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Surgery > Urology > Flashcards

Urology Flashcards

1
Q

What are the 3 zones of the prostate and their significance?

A
  • Central Zone – Surrounds ejaculatory duct
  • Transitional Zone – Commonest site of BPH
  • Peripheral Zone – Commonest site of CA Prostate [70-80%]
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2
Q

What are the 3 parts of the urethra?

A
  • Prostatic Urethra
  • Penile Urethra
    • Membranous – Fixed, surrounded by external sphincter
    • Spongy – Surrounded by corpus spongiosum
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3
Q

How does Prostate CA typically present?

A
  1. Incidental Finding – Palpated in DRE, ↑PSA in routine check-up, Microscopic tumour in histologic exam of specimen after prostatectomy for BPH
  2. Lower Urinary Tract Symptoms [only in very advanced disease]
  • Haematuria, Dysuria, Incontinence, Retention [↓common ∵peripheral zone involvement rather than transitional zone]
  • Obstructive – DISH

3. Cancer Symptoms

  • Constitutional
  • Metastatic – Bone pain, Pathological Fractures
  1. May have + FHx
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4
Q

How does Prostate CA metastasize?

A
  • Locally – Beyond prostatic capsule, seminal vesicle, urethra, bladder base
  • Lymphatic – Sacral, Iliac, Para-aortic nodes
  • Haematogenous – Lung, Liver, Bone [lumbosacral spine, femur, pelvis]
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5
Q

What PE would you perform for suspected Prostate CA?

A
  1. DRE – Asymmetrical area of induration/Hard irregular nodule fixed to pelvic wall
  2. Assess Metastasis
  • Local invasion – ballot kidneys for hydronephrosis
  • Bone – Percuss Spine for any tenderness/pathological fractures
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6
Q

Differentials for Palpable nodule on DRE

A
  1. Prostate CA
  2. BPH
  3. Prostate Calculi
  4. Prostatitis
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7
Q

What is PSA?

A
  • A glycoprotein secreted by the prostate glandular epithelial cell to liquefy semen
  • Majority → semen; Some → blood
  • CA prostate produces 10x serum PSA [hence serum PSA is measured]
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8
Q

What causes elevated PSA?

A

[PSA is organ specific but not disease specific]

  1. Malignant – Prostate CA
  2. Benign – BPH, AROU, Prostatitis, Trauma [Biopsy, Instrumentation]
  3. Physiological – Ejaculation, Cycling, Prostate Massage
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9
Q

Indications for PSA Measurement

A

[These DO NOT apply to patients with palpable nodule on DRE]

  • Patients with CA Prostate for FU
  • Patients with BPH if implications of test are explained
  • Positive family history
  • DO NOT perform if life expectancy <10 years
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10
Q

What is the cut-off for PSA value?

A
  • PSA cut-off values are age-dependent [↑age = ↑cut-off]
  • 40s = 2.5 → 50s = 3.5 → 60s = 4.5 → 70s = 6.5

General rule of thumb for PSA interpretation

  • PSA < 4ng/mL – Normal; Biopsy not indicated
  • 4-10ng/mL – 20% chance of CA; Consider biopsy
  • ≥10ng/mL – >50% chance of CA; biopsy indicated
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11
Q

What if the PSA is between 4-10ng/mL?

A
  • Other PSA indices can be used for additional reference
  • PSA Density – PSA/Prostate Volume = >0.15 = ↑Probability
  • PSA Velocity – Rate of ↑of PSA > 0.75ng//mL/yr = ↑Probability
  • % Free PSA
    • 0-10% = >50% probability of CA
    • 10-15% = 28%
    • 15-20 = 20%
    • >25% = 8%
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12
Q

If the PSA is <4 does it rule out Prostate CA?

A

NO, around 23% patients with prostate CA can have a PSA of ≤3

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13
Q

What are the other laboratory markers for prostate CA?

A
  1. Prostate Health Index [PHI] – Uses proPSA; ↑Specific for prostate CA c.f. PSA
  2. PCA3 – Urine gene based test for prostate specific mRNA
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14
Q

What are the two forms of screening and how is PSA used?

