Urological Surgery Flashcards
1
Q
What is obstructive uropathy?
A
- Obstructive uropathy is blockage of urinary flow, which can affect one or both kidneys depending on the level of obstruction.
- If only one kidney is affected, urinary output may be unchanged and serum creatinine can be normal.
- When kidney function is affected, this is termed obstructive nephropathy.
- Hydronephrosis refers to dilation of the renal pelvis and can be present with or without obstruction
2
Q
What are some of the symptoms of obstructive uropathy?
A
- Flank pain
- Fever
- Lower urinary tract symptoms
- Distended abdomen/palpable bladder
- Inability to urinate
- Enlarged or hard nodular prostate on rectal examination
- Costovertebral angle tenderness
3
Q
What are some of the causes of obstructive uropathy? How would these be classified?
A
- Luminal: stones, blood clot, sloughed papilla, tumour: renal, ureteric, or bladder
- Mural: congenital or acquired stricture, neuromuscular dysfunction, schistosomiasis
- Extra-mural: abdominal or pelvic mass/tumour, retroperitoneal fibrosis, or iatrogenic—eg post surgery
4
Q
What are some of the RFs for urological surgery?
A
- BPH
- Constipation
- Medication (anticholinergic agents, narcotic analgesia, alpha receptor agonists)
- Urolithiasis (ureteric calculi)
- Spinal cord injury, Parkinson’s disease, or multiple sclerosis
- Malignancy
5
Q
What investigations should be considered for obstructive uropathy?
A
- Bedside: urine dipstick, pregnancy for female, urine MC+S
- Bloods: FBC, UE, CRP, PSA, CK,
- Others to consider: tumour markers (CEA, CA125))
- Imaging: renal USS, CT (if there is hydronephrosis or hydroureter)
6
Q
How would you manage obstructive uropathy?
A
Upper Tract Obstruction
- 1st: analgesia (diclofenac) and rehydration (IV fluids)
- 2nd: ureteric stent or nephrostomy
- alpha blockers e.g. tamsulosin
- Abx (if needed) e,g, gentamycin
Lower Tract Obstruction
- Urethral or suprapubic catheter - Monitor weight, fluid balance, and u&e closely
- After 2-3 days TWOC
7
Q
What are renal stones and who do they affect?
A
- Renal stones (calculi) consist of crystal aggregates.
- Stones form in collecting ducts and may be deposited anywhere from the renal pelvis to the urethra
- 2-3% of the Western population.
- Males <65yrs
- They can form as both renal stones or ureteric stones
8
Q
Where do kidney stones commonly form?
A
- Pelviureteric junction
- Pelvic brim
- Vesicoureteric junction.
9
Q
What types of kidney stones do you get?
A
- Calcium oxalate (75%).
- Magnesium ammonium phosphate (struvite/triple phosphate; 15%).
- Also: urate (5%), hydroxyapatite (5%), brushite, cystine (1%), mixed.
10
Q
How do kidney stones present generally?
A
- Can be assymptomatic
- Pain: ‘loin to groin’ (or genitals/inner thigh), with
- Nausea/vomiting.
- Cannot lie still
- Haematuria
- Proteinuria
- Sterile pyuria
- Anuria
11
Q
Depending on where the stone is obstructed, what type of symptoms do you get?
A
- Obstruction of kidney: felt in the loin, between rib 12 and lateral edge of lumbar muscles (like intercostal nerve irritation pain; not colicky, worsened by specific movements/pressure on a trigger spot).
- Obstruction of mid-ureter: mimic appendicitis/diverticulitis.
- Obstruction of lower ureter: sx of bladder irritability. Pain in scrotum, penile tip, or labia majora.
- Obstruction in bladder or urethra: pelvic pain, dysuria, strangury (desire but inability to void) ± interrupted flow.
12
Q
How do the stones appear depending on their composition?
A
- Calcium (oxolate, phosphate) - radio-opaque (spikey, smooth)
- Magnesium ammonium phosphate (struvite) - stag horn calculi, radio-opaque
- Urate - radio lucent
13
Q
Why do kidney stones appear?
