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MSRA Content > Urinary System - Level 2.2 > Flashcards

Urinary System - Level 2.2 Flashcards

1
Q

Pathology of bladder cancer?

A

o Calyces, renal pelvis, ureter, bladder and urethras lined by transitional epithelium
o 50% in bladder

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2
Q

Spread of bladder cancer?

A

o Local – pelvic structures
o Lymph – iliac and para-aortic nodes
o Bloods – liver and lungs

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3
Q

Epidemiology of bladder cancer?

A
  • Men > Women

- Age >40

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4
Q

Cell types of bladder cancer?

A

o 90% transitional cell carcinoma

o Rare – adenocarcinoma, SCC (from schistosomiasis)

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5
Q

Aetiology of bladder cancer?

A 
o	Cigarette smoking
o	Aromatic amines (rubber industry)
o	Chronic cystitis
o	Drugs – cyclophosphamide
o	Schistosomiasis (SCC)
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6
Q

Symptoms of bladder cancer?

A 
o	Painless haematuria
o	UTI symptoms without bacteriuria
o	Pain
o	Voiding irritability
o	If in ureters, pelvis – flank pain due to obstruction
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7
Q

When to refer on 2 week pathway of bladder cancer?

A

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

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8
Q

When to refer non-urgently of bladder cancer?

A

o Non-urgent referral in over 60 with recurrent or persistent UTIs

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9
Q

Diagnostic investigations performed in secondary care of bladder cancer?

A

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

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10
Q

Staging investigations of bladder cancer?

A

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

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11
Q

Management of bladder cancer - general advice?

A

o Clinical nurse specialist – support

o Smoking cessation

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12
Q

Management of bladder cancer - non-muscle invasive - risk classification?

A

o Risk Classification – determined on size, number, histology, type, grade, stage

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13
Q

Management of bladder cancer - non-muscle invasive - low risk?

A

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

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14
Q

Management of bladder cancer - non-muscle invasive - medium risk?

A

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

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15
Q

Management of bladder cancer - non-muscle invasive - high risk?

A

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
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16
Q

Management of bladder cancer - muscle invasive?

A

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
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17
Q

Management of bladder cancer - locally advance or metastatic cancer?

A

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

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18
Q

Management of bladder cancer - symptoms management?

A

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

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19
Q

Type of prostate cancer?

A
  • 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
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20
Q

Spread of prostate cancer?

A
  • Spread may be local (seminal vesicles, bladder, rectum), via lymph or haematogenous (sclerotic bony lesions)
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21
Q

Epidemiology of prostate cancer?

A
  • Commonest cancer in males
  • 1 in 8 men will get prostate cancer in lives
  • Older men - >50% occur after 75 years
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22
Q

Risk factors of prostate cancer?

A 
o	Genetics
	BRCAII &amp; pTEN genes
o	Radiation exposure
o	Diet
o	Anabolic Steroids (due to increased testosterone)
o	Age
o	African/Afro-Caribbean
o	Family History
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23
Q

Symptoms of prostate cancer?

A 
o	Asymptomatic
o	Poor stream
o	Nocturia
o	Terminal dribbling
o	Polyuria
o	Metastatic symptoms
	Weight loss, anaemia, lower back pain, MSCC
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24
Q

Signs of prostate cancer?

A

o Rectal Examination
 Enlarged, hard, craggy gland
 Loss of median sulcus

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25
Q

Investigations in primary care of prostate cancer?

A

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

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26
Q

Investigations in secondary care in suspected prostate cancer?

A 
	Transrectal USS and biopsy
	If curative intent:
•	MRI
	If metastatic concerns:
•	Radiolabelled technetium bone scan
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27
Q

Staging of prostate cancer?

A

 TMN

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28
Q

Grading of prostate cancer?

A

 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

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29
Q

When to refer for 2-week appointment of prostate cancer?

A

o DRE – prostate feels malignant

o PSA raised

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30
Q

2-week referral assessment of prostate cancer?

A

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

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31
Q

Management of prostate cancer - observational?

A

 Asymptomatic prostate cancer confined to prostate, particularly in elderly and where other conditions limit length of survival

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32
Q

Management of prostate cancer - surgery?

A

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

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33
Q

Management of prostate cancer - radiotherapy?

A

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

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34
Q

Management of prostate cancer - brachytherapy?

A

 TRUS used and used in fit men with no-comorbidity

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35
Q

Management of prostate cancer - hormonal?

A

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

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36
Q

Management of prostate cancer - chemotherapy?

