pelvic structures
o Lymph – iliac and para-aortic nodes
o Bloods – liver and lungs
Epidemiology of bladder cancer?
- Men > Women
- Age >40
Cell types of bladder cancer?
o 90% transitional cell carcinoma
o Rare – adenocarcinoma, SCC (from schistosomiasis)
Aetiology of bladder cancer?
o Cigarette smoking o Aromatic amines (rubber industry) o Chronic cystitis o Drugs – cyclophosphamide o Schistosomiasis (SCC)
Symptoms of bladder cancer?
o Painless haematuria o UTI symptoms without bacteriuria o Pain o Voiding irritability o If in ureters, pelvis – flank pain due to obstruction
When to refer on 2 week pathway of bladder cancer?
Over 45 with:
• Unexplained visible haematuria without UTI OR
• Visible haematuria persisting or recurring after treatment of UTI
Over 60 with unexplained non-visible haematuria and either:
• Dysuria OR
• Raised WCC
When to refer non-urgently of bladder cancer?
o Non-urgent referral in over 60 with recurrent or persistent UTIs
Diagnostic investigations performed in secondary care of bladder cancer?
US KUB
Cystoscopy with biopsy
If invasive – CT/MRI
Transurethral Resection of bladder tumour
• With photodynamic diagnosis, narrow-band imaging, cytology or urinary biomarker test
• Obtain detrusor muscle
• Record size and number of tumours
• Offer single dose of intravesical mitomycin C
Staging investigations of bladder cancer?
TURBT within 6 weeks if no detrusor muscle
CT scan
• If diagnosed with muscle-invasive or high-risk and being assessed for radical treatment
CT urography
CT thorax
PET scan – if indeterminate findings on CT or high risk of metastatic disease
Management of bladder cancer - general advice?
o Clinical nurse specialist – support
o Smoking cessation
Management of bladder cancer - non-muscle invasive - risk classification?
o Risk Classification – determined on size, number, histology, type, grade, stage
Management of bladder cancer - non-muscle invasive - low risk?
White-light guided TURBT
o With photodynamic diagnosis, narrow-band imaging, cytology or urinary biomarker test
o Obtain detrusor muscle
o Record size and number of tumours
o Offer single dose of intravesical mitomycin C
o TURBT within 6 weeks if no detrusor muscle
Follow-Up
o Cystoscopy at 3 months and 12 months after diagnosis
o Discharge if no recurrence
Management of bladder cancer - non-muscle invasive - medium risk?
6 doses of intravesical mitomycin C
o If recurs, specialist MDT
Follow Up
o Cystoscopy follow up at 3, 9 and 18 months and annually after
Management of bladder cancer - non-muscle invasive - high risk?
TURBT before 6 weeks – if 1st TURBT shows high risk
Intravesical BCG or
o Induction and maintenance
Radical cystectomy
o Urinary stoma or urinary diversion (unless cognitive impairment, impaired renal function or bowel disease)
Follow Up o Cystoscopy every 3 months for 2 years, every 6 months for 2 years and then annually o CT every 6 months for 2 years o Annually Measure eGFR US of KUB B12 and folate level Urethral washing for cytology
Management of bladder cancer - muscle invasive?
Neoadjuvant Chemotherapy – cisplatin then:
Radical Cystectomy OR
• Urinary stoma or urinary diversion (unless cognitive impairment, impaired renal function or bowel disease)
• Adjuvant chemotherapy - cisplatin
Radiotherapy with Radiosensitiser
• Mitomycin in combo with 5-FU
• Over 6.5 or 4 weeks
Follow up Cystoscopy every 3 months for 2 years, every 6 months for 2 years and then annually CT every 6 months for 2 years Annually • Measure eGFR • US of KUB • B12 and folate level • Urethral washing for cytology
Management of bladder cancer - locally advance or metastatic cancer?
