Urology

Question 1

URINARY TRACT INFECTION

Answer 1

• Common in Women; Uncommon in Men and Children and require further investigation
• Recurrent infection causes considerable morbidity; Complicated UTI may even lead to severe
Renal Disease E.g. Pyelonephritis and ESRF; Common source of Gram Negative Septicaemia
• Most infection from Bowel Flora; Symptomatic infection associated with virulence of
organism (e.g. Presence of Adhesins); Inflammation and Injury due to host response
• Urine Osmolality >800mOsm/kg or low/high pH can reduce bacterial survival; IgA production
plays a role in defence against UTI; Commensal organisms (e.g. Lactobacilli, Corynebacterium)
• Urine flow and Micturition wash out bacterial; Stasis promotes UTI

Question 2

Natural History of Urinary Tract Infection

Answer 2

90% are Single/Isolated attacks; Recurrence due to Relapse or Reinfection

Question 3

Relapse

Answer 3

• Recurrence of Bacteriuria with same
organism within 7 days of completing
antibiotics; Failure to eradicate infection
• Occurs in Stone disease, Fibrosis, PKD

Question 4

Reinfection

Answer 4

• Bacteriuria is absent after infection for
>14 days followed by recurrence;
Reinvasion of susceptible tract

Question 5

Uncomplicated UTI

Answer 5

Functionally Normal Urinary Tracts – Persistent or Recurrent infection seldom results in
serious kidney injury

Question 6

Complicated UTI

Answer 6

Stone disease, Diabetes etc might be made worse with infection = Complicated UTI; UTI with
Proteus predisposes to Stone formation
o Combination of Infection and Obstruction results in Obstructive Pyonephrosis; Major
cause of Gram-Negative Septicaemia

Question 7

Acute Pyelonephritis

Answer 7

Fever, Loin pain and Tenderness,
Bacteraemia implies infection of the Kidney; Small Renal
Cortical Abscesses and Streaks of Pus in Renal Medulla
o Focal infiltration by Polymorphonuclear cells,
many in Tubular lumen

Question 8

Reflux Nephropathy (Chronic Pyelonephritis)

Answer 8

Vesicoureteric Reflux and Infection acquired in Infancy
or Early Childhood; Ascending infection and incomplete
Bladder emptying; Papillary damage, Tubulointerstitial
nephritis and Cortical scarring in areas adjacent to
“Clubbed Calyces”
o Usually ceases at Puberty following growth of
the Bladder base; Progressive Renal Fibrosis
might follow even in absence of infection
o Chronic Reflux Nephropathy – Predisposes to
HTN, relatively common cause of ESRD in the
young; Detection, Treatment of infection can
prevent disease incidence
o ? Place in therapy of Ureteral Reimplantation

Question 9

Presentation of Urinary Tract Infection

Answer 9

• Lower Urinary Tract – Polyuria, Nocturia, Dysuria, Suprapubic pain and Tenderness,
Haematuria, Smelly Urine; Upper Tract Involvement – Loin pain, Tenderness, Fever
• UTI can also present asymptomatically, or with atypical symptoms; Abdominal Pain, Fever or
Haematuria without Frequency or Dysuria
• In the Elderly, can be non-specific symptoms including Confusion, Malaise, Restlessness, Falls

Question 10

Diagnosis of Urinary Tract Infection

Answer 10

• Quantitative Culture of Clean Catch
Midstream Urine (MSU); Most Gram-negative
organisms reduce Nitrates to produce Nitrites
• Complicated UTI – Ultrasound KUB, CT with
Contrast, MRI if unable to tolerate

Question 11

Treatment of Isolated Urinary Tract Infection

Answer 11

• Pre-treatment Urine Culture is desirable for
Antibiotic sensitivity
• Antibiotics for 3-5 days e.g. Amoxicillin,
Nitrofurantoin, Trimethoprim, Cephalosporins
o Resistant organisms – Co-Amoxiclav or Ciprofloxacin (Fluoroquinolone)
• Single IM Amoxicillin or Co-Trimoxazole for Acute Cystitis without previous UTI history
• High Fluid Intake encouraged during treatment and subsequent weeks; Urine Culture
repeated 5 days after treatment
• IV antibiotics if patient is Acutely ill e.g. Cefuroxime, Gentamicin; Oral switch after 7 days; IV
fluids may be required to achieve Urine Output
o First-time presentation with Upper tract signs need to undergo urgent Ultrasound to
exclude Obstructed Pyonephrosis; Drained by Percutaneous Nephrostomy

