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Surgery - 4th year > Urology - prostate > Flashcards

Urology - prostate Flashcards

1
Q

What are voiding symptoms?

A
  • hesitancy
  • weak stream
  • intermittency
  • straining
  • incomplete emptying
  • terminal dribbling
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2
Q

Causes of voiding symptoms

A
  • BPH: the most common cause of voiding symptoms
  • Drugs with an antimuscarinic action* (such as TCAs, sedating antihistamines, antimuscarinic drugs for urinary incontinence, and disopyramide).
  • Diabetic autonomic neuropathy and neurogenic bladder
  • Urethral stricture and phimosis (constriction of the foreskin).
  • Cancer of the prostate, bladder, or rectum.

*anticholinergic –> Anti Ach (anti parasympathetic so inhibits bladder activity)

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3
Q

What are storage symptoms?

A
  • urgency
  • frequency
  • nocturia
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4
Q

Overactive bladder syndrome

A

Overactive bladder syndrome is the set of symptoms that include urgency, with or without urgency incontinence, and the sensation of needing to pass urine again just after urinating.

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5
Q

overactive bladder - causes

A
  • BPH and benign prostatic enlargement.
  • Neurological conditions (such as dementia, diabetic neuropathy, MS, Parkinson’s disease, and stroke).
  • Lower urinary tract infection, sexually transmitted infections, and prostatitis.
  • Bladder stones.
  • Cancer of the bladder and prostate.
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6
Q

What is stress urinary incontinence and causes? (in men)

A

Involuntary leakage of urine caused by exertion (such as sneezing, coughing, laughing, physical exercise, or sexual intercourse).

Causes:

  • Prostatectomy or other surgery in the pelvic area.
  • Injury to the urethral area.
  • alcohol, caffeine, diuretics, alpha-blockers
  • Neurological or muscular conditions (such as multiple sclerosis and spina bifida).
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7
Q

What is acute urinary retention and causes?

A

Sudden inability to pass urine. It can be the first presentation of LUTS in men, or a complication of benign prostatic enlargement or prostate cancer.

Causes include:
- Chronic outflow obstruction (for example due to BPH [common] or prostate cancer [uncommon]).
- Stones or blood clots in the urethra.
- Urethral stricture.
- Severe constipation.
- Pelvic tumour.
- Drugs: Antimuscarinics for overactive bladder.
TCAs, sedative antihistamines, some antipsychotics, Opioid analgesics, Anaesthetics.

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8
Q

BPH - features

A
  • typically presents with LUTS –> voiding, storage, post micturition dribbling
  • complications: UTI, retention, obstructive uropathy
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9
Q

BPH - medical management

A

Alpha 1 blockers e.g. tamsulosin, alfuzosin

  • Relax smooth muscle of prostate (and bladder)
  • Dizziness, reduction in ejaculate, postural hypotension, dry mouth, depression

5 alpha-reductase inhibitors e.g. finasteride

  • Block metabolism of testosterone to dihydrotestosterone (DHT)
  • Cause reduced gland volume and vascularity
  • erectile dysfunction, reduced libido
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10
Q

BPH - surgical management

A
  • Transurethral resection of prostate (TURP):
    Resection of prostate tissue, can cause bleeding, needs irrigating catheter and 3-4 day hospital
  • others: Holep, Urolift, Prostatic Artery Embolisation

Cx of TURP: TURP syndrome = caused by irrigation with large volumes of glycine, which is hypo-osmolar and is systemically absorbed when prostatic venous sinuses are opened up. This results in hyponatremia, hyper-ammonia and visual disturbances, confusion, SOB.

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11
Q

BPH - prostatic obstruction and unfit for surgery

A

Patients with prostatic obstruction and unsuitable for TURP i.e. significant comorbidity may require long term management with catheters:

  • Long term indwelling catheter (LTC)
  • Intermittent self catheterisation (ISC)

Catheter complications include: UTI, catheter erosion, Haematuria, calculus formation and inconvenience.

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12
Q

Prostate cancer - risk factors

A
  • increasing age
  • obesity
  • Afro-Caribbean ethnicity
  • family history
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13
Q

Prostate cancer - clinical features

A
  • LUTS
  • bladder outlet obstruction: hesitancy, urinary retention
  • haematuria, haematospermia
  • pain: back, perineal or testicular
  • digital rectal examination: asymmetrical, hard, nodular enlargement with loss of median sulcus
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14
Q

What is PSA and normal values?

A
  • 34 kD glycoprotein with 240 amino acid chain
  • Produced almost exclusively by the epithelium of the prostate gland
  • Liquefies the ejaculate increasing sperm motility

NICE CKS:
men aged 50-69 years should be referred if the PSA is >= 3.0 ng/ml OR there is an abnormal DRE

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15
Q

What causes a raised PSA?

