Urology Flashcards
causes of haematuria
tumours infection trauma stones nephrological causes (e.g. IgA nephropathy)
what type of cancer is a renal cell carcinoma?
adenocarcinoma of the renal parenchyma
derived from the PCT epithelium
~70% are clear cell which are associated with Von-Hippel Lindau disease
what is the classic triad of pt presentation of RCC?
seen in 10% –> loin pain, haematuria and a palpable mass
what paraneoplastic syndromes can RCC cause?
Stauffer's syndrome (abnormal LFTs) hypercalcaemia hypertension polycythaemia/anaemia pyrexia amenorrhoea, baldness, Cushings
what Ix are needed for visible haematuria?
FBC, U&Es, clotting
USS, CT Urogram with contrast
flexible cystoscopy with LA
cystoscopy and washout under GA if actively bleeding
risk factors for RCC
smoking
obesity
FH
genetic syndromes
how is RCC diagnosed?
USS initially and then CT with contrast to confirm and stage
staging of RCC
T1a = <4cm (needs partial nephrectomy and surveillance)
T2a = 7-10cm (laparoscopic radical nephrectomy)
T2b + >10cm (open radical nephrectomy)
T3a = perinephric fat and renal vein invasion (open radical nephrectomy)
T3b/c = involvement of the IVC (open nephrectomy and IVC thrombectomy/ resection)
T4 = into adjacent structures (open nephrectomy and resection of other structures and LNs)
N1 = regional lymph node spread (open nephrectomy and resection of other structures and LNs)
M1 = metastasis (nephrectomy and resection of mets, also give tyrosine kinase inhibitors)
what is Upper Tract Transitional Cell Carcinoma
an uncommon cancer of the renal pelvis
small and low grade tumours can be treated with laser ablation
non-metastatic tumours can be treated with nephroureterectomy laproscopically
penile cancer
squamous cell carcinoma that is very rare
needs to be excised –> circumcision, glansectomy and partial/total penectomy plus inguinal/pelvis and sentinel node biopsy
if superficial can give topical 5 F-U as an adjuvant
what are the different types of bladder cancer?
~80% are TCC
20% are SCC
1% are adenocarcinomas
how is a bladder cancer assessed?
usually detected by flexible cystoscopy and then initial management is by a transurethral resection of bladder tumour (TURBT)
TURBT allows the histological assessment of type, grading and staging
what is the treatment of bladder cancer?
if a SCC or adenocarcinoma then they are invasive so must have radical treatment and scan for any metastasis
if a superficial TCC:
low risk - cytoscopic surveillance
intermediate risk - 6x weekly mitomycin instillations
high risk - BCG regimen (reduces progression), mitomycin (reduces recurrence) +/- cystectomy
if muscle invasive - organ confined then neoadjuvant chemo, cystectomy and chemoradiotherapy, if metastatic then palliative chemotherapy to slow progression of the disease
how does the BCG regimen used to treat high risk bladder TCCs work?
BCG (same as TB vaccines) regimen is given intravesically to stimulate type IV hypersensitivity reaction in order to active immune cells to the tumour antigen
what are the side effects of the BCG regimen?
dysuria frequency urgency UTIs haematuria rarely - systemic BCGosis, bladder contracture and ureteric stenosis can occur
what is a cystoprostatectomy?
a radical cystectomy in a male
involves removal of the bladder +/- urethra
what is an anterior exenteration?
a radical cystectomy in a female
involves removal of the bladder, uterus, fallopian tubes, ovaries and anterior vaginal wall
types of urinary diversion
ileal conduit
neobladder
continent cutaneous diversion
what is an ileal conduit?
ureters are connected to a section of the small bowel which is brought out as a stoma and drains into a bag
what is a neobladder?
“new bladder” made of small bowel so the pt “voids” urine
CI if the tumour extends to the urethra
neobladder needs to be stretched so pt has to set alarms to void every 3 hours initially, it can kink so pts need to manipulate it to release the urine
what is a continent cutaneous diversion aka Indianna Pouch?
a pouch formed from the right hemicolon
the stoma is catheterisable
CI in those unable to self-catheterise, renal and hepatic impairment, and if their is inadequate small bowel e.g. in Crohn’s
risks of continent urinary diversions
hyperchloraemic metabolic acidosis perforation stones mucus incontinence (leaking)
what type of cancer is prostate cancer?
an adenocarcinoma
why aren’t men routinely screened for CaP?
as 80% of men >80 have prostate cancer but only 3% will die from it
screening would result in over diagnosis, overtreatment and reduced quality of life for those who would have died with their cancer and not from it
risk factors for CaP
age
FH
genetics (HPC1 and BRCA)
ethnic origin
what is PSA?
prostate specific antigen - a serine protease (seminal anticoagulant)
what can cause a raised PSA?
CaP (if >100 then likely to be metastatic)
UTI
BPH
urinary retention
ix for CaP
PSA
DRE
MRI
TRUS biopsy
what is the Gleason Grading (GG) used for?
to grade CaP
a grade of 3-5 is given based on differentiation, overall grade is the sum of the two highest found
low grade = GG 3+3=6
intermediate grade = GG 3+4=7
high grade = GG 4+3=7 or above
what are the treatment options for CaP?
if low grade then active surveillance/watchful waiting
radical prostatectomy (risk of incontinence and impotence)
external beam radiotherapy and hormones
brachytherapy (implantation of radioactive seeds/wires)
HIFU and cryotherapy (fringe/experimental)
if metastatic androgen deprivation therapy
what does androgen deprivation therapy for metastatic CaP consist of?
bicalutamine for 28 days
LHRH analogue injection after 14 days and then every 3/6 months
early docetaxel chemotherapy
how do you treat castrate resistant CaP?
ie PSA continues to be raised despite hormone therapy
add bicalutamide dexamethasone docetaxel chemotherapy abiracterone/ enzalutamide palliative care
testicular cancer types
are uncommon
are mainly Germ cell (non-seminomatous and seminoma) but can be lymphoma and Leydig Cell
non-seminomatous vs seminoma Germ Cell testicular cancer
NSGCT - raised AFP (specific), raised LDH and raised beta-HCG
seminoma (more common) - raised beta-HCG in 10% and raised LDH
O/E what is seen in testicular cancer?
a solid mass that is inseparable from the testis
need to do an USS and CT chest/abdo/pelvis to stage
