Urology

Question 1

Haematuria:

Answer 1

More likely to find pathology in visible or non visible symptomatic.
Hx- Nature of bleeding? Beginning (bladder neck/urethra), throughout, end (prostate).
Other symptoms? Dysuria? (Infection) frequency? Loin pain? Bladder pain? (Infection, cancer) perineal pain? (Prostatitis)
Previous urinary problems?

Question 2

Haematuria examination:

Answer 2

Abdomen exam
PSA
DRE 
PV (vaginal examination in women)
BP

Question 3

Haematuria investigations:

Answer 3

Urine dip (not as reliable in >65yrs) with urine for culture
Asymptomatic non visible haematuria take two samples, if one -ve and one +ve then take another. Unless higher risk then one suffices.
Urine cytology only useful in visible, since lots false +ve.
PSA
U+Es
CT KUB (non contrast- good for stones)
USS (simple, cheap, good for renal masses)
CT with contrast (good for TCC, renal masses)
Flexible cystoscopy (bladder cancer low and high risk)

Asymptomatic NVH- KUB XR and USS
VH- CT with contrast

Question 4

Haematuria causes:

Answer 4

Nephrological
Upper tract- stones, TCC (5%), RCC, trauma
Bladder- TCC, stones, infection
Prostate- cancer, infections

Question 5

Bladder cancer:

Answer 5

TCC most common.
RF: Smoking, printing, chemical exposure, male, schistosomiasis- causes chronic irritation (SCC), bladder irritation.
Adenocarcinoma- <1% where urachus is patent.

Question 6

TCC:

Answer 6

Superficial don’t have much p53 mutations, but recur. (PTA- just superficial) TURBT + mitomycin C wash after the first resection to reduce recurrence.
Muscle invasive are much more aggressive. Options include radical cystectomy (if fit) or radiotherapy. Give neoadjuvant chemo before both to reduce the chance of mets. Also remove the prostate and urethra depending on the location of the tumour.
If younger and fitter and MI not in the bladder neck, do a bladder reconstruction.
If metastatic disease give chemo instead of radical treatment.
Advanced disease consider palliative
STOP SMOKING

Question 7

TCC group in the middle:

Answer 7

Signs of being aggressive but not yet muscle invasive.
G3 T1
Half will become invasive- high risk.
Could potentially offer younger and fitter pt cystecomy.
Less fit pt will resect the tumour and offer BCG (more effective than mitomycin c). Will lead to an immune response since its foreign, therefore the immune system will attack the bladder cancer cells. Quite toxic.
1 a week for 6 weeks, then gap for few weeks then 1 week for 3 weeks. Then 1 every 3 months for 3 yrs.

Also in carcino in situ use BCG induction dose.