Urology Flashcards
Urological cancers
Prostate Kidney Bladder Testis Penile
Risk factors for prostate cancer
Age
FHx
BRCA2
Ethnicity - black African
Presentation of prostate cancer
Asymptomatic - high PSA
LUTS
Suspicious DRE
Bone pain - bone mets
Rare - ejaculatory problems
LUTS
Hesitancy
Weak stream
Frequency
Feeling of incomplete urination
Investigations for prostate cancer
DRE
PSA - before DRE
MRI prostate/pelvis before biopsy
- helps decide biopsy technique
- may not need biopsy
Biopsy
Methods of prostate biopsy
TRUS - transrectal ultrasound guided biopsy
Transperineal biopsy
TRUS
Targets posterior area of the prostate
Local anaesthetic
Transperineal biopsy
Targets whole area of prostate
General anaesthetic
Common causes of raised PSA
Prostate cancer Urinary infection Prostatitis Enlarged prostate - BPH Acute urinary retention DRE Intercourse
Problem with PSA
Poor sensitivity - false positives
May have prostate cancer but clinically insignificant
Factors influencing prostate cancer treatment
Age DRE Stage PSA - no robotic prostatectomies when > 20 Biopsy result - Gleason grade MRI scan and bone scan - mets
Gleason score and intervention
Intervention when 3 + 4 or > 8
Castrate resistant prostate cancer
Metastatic prostate cancer
Androgen independent prostate cancer
Metastatic prostate cancer
Bone metastasise - osteoblastic therefore sclerotic
Likely if PSA >20
Treatment of prostate cancer
Hormones (medical castration) - LHRH agonists
Surgical castration
LHRH agonists
LH normally has a pulsatile release
Initial LH flare - more symptomatic therefore give anti-androgen for first 28 days to prevent the flare
Then decreases as downregulated
Palliative options for prostate cancer
Single dose radiotherapy
Bisphosphonates - zoledronic acid
Caution with LHRH antagonists
Can cause anaphylaxis as similar structure to histamine
Treatment of metastatic castration resistant prostate cancer
Add antiandrogen - bicalutamide
Consider prednisolone + docetaxel chemo if good performance status
Locally advanced prostate cancer treatment (no mets)
Radical radiotherapy with adjuvant hormones
Treatment of localised prostate cancer
Active surveillance
Radical prostatectomy - robotic
Radiotherapy - external beam or brachytherapy
Palliative treatment for localised prostate cancer
Deferred hormones - watchful waiting
Prostate screening
Opportunistic screening if patients are counselled
Problems with prostate cancer screening
Lead time bias Length time bias Overdiagnosis Over treatment - side effects Not cost effective
Lead time bias
Identifying the disease earlier does not affect the prognosis however it seems that there are more years of survival
Length time bias
Overestimation of survival duration because prostate cancer can be asymptomatic and slowly progressing with a better prognosis.
More aggressive diseases are asymptomatic for a shorter period and are detected after giving symptoms
Haematuria types
Visible
Non visible - seen on dipstick
When to refer haematuria
40+ with unexplained visible haematuria
65+ with unexplained non visible haematuria
Differentials for haematuria
Cancer:
- RCC
- TCC
- Bladder carcinoma
- Advanced prostate cancer
Other:
- renal stones
- UTI
- glomerulonephritis
- pyelonephritis/ cystitis
- BPH
Investigations for haematuria in secondary care
Radiology - USS
Urine - cytology
Flexible cystoscopy
Investigations for haematuria in primary care
Bloods - U+Es, albumin/creatinine ratio
MSU - dipstick
Presentation of testicular cancer
Lump in body of testis
Painless
When to refer for 2 ww for testicular cancer
Testicular lump
What happens in a 2 ww referral
Urgent USS of scrotum
Testis tumour markers
Testis tumour markers
AFP
Beta - hCG
LDH
Risk factors for penile cancer
Risk factors for STIs
FHx
When to suspect penile cancer
Excluded STI
Lump/ulcer/lesion is persistent despite treatment
Recurrent balanitis and phimosis
Risk factors for bladder cancer
Persistent irritation - indwelling catheter, recurrent bladder stones
Schistosomiasis
Overflow incontinence
Occupational exposure
- rubber or plastic manufacture - arylamines
- carbon/crude oil - polyaromatic hydrocarbons
- painters, mechanics, hairdressers
Smoking
Male
White
Types of bladder cancer
TCC
Squamous cell carcinoma - schistosomiasis
Treatment of bladder cancer
TURBT - transurethral resection of bladder cancer
Single intravesical instillation of mitomycin
Treatment of intermediate/high risk non muscle invasive TCC
Check cystoscopy
Intravesical chemotherapy/ immunotherapy
Treatment of muscle invasive TCC
Potentially curative - neoadjuvant chemotherapy + radical cystectomy or radiotherapy
Palliative chemotherapy or immunotherapy
Treatment of metastatic TCC
Palliative chemotherapy (cisplatin) or immunotherapy
Types of radical cystectomy
Ileal conduit
Reconstruction - orthotopic
Women - also remove fallopian tubes
Standard treatment of upper urinary tract TCC
Nephro - ureterectomy
Risk factors for RCC
White
Male
Smoking
Obesity
Dialysis
Treatment for localised RCC
Active surveillance
Excision - radical or partial nephrectomy
Radical nephrectomy
Removal of kidney, adrenals, peri-nephritic and upper ureter
Metastatic RCC treatment
Palliative biological targeted therapies - targeting angiogenesis
Types of testicular cancer
Germ cell tumours - seminoma or teratoma
- usually in men < 45 yo
Risk factors of testicular cancer
Undescended testis
Treatment of testicular cancer
Inguinal orchidectomy
Which lymph nodes does scrotal cancer spread to
Inguinal lymph nodes
Which lymph nodes does testicular cancer spread to
Para - aortic
What type of cancer is penile cancer
Squamous cell carcinoma
Risk factors for penile cancer
Phimosis
HPV 16 and 18