Question 12

Treatment for Recurrent Infections

Answer 12

• Urine Cultures to determine Relapse or Recurrence; Search for cause in Relapse, IV Antibiotics
required; Failure to treat requires long term Antibiotic use
• Reinfection – Contraceptive practice reviewed, Atrophic Vaginitis (due to Oestrogen
deficiency causing dryness); All patients require high fluid intake, voiding at 2-3-hour
intervals, Voiding before bed and after intercourse, Low-dose Antibiotics Prophylaxis
o ? Cranberry Juice said to reduce risk by 12-20%

Question 13

Urinary Tract Infection due to Catheterisation

Answer 13

• Colonisation common after Catheterisation due to Bacterial Biofilm formation; Antibiotic
treatment not useful while catheter in-situ
• Antibiotics used if symptomatic/evidence of infection followed by replacement of catheter
o Single injection of Gentamicin while changing catheters
• Infection with Candida is a frequent complication of prolonged Catheterisation; Treat if
evidence of invasive infection or in Immunosuppressed patients
o In severe Candida infections, Bladder irrigation with Amphotericin

Question 14

Schistosomiasis (Snail Fever)

Answer 14

– Parasitic flatworms which
might infect Urinary Tract and Intestines, leading to
Abdominal Pain, Diarrhoea, Bloody Stool or Haematouria
o Fresh water contaminated with parasites, from
Freshwater snails; Common in developing countries
amongst Children, Farmers, Fishermen etc
o Serological diagnosis, or ova within stool or urine;
Treated with Praziquantel
o Associated with Squamous Bladder Carcinoma

Question 15

Urinary Tuberculosis

Answer 15

Cystitis unresponsive to typical antibiotics, Urinary Frequency, Dysuria,
Loin discomfort, Malaise and other Generalised TB symptoms
o Often asymptomatic and insidious over long time; ‘Sterile’ Pyuria and Haematuria
o May cause strictures, which may heal after infection treated

Question 16

Fourier’s Gangrene

Answer 16

• Rapidly progressive Necrotising Fasciitis of the Deep Fascia (Group-A Streptococci is major
cause, but often multiple organisms); Localisation to Scrotum and Perineum
• Radical Debridement, IV Antibiotics (Benzylpenicillin, Clindamycin)

Question 17

TESTICULAR TORSION

Answer 17

• Torsion must be dealt with immediately to preserve Testicular function; Commonest cause of
referral for Acute Testicular Pain
• Peak Age of Incidence 12-18yrs; Occurs more commonly in Anatomical Variants e.g. Bell
Clapper Testicular which allows Rotation within the Tunica Vaginalis
• Torsion causes Venous obstruction initially but increased Venous Pressure leads to Arterial
Compression and Development of Ischaemia and Necrosis
• Testicular Salvage depends on Degree of Torsion; Torsion >360o

for more than 24hrs leads to

complete or very severe atrophy
o Spermatogenic cells more susceptible to Ischaemic than Leydig cells; Subfertility
might occur even if Macroscopically normal after treatment

Question 18

Presentation of Acute Testicular Pain

Answer 18

• Testicular Torsion – Sudden Onset Moderate-Severe Constant Unilateral Scrotal Pain often
with Nausea, Vomiting and Abdominal Pain
o Testes globally Tender, Sitting High in Scrotum, might have Transverse Axis and may
be slightly Enlarged; If Infarcted, Scrotal Wall Oedema and Tenderness
o Absence of Ipsilateral Cremasteric Reflex is most reliable sign
• Testicular Appendage Torsion – Torsion of Hydatid of Morgagni or Epididymal Appendages;
Presents similarly to Testicular Torsion, but Testes and Epididymis might be non-tender;
Cremasteric Reflex should be preserved
o Blue Dot Sign – Cyanosis of affected Testicular Appendage
• Acute Epididymo-orchitis – Peak incidence 35yrs and >55yrs; In young, Chlamydia or
Gonorrhoea more common; 1/3 of Male Adolescents with Mumps develop Orchitis
o E coli, Proteus occur in Chronic Bladder Outflow Obstruction or Instrumentation

