Urological Cancers Flashcards
What investigations are done in anyone presenting with painless haematuria?
Flexible cystoscopy
CT urogram
Renal function
What investigations are done in anyone presenting with persistent non visible haematuria?
Flexible cystoscopy
US KUB
Less associated with cancer than visible
What is grading?
Looks at histology
What does ASA status assess?
How fit a patient is
Describe the epidemiology of bladder cancer?
10,200 new bladder cancer cases in the UK every year
Bladder cancer is the 11th most common cancer in the UK
Incidence and mortality declining
What are the types of bladder cancer?
> 90% of bladder cancer is transitional cell carcinoma
1-7% squamous cell carcinoma (75% SCC where schistosomiasis is endemic)
Adenocarcinoma(2%)
What are the risk factors for bladder cancer?
Smoking
Radiotherapy for other cancers
Chronic inflammation e.g. schistosomaisis
Occupational e.g. dye industry
What are the clinical features of bladder cancer?
Painless haematuria/persistent microscopic haematuria - red flag symptom
Suprapubic pain
Lower urinary tract symptoms
Metastatic disease symptoms –bone pain, lower limb swelling
What is cytoscopy
Excision and biopsy of lesion
What are the TNM staging guidelines for bladder cancer? (T)
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
What are the TNM staging guidelines for bladder cancer? (N)
N1 – 1 LN below common iliac birufication
N2 - >1 LN below common iliac birufication
N3 – Mets in a common iliac LN
What are the TNM staging guidelines for bladder cancer? (M)
N3 – Mets in a common iliac LN
M1- distant mets
How is bladder cancer graded?
G1 = well differentiated G2 = moderate differentiated G3 = poorly differentiate
What is the management protocol for non-muscle invasive bladder cancer?
If low grade and no CIS then consideration of cystoscopic surveillance
+/- intravesicular chemotherapy
BCG - elicits inflammatory response the reduces progression of lesion
What is the management protocol for muscle invasive bladder cancer?
Cystectomy
Radiotherapy
+/- chemotherapy
Palliative treatment
Describe the epidemiology of prostate cancer?
48,500 new prostate cancer cases in the UK every year
Prostate cancer is the most common cancer in men within the UK
Incidence rising but mortality rates declining
What are the types of prostate cancer?
> 95% of prostate cancer is adenocarcinoma
What are the risk factors for prostate cancer?
Age
Western nations
African-americans
What is important about prostate cancer?
Often asymptomatic unless metastatic
What blood test is done to investigate prostate cancer?
PSA is prostate-specific but no prostate-cancer specific
Can be elevated in (UTI, prostatitis)
What has happened in the last 10 years with regards to management?
MRI prior to biopsy
Huge over-detection of low grade lesions that were not issues
Allows for more specific detection of high grade lesions - better idea of lesion locations
How is the biopsy conducted?
Trans perineal prostate biopsy:
Systematic template biopsies of the prostate
Widely used in most centres over transrectal biopsies as less risk of infection and able to sample all areas of the prostate
What are the TNM staging guidelines for prostate cancer? (T)
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
What are the TNM staging guidelines for prostate cancer? (N)
N1 – regional LN (pelvis)
What are the TNM staging guidelines for prostate cancer? (M)
M1a- non regional LN
M1b- bone
M1x- other sites
How is prostate cancer graded?
Gleason score
Since multifocal two scores based on level of differentiation
2-6 = Well differentiated
7 = Moderately differentiated
8 – Poorly differentiated
How is prostate cancer treated in a young, fit person?
High grade cancer Radical prostatectomy/Radiotherapy
Low grade cancer Active surveillance ( Regular PSA, MRI and Bx)
Post prostatectomy – monitor PSA ( should be undetectable or <0.01ng/ml). If >0.2ng/ml then relapse
Why is there hesitancy to treat low grade lesions?
Erectile dysfunction
Urinary incontinence
How is prostate cancer treated in an old/unfit person?
high grade cancer/Metastatic disease Hormone therapy (lower testosterone)
Low grade cancer Watchful waiting (regular PSA testing)
What are the potential side effects of prosatectomy?
