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Surgery block (Y3) > Urology (2) (Cancer and stones) > Flashcards

Urology (2) (Cancer and stones) Flashcards

1
Q

Testis cancer

A

Usually from germ cells (produce sperm) in the testes (can also be non-germ cell tumours and secondary metastases).

  • Seminomas (slightly better prog)
  • Non-seminomas (mostly teratomas)

In general good prognosis >90% cure rate.

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2
Q

The common places for testicular cancer to metastasise to are:

A
  • Lymphatics
  • Lungs
  • Liver
  • Brain
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3
Q

RF for testes cancer

A
  • cryptorchidism- Undescended testes
  • Male infertility
  • Family history
  • Increased height
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4
Q

presentation of testis cancer

A
  • Painless lump (occasionally pain)
    • Arising from testicle
    • Hard
    • Irregular
    • Non fluctuant
    • No transillumination
  • Rarely gynaecomastia- Leydig cell tumour
  • Evidence of metastasis may present with weight loss, back pain (from retroperitoneal metastases), or dyspnoea (secondary to lung metastases).
    • *Lymphatic drainage of the testes is to the para-aortic nodes, therefore localised lymphadenopathy may not be present, even in cases of metastatic disease
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5
Q

investigations for testicular cancer

A
  • Scrotal US
  • Tumour markers
    • Alpha-fetoprotein (teratomas)
    • Beta-hCG- teratomas and seminomas
    • Lactate dehydrogenase (LDH)- no specifc tumour marker
  • Staging CT CAP
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6
Q

tumour marker for teratoma (NSGCTs)

A

alpha-feto-protein

(AFP)

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7
Q

seminoma tumour marker

A

beta-hCG

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8
Q

LDH and testicular cancer

A

LDH can also be used as a surrogate marker for tumour volume and necrosis, as well as for tumour response to oncological treatment.

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9
Q

staging system for testicular cancer

A

Royal Marsden

  • Stage 1 – isolated to the testicle
  • Stage 2 – spread to the retroperitoneal lymph nodes
  • Stage 3 – spread to the lymph nodes above the diaphragm
  • Stage 4 – metastasised to other organs
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10
Q

management of testicular cancer

A
  • Surgery to remove the affected testicle (radical orchidectomy) – a prosthesis can be inserted
  • Chemotherapy
  • Radiotherapy
  • Sperm banking to save sperm for future use, as treatment may cause infertility
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11
Q

long term side effects of testis cancer treatment

A

of treatment are particularly significant, as most patients are young and expected to live many years after treatment of testicular cancer. Side effects include:

  • Infertility
  • Hypogonadism (testosterone replacement may be required)
  • Peripheral neuropathy
  • Hearing loss
  • Lasting kidney, liver or heart damage
  • Increased risk of cancer in the future
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12
Q

categorisation of testicular cancer

A

germ cell tumours (GCT)

non germ cell tumours (NSGCT)

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13
Q

Germ cell tumours (GCT)-95%

A
  • Seminomas
    • Remain localised- very good prognosis
  • Non-seminomatous GCTs (metastasise early)
    • Yolk sac tumours
    • Choriocarcinoma
    • teratoma
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14
Q

Non germ cell tumours (NSGCT)

A
  • Usually benign
  • Comprise
    • Leydig cell tumour
    • Sertoli cell tumours
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15
Q

penile cancer

A

Most common is squamous cell carcinoma, arising from the epithelium of the inner prepuce or the glans- Rare

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16
Q

RF for penile cancer

A
  • HPV 6,16,18
  • BXO
  • Phimosis
  • Smoking
  • Lichen sclerosis
  • Untreated HIV infection
  • Previous Psoralen-UV-A photochemotherapy (PUVA)
    • Treatment for psoriasis
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17
Q

protective factors for penile cancer

A

circumcision

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18
Q

presentation of penile cancer

A
  • Palpable/ ulcerating lesions on the penis usually located on the glans
  • Painless
  • May discharge or bleed
  • Inguinal lymphadneopathy (30-60%)
  • Distant mets uncommon
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19
Q

