Urology TA17-B11 COPY Flashcards
What is Endourology?
Definition: A branch of urological surgery that involves closed procedures for visualizing or manipulating the urinary tract.
What is retrograde instrumentation in endourology?
Retrograde Instrumentation: Techniques that invade the urinary tract via the urethra.
What is percutaneous antegrade endourology?
Percutaneous Antegrade Endourology: Accessing the urinary tract via a percutaneous puncture under fluoroscopy or ultrasound guidance.
What is Antegrade Pyelography used for?
Antegrade Pyelography: Used alongside a Whitaker test to assess pyelo-ureteral resistance.
When is Percutaneous Catheterization indicated?
Indications:
In cases where retrograde methods are not possible.
Examples: Sepsis secondary to ureteral obstruction or complete blockage by a stone.
What are nephrostomy catheters used for?
Nephrostomy Catheters:
Used to perfuse the renal collecting system with chemolytic agents to dissolve kidney stones.
Often used after open surgery, PNL, or ESWL.
Why should chemolysis use a double-catheter system?
Double-catheter System: Ensures simultaneous irrigation and drainage during chemolysis.
What is Nephroscopy?
Nephroscopy: The use of nephroscopes inserted percutaneously through a nephrostomy, usually for PNL (Percutaneous Nephrolithotomy).
What is Percutaneous Aspiration Biopsy?
Percutaneous Aspiration Biopsy: A procedure involving percutaneous puncture and sampling of a cystic or solid lesion of the kidney, often combined with therapeutic drainage.
Guidance: Done with US or CT.
Major Complication: Bleeding; renal parenchymal biopsies have a 0.1% mortality rate from bleeding.
What is Retrograde Endourology?
Retrograde Endourology: Techniques performed via the urethra; an example is urethral catheterization, which is done “blindly.”
What is Urethroscopy?
Urethroscopy: Allows for the identification of urethral lesions and procedures such as biopsies or internal urethrotomies under direct vision.
What is Cystourethroscopy?
Cystourethroscopy: The best method for evaluating disorders of the urethra, prostate, and bladder.
Can be done with rigid or flexible instruments.
When is Ureteral Catheterization performed?
Ureteral Catheterization: Used when small lesions in the collecting system can’t be identified via standard imaging (e.g., CT, MRI) or when a person is allergic to contrast dye.
Can be inserted through cystoscopes or ureterorenoscopes.
Baskets (e.g., Dormia basket) or loop catheters (Zeiss loop) can be used to retrieve stones.
What are Ureterorenoscopes?
Ureterorenoscopes: Endoscopes used for retrograde insertion into the ureter, indicated for ureteral and renal lesions that can’t be classified with other less invasive methods.
When is a Suprapubic Cystostomy preferred over Transurethral Catheterization?
Indications for Suprapubic Cystostomy:
Severe urethral stricture.
Urethral trauma.
Drainage after urinary retention due to acute prostatitis (to avoid triggering another inflammatory process).
- What is the general definition of infertility?
Infertility: Inability to achieve pregnancy after one year of unprotected sex.
What is the gender distribution for infertility?
Even distribution between males and females, with females being slightly more likely.
How does age affect male fertility?
Testosterone levels decrease with age.
Estradiol and estrone levels increase.
Sperm density also decreases with age.
What is the most common cause of male infertility?
Idiopathic: In 75% of cases, the cause of male infertility is unknown.
What is Azoospermia?
Azoospermia: Absence of sperm in the ejaculate.
Could be due to production problems (primary testicular failure) or obstruction (ejaculatory duct obstruction).
What is Sertoli-cell only syndrome?
Sertoli-cell only syndrome: Germinal cell aplasia, causing azoospermia.
FSH levels are elevated, but the cause is unknown
What is Hypogonadotrophic Hypogonadism?
A hypothalamic or pituitary problem leading to absence of testicular stimulation.
What are common genetic problems related to male infertility?
Klinefelter’s syndrome.