A
  • Organised (Routine) Screening – Organised by authorities; everyone is screened; screening test must be of high standard [meet Wilson’s criteria]
  • Opportunistic Screening – Screening requested by the patient
  • Wilson’s Criteria – 1) Important PH problem; 2) Natural history well understood; 3) Has recognisable early pre-malignant stage [long progression]; 4) Effective investigations and treatments available; 5) Cost effective test
  • PSA screening is not recommended for routine screening as it has poor Spe and Spec PLUS many patients die with Prostate CA; not of it; thus +ve PSA result may → invasive tests done on patients who would not benefit from it
  • PSA opportunistic screening done if indicated
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15
Q

Indications for Prostate Biopsy

A
  1. Elevated PSA + Age <75yo [if diagnosis would affect treatment decision]
  2. Palpable nodule on DRE
  3. Diagnosis of CA prostate in clinically evident metastatic disease
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16
Q

How is prostate biopsy performed?

A

Trans-rectal Ultrasound [TRUS] guided → 10-12x biopsies taken → labelled according to which area taken

  • Hypo-echoic lesion [30% chance of CA]
  • Cx [3%] – Bleeding [Haematuria, Haemospermia, PR Bleed], Infection [4% UTI; 1% urosepsis - could be severe]

MRI guided/Robotic assisted biopsy may be done in some centres

17
Q

How would you manage a patient with sudden onset fever post-TRUS biopsy?

A
  • Treat as Post-TRUS biopsy urosepsis
  • Urological emergency urgent management required
  • ABC + Vitals → Resuscitate → Hx, PE , Ix + Empirical antibiotics
  • PE – must perform DRE for prostate abscess requiring drainage from interventional radiologist
  • Most common organism = E. coli
  • Augmentin/Ciprofloxacin routinely used for UTI but NOT in this case as prophylactic antibiotics already given before TRUS; organism likely resistant if big guns not used
  • Meropenem required
18
Q

Investigations to stage prostate CA

A
  • Clinical – Palpable nodule = T2 at least
  • Histological – TRUS + Biopsy
  • Radiological – Assess local invasion & nodal involvement
    • MRI – Endorectal Coli MRI [ERC]
    • CT Abdomen + Pelvis
  • Metastatic – PET-CT/Bone Scan

[MRI and Bone scan only performed in high risk disease guided by PSA and GS]

19
Q

How is prostate CA staged?

A

Prostate CA is staged according to the TMN staging system​

T = Tumour Size

  • T1 = Not palpable
  • T2 = Confined to Prostate
  • T3 = Extra-Prostatic spread [Beyond capsule; Seminal vesicle]
  • T4 = Spread to adjacent pelvic structures [External Sphincter, Bladder neck, Rectum, Pelvic floor muscles]

M = Metastasis – Either present or not

N = Nodal – Either present or not

20
Q

What is the Gleason Score and Significance?

A
  • Based on architectural features of prostatic CA cells seen on low power field microscopy

Calculation

  • Tumours graded 1 to 5; 1 = most and 5 = least differentiated
  • Sum of scores for the two most prevalent differentiation patterns = Gleason score

Significance

  • ↑Gleason score = Worse prognosis [15yr mortality rate]
  • Guides further investigation
    • GS ≤ 4+3 AND PSA≤20 → No further investigations
    • GS ≤ 4+3 AND PSA≥20 → CT/MRI
    • GS ≥ 8 AND PSA≤10 → No further investigations
    • GS ≥ 8 AND PSA≥10 → CT/MRI
21
Q

What would you look for in XR spine of a patient with Prostate CA?

A
  • CA prostate is osteoblastic metastasis
  • Focus on the pedicles to look for radio-opaque lesions and for symmetry of the pedicles
22
Q

What are the two variations in Gleason Score calculation?