Question 19

Emergency Management of Testicular Torsion

Answer 19

• Analgesia – E.g. Morphine 5-10mg IV
• Immediate Surgical Exploration for all cases where Diagnosis is possible and History is short (If
Viability is still at issue); Otherwise Colour Duplex Ultrasound
• MSU, Urethral Swab and Chlamydia Serology if suspected infection
• Surgery – Viable Testicle Detorted and Fixed; Non-Viable Testicle is Excised; Opposite Testicle
is fixed (Orchidopexy) to prevent opposite site from torsion in future

Question 20

Hydrocoele

Answer 20

Accumulation of Serous fluid, secreted by remnant peritoneum, within the
Tunica Vaginalis; If no hernia present, will resolve spontaneously if <1yr age
o Soft, non-tender swelling, with non-palpable testis; Unless communicating
Hydrocoele, unable to ‘get above the mass’; Large hydrocoeles might cause Atrophy
due to compression or obstruction to vascular supply
o Surgery; typically, general anaesthetic as local anaesthetic might not provide
sufficient analgesia due to Spermatic cord traction

Question 21

Varicocoele

Answer 21

Abnormal enlargement of Pampiniform Plexus; typically, on Left due to
drainage of Testicular vein into Renal vein (Possible venous congestion and poor drainage)
o Surgery – Laparoscopic or Percutaneous Embolisation

Question 22

Circumcision

Answer 22

• Normal for baby’s foreskin to be retractable in first few years of life; Around 2yrs should be
able to separate naturally, Full separation in most by 5yrs
• Medical reasons (Phimosis or Recurrent Balanitis in most cases), or religious/cultural reasons
(Jewish and Islamic communities, and other cultures)

Question 23

URETHRAL STRICTURE

Answer 23

• Different Aetiology – E.g. Post-inflammatory/Infective, Traumatic (Fractures, Instrumentation)
• Graded according to Length and Degree of Fibrosis of Corpus Spongiosum
• Annular Narrowing by Scar Tissue of dense Collagen and Fibroblasts that might extend into
Corpus Spongiosum causing Spongiofibrosis
• Often with background of Urethritis, Trauma or previous Instrumentation
• Presents as LUTS, Haematuria (Initial or Terminal), UTI (Often Recurrent), Acute/Chronic
Urinary Retention and Overflow Incontinence
• Complications of Bladder Outflow Obstruction include Stone Disease, Infection (UTI,
Prostatitis, Epididymitis and rarely Fournier’s Necrotising Fasciitis); Reflux/Obstructive
Nephropathy if chronic

Question 24

Management of Urethral Stricture

Answer 24

• U&Es, Urinalysis and MCS; Uroflowmetry and Measurement of Post-Void Residual Volume
• Voiding Cystourethrogram ± Retrograde Urethrogram
• Transurethral Endoscopy; MRI Pelvis
• Transperineal or Endoluminal Ultrasound to assess Spongiofibrosis
• Treat Infections before Surgical Treatment; Temporary Suprapubic Catheterisation if Acute
Retention, Severe Symptoms or Renal Failure
o Suprapubic Catheter CI: Lack of Palpable bladder, Previous Surgery/Radiotherapy
(Adhesions), Pelvic Malignancy, Coagulopathy

• Surgical Management – Internal Urethrotomy, Urethroplasty or Perineal Urethrostomy

Question 25

STONE DISEASE

Answer 25

• Prevalence of Stone Disease higher in Middle East; Most Stones occur in Upper Urinary Tract; 2× more common in Men • Most stones comprise Calcium Oxalate and Phosphate; More common in Men; Mixed Infective Stones (15% of all Calculi) are twice more common in Women • 50% of patients with past stone will develop recurrence within 10yrs; Risk of Recurrence increases if Metabolic or Abnormality present • Associated with Increased risk of ESRF, Bone Diseases, Hypertension and MI • Predisposing Factors – Chemical composition of Urine, Concentration of Urine, Impairment of Crystal Formation Inhibitors • Aetiology – Hypercalcaemia (Hyperparathyroidism, Idiopathic, Malignancy, Sarcoidosis, Hypervitaminosis D), Familial Metabolic causes, Infection, Impaired Urinary Drainage/Stasis

