Urology

Question 1

how common is testicular cancer?

Answer 1

• <1% call new cancer in UK are testicular cancer
• incidence is highest in males aged 30-34
• most common solid cancer in men aged 20-45, rare below 15 and above 60

Question 2

what can be secreted by testicular cancers to pick it up on blood tests?

Answer 2

• AFP - secreted by foetal yolk sac, liver and GI tract and appears in high levels in foetal blood
  
  • secreted in non-seminomatous germ cell tumours like embryonal, yolk and teratoma

Question 3

how are testicular cancers classified?

Answer 3

• germ cell: seminoma good prognosis, non-seminomatous which metastasises early
• non germ cell: leading or Sertoli cell

Question 4

what are some risk factors for testicular cancers?

Answer 4

history of cryptorchidism
Fix
racial origin - caucasian and Northern Europeans
maternal oestrogen
hx of sub fertility
contralateral cancer
HIV & seminoma

Question 5

how does testicular cancer present?

Answer 5

• most common - testicular lump
  
  • unilateral, painless
  • irregular, firm and fixed with no transillumination
• evidence of metastasis - WL, back pain (retroperitoneal mets) and dypnoea

Question 6

what are some differential diagnoses for a testicular lump?

Answer 6

• tumours - seminoma or non-seminomatous germ cell tumours
• epididymal cysts or spermatocele
• trauma
• haematoma
• torsion
• epididymitis
• orchitis
• strangulated hernia

Question 7

how is a testicular lump investigated?

Answer 7

USS scrotum
CXR
bloods - FBC, U&E, LFT
tumour markers - AFP, LDH, bHCG
*urology MDT
trans-scrotal percutaneous biopsy
urgent radical inguinal orchidectomy +/- prosthesis
sperm banking - pre-orchidectomy and chemo
CT CAP - ideally 1/52 after orchidectomy

Question 8

how is testicular cancer staged?

Answer 8

royal Marsden classification

Question 9

how is testicular cancer treated?

Answer 9

• MDT - surgery, radiotherapy, chemo
• surgery - inguinal radical orchidectomy with fertility steps taken
• NSGCT - orchidectomy, adjuvant chemo for vascular invasions, surveillance imaging and tumour markers
  
  • mets - chemo
• seminomas - orchidectomy and surveillance monitoring, adjuvant chemo for high relapse risk
  
  • surveillance includes regular examinations, surveillance CT, tumour markers
  • mets - radiotherapy, chemo

Question 10

what is the prognosis for testicular cancer?

Answer 10

• 91% survive for 10+ years
• depends on tumour type and stage
• 5 year survival of patient with metastatic seminoma 88-95%

Question 11

what is the pathophysiology of bladder cancer?

Answer 11

• urothelial carci
  noma - AKA TCC *common
• squamous cell - inner lining of bladder, can be caused by long term irritation or infection with schistosomiasis
• adenocarcinoma - glandular cells in lining of bladder that make mucus
• small cell - neuroendocrine cells

Question 12

what are some classifications for bladder cancer?

Answer 12

• non-muscle invasive - do not penetrate deeper layers of bladder wall
• muscle invasive - penetrates into deep layers
• metastatic - beyond bladder wall distally

Question 13

what are some causes of haematuria?

Answer 13

• kidney - tumour, trauma, stones, infection, nephropathy, PCKD
• ureter - tumour, stone, stents, strictures
• bladder - stones, cystitis, radiation cystitis, infection and trauma
• prostate - tumour, prostatitis, BPH
• urethra - stricture, foreign bodies

Question 14

what are some risk factors of haematuria?

Answer 14

• aromatic amine and dye use in occupation
• smoking
• infections - recurrent UTI, schistosomiasis and squamous cell carcinoma, untreated kidney stones
• previous treatments - cyclophosphamide, radiotherapy to pelvis
• industrial carcinogens used in industries like rubber, leather, hairdresser, textile, painting carcinogen exposure
  
  • up to 25y latency
• FHx
• diabetes - pioglitazone link

Question 15

what would the presentation be like for bladder cancer?