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.
What is cytoscopy?
Telescope examination of the bladder done under GA
Can be used to take biopsies and cauterise
What is the difference between watchful waiting and active surveillance?
Both monitoring PSA
Active surveillance for those fit for surgery
Watchful waiting - palliative hormone therapy
How does testicular cancer most commonly present?
Hard, painless nodules
Young adult men (20-34 years)
Gynaecomastia
Hydrocele
What are RFs for testicular cancer?
Cryptochidism FH Prev diagnosis Testicular atrophy White ethnicity HIV infection
What are the investigations for testicular cancer?
US of testis CXR to check for lung mets CT to check for extra-testicular mets (enlarges retroperitoneal lymph nodes) bhCH elevated LDH elevated
What is the initial management for testicular cancer?
Inguinal orchiectomy
Curative in early stages
OR
Testis sparing surgery
1. if wishing to preserve gonadal function
2. if 100% not tumour (markers, examination)
What occurs in TSS?
Multiple biopsies of the ipsilateral testicle normal parenchyma are obtained in addition to the suspicious mass for evaluation
What is the treatment for confirmed seminoma?
orchidectomy
chemotherapy and radiotherapy may be given depending on staging and tumour type
What tumour markers are raised in seminoma?
HCG elevated in 10%
LDH elevated in 10-20%
What is epidiymitis?
Acute inflammation of the epididymis, often involving the testis and usually caused by bacterial infection
Lasts a few days and upto 6 weeks
May be associated with LUTS
What causes epidiymitis?
Infection spreads from the urethra or bladder. In men <35 years, gonorrhoea or chlamydia are the usual infections
Amiodarone can also cause it
What are are the presenting features of epidiymitis?
> 19 yrs
Unilateral scrotal pain and swelling (gradual onset)
Tenderness
Hot, red, swollen hemiscrotum
What are some RFs for epidiymitis?
Unprotected sex
Bladder outflow obstruction
e.g. BPH, urethral stricture
Urethral catheterisation
What are the investigations for epidiymitis?
Gram stain of urethral sections (swab)
Urine dip/microscopy/culture
What is the management for epidiymitis?
Supportive and dependent on cause
e.g.
ABs
Stop amiodarone
What is testicular torsion?
Twist of the spermatic cord resulting in testicular ischaemia and necrosis
Urological emergency
What are the presenting features of testicular torsion?
Most common in males aged between 10 and 30
Pain is usually severe and of sudden onset.
Elevation of testes does not ease pain
Absent cremasteric reflex (lifting of testes on stroking inner thigh)
What are the investigations for testicular torsion?
US
Doppler
What is the management for testicular torsion?
Uro consult for emergency scrotal exploration
Supportive care
+/- prosthetic device
Manual de-torsion
What is the most common cause of scrotal swelling?
Epididymal cysts
separate from the body of the testicle
found posterior to the testicle
What else might cause scrotal pain?
Hydrocele
Varicocele
What is hydrocele?
accumulation of fluid within the tunica vaginalis
What is varicocele?
Abnormal enlargement of the testicular veins
What is erectile dysfunction?
persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance
What are the two categories of causes of ED?
Organic
Psychogenic
What factors favour organic ED causes?
Gradual onset of symptoms
Lack of tumescence
Normal libido
What factors favour
pyschogenic ED causes?
Sudden onset of symptoms Decreased libido Good quality spontaneous or self-stimulated erections Major life events Problems or changes in a relationship Previous psychological problems History of premature ejaculation
What are RFs for erectile dysfunction?
cardiovascular disease risk factors: obesity, diabetes mellitus, dyslipidaemia, metabolic syndrome, hypertension, smoking
alcohol use
drugs: SSRIs, beta-blockers
What investigations are done for erectile dysfunction?
Q-risk check
Free testosterone measured in morning
What is the management for ED?
PDE-5 inhibitors (such as sildenafil, ‘Viagra’)
What are differentials for a groin lump?
Indirect inguinal hernia Direct inguinal hernia Femoral hernia Inguinal lymphadenopathy Psoas abscess/brsa Femoral aneurysm