Question 26

Types of Urinary Stones

Answer 26

• Calcium Stones – 75% of Stones; Usually combined with Oxalate or Phosphate; Sharp and may cause symptoms even if small stones • Triple Phosphate/Struvite Stones – 15% of Stones; Magnesium, Ammonium and Calcium Phosphate; Commonly occurs in Chronic Urinary Infection; May grow rapidly; Can form Staghorn Calculi • Uric Acid Stones – 5% of Stones; Due to High Urinary Uric Acid; Radiolucent Stones • Cysteine Stones – 1-2% of cases; Extremely hard consistency • Other stones include Xanthine, Pyruvate – 1% of Stones

Question 27

Presentation of Stone Disease

Answer 27

• Ureteric/Renal Colic – Severe, Intermittent, Stabbing Pain radiating from Loin to Groin • Microscopic or rarely Frank Haematuria; Nausea, Vomiting, Tachycardia, Pyrexia • Loin/Renal Angle Tenderness due to Infection or Inflammation; Iliac Fossa Tenderness if Calculus has passed into Distal Ureter

Question 28

Investigations for Stone Disease

Answer 28

• FBC (↑WCC, CRP suggest superadded infection), U&Es, MSU, Serum Calcium, Phosphate and Uric Acid; 24-hour Urine Calcium, Phosphate, Oxalate, Urate, Cysteine and Xanthine • XR KUB, Non-contrast Spiral CT (Gold Standard), Contrast XR (IVU) and Renal Ultrasound

Question 29

Management of Stone Disease

Answer 29

• Acute Presentation – Initially manage with Analgesia and Antiemetics with IV Fluids o Small Stones (<0.5cm) may be managed expectantly as most will pass o Emergency Percutaneous Nephrostomy or Ureteric Stent Insertion if Pain or Obstruction is persistent • Extracorporeal Shock Wave Lithotripsy – Focused Electrohydraulic or Ultrasonic Shock Waves targeting using Ultrasound or XR Guidance; Stone disintegration and fragments voided • Percutaneous Nephrolithotomy – Stones in Renal Pelvis/Calyces or Upper Ureter; Fluoroscope-guided insertion of Nephroscope and Calculus removed/fragmented • Endoscopic – Ureteroscope inserted and stone visualised; Stone fragmented by Ultrasound, Electrohydraulic or Laser • Open Nephrolithotomy/Ureterolithotomy – Large Staghorn Calculi or Complex Stones (E.g. Above Ureteric Stricture)

Question 30

Prevention of Recurrent Stone Disease

Answer 30

• Oral Fluid Intake and reduce Calcium Intake; Correct Present Metabolic Abnormalities or Underlying Conditions • Treatment of Chronic Urinary Tract Infection if present • Alkalization of Urine (Sodium Bicarbonate) for Cysteine and Urate Stones • Thiazide Diuretics for Idiopathic Hypercalciuria

Question 31

The Pelvic Floor (=Pelvic Diaphragm)

Answer 31

• Muscle fibres of Levator Ani (Puborectalis and Pubococcygeus, Iliococcygeus), Coccygeus (=Ischiococcygeus) and connective tissues, separating th Perineal region and Pelvis • Supporting pelvic viscera – Bladder, Intestines and Uterus etc; Also, part of the Anal and Urinary Sphincters, important for maintaining continence o Damage can lead to incontinence as well as organ prolapse; Damage can result from Excessive muscle tone, Trauma; Degeneration with Age and Pregnancy as well o Tone and Function of Pelvic floor can be improved with Exercise (Kegel); Ineffective mostly due to poor compliance; Biofeedback and Supervision improves outcomes

Question 32

Pelvic Floor Dysfunction

Answer 32

Includes Urinary Incontinence, Faecal Incontinence, Pelvic Organ Prolapse, Sexual Dysfunction and other Chronic Pain Syndromes

Question 33

Differential for Urinary Urgency

Answer 33

* Urinary Tract Infection, Stone Disease (Irritation of the Bladder and Tract) * Delirium and other Psychological factors, Restricted Mobility * Excess Urine Output, Pharmacological factors – E.g. Diuretics * Increased Intra-Abdominal Pressure – E.g. Due to Ascites, Pregnancy, Masses

Question 34

Urge Incontinence (OAB)

Answer 34

Detrusor Overactivity with leakage of urine due to perception of fullness; Common in Elderly; Occurs as isolated event, or secondary to other factors (e.g. Infection, Stones) or Central factors (Stroke, Dementia, Parkinson’s Disease) o OAB is a clinical diagnosis; Typically, small amount of urine passed; Overactivity is identified with Urodynamics, although unnecessary for diagnosis