A

 Used in castrate-refractory metastatic disease

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37
Q

Follow up of prostate cancer?

A

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

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38
Q

Definition of urinary tract obstruction?

A

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

39
Q

Points most susceptible to urinary tract obstruction?

A

 Pelvi-ureteric junction
 Where ureters cross pelvic brim, at level of iliac vessels
 Vesico-ureteric junction

40
Q

definition of hydronephrosis?

A

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

41
Q

Epidemiology of urinary tract obstruction?

A
  • In older men, BPH
  • 1 in 100 foetuses have hydronephrosis on US
  • Women – pelvic tumours, prolapse or pregnancy
42
Q

Causes of urinary tract obstruction - within lumen?

A

 Blood clot
 Calculi
 Sloughed papillae
 Tumour of renal pelvis or ureter

43
Q

Causes of urinary tract obstruction - within wall?

A 
	Ureteric, urethral strictur
	Congenital megaureter
	Bladder neck obstruction
	Congenital urethral valves
	Pinhole meatus
	Neurogenic bladder
	SCI or MS
44
Q

Causes of urinary tract obstruction - pressure from outside?

A 
	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
45
Q

Symptoms of acute upper urinary tract obstruction?

A

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

46
Q

Symptoms of chronic upper urinary tract obstruction?

A

o Flank or abdominal pain
o Chronic kidney disease
o Polyuria

47
Q

Symptoms of acute lower urinary tract obstruction?

A 
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
48
Q

Symptoms of chronic lower urinary tract obstruction?

A 
o	Urine hesitancy
o	Narrow/Weak urine stream
o	Terminal dribbling
o	Incomplete bladder emptying
o	May have signs of UTI
o	Distended bladder
49
Q

Investigations in urinary tract obstruction?

A

DRE

Blood Tests
o	FBC – anaemia, infection
o	U&amp;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

50
Q

Imaging in urinary tract obstruction?

A

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

51
Q

Urological emergencies requiring urgent treatment in urinary tract obstruction?

A 
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
52
Q

Management of urinary tract obstruction - general management?

A 
o	Analgesia
o	Hydration
o	Relieve blockage 
	Acute lower – catheter
	Acute upper – nephrostomy or ureteric stent
53
Q

Management of urinary tract obstruction - PUJ obstruction?

A

o Pyeloplasty – open, laparoscopic or robot-assisted
o Endopyelotomy – full-thickness incision through stenosis and leaving stent
o Ureteroscopic endoureterotomy – strictures

54
Q

Management of urinary tract obstruction - malignancy?

A

o Treat cause

o Percutaneous nephrostomy to relieve obstruction

55
Q

Management of urinary tract obstruction - idiopathic retroperitoneal fibrosis?

A

o Ureterolysis or stent placement
o Corticosteroids and/or axathioprine, tamoxifen
o Biopsy to exclude malignancy

56
Q

Management of urinary tract obstruction - BPH?

A

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

57
Q

Complications of urinary tract obstruction?

A 
o	Infection
o	Extravasation
o	Fistula formation
o	CKD
o	Pain
58
Q

Epidemiology of renal carcinoma?

A
  • Mostly males

- Mean age 55

59
Q

Types of renal carcinoma?

A

o 90% are renal cell carcinoma (Grawitz tumour)

 Arise from proximal tubular epithelium – highly vascular with large cells with clear cytoplasm (clear cell carcinoma)

60
Q

Risk factors of renal carcinoma?

A 
o	Smoking
o	Males
o	Older age
o	Obesity
o	FHx
o	Von Hippal Lindau – bilateral RCC common
61
Q

Spread of renal carcinoma?

A

o Direct – renal vein
o Lymph
o Haematogenous – bone, liver, lung

62
Q

Symptoms of renal carcinoma?

A 
o	Asymptomatic
o	Haematuria
o	Loin pain
o	UTI
o	Mass in flank
o	Anorexia, malaise, weight loss
63
Q

Signs of renal carcinoma?

A

o Anaemia, PCV, high calcium

64
Q

Investigations to perform if suspected of renal carcinoma?

A 
-	Bloods
o	FBC – elevated RBC, reduced Hb
o	LDH raised
o	High Ca
o	U&amp;Es
  • Urinalysis
    o Haematuria
    o Proteinuria
65
Q

When to refer for 2 week appointment of renal carcinoma?

A
  • 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
66
Q

Diagnostic investigations of renal carcinoma?

A

o US KUB
o CT scan
o Biopsy

67
Q

Management of renal carcinoma - risk assessment?

