Urology Flashcards
Risk factors for prostate cancer
Increasing age FHx Being black Being tall Use of anabolic steroids Genetics - BRCA2 mutation and lynch syndrome Diet - red meat, fat, diary, calcium Chemicals - high pesticide exposure
Presentation of prostate cancer
Often asymptomatic Haematuria Erectile dysfunction Weight loss Fatigue Bone pain LUTS - hesitancy - urgency - frequency - intermittency - straining to void - terminal dribbling - incomplete emptying
Features of PSA test
Done prior to DRE to avoid stimulating PSA release
Not very sensitive or specific
Most useful in monitoring progression of disease and success of treatment
Features of prostate examination
Benign prostate
- feels smooth, symmetrical and slightly soft with a maintained central sulcus
Cancerous prostate
- feel firm/hard, asymmetrical, craggy or irregular with loss of central sulcus
Ix for prostate cancer
DRE
PSA
Prostate biopsy
- not particularly sensitive because cancers may be located in areas not biopsied - multiple needle biopsies taken
- Transrectal Ultrasound-Guided Biopsy (TRUS)
- USS inserted into rectum and needle biopsy taken through rectal wall into prostate
- take around 10 biopsies
- Transperineal
- allows more biopsies to be taken
- takes longer than TRUS and requires general anaesthetic
Grading of prostate cancer
Gleason Grading System 1 - well differentiated cancer 2 - moderately differentiated 3 - moderately differentiated 4 - poorly differentiated 5 - anaplastic (poorly differentiated)
Mx of prostate cancer
Localised ○ Curative intent ■ Active surveillance ■ Radical prostatectomy ■ External beam radiotherapy ■ Brachytherapy ○ Palliative intent ■ Watchful waiting Metastatic ○ Surgical castration ○ Medical castration using LHRH agonists (in combination with anti-androgen initially to prevent excess testosterone effects) – patient eventually becomes resistant so add on an antiandrogen ○ Palliation ■ Single dose radiotherapy ■ Zoledronic acid
Side effects of hormonal treatment of prostate cancer
Hot flushes Sexual dysfunction Gynaecomastia Fatigue Osteoporosis
Complications of radical treatment of prostate cancer
Erectile dysfunction
Urinary incontinence
Radiation induced enteropathy - gives PR bleeding, pain and incontinence
Urethral strictures
Define BPH
Benign Prostate Hyperplasia
- caused by hyperplasia of the stromal and epithelial cells of the prostate
- usually present with LUTS in older men
LUTS
Hesitancy Urgency Frequency Intermittency Straining to void Terminal dribbling Incomplete emptying
Ix for BPH
Urine dipstick - exclude infection
PSA - prior to DRE
Rectal exam to assess prostate size, shape and characteristics
Mx of BPH
Reassurance and monitoring
Medical
- alpha-blockers (Tamsulosin) - relax smooth muscle
- 5-alpha reductase inhibitors (finasteride) - block testosterone and reduce size of prostate
Surgery
- Transurethral resection of prostate (TURP)
- Transurethral electrovaporisation of prostate (TUVP)
- Holmium laser enucleation of prostate (HoLEP)
- Open prostatectomy via abdominal or perineal incision
Features of TURP
Involves accessing the prostate through the urethra and shaving off prostate tissue using a diathermy
- aims to create a wider space for urine to flow through
Major complications of TURP
Bleeding Infection Incontinence Retrograde ejaculation Urethral strictures Failure to resolve symptoms Erectile dysfunction
Alternatives to TURP
TUVP - prostate tissue removed using a laser
HoLEP - prostate tissue removed using electrical current
Presentation of renal cancer
Often asymptomatic
Haematuria
Vague loin pain
Non-specific symptoms of cancer - weight loss, fatigue, anorexia, night sweats
Types of renal cancers
Tumour of the renal parenchyma
- Clear cell carcinoma - 75-90%
- Wilms Tumour in children < 5 years old
Risk factors for renal cancer
Smoking Obesity Hypertension Long-term dialysis Von Hippel-Lindau Disease
Mx of renal cancer
Surgery - partial nephrectomy Radiotherapy Chemotherapy Biological therapies
Paraneoplastic features of renal cancer
Polycythaemia - RCC secretes unregulated erythropoietin
Hypercalcaemia - RCC secretes hormone that mimics the action of PTH
Stauffer Syndrome - abnormal liver function tests demonstrating an obstructive jaundice
Types of bladder cancer
Transitional cell carcinoma - 90%
Squamous cell carcinoma - 10%
Pathophysiology of bladder cancer
Arise from endothelial lining (urothelium)
Clinical features of bladder cancer
Painless haematuria
Ix for bladder cancer
Urinalysis
USS
Cystoscopy + biopsy
Staging of bladder cancer
TNM
Risk factors for bladder cancer
Smoking
Carcinogens - hair dyes, industrial pain, rubber, motor, leather and rubber workers
Schistosomiasis - squamous cell carcinoma
Mx of bladder cancer
Not invading the muscle - transurethral resection of a bladder (TURBT) - chemo into bladder post surgery - weekly treatments for 6 weeks with BCG vaccine into bladder via catheter Muscle-invasive - radical cystectomy with ileal conduit - radiotherapy - IV chemotherapy
Features of testicular cancer on USS
Non tender Arising from testicle Hard without fluctuance or transillumination Irregular Age 15-40 years
Types of testicular cancer
Seminoma - 50%
Teratoma - 50%
Tumour markers for testicular cancer
Alpha-fetoprotein - raised in teratomas
Beta-hCG - raised in teratomas and seminomas
LDH - raised in all
Metastasis spread of testicular cancer
Lymphatics
Lungs
Liver
Brain
Prognosis of testicular cancer
Good prognosis unless metastatic - 90% cure rate
Metastatic disease still often curable
Better prognosis for seminomas
Mx of testicular cancer
Orchidectomy
- testicular prosthesis
Chemotherapy/radiotherapy based on staging
Monitoring post treatment with tumour makers and imaging
Common causes of raised PSA
Prostate cancer UTI Prostatic inflammation (prostatitis) Enlarged prostate (BPH) Acute urinary retention
Issues for PSA screening
Overdiagnosis
Over-treatment
QoL - co-morbidities of establish treatments
Cost-effectiveness
Ddx of haematuria
Cancer - RCC - upper tract TCC - bladder carcinoma - advanced prostate carcinoma Stones Infection Inflammation BPH Nephrological origin - glomerulonephritis
BCG side effects
Dysuria, frequency and urgency UTI Haematuria Systemic BCGosis Bladder contracture/ureteric stenosis
