Urology Flashcards
Medical Tx of BPH - names, MOA, SE
- Alpha blockers: tamsulosin, alfuzosin
reduce outflow resistance at bladder neck, prostate, urethra
reduce bladder instability
SE: postural hypotension - fall risk, lethargy, giddiness
(3 days to be effective) - 5-alpha reductase inhibitors: finasteride, dutasteride
reduce prostate size by inhibiting conversion from testosterone to dihydrotestosterone
SE: impotence, dec libido, erectile dysfunction, ejaculation dysfunction, gynaecomastia
(need 6m to work) - combodart - tamsulosin + dutasteride
consider: Ach inhibitors, phosphodiesterase inhibitors
Complications of TURP
Transurethral resection of prostate
EARLY CX
- GA cx: CVM, MI, allergic reaction
- bleeding, infection, urosepsis
- risk of perforation, fistula formation
- retrograde ejaculation (less ejaculate but penile erectile and sexual function preserved)
- local injury - sphincter (incontinence), nerves, arteries/veins
- TURP syndrome - hypoNa due to constant irrigation during TURP (RF: high pressure, prolonged procedure - but now rare as current practice uses isotonic irrigation) (presents as N&V, confusion, HTN, giddiness, seizure)
LATE CX
- urethra stricture, bladder neck stenosis
- prostate regrowth/ recurrence of symptoms
- incontinence
- retrograde ejaculation
- impotence
Indications for TURP
- significant symptoms, failed med tx
- complications
- lower tract: UTI, ARU, recurrent gross hematuria, bladder calculi
- upper tract: hydronephrosis, obstructive uropathy, renal impairment
Cancer marker for prostate
- what is normal
- screening guidelines
- when is it falsely elevated
- when is it falsely low
Prostate specific antigen (PSA)
normal: <4
SCREENING
- > 10: yes, 60% risk
- 4-10: yes, 20% risk
- <4: look at PSA density (serum psa/ prostate volume), PSA velocity (rate>0.75), free/total PSA ratio (<10%)
ELEVATED in: recent UTI, ARU, IDC, ureteric instrumentations, prostatitis
LOW: medications - NSAIDS, statins, 5alpha reductase
Diagnostic/ prognostic tool in prostate cancer
Transrectal ultrasound + biopsy (TRUS)
- hypoechoic lesions are suggestive
Gleason Classification - architecture of gland under low magnification
- addition of primary and sec score
- higher = more aggressive
anti-androgen treatment of prostate CA
- Castration (surgical - orchidectomy/ medical)
- med: GnRH agonists (Goserelin, Leuprorelin)
- -> give together with 5alpha reductase inhibitors: finasteride (to reduce interim spike in testosterone) - Anti-androgen
- non-steroidal: flutamide, bicalutamide, enzalutamide
- steroidal: cyproterone acetate - Combination
- Estrogen therapy
Castration resistant prostate CA
- what and mgx
2 consecutive rise in PSA (2w apart) despite castrate levels of testosterone
- Med:
- androgen synthesis inhibitors
- glucocorticoids
- estrogen therapy
- adrenal suppressives: ketoconazole - Chemo
Mets from prostate to bone commonly via
Batson venous plexus
How to differentiate bladder outlet obstruction from detrusor dysfunction
NOT via uroflowmetry
via VUDS - video, urodynamic study
(compulsory to do before TURP for BPH)
Significant positive uroflowmetry
minimum >150ml void
Qmax<15ml/sec
Residual urine >0 (young), >100 (elderly)
duration ~30s male, ~20s female
Complications of BPH
Hematuria - anemia Lower tract: stones, UTI Upper tract: renal insufficiency, hydronephrosis, pyonephrosis, hydroureter Renal impairment - fluid overload, AVF overflow incontinence Chronic straining - hernias
Microcytic anemia causes
Iron deficiency anemia
Sideroblastic anemia
Thalassemia
Normocytic anemia causes
Anemia of chronic dz acute blood loss renal failure isolated red cell aplasia aplastic anemia sec bone marrow failure - chemoRT, Myelodysplastic syndrome
Macrocytic anemia causes
Folate, B12 deficiency Liver dz, hypothyroidism alcohol MDS reticulocytosis
Gross hematuria causes
TITS
Trauma: procedures, instrumentations, IDC, TURP
Cancer: TCC (bladder, ureter), prostate cancer
BPH
Stones: renal, ureter, bladder
Infection: UTI, cystitis, prostatitis
Timing of hematuria & causes
- initial
- terminal
- throughout
initial: urethral
terminal: bladder neck, prostatic urethra
throughout: bladder, renal causes, ureter
spotting: urethral meatus
Things to exclude when u see hematuria
food dye - beet root
drugs - levodopa, rifampicin, Senna
mimics - bilirubinuria, porphyria, hemoglobinuria, myoglobinuria
benign causes - sexual intercourse, menses, trauma, exercise induced myoglobinuria
Glom vs non glom causes of hematuria
glomerular vs non glom:
(Urine phase contrast)
>Glom: coke coloured, no clots, RBC cast, dysmorphic rbcs, w proteinuria (>500mg/day)
>Non glom: red, clots, no casts, isomorphic rbcs, no proteinuria <500
hematuria red flags
male, >35, family hx, occupational exposure to dyes, carcinogens, smoker, analgesia abuse
Previous uro dz/ hematuria, pelvic irradiation, chronic UTI, indwelling FB, chemotherapy (hemorrhagic cystitis)
Renal causes of hematuria
- antibodies
anti-GBM: Goodpasture (a/w hemoptysis, lung haemorrhage)
ANCA related: wegener (cANCA), microscopic polyangitis (pANCA), eosinophilic granulomatosis with polyangitis (CS)
Immune complex (renal): post strep (2w after infection - low C2, high ASO), IgA Nephropathy (synpharyngitic, young male), MPGN
Immune cx (sys): SLE T3,4 , HSP, IE (duke critieria)
Others: alport (bl SNHL + occular abnormalities), APKD, thin basement mb
why is a L varicocele significant?