Question 35

Stress Incontinence

Answer 35

Increased Intra-Abdominal Pressure (due to Cough, Sneeze) with a weak Pelvic floor or Urethral Sphincter; Common after Childbirth

Question 36

Overflow Incontinence

Answer 36

Leakage of Urine through Full Distended Bladder; Commonly in men with Prostatic Obstruction, Women with Cystocoeles or after Gynaecological surgery

Question 37

Functional Incontinence

Answer 37

Passage of Urine occurs due to inability to get to a toilet

Question 38

Management of Incontinence

Answer 38

• Treatment of causal factors – Constipation, Drug therapy, Co-existing disease, UTI • Urge Incontinence (OAB) – Bladder Training initially, before trialling Anti-muscarinic drugs (E.g. Oxybutynin, Tolterodine, Solifenacin/Darifenacin) • Stress Incontinence – Pelvic Floor exercises, US-guided, Transurethral Autologous Myoblasts (Regeneration of muscular sphincter) and Fibroblasts (Regeneration of Submucosa); Superior to Endoscopic Collagen injections o Mid-urethral Slings also increasingly used; Retropubic, or Trans-Obturator approach • Overflow Incontinence – Removal of Obstruction • Functional Incontinence – OT, Regular Urine Voiding, Absorbent Padding; Radar Key provides access to disabled toilet access (7,000 in the UK)

Question 39

Management of Pelvic Organ Prolapse

Answer 39

• Assess Extent and Symptoms of Prolapse, and segments of organs affected; Observe while both standing and straining to reproduce • Pelvic Floor Muscle training and Pessaries (Reduce prolapsed Vaginal tissues internally; most commonly Ring Pessaries; Effective in 60% of women o Surgery reserved for patients with at least stage 2 prolapse on examination, not responsive to conservative treatment • Aim of surgery to restore normal Pelvic Anatomy, eliminate symptoms and Normalise Bowel, Bladder and Sexual Function; Transvaginal Approach (80-90%); Trans-Abdominal, Laparoscopy or Laparotomy also options o Native tissue (Non-mesh) or Synthetic Mesh Augmented surgery

Question 40

Benign Prostatic Hyperplasia

Answer 40

• Stromal and Glandular Enlargement; Commonest cause of Lower Urinary Tract Symptoms (LUTS) in Middle aged and Elderly Men (25% of 40-60yrs, 40% in 60+yrs) • Aetiology largely unknown; Possible factors include Androgens, Oestrogens (Increased Oestrogen Androgen Ratio with age), Growth Factors (TGF-α) • May lead to intractable LUTS, UTI, Stone Formation, Retention, Overflow Incontinence and Obstructive Renal Failure

Question 41

Presentation of Benign Prostatic Hyperplasia

Answer 41

* Voiding Symptoms – Poor Urine Flow, Hesitancy, Post-micturition drippling * Storage Symptoms – Frequency, Nocturia, Urgency, Urge incontinence * Dysuria, Haematuria from Superimposed Infection; Incomplete emptying leading to retention * Smooth Enlargement of Prostate Gland on DRE; Palpable bladder if Chronic Retention * Exam for Neurological Signs (Red Flags for Cauda Equina etc)

Question 42

Diagnosis and Investigations for Benign Prostatic Hyperplasia

Answer 42

• International Prostate Symptom Score – Patient perception of severity of symptoms • Digital Rectal Examination and Serum PSA to assess for features of Malignancy • Serum Creatinine and Urinalysis; Urine Flowmetry and Residual Volume Estimation if considered for intervention • Cystoscopy to exclude Bladder Disease; Transrectal Ultrasound ± Biopsy if concerned about underlying malignancy; Renal Ultrasound, Invasive Urodynamic studies

Question 43

Management of Benign Prostatic Hyperplasia

Answer 43

• Treatment is recommended for patients whose symptoms are impacting on quality of life or if complications arise; Conservative management for mild symptoms (Watchful Waiting) • α-Adrenergic Antagonists (e.g. Tamsulosin) – Relaxation of Prostatic Urethral Smooth Muscle; SE: Dizziness, Postural Hypotension • 5α-Reductase Inhibitors – Inhibition of Pubic/Testicular Testosterone conversion to Dihydrotestosterone; SE: Loss of Libido, Erectile Dysfunction

