Urological Flashcards
How does prostate cancer present?
Can present due to decrease in normal function —> LUTS
Due to local invasion —> haematochezia, haematospermia, haematuria, urinary obstruction and incontinence, erectile dysfunction
Due to METS —> lethargy, anorexia, pain, spontaneous fractures, weight loss
Asymptomatic
What is the role of the prostate?
Secretes proteolytic enzymes into the semen which then prevents sperm from clotting.
What is PSA?
Protease enzyme which is produced by both malignant and normal cells.
When is PSA raised?
It has a low specificity, and variable sensitivity.
It needs to be age adjusted
What causes PSA to be raised?
. Catheter in situ . Prostate cancer . BPH . Acute urinary retention . Prostatitis . Vigorous exercise . Ejaculation . DRE
What would prostate cancer feel like on a DRE?
Enlarged, craggy, nodular, thick and firm.
What should you do if you are suspecting prostate cancer?
PSA levels
If there are abnormal/ rising PSA levels
And/ or a clinically abnormal prostate then refer the patient on a 2 week wait.
What are the investigations done for prostate cancer at the 2WW clinic?
Multi parametric MRI is the gold standard, followed by a biopsy.
What are the two options for biopsy of the prostate?
1= TRUS
Trans rectal US guided core biopsy
2) transperineal
How do Trans recral US guided core biopsy and transperineal biopsies differ?
TRUS: 12 samples taken trans rectally under local anaesthetic, there is a higher risk of infection and pain
Transperineal: under GA, lower risk of infection and easier access to the anterior part of the prostate
What other investigations can be carried out for prostate cancer in secondary care?
PSA density
Free : total PSA ratio
Bloods: FBC, U and Es, LFTs, bone profile
If there is evidence of high grade disease; bone scan, staging CT, MRI
How is prostate cancer staged?
. Gleason + TNM + PSA levels
What is the treatment of prostate cancer?
Staging of prostate cancer can be split into low, intermediate and high.
For low or intermediate risk you can do watchful waiting or active surveillance…
active surveillance includes 3/12 PSA levels, serial DRE and biopsies
Watchful waiting is done in those with significant morbidities or a life expectancy of 10-12 years
It involves- no regular tests, patient presenting when symptomatic, patients can have conservative management for their symptoms.
What is the treatment offered for high risk/intermediate risk prostate cancer?
Radical prostatectomy or radiotherapy are offered with 6 months androgen deprivation therapy.
What are the complications of radical prostectomy?
Recurrence
Erectile dysfunction
Unfertility
Urinary incontinence
What forms can androgen deprivation therapy/hormonal therapy take?
Bilateral orchidectomy
GnRH analogues/LHRH agonists
GnRH antagonists/ LHRH antagonists
When starting someone on GnRH analogues/LHRH agonists, what should you also prescribe?
Give patients 2 weeks of anti androgen drugs in initiation
Also with anti androgen drugs you should give the patient bisphosphonates to prevent osteoporosis.
What is the difference between non visible and visible haematuria?
Non visible haematuria= anything more than a trace of blood on dipstick, this has a 5% risk of malignancy
Visible haematuria= 20% risk of malignancy
What causes false +ves and false -ves on a urine dipstick?
False +ves= exercise, myoglobin
False -ves= vit C intake, heavy proteinuria
What is Ultrasound useful for in terms of urology?
Can detect renal masses
Hydronephrosis
Bladder masses (if there is a full bladder during scan).
What is CT urograms useful for?
More sensitive test for upper tract TCC
Also shows renal masses (RCC) and may show filling defects in the bladder (tumour/stones)
CT urograms are normally used as a second line in recurrent visible haematuria where USS and cystoscopy are negative
How do CT urograms work?
Uses a CT scan and special dye (contrast medium(p) to look at the urinary system
How does cystocopy work?
Flexible cystoscopy is done with local anaesthesia (instillagel), it is mainly used for diagnostic purposes as you can take tiny biopsies, however flexible cystocopy is not useful during active bleeding as the views are generally poor.
What are the tumours affecting the urological system?
Kidney (and renal pelvis)
- renal cell carcinoma
- transitional cell carcinoma
Ureter
TCC
Bladder
TCC
(Less commonly- squamous carcinoma and adenocarcinoma)
Prostate
BPH
Adenocarcinoma
What is Renal cell carcinoma?
Tumour cell parenchyma
Clear cell= commonest type
What is clear cell renal cell carcinoma associated with?
Von Hippel Lindau
What is the presentation of renal cell carcinoma?
Majority present as an incidental finding
May cause haematuria
Cause a classic triad- loin pain, haematuria, palpable mass, but thid id actually seen in <10%
What is the most common type of bladder cancer?