A
  • Core Principle – Glandular architecture on low power field microscopy
    1. For TRUS biopsy specimen
  • Most common pattern + Most malignant pattern
    1. For prostate specimen following prostatectomy
  • Most common + Second most common pattern
23
Q

Principles of Treatment for Prostate CA

A
  • If ≥75yo / Life expectancy ≤10yrs → Conservative [Watchful Waiting]

T1 or 2 + Life expectancy ≥10 yrs

  • Conservative – Active Surveillance
  • Curative [treatment of choice] – Radical Prostatectomy +/- Radiotherapy

T3 or 4 → Palliative

  • Radiotherapy + Androgen Deprivation
24
Q

Active Surveillance for Prostate CA

A
  • For young [>10yr LE] patients fit for surgery with low risk disease [T1 or 2 & GS<7 + PSA<10] who want to avoid complications of tx [ED, Incontinence]
  • Involves frequent PSA testing and biopsies to monitor tumour progression
  • Curative treatment required if 1)↑PSA doubling time; 2) Progression of tumour on biopsy [↑grade/extensive]
25
Q

How do you assess the outcome of radical prostatectomy?

A
  • [Use the mnemonic CUP for ‘Trifecta’ outcomes]
  • Continence
  • Undetectable PSA
  • Potency
26
Q

Watchful Waiting for Prostate CA

A
  • For old [<10-15yr LE] patients unsuitable for surgery with any stage of disease [Any T & GS<7 + no limit for PSA] to avoid complications of tx
  • No need for frequent PSA testing or biopsies
  • Palliative treatment if tumour progresses
27
Q

What are the modalities of curative treatment for Prostate CA?

A

Radical Prostatectomy +/- Pelvic LN dissection

  • Methods – Open [retropubic or perineal approach], Laparoscopic or Robotic
  • Cx – ED [30-80%], Bleeding, Incontinence [50% initially; 10% permanent], Bladder neck stenosis [10%], GA risks, Rectal/Bowel injury

Radiotherapy

  • Modalities – External Beam [EBRT; 33x]; Brachytherapy [insert radioactive implants]
  • Cx – ED [30%], Radiation cystitis, Prostatitis, Proctitis, OAB
28
Q

What are the modalities of palliative treatment of Prostate CA?

A

Palliative RT – Prolong survival; Relieve SCI, Symptomatic control

Androgen Deprivation Therapy

  • Castration
    • Surgical – Orchiectomy [😊fastest onset, ☹S/E, permanent & psychological]
    • Medical – LHRH agonist [Groserelin and Leuprolide]
  • Anti-Androgen – Flutamide [Non-steroidal]; Cyproterone acetate
  • Oestrogens

Prevent bone loss – Denosumab, Bisphosphonates [alendronate]

29
Q

Time required for testosterone to fall to post-castration levels in different ADT modalities

A
  • Orchiectomy – 3h
  • LHRH antagonist – 3d
  • LHRH analogue – 3mo
30
Q

What is the mechanism of action and the drawbacks of LHRH analogues?

A
  • [Nomenclature – GnRH = LHRH]
  • Mechanism – Gonadotropin release in the body is pulsatile; prolonged use of LHRH analogue will lead to negative feedback → inhibit
  • Drawbacks
  • LHRH analogues can cause initial flare up of disease [↑risk of fractures/cord compression] while the effect is being achieved
  • Anti-androgens must be given therefore before LHRH analogue use
31
Q

How would you manage patients who do not respond to ADT in palliative CA Prostate?

A
  • CA Prostate will progress into castration resistance stage

Secondary Hormonal Manipulation

  • Adrenal Suppression – Ketoconazole
  • Steroids – Prednisolone
  • Progesterone

Chemotherapy – Docetaxel + Prednisolone

32
Q

What are the side effects of ADT?

A

[Use the mnemonic ABCDEFG]

  • Anaemia
  • Bone loss [Osteoporosis]
  • CVS risk/Cognitive impairment
  • DM/Dyslipidemia
  • Erectile Dysfunction
  • Flushes (Hot)
  • Gynaecomastia
33
Q

Important Vessels around Prostate

A

[I Observe Prostate Vessels]

  • Iliac – External & Internal Iliac Veins
  • Obturator – a & v
  • Pudendal vessels
  • Vesical – Superior and Inferior arteries

Surgery (8 decks)

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