Urology Flashcards
Definition of benign prostatic hyperplasia
Nonmalignant proliferation of the epithelial and stromal cells of the prostate gland. It is a gradually progressive histologic change primarily in the transitional zone of the prostate, which leads to enlargement of the prostate especially in older men and causes lower urinary tract symptoms
Risk factors for developing BPH
Advanced age Obesity Reduced physical activity Diabetes Fatty diet Diet high in beef Systemic HTN
Protective factors:
Alcohol, liver cirrhosis (high oestrogen relative to androgen)
Clinical features of BPH
gradual onset and progression Lower urinary tract symptoms - inc frequency - nocturia - hesitancy - urgency - weak urinary stream - incomplete voiding - incontinence - +/- haematuria
Complications of BPH
Acute urinary retention
Recurrent UTIs
Hydronephrosis
Renal failure
BPH on DRE
firm, symmetrical enlargement
Non-tender
Normal sphincter tone
No saddle anaesthesia
Grading of BPH
IPSS (international prostate symptom score) Score of 0-5 for the following topics: - incomplete emptying - frequency - intermittency - urgency - weak stream - straining
0-7 without bother: non-pharmacological
0-7 + bothered about symptoms: nonpharmacological therapies + alpha blocker
9-35: nonpharmacological + alpha blocker and/or 5a-reductase inhibitor
Non-pharmacological management of BPH
Watchful waiting Life-style modification - reduce fluid intake - bladder training exercises - double voiding - reduced caffeine and alcohol intake - monitoring of symptoms for progression
Pharmacological therapies for BPH
Alpha-blockers (e.g. prazosin)
- onset of action 1 week
- red. smooth muscle tone, red. prostatic and bladder neck contraction - reduced symptoms
5a-reductase inhibitors
- e.g. finasteride/dutasteride
- onset of action 3-6m
- reduced conversion of testosterone to DHT - reduced stimulation of prostate tissue - reduced progression of hypertrophy
Side effects of alpha blockers used in BPH e.g. prazosin
Orthostatic hypotension
1st dose syncope
Nasal congestion
tachycardia
Side effects of 5a-reductase inhibitors (e.g. finasteride used in BPH)
Reduced libido
Erectile dysfunction
Breast tenderness
Surgical therapies for BPH
Minimally invasive: - TUNA (transurethral needle ablation) - TUMT (transurethral microwave therapy) Standard surgical therapies: - TURP (transurethral resection of the prostate) - laser prostatectomy - open prostatectomy
Indications for TURP
- Symptoms of BPH unresponsive to medical therapy
- Persistent haematuria (other causes excluded)
- Renal failure
- Bladder stones
- recurrent UTI
When to refer man with BPH to urologist
No improvement within 6 weeks of treatment with best pharmacological regime
Risk factors for prostate cancer
Africa background
high dietary fat
Family history: one 1st degree - 2x risk, two 1st degree - 5x risk
Most common types and sites of prostate cancer
Adenocarcinoma (over 95%) Urothelial carcinoma (4.5% associated with TCC of bladder, not hormone-responsive)
70% arise from peripheral zone (classically posterior)
20% arise in transition zone
10% arise in central zone
Clinical features of prostate cancer
Obstructive voiding symptoms (reflects locally advanced disease into bladder neck or urethra) - hesitancy - intermittent urinary stream - reduced force of stream Locally advanced tumours: - haematuria - haematospermia - painful ejaculation Spread to regional LN: - LL oedema - discomfort in pelvic/perineal areas Bony mets: - severe unremitting pain - pathological fractures - spinal cord compression
Diagnosis of Prostate cancer
Made by DRE, PSA and TRUS biopsy
PSA not useful for diagnosis, used to monitor treatment and relapse
Histology of prostate adenocarcinoma
Smaller glands lined by single uniform layer of cuboidal or low columnar epithelium
More crowded glands than normal
Lack branching and papillary infolding
Absent basal cell layer typical of benign glands!
Procedure of transrectal ultrasound guided biopsy
Local anaesthetic (lignocaine)
lie in lateral position
US probe inserted into rectum
Take 10-12 core specimens (target peripheral zone, try to avoid transitional zone {BPH} at least on first biopsy)Complications/risks of transrectal US guided biopsy
Bleeding (rarely serious)
Infection - give prophylactic antibiotics in periprocedural time
Missed diagnosis (may require 2nd or 3rd biopsies)
Grading and staging of prostate cancer
Staging by TNM score
Grading by Gleason’s score:
- score our of 10
- addition of the 2 most predominant patterns
1 - 5 from well differentiated to poorly differentiated (higher score = worse prognosis)
management of prostate cancer
Watchful waiting:
- if PCa is slow growing and unlikely to cause problems
- treat with palliative intent when symptoms arise
Active surveillance:
- younger men who are candidates for definitive treatment
- delay curative treatment until evidence of progression
- Frequent PSA review and biopsy
Radical prostatectomy
Radiotherapy (localised cancer with curative intent - local ductal seeds, external beam)
Hormonal therapy: non-curative intent for metastatic disease
- 3-monthly injection of GnRH agonist
Complications of prostatectomy
Similar in robotic v laparoscopic v open
- erectile dysfunction 40% (may be able to manage with viagra, penile injections or vacuum pumps)
- dry orgasm
- incontinence
Complications of hormonal therapy for prostate cancer
GnRH agonist
- flushes
- reduced libido
- DM
- reduced body fat
- osteoporosis