Question 44

Surgical Management of Benign Prostatic Hyperplasia

Answer 44

• For patients with complications or symptoms not responding to medical therapy • Transurethral Resection of Prostate (TURP) – Most commonly performed procedure • Open Retropubic Prostatectomy • Bladder Neck Incision • Transurethral Incision of the Prostate (TUIP) • Laser Prostatectomy and Microwave Thermotherapy Ablation of Prostate

Question 45

PROSTATE CANCER

Answer 45

• Most commonly diagnosed cancer in Males; Peak incidence in 80yrs; 40% present as Early disease, 20% have Metastases at presentation • Presents majority with LUTS; May be diagnosed by DRE • Metastatic Disease might present as Bone Pain, Pathological Fractures, Hypercalcaemia

Question 46

Investigations for Prostatic Adenocarcinoma

Answer 46

• Serum Prostate Specific Antigen – High sensitivity but low specificity; Used for screening; Age-specific levels used as indicator for Biopsy • Transrectal Ultrasound (TRUS) – Detailed Imaging of the Prostate; Also for guiding Needle Biopsy while under antibiotic prophylaxis (Multiple samples) o Gleason Grading – Most common pattern + Second most common pattern • Pelvic MRI – Detect presence of Extracapsular Extension or Presence of Pelvic Lymphadenopathy (suggesting Spread) • Laparoscopic Node Biopsy – Sample enlarged nodes prior to considering Radical treatment • Isotope Bone Scan for Bony Metastases

Question 47

Treatment of Prostatic Adenocarcinoma

Answer 47

• Localised Disease in Life Expectancy <10yrs – Active Disease Monitoring; Hormonal Therapy or α-Adrenergic Antagonists; TURP for severe symptoms with features of Obstruction • Localised Disease in Life Expectancy >10yrs o Radical Prostatectomy (Severe Incontinence in 3%, Erectile Dysfunction in 40-50%) o External Beam Radiotherapy (Cystitis, Proctitis, Erectile Dysfunction) o Brachytherapy – TRUS guided placement of Radioactive seeds • Locally advanced disease – Incurable; Hormone Therapy (LHRH Agonist or Anti-Androgens) • Metastatic disease – Hormone Therapy with LHRH analogues; Anti-androgens if PSA relapse; Pain from Bony Metastases • Hormone Resistance develops in the long term – Chemotherapy if good performance status; Palliative Radiotherapy and Bisphosphonates for Bony Metastases

Question 48

TRANSITIONAL CELL CARCINOMA

Answer 48

• Can affect any part of Urinary Epithelium; Spectrum of disease includes Benign Superficial “Papilliferous” Growth to Frank Invasive Transitional Cell Carcinoma • Bladder TCC – Fifth commonest cause of cancer death; More common form of Bladder cancer o 3× more common in Males o Associated with exposure to Aromatic Hydrocarbons (Petrochemical, Industrial Dyes, Rubber, Chimney Sweeps) and Smoking (Especially in Women) • 70% of TCCs are superficial (Confined to Mucosa); Invasion into Lamina Propria, Muscle and Perivesical fat can occur leading to Lymphatic and Distant spread o TCC in-situ has high risk of Muscle-Invasive Disease if not adequately treated • Majority present with Painless Haematuria; Other features might include painful micturition, Renal Colic due to Thrombosis, Disturbance of Urinary Stream and Urinary Retention

Question 49

Investigations for Transitional Cell Tumours

Answer 49

• Urine Cytology – Reveal Malignant cells; TCC or TCC in-situ will probably be present • Cystoscopy – Suspect lesions for Transurethral Resection under GA • Transurethral Resection – Rigid Endoresectoscopy under GA; Uses Diathermy loop to resect tumour to the deep muscle wall; Biopsy of sample for Grading and Local Staging • IVU or Ultrasound for Pelviureteric Tumours; Bladder tumours might show filling defect • Local Staging by MRI and CT to detect Local or Systemic Spread

Question 50

Management of Transitional Cell Tumours

Answer 50

• Superficial TCT – Removal followed by Regular Endoscopic Surveillance; Intravesical Chemotherapy (Mitomycin C Instillation); 6 treatments given for Recurrent/Multiple TCC • Carcinoma-in-situ – Immunotherapy with Intravesical BCG (Success in 60% of cases); Close Endoscopic Surveillance with Regular Bladder Biopsy • Invasive TCC – Poor prognosis if Muscle-Invasive; Curative only with Radical Cystectomy (and Urinary Diversion by Ileal Conduit) or Radical Radiotherapy • NB: Squamous Cell and Adenocarcinoma usually resistant to Chemoradiotherapy