Chemotherapy
MVAC with G-CSF (if ECOG 0,1 and GFR >60)
• Carboplatin with gemcitabine (if ECOG 2 or GFR<60)
• Pembrolizumab if cisplatin unsuitable
Gemcitabine with MVAC and G-CSF
Management of bladder cancer - symptoms management?
Bladder (haematuria, dysuria, frequency, nocturia)
• Radiotherapy
Loin Pain or Renal Failure
• Percutaneous nephrostomy or retrograde stenting
Bleeding
• Radiotherapy or embolization
Pelvic Pain
• Radiotherapy
• Nerve block
• Palliative chemotherapy
Type of prostate cancer?
- Malignant tumour of the prostate
o >95% are adenocarcinomas, developing in glandular tissue in posterior or peripheral parts of prostate - BPH more common in centre of gland
Spread of prostate cancer?
- Spread may be local (seminal vesicles, bladder, rectum), via lymph or haematogenous (sclerotic bony lesions)
Epidemiology of prostate cancer?
- Commonest cancer in males
- 1 in 8 men will get prostate cancer in lives
- Older men - >50% occur after 75 years
Risk factors of prostate cancer?
o Genetics BRCAII & pTEN genes o Radiation exposure o Diet o Anabolic Steroids (due to increased testosterone) o Age o African/Afro-Caribbean o Family History
Symptoms of prostate cancer?
o Asymptomatic o Poor stream o Nocturia o Terminal dribbling o Polyuria o Metastatic symptoms Weight loss, anaemia, lower back pain, MSCC
Signs of prostate cancer?
o Rectal Examination
Enlarged, hard, craggy gland
Loss of median sulcus
Investigations in primary care of prostate cancer?
Prostate Specific Antigen (PSA) increased
• Test in men with:
o Lower UT symptoms
o Erectile dysfunction
o Visible haematuria
• Better prognosis if picked up, may be high or low falsely
• 75% of men with abnormal PSA do not have cancer
• Most men who have abnormal test will have biopsy which is invasive
Digital Rectal Examination
After PSA
Investigations in secondary care in suspected prostate cancer?
Transrectal USS and biopsy If curative intent: • MRI If metastatic concerns: • Radiolabelled technetium bone scan
Staging of prostate cancer?
TMN
Grading of prostate cancer?
Gleason grading 2-5 and then added together, scored on basis of histological patterns 2-10
• Low risk – GS<7, T1/2, PSA<10
• Moderate risk – GS=7, T2, PSA 10-20
• High risk – GS>7, PSA>20
When to refer for 2-week appointment of prostate cancer?
o DRE – prostate feels malignant
o PSA raised
2-week referral assessment of prostate cancer?
o Urology clinic appointment
o Imaging MRI/USS/X-rays
o Trans-rectal Biopsy – 10 cores
Rectal discomfort, blood in urine or semen, 3% risk of sepsis
Management of prostate cancer - observational?
Asymptomatic prostate cancer confined to prostate, particularly in elderly and where other conditions limit length of survival
Management of prostate cancer - surgery?
Radical Prostatectomy with curative intent
• T2 or less
• Perineal or retroperineal routes
• May have temporary or lasting impotence and incontinence
Palliative surgery
• Used to relieve prostatic symptoms or urinary obstruction
Management of prostate cancer - radiotherapy?
Performed by external beam irradiation, interstitial implantation of radioisotopes or both
Radical radiotherapy
• Can be used in T1/T2 tumours or to control locally advanced tumours
Adjuvant radiotherapy
• Following radical surgery if concerns about residual disease
Palliative used to palliate primary tumour or treat complications
Side Effects: Dysuria, rectal bleeding, diarrhoea, impotence, incontinence
Management of prostate cancer - brachytherapy?
TRUS used and used in fit men with no-comorbidity
Management of prostate cancer - hormonal?