- anaemia
- muscle atrophy
Staging of bladder cancer
T1: superficial
T2: into muscle
T3: into perivesicular fat
T4: invasion into another organ
Risk factors for bladder cancer
Age Smoking Family history (esp. young) Occupational carcinogens: dyeing, rubber, printing, metal industries Chronic indwelling foreign body Chronic cystitis Chronic analgesic use Pelvic irradiation
Types of bladder cancer
Over 90% transitional cell carcinoma
Some squamous cell carcinomas and adenocarcinomas
Clinical features of bladder cancer
Painless haematuria
- may be intermittent
- passing clots MAY BE PAINFUL - needs admission, 3-way catheter for washout
Often associated with UTI/cystitis (irritative symptoms)
Investigations in bladder cancer
Cystoscopy and biopsy Urine cytology (very specific but low sensitivity)
Management of bladder cancer
Carcinoma in situ:
- high-grade and invasive in bladder cancer
- CTx or Immunotherapy (mitomycin)
- cystectomy if young
- BCG (tuberculosis) - causes huge immune response - reduces recurrence and progression to deeper layer)
Ta: superficial, can burn off TURBT
Muscle-invasive:
- radical cystectomy
- radiotherapy or combined treatments
What does a radical cystectomy involve
In males: bladder and prostate
In females: bladder, urethra, uterus, most of vagina, ovaries, fallopian tubes
Reconstruction: ileal conduit (ureters - bit of bowel)
Use lots of ileum to reconstruct neobladder (absorbs toxins as urine sits waiting to void)
Causes of haematuria
Bladder cancer Renal cancer Prostate cancer Renal calculi (painful) BPH Ureteric cancer Infection Trauma (e.g. catheter) Renal (glomerular disease, polycystic kidney) Papillary necrosis Bleeding disorders or anticoagulants
Kidney tumours
Renal cell carcinomas - arise from renal cortex (85%)
Transitional cell carcinomas - arise from renal pelvis (8%)
Secondary tumours usually clinically insignificant and discovered post-mortem
Risk factors for renal cell carcinoma
Cigarette smoking
HTN
Obesity
Acquired cystic disease of the kidney
Most common histological group of renal cell carcinoma
Clear cell carcinoma
Notoriously resistant to chemotherapy
Classic triad of renal cell carcinoma
Flank pain, haematuria and palpable abdominal mass (less than 10% of patients, only occurs when locally advanced)
Flank pain, haematuria and palpable abdominal mass is the classic triad of what
Renal cell carcinoma
Symptoms and signs of renal cell carcinoma
Related to invasion of adjacent structures or distant mets - haematuria - abdo or flank mass - scrotal varicoceles (mainly L sided) - IVC involvement - pitting oedema, ascites, hepatic dysfunction Paraneoplastic syndromes: - anaemia - hepatic dysfunction - hypercalcaemia - cachexia - erythrocytosis - secondary amyloidosis - thrombocytosis - polymyalgia rheumatica
Investigations for unexplained haematuria
Abdo USS
Abdo CT
MRI
Management of renal cell carcinoma
Localised (stage I-III):
- Radical nephrectomy
- Renal sparing (partial nephrectomy or ablative techniques)
- -tumours less than 4cm, solitary kidneys, bilateral renal cancer
- Acute surveillance in elderly or not fit for surgery
Advanced disease: generally unresectable
- medical therapy (molecularly targeted)
- bevacizumab (humanised VEGF neutralising monoclonal antibody)
- tyrosine kinase inhibitors
Why does renal cell carcinoma respond poorly to chemotherapy
Proximal tubule multiresistance
Risk factors of nephrolithiasis
History of nephrolithiasis Gout - uric acid stones Hypercalcaemia Low fluid intake Occupational exposure to continual high temperature Obesity HTN Diabetes Excessive physical activity IBD/bariatric surgery (inc. enteric absorption of oxalate)
Types of stones in nephrolithiasis
Clacareous stones (calcium containing) - 80%
- Calcium oxalate (70%)
- Calcium phosphate (5-10%)
- Radiopaque on plain film
Noncalcareous Stones:
- struvite/infection (15-20%)
- uric acid (10%)
- Cysteine stones (less than 1%) - associated with autosomal recessive cystinuria
- all are radiolucent on plain film, can be seen on CT
Struvite stones: composition and cause
Magnesium, ammonium and calcium phosphate
Leading cause of staghorn stones (occupying entire renal pelvis)
Cause by urea-splitting bacteria - alkalisation of the urine
- Klebsiella
- proteus
- mirabilis
Clinical features of nephrolithiasis
- intermittent crampy loin-groin pain
- paroxysms of severe pain 20-60min
- passage of stone or gravel
- haematuria
- nausea, vomiting
- dysuria, urgency
- costovertebral or flank tenderness
indications for conservative management of nephrolithiasis
- small stones (under 7mm)
- no signs of sepsis
- normal renal function (with 2 kidneys)
- no ISS
Hydration Analgesia (indomethacin) Medical expulsive therapy (relax ureter) - prazocin, nifedipine Repeat imaging in 2-3w to ensure pasasge
Stones under 5mm will pass up to 98% of the time, over 5mm will pass less than 50%
Indications for urgent urological consultation in nephrolithiasis
- single kidney
- bilateral calculi
- pre-existing renal impairment
- obstructed infected kidney
- pregnancy (increases risk of miscarriage)
- ongoing pain with simple analgesia
- severe sepsis
Definitive management of nephrolithiasis
If systemically unwell: urgent renal compression (percutaneous nephrostomy, cystoscopy with ureteric stent placement)
Medical: for uric acid stones - allopurinol/ural
Surgical:
- extracorporeal shock wave lithotripsy
- ureteroscopy/laser
- percutaneous nephrolithotomy for larger stones