Question 51

RENAL CANCER

Answer 51

• Accounts for 2% of all cancer; 3× more common in Males • May be asymptomatic at presentation; Symptoms include Painless Haematuria, Groin Pain, Flank Palpable mass; Chest Symptoms and Bone Pain if Metastatic Disease; Local spread involves invasion into Renal Vein and Inferior Vena Cava • Positive family history or presence of Neurological or Ocular Disease might raise possibility of von-Hippel-Lindau Disease • FBC, U&Es, Calcium and Alk Phos (Bony Metastases) • Pre- and Post-IV Contrast CT of Abdomen and Chest; Isotope Bone scan if metastases

Question 52

Treatment of Renal Adenocarcinoma

Answer 52

• Surgery – Recommended except in very Elderly, Extensive Disease, Presence of Metastases o Open or Laparoscopic approach; Radical Nephrectomy if Large tumour o Partial Nephrectomy if <4cm and Peripheral Tumours o Resection of Primary Cancer appropriate if solidary metastasis that is amenable to complete local resection • Metastatic Disease with Multiple Metastasis not suitable for Surgery o Biological Therapy – Interferons, Interleukins; For patients with good performance status; 15-20% Partial Response rates o Chemotherapy is rarely used as Renal Carcinomas are not Chemosensitive o Hormone Therapy – Androgens, Tamoxifen might have some benefit o Palliative Radiotherapy for Painful Bony Metastases

Question 53

TESTICULAR CANCER

Answer 53

• Commonest Malignancy in Men between 18-40yrs; Associated with Maldescent; Increased risk if higher Exogenous Oestrogens (Perinatally or Childhood) • Common Types are Seminoma and Non-Seminomatous Germ Cell Tumours o Lymphoma is a rare cause of Testicular Tumour; Peak incidence >60yrs • Marsden Staging – Stage 1 (Confined to Testis), Stage 2 (Abdominal Node), Stage 3 (Nodal Spread outside Abdomen) and Stage 4 (Extralymphatic) • Usually presents as Painless Testicular Mass; Typically, Irregular, Firm, Fixed and does not Transilluminate; Intra-abdominal masses (Para-aortic, Hepatomegaly) might be present

Question 54

Seminoma

Answer 54

* Peak Incidence 30-40yrs * Lymphatic > Haematogenous spread • Lymphatic spread to Iliac and Para- aortic Nodes

Question 55

Non-Seminomatous Germ Cell Tumours

Answer 55

• Peak Incidence 20-30yrs • Haematogenous Spread to Lungs, Brain and Liver

Question 56

Management of Testicular Tumours

Answer 56

• Any clinically suspicious mass requires Urgent Testicular Ultrasound; Non-homogenous mass with Increased Vascularity • Serum Tumour Markers (β-HCG, AFP); Increased levels suggest Metastatic disease in NSGCT; Not in Seminomas even if Metastatic disease • CT TAP; CT Brain and Bone only if indicated • Orchiectomy at earlier opportunity – Inguinal Approach; Spermatic Cord can be clamped prior to mobilisation of the Testis • Seminomas respond well to Radiotherapy; Spread can be treated with Chemoradiotherapy • NSGCTs are Chemosensitive but not as Radiosensitive • Cure rates >95% in Stage 1 Tumours; Excellent long-term survival even in Metastatic disease

Question 57

PENILE CANCER

Answer 57

• Rarest Urological Cancer; Primarily occurs in Older Men; 95% are Squamous Cell Carcinoma • Usually affects the Glans but may involve Shaft; Associated with Chronic Infection especially in present of Phimosis • May present as Painless Ulcer, Nodule or Warty Outgrowth • Advanced disease as Fungating mass, usually Ulcerated; Reactive or Metastatic Inguinal Lymphadenopathy; Antibiotics given prior to further assessment

Question 58

Management of Penile Carcinoma

Answer 58

• Biopsy to confirm diagnosis; Pelvic and Abdominal CT for evidence of Nodular involvement • If Primary Tumour confined to Glans – Partial Amputation or Radiotherapy • More advanced Carcinoma requires Total Penectomy; Inguinal and Iliac Lymph Node Dissections are considered