RCC of left kidney with extension of tumour into renal vein, blocking testicular vein which drains into L renal vein
CI of IV Urogram
contrast allergy
renal impairment (Cr >200)
Pt on metformin (cause lactic acidosis, stop 2 days before and after)
Pt w asthma (give steroid 3 d before study)
Pregnancy: ask LMP
What suggests renal hematuria
proteinuria
rise in creatinine
hypertension
other RF
Differentials for renal mass
Benign - angiomyolipoma - renal adenoma/cyst/abscess - renal oncocytoma Malignant - RCC - wilms tumour (nephrolblastoma) - mets - sarcoma
Dz a/w RCC
von hippel Lindau syndrome (AD) - clear cell
Hereditary papillary RCC (HPRCC) - multifocal b.l pap carcinomas
acquired polycystic kidney dz (chronic dialysis) - needs yearly ultrasound
histo types for RCC
clear cell (prox tubules), papillary (distal tubules), chromophobe (collecting tubules)
RCC triad and presentations
- Paraneoplastic symptoms
flank pain, painless gross hematuria, palpable flank mass
- asym
- local: triad, acute pain (hemorrhage into tumor)
- regional: L varicocele, IVC extension (LL edema, ascites, liver dysfunction, pul embolism)
- mets: lung, liver, bone, brain, LN
- constitutional: LOW,LOA
- paraneoplastic: HTN (renin), non mets liver dysfunction (Stauffer syn - hepatosplenomeg), hyperCa, polycythemia (erythropoietin), cushings, feminisation or musculinisation (due to gonadotropin release)
Bosniak classification
1 simple 0%
2 minimally complex 0%
2F: thin sep, thick cal (5%) - follow up CT
3 indeterminate (multiple thick septation, mural nodule) - partial nephrec (50%)
4 solid mass with cystic spaces
- total nephrectomy (100%)
Cx of nephrectomy
GA: AMI, CVA
Sx: plural injuries - pneumothorax, injury to surrounding orgs - GI/ major blood vessels
Post op: temp/ permanent renal failure, ileus, superficial/ deep wound infections
Tx for RCC
sx:
- small tumors: partial nephrectomy (spares adrenals)
- T2 and above: radical nephrectomy with clearance of gerota fascia, surrounding LN and affected structures
- if elderly: consider cryoablation and RFA
Chemo/RT: little evidence
Advanced cancers: immunotherapy or VEGFR targeted therapy
Angiomyolipoma
- a/w dz
- cx
- tx
a/w tuberous sclerosis complex, pulmonary lymphangioleiomyomatosis (LAM)
CX: retroperitoneal hemorrhage, hematuria, renal impairment
Tx:
- not growing: leave
- AML<3 + grow: RFA, cryoablation
- AML>4 + high vascularity: partial nephrec, selective renal art embolisation
Management of bladder CA
muscle sparing (T1)
- TURBT (transurethral resection of bladder tumour)
(chemo for high risk pts: high grade, multifocality, multiple recurrences, tumor size >3cm, pri or co-existing CA in situ, prostatic urethral development)
- intravescial chemo (mitomycin) within 24h
- intravesical BCG therapy (1/7 x6)
- close surveillance
muscle invasive (T2and above)
- radical cystectomy + urine diversion
a. males: radical cystoprostatectomy with pelvic lymphadenectomy
b. females: anterior exenteration with pelvic lymphadenectomy
urine diversion:
- not continent: cutaneous ureterostomy, ileal conduit, stoma with pouch construction under ab wall
- continent: neobladder construction with ileum
bladder salvage regime (combined modality): TUR + plt chemo + ext beam RT
METS
- chemo (for mets or locally advanced): GC, MVAC
RF for urolithiasis
- associated diseases
modifiable
- diet: high protein, Na intake
- dehydration
- hyperparathyroidism
- hypervitD
- milk-alkali sydnrome
- drugs: antacids, salicylic acid, anti virals
non modifiable
- age, male
- cystinuria (AR)
- inborn error of purine metabolic
- chemotherapy
- idiopathic hyperCa
- family hx
assoc diseases to ask in history!
crohns. (hyperoxaluria) hyperparathyroidism. MEN1, hyperthyroidism. gout. RTA T1 distal (alkaline urine), mets ca. paraneoplastic.
