Urological Cancers

Question 1

What is the epidemiology of kidney cancer?

Answer 1

13,100 new kidney cancer cases in the UK every year
7th most common in the UK
Incidence and mortality rates are rising

Question 2

What are the different types of kidney cancers?

Answer 2

Renal Cell Carcinoma (RCC / adenocarcinoma) = 85%
Transitional cell carcinoma = 10%
Sarcoma / Wilms tumour / other types = 5%

Question 3

What are the risk factors for kidney cancer?

Answer 3

Smoking
Renal failure and dialysis
Obesity
Hypertension
Genetic predisposition with Von Hippel-lindau syndrome - (50% of individuals will develop RCC

Question 4

How does kidney cancer present clinically?

Answer 4

Haematuria
Loin pain
Palpable mass
Matastatic disease symptoms - bone pain, haemoptysis

Question 5

What is the red flag symptom clinically for kidney cancer?

Answer 5

Painless haematuria - esp. painless because if it is painful, it is also likely to be an infection etc.
OR
Persistent microscopic haematuria

Question 6

What is the first line investigation with anyone presenting with the red flag symptoms of (painless OR persistent non-visible microscopic) haematuria?

Answer 6

Painless =
Flexible cystoscopy (looks at bladder and urethra) 
CT urogram  (looks at kidneys and ureter- doesn't fully look at bladder)
Renal function 

Persistent non-visible haematuria =
Flexible cystoscopy
USS KUB (ultrasound scan kidneys, ureter, and bladders)

Question 7

What investigations are done next if the first line imaging shows suspected kidney cancer?

Answer 7

CT renal triple phase (corticomedullary, nephrogenic and renal phase- allows you to see urinary tract at different times)
Staging CT chest
Bone scan if symptomatic

Question 8

How is kidney cancer staged using the TNM staging or Fuhrman grade system?

Answer 8

TNM staging of RCC =
T1 – Tumour ≤ 7cm
T2 – Tumour >7cm
T3 – Extends outside kidney but not beyond ipsilateral adrenal or perinephric fascia
T4 – Tumour beyond perinephric fascia into surrounding structures
N1 – Met in single regional LN
N2 – met in ≥2 regional LN
M1 – distant met

Fuhrman grade =
1 = well differentiated (not worrying)
2 = moderate differentiated
3 + 4 = poorly differentiated

Question 9

How is kidney cancer managed?

Answer 9

Patient specific - depends on:

• ASA status (can they tolerate anasthsia and surgery)
• comorbidities
• classification of the lesion itself - staging and metastases

Gold standard = excision of partial or whole kidney (takes out ureter too)
AKA partial or radical (entire thing) nephrectomy

Question 10

When is partial nephrectomy chosen over radical nephrectomy?

Answer 10

Partial = if they have a single functioning kidney, bilateral tumour, multifocal (multiple small lesions) RCC in patients with Von Hippel Lindau, a small tumour (T1 tumours up to 7cm) etc.

Question 11

What is the management for patients with small tumours that are unfit for surgery?

What is the management for patients with metastatic disease?

Answer 11

In patients with small tumours unfit for surgery = cryosurgery (use of extreme cold to destroy abnormal tissues e.g. using liquid nitrogen)

Metastatic disease = Receptor Tyrosine Kinase inhibitors

Question 12

What is the epidemiology for bladder cancer?

Answer 12

10,200 new bladder cancer cases in the UK every year
11th most common cancer in the UK
Incidence and mortality declining (more screening, less smokers)

Question 13

What are the different types of bladder cancer?

Answer 13

Transitional cell carcinoma = >90%
Squamous Cell Carcinoma = 1-7% (75% SCC where schistosomiasis is endemic)
Adenocarcinoma = 2%

Question 14

What are the main risk factors for bladder cancer?

Answer 14

Smoking
Occupational exposure e.g. aromatic hydrocarbons, dye industry etc., less of an issue now with better regulations
Radiotherapy - for other conditions
Chronic infections - e.g. long-term catheters, gallstones, schistosomiasis (parasitic flatworms)

Question 15

How does bladder cancer present clinically?

Answer 15

Haematuria
Suprapubic pain
Lower urinary tract symptoms
Metastatic disease symptoms - bone pain, lower limb swelling

Question 16

What is the main red flag sign clinically for bladder cancer?

Answer 16

Painless haematuria - esp. painless because if it is painful, it is also likely to be an infection etc.
OR
Persistent microscopic haematuria

Question 17

What is the first line investigation with anyone presenting with the red flag symptoms of (painless OR persistent non-visible microscopic) haematuria?

Answer 17

Painless visible =
Flexible cystoscopy
CT urogram
Renal function

Persistent non-visible / microscopic =
Flexible cystoscopy
Ultrasound (USS) kidneys, ureters, and bladders (KUB)

Question 18

What investigations are done next if the first line imaging shows suspected bladder cancer?

Answer 18

Cystoscopy = camera placed via urethra to look into bladder and biopsy of lesion
Biopsy - check for muscle invasion

Question 19

How is bladder cancer staged using the TNM system and WHO classification?