Treating advanced disease or in conjunction with radiotherapy for localised disease
LHRH agonists (leuprorelin, goserelin)
• Reduces level of testosterone
• Given monthly or 3-monthly via SC/IM depots
• Medical castration causes increased CVD, osteoporosis
Gonadotrophin-releasing hormone antagonist (degarelix)
• Castrate levels of testosterone within 3 days
• Monthly SC injection
Oestrogen Therapy
• Inhibit LHRH, rarely used
Anti-Androgens (bicalutamide)
• Slows progression and survival benefit combined with LHRH
Management of prostate cancer - chemotherapy?
Used in castrate-refractory metastatic disease
Follow up of prostate cancer?
Watchful waiting followed up in primary care according to MDT outcome
PSA measured once a year
Radical treatment
PSA 6 weeks after treatment, 6 monthly for 2 years, then yearly
Definition of urinary tract obstruction?
o Impaired urinary flow which results in proximal distention of urinary tract depending on location:
Urethra – bladder dilation, secondary hypertrophy and diverticulae formation
Ureter – megaureter and hydronephrosis
Points most susceptible to urinary tract obstruction?
Pelvi-ureteric junction
Where ureters cross pelvic brim, at level of iliac vessels
Vesico-ureteric junction
definition of hydronephrosis?
o Urine-filled dilation of renal pelvis and calyces due to obstruction
o Increased pressure being transmitted to kidney, leading to infection, stones and decreasing renal function
Epidemiology of urinary tract obstruction?
- In older men, BPH
- 1 in 100 foetuses have hydronephrosis on US
- Women – pelvic tumours, prolapse or pregnancy
Causes of urinary tract obstruction - within lumen?
Blood clot
Calculi
Sloughed papillae
Tumour of renal pelvis or ureter
Causes of urinary tract obstruction - within wall?
Ureteric, urethral strictur Congenital megaureter Bladder neck obstruction Congenital urethral valves Pinhole meatus Neurogenic bladder SCI or MS
Causes of urinary tract obstruction - pressure from outside?
PUJ compression Tumours BPH Retroperitoneal fibrosis • Present with dull abdominal pain, or complications of that • 50% hypertension • Anaemia, raised ESR/CRP Pancreatitis Crohn’s Disease Phimosis
Symptoms of acute upper urinary tract obstruction?
o Flank pain
Dull, sharp or colicky, varies in severity
Unable to lie still
Radiates to iliac fossa, inguinal area, testis or labium
Provoked by alcohol, diuretics or high fluid intake
o Nausea & Vomiting
o Loin tenderness, enlarged kidney
o Anuria – bilateral
Symptoms of chronic upper urinary tract obstruction?
o Flank or abdominal pain
o Chronic kidney disease
o Polyuria
Symptoms of acute lower urinary tract obstruction?
o Severe suprapubic pain o Distended bladder – abdominal distention, suprapubic dullness on percussion o Urine hesitancy o Narrow/Weak urine stream o Terminal dribbling o Incomplete bladder emptying
Symptoms of chronic lower urinary tract obstruction?
o Urine hesitancy o Narrow/Weak urine stream o Terminal dribbling o Incomplete bladder emptying o May have signs of UTI o Distended bladder
Investigations in urinary tract obstruction?
DRE
Blood Tests o FBC – anaemia, infection o U&Es o If stones – serum calcium, phosphate and urate levels o If prostate enlarged - Serum PSA
Urinalysis – dipstick and M,C&S
Blood cultures if signs of sepsis
Imaging in urinary tract obstruction?
