Urology (2) (Cancer and stones) Flashcards
Testis cancer
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.
The common places for testicular cancer to metastasise to are:
- Lymphatics
- Lungs
- Liver
- Brain
RF for testes cancer
- cryptorchidism- Undescended testes
- Male infertility
- Family history
- Increased height
presentation of testis cancer
- 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
investigations for testicular cancer
- Scrotal US
- Tumour markers
- Alpha-fetoprotein (teratomas)
- Beta-hCG- teratomas and seminomas
- Lactate dehydrogenase (LDH)- no specifc tumour marker
- Staging CT CAP
tumour marker for teratoma (NSGCTs)
alpha-feto-protein
(AFP)
seminoma tumour marker
beta-hCG
LDH and testicular cancer
LDH can also be used as a surrogate marker for tumour volume and necrosis, as well as for tumour response to oncological treatment.
staging system for testicular cancer
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
management of testicular cancer
- 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
long term side effects of testis cancer treatment
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
categorisation of testicular cancer
germ cell tumours (GCT)
non germ cell tumours (NSGCT)
Germ cell tumours (GCT)-95%
-
Seminomas
- Remain localised- very good prognosis
-
Non-seminomatous GCTs (metastasise early)
- Yolk sac tumours
- Choriocarcinoma
- teratoma
Non germ cell tumours (NSGCT)
- Usually benign
- Comprise
- Leydig cell tumour
- Sertoli cell tumours
penile cancer
Most common is squamous cell carcinoma, arising from the epithelium of the inner prepuce or the glans- Rare
RF for penile cancer
- HPV 6,16,18
- BXO
- Phimosis
- Smoking
- Lichen sclerosis
- Untreated HIV infection
- Previous Psoralen-UV-A photochemotherapy (PUVA)
- Treatment for psoriasis
protective factors for penile cancer
circumcision
presentation of penile cancer
- Palpable/ ulcerating lesions on the penis usually located on the glans
- Painless
- May discharge or bleed
- Inguinal lymphadneopathy (30-60%)
- Distant mets uncommon
DD for penile cancer
- Herpes or syphilis
- Psoriasis
- Lichen planus
- Balanitis
- Premalignant -condyloma acuminatum (genital warts)
investigations fo penile cancer
- Penile biopsy to confirm diagnosis
- PET-CT imaging to determine inguinal involvement
- If inguinal involvement- CT CAP
staging of penile cancer
TNM
penile cancer management aim
complete tumour removal and oncological control and organ preservation
combination treatment of penile cancer
- 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
- Organ sparing treatment
other options for penile cancer management
- 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
stone disease
They can form as both renal stones (within the kidney) or ureteric stones (within the ureter).
types of renal stone
- Calcium oxalate
- Calcium urate (uric acid)
- Calcium phosphate
- Struvite (UTI- infection) – ammonia, Mg2+, Phosphate
- Staghorn calculi
most common renal stone type
calcium oxalate stones and calcium phosphate stones
struvite stone
associated with infection e..g UTI Proteus mirabilis
containL NH3, Mg2+ and Phosphate
staghorn calculi
causes of renal stones
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
RF for stone disease
- 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
alkaline urine
struvite- ifnection
acidic urine
uric acid stone
inhibitors of stone formation
Urine citrate and Urate magnesium
e.g. Prevention: Potassium citrate- makes urine more alkaline- prevents stone formation
locaiton of ureteric stone
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
presentation of ureteric stone
- 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
hisotry for stones
- SOCRATES
- Risk factors
- Family history
- Any previous history of stones
exmaintion ofr stones
abdominal and genital area
Investigations
- 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
CT in cancer and stones
cancer- contrast
stone- non-contrast
intitial management of stones disease
- 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
analgesia of choice for stones
diclofenac
criteria for inpatient admission- stones
- Post-obstructive acute kidney injury- renal impairment
- Uncontrollable pain from simple analgesics
- Evidence of an infected stone(s)
- Large stones (>5mm)
obstructive nephropathy e.g. if stone in ureter to stop hydronephrosis
-
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.
definitive managemnt of renal stones
- 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
complications of renal stones
- 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
causes of bladder stones
due to urine stasis in the bladder e.g. chronic urinary retention .
- May also occur secondary to infection (classically schistosomiasis) or passed ureteric stone
presentation of bladder stones
LUTS
investigations for bladder stones
- Same for renal and ureteric stone
management of cystoscopy
- Allowing stones to drain or fragmented through lithotripsy
DD for loin to groin pain
- Pyelonephritic
- Acute renal colic
- AAA if RF present
- Man
- Obese
- HT
- smoker
non-acute stone disease general management
Stay hydrated
non-acute stone disease specific management
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)