A
- Over-saturation of urine
- High levels of purine in the blood (diet, haematological disorders)
14
Q
What are some of the more specific reasons kidney stones appear?
A
- Diet: chocolate, tea, rhubarb, strawberries, nuts, and spinach (↑oxalate)
- Season: variations in calcium and oxalate levels mediated by vitamin d synthesis
- Work: Water consumption (can they hydrate regularly)
- Medications: diuretics, antacids, acetazolamide, corticosteroids, theophylline, aspirin, allopurinol, vitamin c and d, indinavir.
15
Q
What are some of the predisposing factors to kidney stones?
A
- Recurrent UTIs (magnesium ammonium phosphate )
-
Metabolic abnormalities:
- Hypercalciuria/hypercalcaemia, hyperparathyroidism, neoplasia, sarcoidosis, hyperthyroidism, Addison’s, Cushing’s, lithium, vitamin d excess
- Hyperuricosuria/↑plasma urate: on its own, or with gout
- Cystinuria
- Renal tubular acidosis
- Urinary tract abnormalities: PUJ obstruction, hydronephrosis, horseshoe kidney, vesicoureteric reflux, ureteral stricture
- Foreign bodies: cathetar, stents
- FMH: ↑3-fold
16
Q
What investigations are needed for diagnosis of kidney stones?
A
- Urine dipstick: Usually +ve for blood (90%) (non visible haematuria)+ mc&s
- Bloods: fbc, u&e, Ca2+, po43−, glucose, bicarbonate, urate
- Urine pH; 24h urine for: calcium, oxalate, urate, citrate, sodium, creatinine; stone biochemistry (sieve urine & send stone)
-
Imaging:
- GOLD STANDARD: CT KUB (high sensitivity and specificity)
- AXR - sometimes used for initial assessment, - will only show radio opaque stones (80% but not all)
- USS (hydronephrosis)
17
Q
What would the initial management be for kidney stones?
A
- IV fluid resuscitation
- Analgesia: PR diclofenac 100mg
- If infection: Abx (eg piperacillin/tazobactam 4.5g/8h iv, or gentamicin)
- Anti emetic: ondansetron
- ↑Fluid intake
Renal stones will pass spontaneously if in the lower ureter or <5mm in diameter
Unless pregnant: remove stones via Ureteroscopy
18
Q
When should you admit a patient for kidney stones?
A
- Post-obstructive AKI
- Uncontrollable pain from simple analgesics
- Infected stone(s)
- Large stones (>5mm)
19
Q
What management is required for stones >5mm or pain not resolving?
A
Medical expulsive therapy:
- α-blockers (tamsulosin 0.4mg/d) - Most pass within 48h
- ESWL (extracorporeal shockwave lithotripsy) - US waves shatter stone. Small stones: <2cm, performed via radiological guidance (either X-ray or USS). SE: renal injury, may also cause ↑bp and dm
- PCNL (Percutaneous nephrolithotomy): Keyhole surgery to remove stones, when large, multiple, or complex. For: large renal stones (including staghorn calculi).
- URS (Flexible uretero-renoscopy) - passing a scope retrograde up into the ureter, allowing stones to be fragmented through laser lithotripsy and fragments removed
20
Q
How are kidney stones prevented generally and specifically?
A
Generally
- Drink plenty
- Normal dietary Ca2+ intake
Specifically:
- Calcium stones: thiazide diuretic to ↓Ca2+ excretion.
- Oxalate: ↓oxalate intake; pyridoxine
- Struvite (phosphate mineral): treat infection
- Urate: allopurinol (100–300mg/24h po)
- Cystine: vigorous hydration and urinary alkalinization
21
Q
How is obstructive nephropathy or significant infection secondary to renal stones managed?