US KUB
If abnormal – CT KUB or XR KUB
If suspected calculi – non-contrast helical CT
If renal pathology – contrast CT
Renal scintigraphy – shows function and excretion
Retrograde urethrography – demonstrates structural abnormalities
Nephrostography
Urodynamic studies
Urological emergencies requiring urgent treatment in urinary tract obstruction?
o Complete UT obstruction o Any obstruction in single kidney o Obstruction with fever/infection o CKD o Suspicion of neurological dysfunction o Uncontrolled pain
Management of urinary tract obstruction - general management?
o Analgesia o Hydration o Relieve blockage Acute lower – catheter Acute upper – nephrostomy or ureteric stent
Management of urinary tract obstruction - PUJ obstruction?
o Pyeloplasty – open, laparoscopic or robot-assisted
o Endopyelotomy – full-thickness incision through stenosis and leaving stent
o Ureteroscopic endoureterotomy – strictures
Management of urinary tract obstruction - malignancy?
o Treat cause
o Percutaneous nephrostomy to relieve obstruction
Management of urinary tract obstruction - idiopathic retroperitoneal fibrosis?
o Ureterolysis or stent placement
o Corticosteroids and/or axathioprine, tamoxifen
o Biopsy to exclude malignancy
Management of urinary tract obstruction - BPH?
o Acute retention – catheterisation
o Mild symptoms – reduce fluid intake, avoid caffeine and alcoholic drinks
o Medical treatment – alpha blockers (tamsulosin, alfuzosin, doxazosin, terazosin) & 5-alpha reductase inhibitors (finasteride)
o Surgical treatment – Transurethral resection of the prostate
Complications of urinary tract obstruction?
o Infection o Extravasation o Fistula formation o CKD o Pain
Epidemiology of renal carcinoma?
- Mostly males
- Mean age 55
Types of renal carcinoma?
o 90% are renal cell carcinoma (Grawitz tumour)
Arise from proximal tubular epithelium – highly vascular with large cells with clear cytoplasm (clear cell carcinoma)
Risk factors of renal carcinoma?
o Smoking o Males o Older age o Obesity o FHx o Von Hippal Lindau – bilateral RCC common
Spread of renal carcinoma?
o Direct – renal vein
o Lymph
o Haematogenous – bone, liver, lung
Symptoms of renal carcinoma?
o Asymptomatic o Haematuria o Loin pain o UTI o Mass in flank o Anorexia, malaise, weight loss
Signs of renal carcinoma?
o Anaemia, PCV, high calcium
Investigations to perform if suspected of renal carcinoma?
- Bloods o FBC – elevated RBC, reduced Hb o LDH raised o High Ca o U&Es
- Urinalysis
o Haematuria
o Proteinuria
When to refer for 2 week appointment of renal carcinoma?
- Refer for 2-week appointment if >45 and have:
o Unexplained visible haematuria without UTI OR
o Visible haematuria that persists or recurs after treatment of UTI
Diagnostic investigations of renal carcinoma?
o US KUB
o CT scan
o Biopsy
Management of renal carcinoma - risk assessment?
o <1 year to systemic therapy o Performance status o Hb low o Calcium high o Neutrophils high o Platelets high
Management of renal carcinoma - screening in VHL?
o Annual abdominal US at 11 years
o CT every year after 20
Management of renal carcinoma - Stage 1/2?
o Surgical Procedures Laparoscopic cryotherapy Percutaneous cryotherapy Percutaneous radiofrequency ablation Laparoscopic partial nephrectomy Laparoscopic nephrectomy
o Not fit for surgery
Surveillance
Management of renal carcinoma - Advanced or metastatic cancer?
o First-Line
Nivolumab + Ipilimumab
Cabozantinib
Tivozanib
o Second-Line
Lenvatinib + everolimus
Cabozantinib
Everolimus
Definition of renal stones/colic?
- Deposition of stones/blood clots within the urinary tract causing spasmodic pain
- Commonly deposited in pelvoureteric junction, pelvic brim, vesicoureteral junction
Types of renal stones/colic?
o Calcium Oxalate (65%)
o Struvite (15%)
o Urate (5%)
o Mixed
Pathology of renal stones/colic?
o Pressure necrosis causes direct damage to renal parenchyma
Epidemiology of renal stones/colic?