Types of urolithiasis
- special characteristics
- Calcium oxalate (75%): small and sharp - alkaline urine
- Calcium phosphate
- struvite stones - alkaline urine, staghorn a.w proteus, pseudomonas, klebsiella (urea splitting organisms)
- urate stones - acid urine (radiolucent)
- cystine stone
- rare - xanthine, pyruvate
Ix to measure kidney function
MAG-3 renogram
N: 50% per kidney
if <15%: not worth salvaging
Tx of urolithiasis
Conservative (<5mm)
kidney stones: <5mm observe, tx if >7mm
ureteric stones: Trial of passage if <7mm
(tx if do not pass out after 4-6w or causing symptoms)
- analgesia:IM pethidine, tramadol
- hydration
- alpha blocker: tamsulosin (SE: postural hypotension)
- change diet: low protein, sugar, Na. high fibre. normal calcium diet.
- tx underlying UTI, predisposing facotrs/ dz
- chemical dissolution: alkalinise/ acidify urine
Surgical: depends on site
- extracorporeal shockwave lithotripsy (ESWL)
- Percutaneous nephrolithotomy (PCNL)
- ureterorenoscopy (URS) lithotripsy
- cystolithopaxy
- open cystolithotomy
Adjuncts: Double J stent
Mechanical Causes of ARU
MECHANICAL
- intramural: stones, blood clot (bladder tumour), FB
- mural: bladder neck tumour, urethritis, stricture
- extramural: BPH, prostate CA, fecal impaction, pelvic/ GI/ retroperitoneal masses, UV prolapse - cystocele/ rectocele
Functional causes of ARU
FUNCTIONAL
- infx: prostatitis
- neuro
> brain: CVA, PD, MS, NPH
> spinal cord: cord trauma, spinal stenosis, transverse myelitis, hematoma/abscess
> peripheral n: DM neuropathy. GBS
- drugs: opioid, anticholinergics, sympathomimetics
- others: prolonged immobility, post anesthesia, post op cx, pain/trauma
Complications post IDC insertion for RU
- post obstructive diuresis
>200ml/h for 2 hours
tubular damage from CRU
leads to hypotension, and electrolyte ab: hypoNa, hypoK, hypovol - transient hematuria
- hypotension: vasovagal, relief of pelvic venous congestion
options for failed TOC
long term catherisation
SE: infx, strictures, stones, devt of scc
clean intermittent self catheterisation (for neurogenic bladder)
- avoid cx of obstructive nephropathy
if BPH: alpha blocker, 5a reductase inhibitors (take time to work)
- elective TURP
Paraneoplastic syndromes of RCC
(a) hypertension secondary to renin overproduction by RCC cells
(b) polycythaemia secondary to ectopic erythropoietin production
(c) Stauffer Syndrome (hepatic injury associated with non-metastatic RCC)
(d) Cushing’s syndrome,
(e) amyloidosis
(f) hypercalcemia mediated by PTH-related peptide
(g) trousseau sign (thrombophlebitis migricans)
Diagnosis and typical features for RCC
DIAGNOSIS
- IVU: mottled central calcification (90%), peripheral cal (20%), renal enlargement, displacement of renal pelvis/ calyces, irregular borders, change in cortical density
- CT urogram (triphasic): renal parenchymal mass with thickened irregular walls and enhancement after contrast injection
- ultrasound: differentiate from cyst (smooth, definite border, no int echogenicity, with post acous enhancement)
- biopsy (done during op itself or over metastatic site)
- MRI kidneys
T staging for RCC
T1a: <4cm, limited to kidney T1b: <7cm T2a: <10cm T2b: >10cm, limited to kidney T3a: extend into renal vein and perinephric tissues T3b: extend into IVC below diaphragm T3c: ICV above diaphragm T4: beyond gerota fascia
RF for bladder CA
- Occupational: industrial chemicals
- Non occupational: smoking, chronic analgesia abuse (phenacetin), chronic parasite infection (schistosomiasis), chemotherapy (cyclophosphomide - hemorrhagic cystitis), pelvic irradiation, males
how to describe
- benign BPH on DRE
- prostatic cancer on DRE
BENIGN - smooth, symmetrically enlarged (>3FB), no nodule - median sulcus is intact - firm consistency - rectal mucosal is smooth, not attached to prostate CANCER - asymmetrical are of induration - hard, irregular, craggy enlargement - nodule fixed to pelvic wall
what is the precursor of prostate cancer
prostatic intraepithelial neoplasm: architecturally benign prostatic acini and ducts lined by atypical cells
- low grade PIN1: mild dysplasia, no increased risk of CA
- high grade PIN2/3: mod and severe dysplasia, 30-40% chance of invasive cancer
2 main tx approaches for prostate cancer
active surveillance vs watchful waiting (life expectancy <10y, poor premorbids/ surgical candidate)