Transitional cell carcinoma
What is the classic (buzzword) presentation of bladder cancer?
Painless haematuria
What ethnicity is most likely to develop bladder cancer?
Most frequently occurs in white people compared to those of black or asian heritage.
What are the risk factors for bladder cancer?
. Age . Smoking . FHx . Chronic bladder infections/irritations . Occupation and chemical associated exposures- Polycyclic aromatic hydrocarbons . Medications . Family history . Schistosoma haematobium
What is schicstosoma haematobium associated with?
It is associated with squamous cell carcinoma, common in many regions- egypt and the middle east
What is the clinical presentation of bladder cancer?
Haematuria (microscopic or macroscopic)
LUTS
Dysuria
Urgency
Urinary frequency
What are the symptoms of advanced disease that patients may develop?
Pelvic pain Flank pain Bone pain Peripheral oedema Anorexia Weight loss
What is the 2WW criteria for bladder cancer?
Age over 45 with unexplained visible haematuria without a urinary tract infection
Age 45 and over and have visible haematuria that persists or recurs after successful treatment of a UTI
Age 60 or over who have non visible haematuria AND dysuria or a raised WCC on a blood test
They also advise referral in those over 60 with recurrent or persistent unexplained UTI
What are the investigations of bladder cancer?
Cystoscopy is the diagnostic modality of choice
Bedside- urine dip and MSU, urinary cytology (culture)
Bloods- FBC (anaemia and WCC), U and Es, LFTs
Imaging- USS, CT, MRI
CT or MRI should be considered prior to TURBT if muscle invasive disease is suspected
Can also be used for staging in patients with muscle invasive or high risk non muscle invasive bladder cancer
CT urogram and PET-CT may also form part of the staging work up
Why is cystoscopy the diagnostic imaging of choice?
It allows visualisation of the bladder and biopsies to be taken. It may be diagnostic and therapeutic and allow TURBT to be completed.
How are bladder cancers staged?
They are staged using the TNM classification system
It assigns a score for each of the primary tumour, nodal spread (if any) and distant mets
Bladder cancer is divided into muscle invasive and non muscle invasive
How do you treat bladder cancer which is non muscle invasive?
Non muscle invasive bladder cancer can be categorised as low, intermediate and high risk which is based on the grade and the staging of the tumour
TURBT forms the management in non muscle invasive cases, during cystoscopy.
Numerous adjuncts may be used, those with intermediate risk may have a course of intra vesical mitomycin C
Patients with high risk disease will have a repeat TURBT within 6 weeks
How is muscle invasive bladder cancer treated?
Management is complex and dependent on numerous factors! Specialist urology MDTs should review each case to guide management.
In suitable patients neoadjuvant cisplatin chemo may be offered prior to radical cystectomy or radical radiotherapy, the choice should be discussed with the patient.
What is BPH
Hyperplasia- proliferation occuring primarily in the transition zone of the prostate which leads to restriction of the prostatic urethra and urinary flow.
It is characterised by hyperplasia resulting in LUTS
What symptoms does BPH lead to?
Urinary frequency Incomplete emptying Dribbling Hesitancy Nocturia Can also be complicated by acute or chronic urinary retention
What can be used to assess the impact of prostate symptoms due to BPH?
International prostate symptom score
It is a questionare!!
Prostate impact can be categorised as mild, moderate or severe
What investigations would you do for BPH?
Examination- DRE
Bedside- urine dip and MSU, post voidal residual (bladder scan)
Bloods- FBC, U and Es, LFTs (ALP may be raised in bony mets)
PSA
Imaging- USS can be abdominal or transrectal, this can evaluate the size of the prostate, this is also used in patients with urinary retention to evaluate for hydronephrosis
MRI- this tends to be reserved for evaluation and diagnosis of malignancy
Uroflowmetry
What are the options for treatment of BPH?
Conservative- watchful waiting
Medical:
Alpha blockers- tamsulosin
Inhibit the action of noradrenaline on smooth muscle in the prostate resulting in reduced tone
5-alpha reductase inhibitors (finasteride) reduce the production of Dihydrotestosterone which mediate androgen effects on the prostate.
Surgical:
TURP transurethral resection of the prostate
TUIP transurethral incision of the prostate
Etc
How do you treat acute and chronic retention caused by BPH?
Acute= catheterisation, urology review and work up, on first occasion a patient may be stared on alpha blocker and discharged with TWOC
Chronic= catheterised, particularly where there is renal impairment or hydronephrosis
Often surgery is advised, however intermittent self catheterisation or a long term catheter can be used.
What is the most common kidney cancer in adults?
Renal cell carcinoma
How does renal cell carcinoma present?
Haematuria Loin pain Loin mass and fever Feeatures of paraneoplastic syndrome Found incidentally on abdo imaging