A
- Retrograde stent insertion is the placement of a stent within the ureter, approaching from distal to proximal via cystoscopy
- Nephrostomy is a tube placed directly into the renal pelvis and collecting system, relieving the obstruction proximally
22
Q
What are the nice guidelines for urological referral (haematuria)?
A
- Aged ≥45yrs with either:
- Unexplained visible haematuria without urinary tract infection
- Visible haematuria that persists or recurs after successful treatment of urinary tract infection
- Aged 60yrs with have unexplained non‑visible haematuria and either dysuria or a raised white cell count on a blood test.
23
Q
How is haematuria classified?
A
- Visible haematuria
-
Non-visible haematuria (NVH): Blood is present in the urine on urinalysis, but not visible. Further categorised:
- Symptomatic non-visible haematuria (s-NVH): with associated symptoms, e.g. suprapubic pain or renal colic.
- Asymptomatic non-visible haematuria (a-NVH): + no associated symptoms.
24
Q
What are some causes of haematuria?
A
- Infection, including pyelonephritis, cystitis, or prostatitis
- Malignancy, including urothelial carcinoma or prostate adenocarcinoma
- Renal calculi
- Trauma or recent surgery
- Radiation cystitis
- Parasitic, most commonly schistosomiasis
25
How would you investigate haematuria?
* Bedside: urine dipstick
* Bloods: FBC, UE, CRP, clotting, PSA, tumour markers
* Imaging: USS KUB, CT urogram
* Specialist: **flexible cystoscopy** - gold standard , urine cytology
26
How would you investigate acute urinary retention?
* Examination: palpate bladder, PR exam (check for constipation
* Bedside: **post-void bedside bladder scan**, dipstick
* Bloods: FBC, CRP, and U&Es . Post-catheterisation (see below), a CSU (Catheterised Specimen of Urine)
* Imaging: USS
27
What are some of the causes of acute urinary retention?
* **Obstructive**: BPH, urethral strictures or prostate cancer.
* **Infections**: UTI
* Constipation
* **Medications**: anti-muscarinics or spinal or epidural anaesthesia
* **Neurological**: peripheral neuropathy, iatrogenic nerve damage during pelvic surgery, upper motor neurone disease (such as Multiple Sclerosis Parkinson’s disease), or Bladder Sphincter Dysinergy
28
What are some of the possible complications of obstructive uropathy?
* **Hyperkalaemia**
* **Metabolic acidosis**
* **Post obstructive diuresis** - lots of wee
* **Na and Bicarb losing nephropathy** - as kidneys under diuresis large amounts are lost from kidney. Replace bicarb
* **Infection**
29
What are some of the symptoms of BPH?
* LUTS: post micturition dribbling
* **Voiding symptoms:** hesitancy, weak stream, terminal dribbling, or incomplete empyting
* **Storage symptoms:** urinary frequency, nocturia, nocturnal enuresis, or urge incontinence
30
How do you investigate BPH:
* **Bedside**: urinalysis (to exclude UTI), DRE, post void bladder scan
* **Bloods**: routine + PSA
* **Imaging**: USS, Urodynamic studies
31
How do you treat **BPH**?
* **Conservative**: avoid caffeine + alcohol, relax when voiding. Control urgency by practising distraction methods (eg breathing exercises). Bladder training.
* **Pharmacological:**
1. **Tamsulosin/ doxazosin.** SE: drowsiness; depression; dizziness; ↓bp; dry mouth; ejaculatory failure; extra-pyramidal signs; nasal congestion; ↑weight
2. **5α-reductase inhibitors**: e.g.**finasteride** 5mg/d po
* **Surgical**:
* **TURP**: Transurethral resection of prostate (turp)
* **Transurethral incision of the prostate (TUIP)**: less destruction than turp, and less risk to sexual function, gives similar benefit.
* **Retropubic prostatectomy:** is an open operation (if prostate very large).
* **TULIP**: Transurethral laser-induced prostatectomy
* ? **Robotic prostatectomy** is gaining popularity as a less traumatic and minimally invasive treatment option.