A
  • benign prostatic hyperplasia (BPH)
  • prostate cancer
  • prostatitis and urinary tract infection (NICE recommend to postpone the PSA test for at least 1 month after Tx)
  • ejaculation (ideally not in the previous 48 hours)
  • vigorous exercise (ideally not in the previous 48 hours)
  • urinary retention
  • instrumentation of the urinary tract - catheter
  • cycling
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16
Q

Prostate cancer - red flags

A
  1. Refer men for an appointment within 2 week for prostate cancer* if their prostate feels malignant on DRE
  2. Consider a PSA test and DRE to assess for prostate cancer in men with:
    - Any LUTS, such as nocturia, urinary frequency, hesitancy, urgency or retention or
    - Erectile dysfunction or
    - Visible haematuria
  3. Refer men for an appointment within 2 week for prostate cancer* if their PSA levels are above the age-specific reference range
17
Q

What investigations are done for the 2 week prostate cancer referral?

A

The traditional investigation for suspected prostate cancer was a transrectal ultrasound-guided (TRUS) biopsy*. However, recent guidelines from NICE have now advocated the increasing use of multiparametric MRI as a first-line.

*Risks = Sepsis, Bleeding, False negative result, Urine retention, Over diagnosis

18
Q

What is the Gleason grade?

A

When the prostate is biopsied, 10–12 cores will be taken from different parts of the gland.
The commonest and second most common tumour patterns are analysed and graded from 1 to 5.

The Gleason score is the sum of these two grades and can range from 2 to 10.

The tumour grade is classified into either of three risk categories on the basis of the Gleason score:
Low: 6 or less.
Intermediate: 7.
High: 8–10.

19
Q

Prostate cancer Staging - TNM

A

T1 - Clinically inapparent tumour that is not palpable
T2 - Tumour is palpable and confined within the prostate
T3- Tumour extends through the prostatic capsule (up to the seminal vesicles)
T4- Tumour is fixed or invades adjacent structures other than seminal vesicles: bladder neck, external sphincter, rectum, levator muscles, and/or pelvic wall

NX, N0, N1
M0, M1

20
Q

Prostate cancer - Treatment options

A
  • Active Surveillance (AS)
  • watchful waiting
  • Surgery: open prostatectomy, robotic prostatectomy, laparoscopic prostatectomy
  • Radiotherapy: external beam (EBR), brachytherapy
  • hormone manipulation: androgen deprivation therapy
  • HIFU (High-intensity focused ultrasonography) and cryotherapy – limited long term data
21
Q

Active Surveillance (AS)

A

Allows delayed primary treatment if there is biochemical or histological evidence of disease progression.

Avoids potential side effect of treatment in suitable men.

Require stringent follow up regime (PSA testing, clinical examination and repeat biopsies).

22
Q

Prostate cancer - surgery

A

Robot, Open or Lap

Robot vs Open/Lap: reduced length of stay, reduced blood loss, improved functional outcome

Risks of surgery: impotence, incontinence

23
Q

Radiotherapy

A
  • External-beam radiotherapy (EBRT) directs an external source of radiation at the tumour from outside the body.
  • Brachytherapy is a type of radiotherapy in which the radioactive source is implanted in the prostate
  • Risks: urinary incontinence, erectile dysfunction, bowel dysfunction, secondary cancers - bladder, colon, rectal
24
Q

What are HIFU and cryotherapy?

A

High-intensity focused ultrasound (HIFU) uses ultrasound waves to heat the prostate gland and destroy the tissue.

Cryotherapy is used to destroy the prostate tissue by freezing.

25
Q

What is Androgen deprivation therapy? (ADT)

A

All ADT reduce the ability of androgen to activate androgen receptors in the prostate

  1. Synthetic GnRH agonist e.g. Goserelin (Zoladex)
  2. Anti-androgen - cyproterone acetate
    prevents DHT binding
  3. Orchidectomy - removal of one or both testicles

Side effects = Hot flushes, Loss libido/erections, Osteoporosis, Impaired glucose tolerance, Lethargy

26
Q

How do you treat localised prostate cancer (T1/T2) ?

A

Treatment depends on life expectancy and patient choice. Options include:

  • conservative: active monitoring & watchful waiting
  • radical prostatectomy
  • radiotherapy: external beam and brachytherapy
27
Q

How do you treat localised advanced prostate cancer (T3/T4)?

A

Options:

  • Watchful Waiting
  • Androgen Deprivation Therapy
  • Radiotherapy +/- Androgen Deprivation Therapy
  • Surgery in selected patients
28
Q

Treatment for metastatic prostate cancer?

A

Hormonal therapy - ADT
- not curative

(Adjuvant early chemotherapy may extend survival in newly diagnosed metastatic prostate cancer)

29
Q

Prostate - histology

A
  • Peripheral zone: majority of the glandular tissue and where most prostate cancers originate
  • Transitional zone: sorrounds the anterior face of utethra; most BPH arise from here
  • Central Zone: crossed by the ejaculatory ducts
  • Fibromuscular stroma

Surgery - 4th year (7 decks)

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