A 
o	<1 year to systemic therapy
o	Performance status
o	Hb low
o	Calcium high
o	Neutrophils high
o	Platelets high
68
Q

Management of renal carcinoma - screening in VHL?

A

o Annual abdominal US at 11 years

o CT every year after 20

69
Q

Management of renal carcinoma - Stage 1/2?

A 
o	Surgical Procedures
	Laparoscopic cryotherapy
	Percutaneous cryotherapy
	Percutaneous radiofrequency ablation
	Laparoscopic partial nephrectomy
	Laparoscopic nephrectomy

o Not fit for surgery
 Surveillance

70
Q

Management of renal carcinoma - Advanced or metastatic cancer?

A

o First-Line
 Nivolumab + Ipilimumab
 Cabozantinib
 Tivozanib

o Second-Line
 Lenvatinib + everolimus
 Cabozantinib
 Everolimus

71
Q

Definition of renal stones/colic?

A
  • Deposition of stones/blood clots within the urinary tract causing spasmodic pain
  • Commonly deposited in pelvoureteric junction, pelvic brim, vesicoureteral junction
72
Q

Types of renal stones/colic?

A

o Calcium Oxalate (65%)
o Struvite (15%)
o Urate (5%)
o Mixed

73
Q

Pathology of renal stones/colic?

A

o Pressure necrosis causes direct damage to renal parenchyma

74
Q

Epidemiology of renal stones/colic?

A
  • Lifetime risk 10%
  • Higher prevalence in Middle East
  • Most occur in upper UT
  • Male 2x and peak age 20-40 years
75
Q

Aetiology of renal stones/colic?

A

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)

76
Q

Symptoms of renal stones/colic?

A

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

77
Q

Signs of renal stones/colic?

A

o Restless, sweaty, pale, nauseated

o Fever, loin tenderness, palpable kidneys

78
Q

Investigations of renal stones/colic?

A
  • Bloods – FBC, U&E, Ca, PO4, urate, glucose
  • Urinalysis
  • Urine M, C&S if infection
79
Q

Immediate admission when in renal stones/colic?

A

o Sepsis
o CKD, solitary kidney, bilateral obstructing stones
o Dehydrated and cannot take oral fluids due to N&V

80
Q

Diagnostic imaging of renal stones/colic?

A 
o	Urgent (within 24 hours) non-contrast helical CT scan in adults
o	Urgent USS in children, or pregnant women
81
Q

Tests to find cause of renal stones/colic?

A

o Serum Ca and urate, 24-hour calcium urine, phosphate, oxalate, urate

82
Q

Management of renal stones/colic - initial management?

A

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

83
Q

Management of renal stones/colic - watchful waiting?

A
  • Watchful Waiting for asymptomatic renal stones

o Stone <5mm OR stone >5mm and person wishes for watchful waiting

84
Q

Management of renal stones/colic - when to refer to urology?

A
  • Refer to urology if >5mm stones
85
Q

Management of renal stones/colic - medical treatment?

A

o Medical expulsion if <10mm

 Give alpha-blocker – tamsulosin, alfuzosin

86
Q

Management of renal stones/colic - surgical treatment - when?

A

• 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

87
Q

Management of renal stones/colic - surgical treatment of renal - what - if stone <10mm?

A

o Shockwave Lithotripsy
o Ureteroscopy extraction if SWL CI, previous failed SWL
o If SWL and URS failed – consider percutaneous nephrolithotomy

88
Q

Management of renal stones/colic - surgical treatment of renal - what - if stone 10-20mm?

A

o Ureteroscopy or Shockwave lithotripsy

o IF SWL and URS failed – percutaneous nephrolithotomy

89
Q

Management of renal stones/colic - surgical treatment of renal - what - if stone >20mm?

A

• Renal Stone >20mm, including staghorn stones
o Percutaneous nephrolithotomy
o URS if PCNL not an option

90
Q

Management of renal stones/colic - surgical treatment of ureteric - if stone <10mm?

A

o Shockwave Lithotripsy

o Ureteroscopy if stones not cleared within 4 weeks of SWL, SWL CI or previous course failed

91
Q

Management of renal stones/colic - surgical treatment of ureteric - if stone 10-20mm?

A

o Ureteroscopy extraction

o Percutaneous nephrolithotomy if URS failed

92
Q

Ongoing management in renal colic/stones?

A

 Stone analysis

 Serum calcium

93
Q

General advice in renal colic/stones?

A 
	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)

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