32
What are the complications of BPH? What is TURP syndrome?
**High-pressure retention:** chronic or acute-on-chronic urinary retention results in a **post-renal kidney injury**
**TURP Syndrome:**
* **TURP** with monopolar energy requires use of **hypoosmolar irrigation** during the procedure -\> causes:
* **Fluid overload**
* **Hyponatremia (**must be corrected)
* **Glycine toxicity** as the fluid enters the circulation through the exposed venous beds.
* Pt: confusion, nausea, agitation, or visual changes
Complications: TURP
T syndrome
U rethral stricture/UTI
R etrograde ejaculation
P erforation of the prostate
33
What is prostatitis?
Who does it affect?
How does it present?
How is it investigated?
How is it treated?
* **What**: inflammation of the prostate gland
* **Causative organisms:** E. Coli (most common), Enterobacter, Serratia, Pseudomonas, and Proteus species. STIs - rare cause.
* **Who**: men \< 50yo
* **Presents**: LUTS, pyrexia, perineal or suprapubic pain, or urethral discharge.
* **DRE:** v**ery tender and boggy prostate** +/- inguinal lymphadenopathy; can be chronic (\>3 mo), **perineum** is the most common site for pain
* Ix: Urine culture, **STI** screen and routine bloods (FBC, CRP, and U&Es, **PSA**)
* Other: **transrectal prostatic ultrasound (TRUS)** or **CT imaging** (if abscess suspected)
* Management:
* **1st: analgesia** (paracetemol + ibuprofen/ diclofenac), Abx prolonged (**cefotaxamine**)
* 2nd: **Alpha blockers** or **5a-redictase inhibitors** (chronic)
* +**Cathetar** (if obstructed)
* **Surgical**: if abscess
34
How would you manage acute urinary retention?
* **Immediate urethral catheterisation**
* Monitored post-catheterisation for evidence of ***post-obstructive diuresis.***
* **BPH:** Tamsulosin
* **CSU** for any evidence of infection and treat with antibiotics if needed.
* Review medications: for any potential contributing causes and treat any constipation if present.
* **TWOC**: after 24-48hrs, If the patient voids successfully, with a minimal residual volume, the TWOC is considered successful, whilst if the patient re-enters retention, the patient will require re-catheterisation.
35
What is post obstructive diuresis?
* Can occur after resolution of the retention through catheterisation, the kidneys can often **over-diurese** due to the loss of their medullary concentration gradient, which can take time to re-equilibrate.
* **-\> Worsening AKI**
* Patients producing **\>200ml/hr urine output should have around 50% of their urine output replaced with IVI** to avoid any worsening AKI.
* **Monitor UO** in these patients over the following 24 hours post-catheterisation.
36
What is a hyrocoele?
How will a hydroceoele present?
How should they be investigated?
* Abnormal collection of peritoneal fluid between the parietal and visceral layers of the **tunica vaginalis**
* Presents as: painless fluctuant swelling that will **transilluminate**, either unilateral or bilateral
* **Urgent ultrasound scan**
* **Treatment: nothing**
37
What is a varicocoele?
How will a varicocoele present?
How should they be investigated?
What are the red flag signs?
How should they be managed?
* **What**? Abnormal dilatation of the pampiniform venous plexus within the spermatic cord
* Can be a sign of ***malignancy***
* Can cause ***infertility***
* **Presents**: lump, “bag of worms” or with a “dragging sensation” may disappear on lying flat.
* Examine patient lying down, standing up and whilst performing a valsava manoeuvre.
* **Red flags:** acute onset, right-sided, or remain when lying flat, and should be investigated urgently.
* **Management**:
* Mild varcicoeles do not need intervention and can be managed conservatively
* **If** not: **embolisation** and **surgical** approaches either **open** or **laparoscopic** approach for ligation of the spermatic veins
38
What are **Epididymal Cysts** and how do they present?
How are they treated?
* **What?** Benign fluid-filled sacs arising from the epididymis. Present: smooth fluctuant nodule, found above and separate from the testis that will transilluminate, often they are multiple.