DD for penile cancer

A
  • Herpes or syphilis
  • Psoriasis
  • Lichen planus
  • Balanitis
  • Premalignant -condyloma acuminatum (genital warts)
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20
Q

investigations fo penile cancer

A
  • Penile biopsy to confirm diagnosis
  • PET-CT imaging to determine inguinal involvement
    • If inguinal involvement- CT CAP
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21
Q

staging of penile cancer

A

TNM

22
Q

penile cancer management aim

A

complete tumour removal and oncological control and organ preservation

23
Q

combination treatment of penile cancer

A
  • Surgery (2cm tumour-free margin for resection)
    • Organ sparing treatment
      • Local excision
      • Partial glansectomy
      • Total glansectomy with reconstruction
      • Radical circumcision if only foreskin tumours
      • Invasive penile cancer
        • Partial amputation with reconstruction
        • Total penectomy
      • If inguinal lymph node involvement- radical inguinal lymphadenectomy, neoadjuvant chemo or radio
    • Radiotherapy
    • Chemotherapy
      • If superficial- topical chemotherapy e.g. imiquimod or 5-fluorouracil (5-FU)- then repeat biopsy and long term surveillance
24
Q

other options for penile cancer management

A
  • Laser
  • Glands resurfacing
    • consisting of complete removal of the glandular epithelium down to the corpus spongiosum, followed by reconstruction with a split skin or buccal mucosa graft
25
Q

stone disease

A

They can form as both renal stones (within the kidney) or ureteric stones (within the ureter).

26
Q

types of renal stone

A
  • Calcium oxalate
  • Calcium urate (uric acid)
  • Calcium phosphate
  • Struvite (UTI- infection) – ammonia, Mg2+, Phosphate
    • Staghorn calculi
27
Q

most common renal stone type

A

calcium oxalate stones and calcium phosphate stones

28
Q

struvite stone

A

associated with infection e..g UTI Proteus mirabilis

containL NH3, Mg2+ and Phosphate

staghorn calculi

29
Q

causes of renal stones

A

Causes

Mostly idiopathic.

How do they form:

  • Supersaturation: Excess minerals in urines due to increased excretion in renal ducts (calcium, phosphate, oxalate)
    • Urate- high levels of purine e.g. from diet or haematological disorders
    • Cystine- homocystinuria
  • Stasis in outflow – anatomical problem
  • Dehydration
  • Reduced inhibitors
30
Q

RF for stone disease

A
  • Race/genetics
  • <65yrs
  • Anatomical
  • Osteoporosis/osteopenia
  • Gout
  • Bowel surgery/IBD
  • Polycystic kidney disease
  • Chemotherapy
  • Diabetes
  • Diet
  • Obesity
  • Urinary
    • Volume
    • Calcium, urate, oxalate
    • Urine pH – diff types of stones form at diff pH
      • Alkaline- struvite
      • Acidic- uric acid stones
    • Inhibitors: Urine citrate and Urate magnesium
31
Q

alkaline urine

A

struvite- ifnection

32
Q

acidic urine

A

uric acid stone

33
Q

inhibitors of stone formation

A

Urine citrate and Urate magnesium

e.g. Prevention: Potassium citrate- makes urine more alkaline- prevents stone formation

34
Q

locaiton of ureteric stone

A

For stones that enter the drainage system of the urinary tract, there are three natural narrowed points where stones are likely to impact:

