Urology 2

Question 1

Prostatic Ca - Definition and Pathology

Answer 1

• The 2nd commonest male malignancy and the incidence increases with age – it affects 80% of those over 80 years of age. It is associated with increased testosterone levels and a positive family history.
• Pathology – most are adenocarcinomas arising in the peripheral prostate. Spread may be local (to seminal vesicles, bladder or rectum) via lymph or haematogenously (e.g. sclerotic bony lesions).

Question 2

Prostatic Ca - Features

Answer 2

* Can be* nocturia, hesitancy, poor stream, terminal dribbling or urinary obstruction.

Weight loss and bone pain suggest presence of metastases on PR there’s a hard, irregular prostate.

Question 3

Prostatic Ca - Diagnosis

Answer 3

Raised PSA (malignant prostate cells produce x10 more PSA – but can be normal in up to 30%), transrectal ultrasound and biopsy, bone x-ray or scan and CT or MRI to detect metastases.

Question 4

Prostatic Ca - TNM Staging

Answer 4

• T1 – tumour identified incidentally at TURP or raised PSA.
• T2 – palpable tumour with extra-capsular extension.
• T3 – spread beyond capsule, mobile.
• T4 – fixed or locally invasive tumour.

Question 5

Prostatic Ca - Management of Local Disease

Answer 5

Radical prostatectomy (open or laparoscopic), radiotherapy or brachytherapy (the placement of radioactive seeds within the prostate) is usually performed in men under 70 years of age with a life expectancy >10 years however the method used remains controversial.

Question 6

Prostatic Ca - Management of Metastic Disease

Answer 6

LHRH agonists e.g. 12 weekly SC goserelin (or oral cyproterone acetate) decrease androgens and help control disease – serial PSA measurements are used to assess response.

Mean survival once metastases are present is 2.5 years.

Symptomatic relief – analgesia, treat hypercalcaemia and radiotherapy for bone mets or spinal cord compression.

Question 7

Prostatic Ca - Screening Problems

Answer 7

The disease very common but in many it would not have affected the patient during his life. A method of detecting which patients will develop metastases would be useful.

Question 8

RCC - Definition

Answer 8

Aka Grawitz tumour – arises from the proximal renal tubular epithelium and accounts for >80% of renal tumours.

Mean age of onset is 55 years, male to female ratio is 2:1 and smoking is a risk factor.

Question 9

RCC - Presentation

Answer 9

• Clinical features – 50% are incidental findings but can present with haematuria, loin pain, abdominal mass, anorexia, malaise or weight loss. Rarely compression of left testicular vein causes a varicocele.
• Kidney vs spleen – the kidney is ballotable, moves down with respiration and is resonant on percussion. The spleen has a notch, moves towards the RIF on inspiration and is dull on percussion.

Question 10

RCC - Investigations

Answer 10

• Blood pressure - raised due to renin secretion.
• Bloods – FBC (polycythaemia due to EPO secretion), ESR, U+Es and ALP (for bony mets) and calcium (raised due to PTH like substance)
• Urine – RBCs and cytology.
• Imaging – US for diagnosus, CT or MRI for staging and CXR (for metastases).

Question 11

RCC - Staging

Answer 11

Robson staging:

• 1 – tumour is confined to the kidney.
• 2 – involves the perinephric fat but not Garota’s fascia.
• 3 – there is spread to the renal vein.
• 4 – there is spread to adjacent or distant organs.

Question 12

RCC - Management

Answer 12

• Radical nephrectomy – remove kidney, fat with Gerota’s fascia ± the adrenal gland.
• Prognosis – the 5 year survival is 45%.

Question 13

Transitional Cell Carcinoma

Answer 13

Can arise in the bladder (50%), ureter or renal pelvis.

It usually occurs over 40 years of age and the male to female ratio is 4:1.

It presents with painless haematuria, frequency, urgency, dysuria or urinary tract obstruction.

Diagnosis is made with urine cytology, IVU, cystoscopy with biopsy and CT scan or MRI.

Question 14

Bladder Ca - Risk Factors

Answer 14

Most cases in the UK are transitional cell carcinoma (98%) as adenocarcinoma and squamous cell carcinoma (often follows schistosomiasis) are rare in the west.

Associated with occupational exposure to chemicals e.g. aromatic amines (in the rubber industry) and analine dyes, chronic cystitis, pelvic irradiation and smoking.

The male to female ratio is 4:1.

Question 15

Bladder TCC - Presentation and Staging

Answer 15

• Presentation – painless haematuria, recurrent urinary tract infections and voiding irritability.
• TNM staging – Tis – carcinoma in situ, Ta – confined to the epithelium, T1 – invasion of lamina propria, T2 – superficial muscle is involved, T3 – deep muscle is involved or T4 – invasion beyond bladder.

Question 16

Bladder TCC - Investigations

Answer 16

Send urine for microscopy and cytology, an IVU may show filling defects ± ureteric involvement, cystoscopy with biopsy is diagnostic and CT scan or MRI to assess metastatic spread.

Question 17

Bladder TCC - Management

Answer 17

• Stages Tis /Ta / T1 – 80% of patients present in this stage – diathermy via transurethral cystoscopy or transurethral resection of the bladder tumour (TURBT). Also consider intravesical chemotherapy e.g. mitomycin – can be used for multiple small tumours or high grade tumours.
• Stages T2 / T3 – radical cystectomy is the gold standard often followed by chemotherapy. 40cm of the patient’s ileum can later be used for orthotopic reconstruction or urostomy formation.
• Stage T4 – palliative chemo/radiotherapy is given often with chronic catheterisation.

Question 18

Bladder TCC - Follow Up

Answer 18

Initially cystoscopy every 3 months if high risk tumour or every 9 months if low risk tumour.

Question 19

Balanitis

Answer 19

There is acute inflammation of the foreskin and glans. It is associated with strep and staph infections.

It commonly occurs in diabetics and is often seen in children with a tight foreskin.

It should be treated with antibiotics, circumcision and hygiene advice.

Question 20

Phimosis

Answer 20

The foreskin occludes the meatus.

In young boys this causes recurrent balanitis and ballooning but time and trials of gentle retraction may obviate the need for circumcision.

In adulthood it presents with pain intercourse, infection, ulceration.

Question 21

Paraphimosis

Answer 21

Occurs when a tight foreskin is retracted and becomes irreplaceable, preventing venous return leading to oedema and even ischaemia of the glans.

Management – ask patient to squeeze glans, try applying a swab soaked in 50% dextrose or ice packs. May require aspiration or circumcision.