* Who? Middle-aged men.
* Do not require treatment
39
What is **Epididymitis** and how do they present?
How are they treated?
* Unilateral acute onset scrotal pain, swelling, erythematous overlying skin, and systemic symptoms such as fever.
* **Above + behind testis - think of where the epidydymis is)**
* On examination, the epididymis is tender and pain may be relieved on elevation of the testis **(+ve Prehn’s sign).**
* Treatment: oral **antibiotics** and **analgesia**.
40
What are testiticular tumours?
Who gets them?
How do they present?
How are they investigated treated?
* PC: Painless lump arising from testes, unilateral, will not transluminate. Irregular, firm, fixed mass. 5% will report pain (if late presentation):
* **Germ cell tumours** (GCT) (95%)
* **Non-germ cell tumours** (NGCTs) **(BENIGN)** (5%)
* **Seminomas**
* **Non-seminomatous GCTs** (NSGCT)
* RFS: **Cryptorchidism** (undescended testes),testicular malignancy, FH, Kleinfelter’s syndrome.
* Who: Men aged **20-40yrs**
* Ix: **Urgent USS, CT +** contrast chest-abdomen-pelvis, do not biopsy
* Tumours markers: **ßHCG** + **AFP**
* Tr: **Radical inguinal orchidectomy**, +/- chemo
* **Pre-treatment fertility assessment** if of repro age
41
What is epididymitis?
Who does it affect?
How does it present?
How do you investigate it?
How do you treat it?
* **What:** Inflammation of epididymis. Local extension of infection from UTI or STI *(chlamyia or gonorrhea)*
* **Who:** men, bimodal, young **15-30yrs** and old **\>60yrs**
* **Presents:** Fever and rigots**,** dysuria, storage LUTS, urethral discharge. Sexual history? Red and swollen. Tenderness on palpation of epididymis +/- the testis
* C**remasteric reflex: intact**
* **Prehn’s sign -** pain is relieved by elevation of scrotum**: +ve**
* **Investigations:** urine dip, first void bladder scan, STI screening, bloods: FBC, UE, CRP, cultures; USS
* **Management**: Abx (doxy for chlamydia, ceftriaxone for gonorhea) - 2-4 wks, analgesia, abstain
* Complications: **infertility**
42
What is orchitis?
How does it present?
What is the treatment?
* Inflammation of the testis. Rare.
* Cause: **mumps** virus. Often preceded with a history of **parotid swelling**.
* Treatment: rest and analgesia.
* Complications: intra-testicular **abscess** - rare - may require drainage and occasionally orchidectomy.
43
What do inguinal hernias present? How are they treated?
* You **cannot “get above”** an inguinal hernia within the scrotum (i.e. cannot palpate its superior surface)
* A **cough** may exacerbate the swelling and **may disappear upon lying flat**
* All inguinal hernia should be assessed for **strangulation** or **obstruction**.
44
When should patients be referred for prostate cancer?
* **'If a hard, irregular prostate typical of a prostate carcinoma i**s felt on **DRE**, then the patient should be referred urgently.
* The PSA should be measured and the result should accompany the referral.
45
What is Testicular torsion ?
Who does it affect?
How does it present?
How do you investigate it?
How do you treat it?
* **What**? Spermatic cord and its contents twists within the tunica vaginalis, compromising the blood supply to the testicle. Surgical emergency
* **Who**: **neonates** and **adolescents** between the ages of **12-25yrs**. Those with **‘bell-clapper deformity’;** lack normal attachment to the tunica vaginalis and is more mobile
* Present: sudden onset, severe unilateral testicular pain; nausea and vomiting; testis will have a **high position\***
* **Absence** of **cremasteric** reflex
* **-ve Prehn’s sign**
* Diagnosis: doppler USS, urine dip, clinical
* Management:
* **surgical emergency** with a 4-6hrs: **bilateral orchidopexy (**the cord and testis will be untwisted and both testicles fixed to the scrotum)
* Pre op: analgesia and anti-emetics
* **Orchidectomy** if testis is non-viable
46
What are the most common types of renal cancer?