  • Pelviureteric Junction (PUJ), where the renal pelvis becomes the ureter
  • Crossing the pelvic brim, where the iliac vessels travel across the ureter in the pelvis
  • Vesicoureteric Junction (VUJ), where the ureter enters the bladder
35
Q

presentation of ureteric stone

A
  • Loin to groin pain (referred pain)
  • Colicky – due to increased peristalsis from site of obstruction
  • Sudden onset, severe
  • N and V
  • Haematuria – typically non-visible
36
Q

hisotry for stones

A
  • SOCRATES
  • Risk factors
  • Family history
  • Any previous history of stones
37
Q

exmaintion ofr stones

A

abdominal and genital area

38
Q

Investigations

A
  • ABCDE
  • Bloods (FBC, UandE’s. CRP)
  • Urine dipstick – haematuria, WCC, leucocytes
  • Urine culture
  • Stone retrieval- Urate and calcium levels – send for analysis
  • Non-contrast CT scan of the renal tract (gold standard) – high sensitivity and specificity
  • AXR less useful- some stones not radio-opaque
  • US used concurrently in cases of known stone disease to assess for hydronephrosis- no radiation risk
39
Q

CT in cancer and stones

A

cancer- contrast

stone- non-contrast

40
Q

intitial management of stones disease

A
  • Adequate fluid resuscitation (reduced fluid intake +/- vomiting)
  • Most stones will pass spontaneously without further intervention, esp if lower ureter or <5mmm in diameter
  • Analgesia - diclofenac
    • Opiate and NSAIDs per rectum
  • SEPSIS 6 if evidence of significant infection- IV Abx
41
Q

analgesia of choice for stones

A

diclofenac

42
Q

criteria for inpatient admission- stones

A
  • Post-obstructive acute kidney injury- renal impairment
  • Uncontrollable pain from simple analgesics
  • Evidence of an infected stone(s)
  • Large stones (>5mm)
43
Q

obstructive nephropathy e.g. if stone in ureter to stop hydronephrosis

A
  • JJ stent
    • Passed up urethra and up ureter à coiled at both ends to keep in placeà drain the kidney into the bladder
  • Nephrostomy
    • Drainage tube placed directly into the renal pelvis (percutaneous) and collecting system- relieving obstruction proximally.
44
Q

definitive managemnt of renal stones

A
  • Extracorporeal shock wave lithotripsy (ESWL)
    • Targeted sonic waves to break up stone so they can pass
    • <2mm- radiologically guided
    • Contraindication- pregnancy or stone position over a bony landmark
  • Percutaneous nephrolithotomy
    • For larger renal stone (e.g. staghorn calculi)
    • Percutaneous access to kidney – nephoscope passed into renal pelvis and stone fragmented using forms of lithotripsy
  • Flexible uretero-renoscopy (URS)
    • Involves passing a scope retrograde up into the ureter- allows stones to be fragmented through laser lithotripsy and the fragments subsequently removed
45
Q

complications of renal stones

A
  • Infection- SEPSIS- commence SEPSIS 6
  • Post renal acute kidney injury
  • Recurrent kidney stones
  • Steinstrasse- bigger stone broken down causes a line of smaller stones lower down in the ureter
46
Q

causes of bladder stones

A

due to urine stasis in the bladder e.g. chronic urinary retention .

  • May also occur secondary to infection (classically schistosomiasis) or passed ureteric stone
47
Q

presentation of bladder stones

A

LUTS

48
Q

investigations for bladder stones

A
  • Same for renal and ureteric stone
49
Q

management of cystoscopy

A
  • Allowing stones to drain or fragmented through lithotripsy
50
Q

DD for loin to groin pain

A
  • Pyelonephritic
  • Acute renal colic
  • AAA if RF present
    • Man
    • Obese
    • HT
    • smoker
51
Q

non-acute stone disease general management

A

Stay hydrated

52
Q

non-acute stone disease specific management

A

Specific management options depend on the underlying stone composition:

  • Oxalate stone formers should be advised to avoid high purine foods and high oxalate foods (such as nuts, rhubarb, and sesame)
  • Calcium stone formers should have PTH levels checked to exclude any primary hyperparathyroidism and avoid excess salt in their diet
  • Urate stone formers should be advised to avoid high purine foods (such as red meat and shellfish) and may need to be considered for urate-lowering medication (e.g. allopurinol)
  • Cystine stone formers may warrant genetic testing for underlying familial disease (homocystinuria)

Surgery block (Y3) (38 decks)

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