Y chromosome micro-deletion syndrome: Deletion on the long arm of Y chromosome, crucial for fertility.
How can infections affect male fertility?
Infections can cause scarring in the epididymis or seminal vesicles.
Prostatitis can alter semen acidity and affect sperm survival.
Viral orchitis (after mumps) is the most common cause of testicular failure in adults.
How does steroid abuse affect fertility?
Steroid abuse → Suppression of LH release → Decreased intra-testicular testosterone → Oligospermia or azoospermia.
What is the impact of radiation or chemotherapy on male fertility?
Radiation and chemotherapy can temporarily or permanently stop spermatogenesis.
What is analyzed in a semen analysis?
Semen analysis looks at:
Volume of ejaculate.
Sperm concentration.
Sperm motility and morphology.
What are the normal values for semen analysis?
Ejaculate volume: 2-5mL.
pH: 7-8.
Sperm density: 20-60 million sperm cells/mL.
What additional examinations can be done for male infertility?
Hormone concentration tests.
WBC count in semen to check for infections.
What role do auto-antibodies play in male infertility?
Auto-antibodies against sperm may attack and reduce sperm function, contributing to infertility.
What imaging techniques are used to evaluate the spermatic system?
Scrotal and trans-rectal ultrasound (US) to evaluate spermatic system anatomy.
What is a vasogram used for in male infertility evaluation?
Vasogram is used to check the patency of the vas deferens and ejaculatory duct.
What medications can stimulate gonadal steroid hormone production in male infertility treatment?
hCG, Menotropins (hMG), GnRH, and FSH are used to stimulate production of gonadal steroid hormones.
What medications are used to modulate estrogen and testosterone in male infertility treatment?
Anti-estrogens (e.g., Clomiphene citrate, Tamoxifen) and androgens can help modulate testosterone levels.
How are corticosteroids used in male infertility treatment?
Corticosteroids are prescribed for patients with anti-sperm antibodies to suppress the immune response.
What is varicocele ligation?
A surgical procedure to ligate (tie off) a varicocele, which is a common cause of oligospermia (low sperm count).
What is vasectomy reversal?
Vasectomy reversal is a surgery to reconnect the vas deferens, allowing men who had a vasectomy to potentially father children again.
What is Testicular Sperm Extraction (TESE)?
TESE is a procedure to extract sperm directly from the testicles for use in fertility treatments.
What is Intra-cytoplasmic Sperm Injection (ICSI)?
ICSI involves injecting a single sperm directly into an egg, allowing it to incubate and then implanting the resulting zygote into the uterus.
What is Erectile Dysfunction (ED)?
The inability to achieve or maintain an erection.
Most common in men over 40.
Most often related to vascular problems (endothelial dysfunction).
What are the main causes of ED?
Vascular (endothelial dysfunction)
Psychological
Neurogenic
Structural
Hormonal
Iatrogenic (medication-related)
What tests are used to diagnose vascular-related ED?
Color-coded duplex ultrasound (to analyze penile arterial blood flow)
Arteriography (specifically of the internal pudendal artery)
Cavernosography (using contrast to visualize corpora cavernosa)
Cavernosometry (pressure-flow evaluation of corpora cavernosa)
How do PDE-5 inhibitors work in ED treatment?
PDE-5 inhibitors (e.g., sildenafil) prevent cGMP breakdown, promoting smooth muscle relaxation in arteries.
They require sexual arousal to be effective as cGMP production depends on arousal.
What are the conservative treatments for ED?
PDE-5 inhibitors (e.g., sildenafil)
Intraurethral therapy (PGE-1 insertion for local absorption)
Intracavernosal injection therapy (PGE-1 injections for patients who can’t take oral therapy)
What are the surgical treatments for ED?
Penile prosthesis (silicone, either semi-rigid or inflatable)
Vascular surgery (rare, for young patients with pure vascular-related trauma)
What is Anejaculation/Aspermia?
Complete absence or failure of ejaculation.
Often due to neurological lesions (central or peripheral).
What medications or substances can cause ejaculatory disorders?