* **RCC:** adenocarcinoma of the renal cortex, **upper pole**
* Can spread through direct invasion in to perinephric tissues, adrenal gland, renal vein\* or the inferior vena cava. RCC can spread via the lymphatic system to pre-aortic and hilar nodes, or by haematogenous sprea
* Other:
* **TCC** (urothelial tumours)
* **Nephroblastoma** in children (Wilm’s tumour)
* **SCC**: chronic inflammation secondary to renal calculi, infection and schistosomiasis
47
What are some of the RFs for renal cancer?
How does renal cancer present?
* smoking
* industrial exposure
* dialysis
* hypertension
* obesity
* Anatomical abnormalities: PCKD, horseshoe kidneys.
* Genetic: von Hippel-Lindau disease (associated with bilateral multifocal toumours), BAP1 mutant disease, and Birt-Hogg-Dube syndrome.
* Presentation: haematuria (visible or non-visible), flank pain, flank mass, or non-specific symptoms, such as lethargy or weight loss
* Left-sided masses may also present with a left varicocoele
* Paraneoplastic syndromes: hypercalcaemia, hypertension due to renin, or pyrexia of unknown origin, or with the clinical features of metastasis (such as haemoptysis or pathological fractures
48
How would you investigate renal carcinoma?
* **Bedside**: urinalysis, send urine for cytology
* **Blood**: FBC, UE, CRP, LFT, calcium
* Imaging: Gold standard: \*\***CT imaging of the abdomen-pelvis pre and post IV contrast**
* **USS**
* **Biopsy**
49
How do you manage RCC?
Management:
Localised - Surgical management (laparoscopic or open)
* **Smaller tumours:** partial nephrectomy
* **Larger**: radical nephrectomy, + remove perinephric fat, and local lymph nodes en bloc.
* **Percutaneous radiofrequency ablation** or **laparoscopic/percutaneous cryotherapy**: if not fit enough for surgical management
**Metastatic:** chemo is useless
* **Nephrectomy** + **immunotherapy** (such as IFN-α or IL-2 agents)
* **Biological agents:** **Sunitinib** (a tyrosine kinase inhibitor) and **Pazopanib** (also a tyrosine kinase inhibitor)
* **Metastasectomy**: surgical resection of solitary metastases is recommended where the disease is resectable and the patient is otherwise well.
50
What are some of the RFs for penile cancer?
How does it present?
How is it managed and investigated?
* **RFS: HPV infection,** phimosis, smoking, lichen sclerosis, untreated HIV infection, Psoralen-UV-A Photochemotherapy (PUVA) treatment (used for some forms of psoriasis and cancer).
* **Circumcision** is deemed protective
* **Presentation**: palpable or ulcerating lesion on the penis, foreskin, penile shaft, and scrotum
* **Investigation**: referred to a specialist regional centre for further investigation, penile biopsy, confirm **inguinal lymphadenopathy** should be determined, typically using **PET-CT imaging** (especially in those with palpable nodes).
* CT chest abdo pelvic: if +ve inguinal lymph nodes
* Management: **complete tumour removal** and oncological control, whilst ensuring as much organ preservation as possible. Management often requires a combination of **surgery**, **radiotherapy**, and **chemotherapy**.
51
What are the different types of urinary incontinence you can get? What are their causes?
* **Stress** - increasing intra abdo pressure.