- Lifetime risk 10%
- Higher prevalence in Middle East
- Most occur in upper UT
- Male 2x and peak age 20-40 years
Aetiology of renal stones/colic?
o Dehydration
o Calcium stones – hypercalcaemia (primary, increased Vit D, sarcoidosis), renal disease (PKD tubular acidosis, medullary sponge kidney), hyperoxaluria
o Urate stones – diet, increased uric acid, gout
o Struvate stones – UTI, recurrent (staghorn calculi)
Symptoms of renal stones/colic?
Pain
Dull loin ache (renal pelvis stones), severe colicky pain often sudden onset
Radiating from loin to groin
Bladder stones cause suprapubic pain and perineal ache
Haematuria often frank
If obstructed then may have dysuria, inability to void
Signs of renal stones/colic?
o Restless, sweaty, pale, nauseated
o Fever, loin tenderness, palpable kidneys
Investigations of renal stones/colic?
- Bloods – FBC, U&E, Ca, PO4, urate, glucose
- Urinalysis
- Urine M, C&S if infection
Immediate admission when in renal stones/colic?
o Sepsis
o CKD, solitary kidney, bilateral obstructing stones
o Dehydrated and cannot take oral fluids due to N&V
Diagnostic imaging of renal stones/colic?
o Urgent (within 24 hours) non-contrast helical CT scan in adults o Urgent USS in children, or pregnant women
Tests to find cause of renal stones/colic?
o Serum Ca and urate, 24-hour calcium urine, phosphate, oxalate, urate
Management of renal stones/colic - initial management?
o Analgesia
Diclofenac 75mg IM repeated after 30 mins
If NSAIDS CI or not sufficient – give IV paracetamol
Opioids used if both NSAIDs and paracetamol not sufficient
o Antiemetic if opioid
o High fluid intake/IV fluids
Management of renal stones/colic - watchful waiting?
- Watchful Waiting for asymptomatic renal stones
o Stone <5mm OR stone >5mm and person wishes for watchful waiting
Management of renal stones/colic - when to refer to urology?
- Refer to urology if >5mm stones
Management of renal stones/colic - medical treatment?
o Medical expulsion if <10mm
Give alpha-blocker – tamsulosin, alfuzosin
Management of renal stones/colic - surgical treatment - when?
• Offer within 48 hours if pain is ongoing and not tolerated OR stone unlikely to pass
Pre-treatment stenting
• Only considered in children having shockwave lithotripsy for renal staghorn stones
Management of renal stones/colic - surgical treatment of renal - what - if stone <10mm?
o Shockwave Lithotripsy
o Ureteroscopy extraction if SWL CI, previous failed SWL
o If SWL and URS failed – consider percutaneous nephrolithotomy
Management of renal stones/colic - surgical treatment of renal - what - if stone 10-20mm?
o Ureteroscopy or Shockwave lithotripsy
o IF SWL and URS failed – percutaneous nephrolithotomy
Management of renal stones/colic - surgical treatment of renal - what - if stone >20mm?
• Renal Stone >20mm, including staghorn stones
o Percutaneous nephrolithotomy
o URS if PCNL not an option
Management of renal stones/colic - surgical treatment of ureteric - if stone <10mm?
o Shockwave Lithotripsy
o Ureteroscopy if stones not cleared within 4 weeks of SWL, SWL CI or previous course failed
Management of renal stones/colic - surgical treatment of ureteric - if stone 10-20mm?
o Ureteroscopy extraction
o Percutaneous nephrolithotomy if URS failed
Ongoing management in renal colic/stones?
Stone analysis
Serum calcium
General advice in renal colic/stones?
Avoid rhubarb, spinach High fluid intake 2.5-3L/day Add fresh lemon juice to water Avoid carbonated drinks Restrict sodium intake to <6g/day Maintain normal calcium intake Medications for recurrent stones • Calcium Oxalate – potassium citrate + thiazide (after restricting sodium to <6d/day)