Anti-hypertensives
Anti-psychotics
Anti-depressants
Alcohol
What is retrograde ejaculation?
Semen passes backwards into the bladder during orgasm.
Leaves the body during urination.
Caused by dysfunction of the internal or external sphincter.
What is premature ejaculation?
Can be primary (lifelong) or acquired.
May be due to psychological factors.
PDE-5 inhibitors help erectile dysfunction patients with premature ejaculation.
What causes painful ejaculation?
Often due to infections like chronic prostatitis or urethritis.
What is hypogonadism?
Reduced or absent testosterone secretion.
May be caused by testicular dysfunction (primary) or hormonal pathway dysfunction (secondary).
How is hypogonadism treated?
Testosterone replacement therapy.
- What are the characteristics of calcium oxalate stones?
Seen in normal sediment.
Can crystallize at normal urinary pH.
Where are phosphate stones usually found and what causes them?
Found in alkaline urine.
Due to Gram-negative bacteria producing urease.
What is special about uric acid stones?
Found only in acidic urine.
What are cystine stones, and why are they rare?
Rare stones usually found in children.
Caused by an autosomal recessive gene defect affecting tubular reabsorption of cystine.
What symptoms are caused by kidney stones?
Usually asymptomatic.
May cause flank pain on the affected side.
What are the symptoms of ureteral stones?
Severe spasmotic pain on affected side.
Nausea and vomiting.
Radiating pain towards the gonadal region.
Possible fever due to urinary stasis and infection.
What are the symptoms of bladder stones?
Urgency to urinate.
Stranguria (inability to pass urine).
Hemato-pyuria (blood and pus in urine).
What are the symptoms of urethral stones?
Severe pain.
Difficulty passing urine.
What are the basic steps in diagnosing urinary stones?
History
Physical examination
Ultrasound (US)
Urinalysis
How can history and physical examination aid in diagnosing urinary stones?
History may reveal previous kidney stones.
Stones in the urethra can sometimes be felt manually.
What imaging methods are used to diagnose kidney stones?
Ultrasound (US) can detect most stones.
Plain X-ray or Intravenous Urography (IVU) can help localize the stone.
What is the role of Intravenous Urography (IVU) in diagnosing stones?
Normal urography takes 20 minutes.
Stones cause delayed contrast passage in the affected kidney.
What can urinalysis reveal in the diagnosis of urinary stones?
Can show microhematuria or macrohematuria.
How are uric acid stones diagnosed?
Only seen with Ultrasound (US), IVU, or CT.
Not visible on plain X-ray.
What is retrograde ureteropyelography, and when is it used?
Performed when other imaging methods fail.
Contrast material is injected via a catheter through a cystoscope into the ureter.
What is antegrade pyelography?
Done via a trans-renal drain.
Contrast is injected, and fluoroscopy is used for visualization
- What is the primary goal in treating renal colic?
Relieve pain
Moderate ureter spasms
What types of medications are used to manage renal colic?
Painkillers: Noraminophenazon
Spasmolytic agents: Papaverine
NSAIDs: Diclofenac (administered parenterally for quick action)
What are alpha-1 blockers, and how do they help in treating ureteral stones?
Examples: Tamsulosin, Unosolazin
Function: Help pass stones by relaxing smooth muscles in the ureter
How can uric acid stones be managed?
Increase fluid intake to make urine more alkaline
What is ESWL and when is it used?
ESWL (Extracorporeal Shock Wave Lithotripsy): Used to break up stones after urgent pain relief
What should be done if a patient with urinary stones has a fever?
Divert infected urine away from the collecting system
Use catheterization or, if there’s complete obstruction, perform percutaneous nephrostomy
What should be done if a patient with urinary stones has a fever?
Perform a urine culture
Prescribe specific antibiotics to treat the infection
After treating the infection, proceed with kidney stone removal
What is the likelihood of spontaneous passage of ureteral stones?