* **Causes**: constipation (due to recurrent straining), obesity, post-menopausal, or pelvic surgery, weak pelvic floor, pregnancy
* **Management:**
* **C: Pelvic floor exercise** x 3m
* **P: Duloxetine**
* **S**: **Tension-free vaginal tape**
* **Urge** - Detrusor instability/ overactive bladder. rise in intravesical pressure and subsequent leakage of urine
* **Causes**: neurogenic causes (eg stroke), infection, malignancy, or idiopathic. Medication (cholinesterase inhibitors)
* **Management**:
* **C: Bladder training**
* P: Anti muscarinics: **oxybutynin** or **tolterodine**
* **S: botulinum toxin A injections**, perc. sacral nerve stimulation, augmentation cystoplasty
* **Mixed** - Stress and Urge
* **Overflow** - complication of **chronic urinary retention.** Stretching of the bladder wall -\> damage of sacral reflex and loss of bladder sensation.
* Causes: **BPH**
* **Continuous** - **fistulae**.
52
What are the different types of bladder cancer that you can get?
What are some RFs for developing bladder cancer?
* **TCC**: most common, 80-90% cases
* **SCC**
* **Rare**: **adenocarcinoma** + **sarcoma**
Bladder cancers can further be classified into:
* **Non-muscle-invasive bladder cancer** – 70-80%
* **Muscle-invasive bladder cancer** – penetrates deeper layers of the bladder wall
* **Locally advanced or metastatic bladder cancer** – spreading beyond the bladder and distally
* **RF**: smoking, age, exposure to aeromatic hydrocarbons (e.g. industrial dyes or rubbers), schistosomiasis infection (**SCC**), and previous radiation to the pelvis.
53
How would you investigate and manage bladder cancer?
* **\*\*Urgent cystoscopy**
* If suspicious lesion is identified from initial cystoscopy \> **rigid cystoscopy -** under general anaesthetic for more definitive assessment
* Tumours identified will require biopsy and **potential resection** via **transurethral resection of bladder tumour (TURBT**), either on initial assessment (if appears superficial) or following biopsy results
* Imaging: **CT staging**
* **Urine cytology**
54
How are bladder cancers managed?
MDT discussion
* **Carcinoma in-situ or T1 tumours: resected via TURBT: Transurethral Resection of Bladder** **Tumour** - resection of bladder tissue by **diathermy** during rigid **cystoscopy**.
* **High risk disease:** adjuvant **intravesical** therapy, such as Bacille Calmette-Guerin (BCG) or Mitomycin C.
* Or **Radical cystectomy:** high-risk disease or limited response to initial treatments.
* **Superficial bladder tumours:** high rate of **recurrence**, with around 70% recurring within 3 years, and these recurrences are more likely to be more **invasive**. Patients require **routine follow-up** with regular surveillance via **cytology** and **cystoscopy**.
* **Muscle-invasive bladder cancer: radical cystectomy +/- neoadjuvant chemotherapy**, typically with a **cisplatin** combination regimen.
* + **Urinary diversion:**
* **Ileal conduit formation** with urine draining via a **urostomy**
* **Bladder reconstruction**, from a segment of small bowel\* (often termed a neobladder) and urine draining urethrally or via catheter
55
What are the most common types of prostate cancer?
How is prostate cancer investigated?
What scoring system is used?
* **Adenocarcinomas** (\>95%) **- \>**75% of prostate adenocarcinomas arise from the **peripheral zone**
* **Acinar adenocarcinoma (most common)**– originates in the **glandular** cells that line the prostate gland
* **Ductal adenocarcinoma** – originates in the cells that line the **ducts** of the prostate gland
Scoring system: **Gleason Scoring SYstem (lowest 3+3)**
Investigations
* **Bloods: PSA** (can become artificially raised with several other conditions, including BPH, prostatitis, vigorous exercise, ejaculation, and recent DRE, reducing its specificity)
* Can also use free:total PSA ratio, PSA density
* **Biopsies of prostatic tissue**
* **Transperineal (Template) biopsy**: sampling prostatic tissue transperineally in a systematic manner, done as a day case under general anaesthetic. good for **anterior**.
* **TransRectal UltraSound-guided (TRUS) biopsy**: sampling the prostate transrectally, usually under local anaesthetic
* **Repeat prostate biopsy:** after previous negative biopsy is recommended for men with rising or persistently elevated PSA and/or suspicious DRE