Answer 15

• 85% visible or non-visible haematuria
• dysuria
• frequency and urgency
• poor flow
• recurrent infections
• lower back pain u/L
• supra-pubic pain
• constitutional sx - WL, loss of appetite, night sweats etc

Question 16

how is bladder cancer staged and graded?

Answer 16

grading - 1 to 3 of well to poorly differentiated

staging - TNM

Question 17

what are the investigations carried out for bladder cancer?

Answer 17

• Hx taking including occupation, DHx
• urinalysis and cytology
• FBC, U&E, PSA
• DRE
• USS KUB
• flexible cystoscopy +/- biopsies
• CT KUB or urogram (eGFR dependent)
• CT chest, abdo, pelvis if muscle invasive

Question 18

what are the management options available for bladder cancers?

Answer 18

low risk - surveillance cystoscopies

intermediate - MMC or BCG
*MMC - anti-tumour abx
*BCG - attaches to urothelium leading to immune response

high risk - cystectomy
*TURBT

Question 19

how would you manage non-muscle invasive vs muscle invasive?

Answer 19

non - resection via TURBT as superficial

muscle invasive - radical cystectomy then radiotherapy

Question 20

how are those with bladder cancer followed up?

Answer 20

• cystoscopy at 3 months and then 5 years followed up!
• superficial have high rate of recurrence with 70% recurring within 3 years
  
  • more likely to be invasive
  • require routine follow-up with regular surveillance via cytology and cystoscopy

Question 21

what is the pathophysiology of renal cancers?

Answer 21

*RCC isadenocarcinoma of the renal cortex, arising predominantly from the proximal convoluted tubules, most often appearing in theupper pole of the kidney

85% renal tubular epithelial

Question 22

how do renal cancers spread?

Answer 22

• direct extension to adrenals through renal capsule, renal vein, IVC, R atrium
• lymphatic spread - hilar, para-aortic nodes
• haematological spread - lung, bone, liver, brain

Question 23

what are the types of renal cancers?

Answer 23

clear cell renal cell carcinoma - 75%
papillary renal cell carcinoma
chromophobe renal cell carcinoma
collecting dust carcinoma.

Question 24

what is the most common presenting compliant of renal cancer?

Answer 24

• 50% incidental
• 50% haematuria
• <10% classic traid - haematuria, pain and abdominal mass
• PUO

Question 25

what are some risk factors of renal cancers?

Answer 25

• Genetic
  
  • von-hippel-lindau (VHL) gene which is autosomal dominant
  • protein polybromo-1 (PRMR-1)
• smoking
• metabolic syndrome
• chronic analgesic use
• renal failure and dialysis

Question 26

what is the clinical presentation of renal cancers?

Answer 26

triad - haematuria, loin mass, loin pain
B sx
PUO
L varicocele
paraneoplastic syndromes

Question 27

why might renal cancers present with a left varicocele?

Answer 27

obstruction of L-testicular vein due to tumour in L. renal vein

Question 28

what paraneoplastic syndromes might you see in renal cancer?

Answer 28

anaemia - haematuria
polycythaemia - EPO
HTN
hypoglycaemia
cushings
hypercalcaemia
ectopic gonadotropins
stuffers syndrome

Question 29

how is renal cancer staged or graded?

Answer 29

grading - furham
staging - TNM

Question 30

how is a suspected renal cancer investigated?

Answer 30

• FOC
• urinalysis
• USS
• CT chest abdo pelvis
• FBC, U&E, LFT
• MRI - if features not clear on CT
• biopsy - depending on size, MDT discussion, before partial nephrotectomy or cryotherapy
• renogram - concern over function of contra-lateral kidney
• bone scan if mets suspected

Question 31

how is renal cancers managed?

Answer 31

radical nephrectomy, or partial
surveillance
cryotherapy
nephro-ureterectomy
immunotherapy
chemotherapy
targeted therapy like MAB, TKI

palliative - radiotherapy, embolisation, conservative

Question 32

what is the prognosis of renal cancers?

Answer 32

• 25% have mets at presentation
• nephrectomy undergone survival 70% at 3 years and 60% 5 years
• worse stage = poorer prognosis