Answer 19

TNM system =
Staged in terms of invasion into the bladder mucosa:
Ta – non invasive papillary carcinoma
Tis – carcinoma in situ
T1 – invades subepithelial connective tissue
T2 – invades muscularis propria
T3 – invades perivesical fat
T4 – prostate, uterus, vagina, bowel, pelvic or abdominal wall
N1 – 1 LN below common iliac birufication
N2 - >1 LN below common iliac birufication
N3 – Mets in a common iliac LN
M1- distant mets

WHO system =
G1 = well differentiated
G2 = moderate differentiated
G3 = poorly differentiated

Question 20

What is one method of resecting a bladder lesion?

Answer 20

cystoscopy and transurethral resection

Use cystoscope to look at the bladder lesion
Then use heat to cut out all visible bladder tumour

Provides histology and can also be curative - but if the tumour extends beyond muscle then the resection is incomplete due to risk of perforating the bladder

Question 21

What is the management protocol for bladder cancer?

Answer 21

Muscle invasive =
Cystectomy (removal of part or whole bladder)
Radiotherapy (sometimes neoadjuvant radio/chemo before therapy)
+/- chemotherapy
Palliative treatment

Non-muscle invasive =
If low grade and no concerns over carcinoma in situ (CIS), then consideration of cystoscopic surveillance
Then use heat and cauterise to excise lesion OR intravesical chemotherapy or BCG (immunological therapy) to limit progression of the lesion

Question 22

What is the epidemiology of prostate cancer?

Answer 22

48,500 new prostate cancer cases in the UK every year
Most common cancer in men within the UK
Incidence rising but mortality rates declining (PSA screening)

Question 23

What are the different types of prostate cancer?

Answer 23

Adenocarcinoma = >95%

Question 24

What are the risk factors for prostate cancer?

Answer 24

Increasing age
Western nations (Scandinavian countries)
Ethnicity - particularly African Americans

Question 25

How does prostate cancer present clinically?

Answer 25

Often asymptomatic unless metastatic

Question 26

So how is prostate cancer usually found?

Answer 26

Via routine prostate screening -

PSA blood test = looks for PSA in the blood

Question 27

What is the issue with using PSA as a marker for prostate cancer?

Answer 27

PSA is prostate specific but not prostate cancer specific - it can be elevated in other conditions e.g. UTI, prostatitis

Question 28

What is the next line of investigation if blood tests show elevated PSA?

Answer 28

MRI =
Imaging prior to biopsy testing

Historically= random biopsies of the prostate meant high detection of low rate prostate cancer and low detection of high grade pc
Now with imaging before biopsy = allows for more specific detection of high grade lesions - better idea of lesion locations

Multiparametric MRI before biopsy and MRI targeted biopsy is superior to the previous gold standard of transrectal ultrasonography-guided prostate biopsies

Question 29

How are prostate biopsies taken?

Answer 29

Previously = trans rectal
Now = trans perineal due to lower infection risk and perineal route gives access to all parts of the prostate

Question 30

How is prostate cancer staged and graded using TNM staging and the gleason score?

Answer 30

TNM staging =
T1 – non palpable or visible on imaging
T2 – palpable tumour
T3 – beyond prostatic capsule into periprostatic fat
T4 – tumour fixed onto adjacent structure/pelvic side wall
N1 – regional LN (pelvis)
M1a-  non regional LN
M1b- bone
M1x- other sites

Gleason = compare prostate imaging to a normal prostate
Take 2 scores due to variability (looks at top two most common patterns and adds their scores)
Both scores are added together

Since multifocal two scores based on level of differentiation
2-6 = Well differentiated
7 = Moderately differentiated
8 = Poorly differentiated

Question 31

How is prostate cancer managed?

Answer 31

If:
Young and fit:
High grade cancer –> radical prostatectomy / radiotherapy = high curative rate but high risk of side effects- many delicate surrounding structures e.g. erectile dysfunction, urinary incontinence

Low grade –> active surveillance via regular PSA testing, MRI and biopsy

Post prostatectomy - monitor PSA (should be undetectable / <0.01 ng/ml, if it rises above 0.2 ng/ml then relapse

Old (life expectancy <5-10yrs) and/or unfit:
High grade / metastatic –> hormone therapy- many side effects, also only temporary so works as palliative care
Low grade –> watchful waiting via regular PSA testing as they are more likely to die from other co-morbidities than the prostate cancer so not worth treating

Question 32

What are the treatment side effects?

Answer 32

High risk of urinary continence and erectile dysfunction

The prostate contains the proximal sphincter

Prostatectomy removes the proximal urethral sphincter and changes urethral length

Risk of damage to cavernous nerves (innervation to bladder and urethra)

Damage to cavernous nerves causes ED (erectile dysfunction)

Question 33

How is UI fixed?

Answer 33

Pelvic floor exercises to strengthen the muscles around that area

Artificial urinary sphincter

Question 34

How is ED fixed?

Answer 34

Hormone therapy
Prostaglandin injections into the penis
Penile prosthesis