80% of ureteral stones pass spontaneously
Chance of spontaneous removal decreases as the stone remains in the ureter longer due to impaction into the ureteral mucosa
What are the surgical methods for removing ureteral stones?
Stone Removing Basket: Inserted through a ureteroscope
High Energy Holmium Laser: Vaporizes stones via a ureteroscope
Percutaneous Ureterolithotomy: For larger, impacted stones
Laparoscopic Lithotomy: Alternative for larger, impacted stones
What are the treatment options for renal stones?
1st Line Treatment:
Diclofenac (NSAID) and Algopyrin (painkiller/antipyretic)
Alpha-blockers
2nd Line Treatment:
ESWL (Extracorporeal Shock Wave Lithotripsy): Only for stones <2 cm
Contraindicated: In pregnancy, infection, or with anticoagulant therapy
3rd Line Treatment:
PCNL (Percutaneous Nephrolithostomy): Includes insertion of a trans-renal drain for 3 days post-removal
How are urinary bladder stones treated?
ESWL (Extracorporeal Shock Wave Lithotripsy)
Urethral Litholapaxy (LPX): For harder stones
Open Surgery: For larger, harder stones; involves an infraperitoneal skin incision (sectio alta) to manually remove stones
What is the treatment for urethral stones?
Push Stone Back into Bladder: Using a catheter if in proximal urethra
Endoscopic Stone Disintegration: For removal if pushing back is impossible
Is there a method to prevent stone formation?
No methods or medicines are capable of preventing stone formation
B1. What is another name for renal cell carcinoma (RCC)?
Clear Cell Carcinoma
Grawitz Tumor
What is the most common malignant tumor of the kidney?
Renal Cell Carcinoma (RCC)
In which population is RCC most commonly seen?
In developed countries
Typically in individuals aged 60-70 years
Slightly more prevalent in men
What are the primary risk factors for RCC?
Smoking
Obesity
Polycystic Kidneys
Horseshoe Kidneys
What is von Hippel-Lindau syndrome, and how does it relate to RCC?
An autosomal dominant syndrome
Mutation in the VHL tumor suppressor gene
Pre-disposes individuals to RCC,
phaeochromocytomas, cerebellar
hemangioblastomas, and pancreatic cysts
About 50% of people with this syndrome develop RCC
What is the pathology of RCC?
Adenocarcinoma arising from tubular epithelium (parenchyma)
Usually solid, with cystic areas
Tendency to grow into the renal vein, then into the IVC and right atrium
What are the subtypes of RCC and their prevalence?
Clear Cell: 80-90%
Papillary: 10-15%
Chromophobe: 4-5%
Collecting Duct Carcinoma: 1%
What are common symptoms of RCC?
Hematuria
Flank/Abdominal Pain
Palpable Mass (in 30% of cases)
Only 10% present with all three signs
What are some less common features of RCC?
Varicoceles (renal vein obstruction)
Bilateral Lower Extremity Edema
To which areas does RCC most frequently spread?
Lungs
Bones
What are some paraneoplastic syndromes associated with RCC?
Cachexia
Hypertension
Fever
Neuromyopathy
Anemia
B2. What is the initial diagnostic method for patients with the classic triad of hematuria, palpable mass, and flank/abdominal pain?
Abdominal Ultrasound (US)
Can show a renal mass or complex cyst
Malignant cysts may have solid elements, irregular, or calcified walls
What imaging method provides better visualization and functional status of the kidney for RCC diagnosis?
3-Phase CT Scan with Contrast
Assesses tumor size and extra-renal spread
When are MRIs used in the diagnosis of RCC?
Venous Involvement
Kidney Failure
Allergy to Contrast Medium
What routine imaging should be performed as part of RCC diagnosis?
Chest X-Ray
What abnormal lab values might be seen in RCC patients?
Polycythemia
Anemia
What additional imaging techniques are used if clinical symptoms or abnormal lab values are present?
Bone Scans
Brain CT
Renal Arteriography
IVC Cavography
What is the standard treatment for localized RCC?
Radical Nephrectomy
Usually laparoscopic
May include thrombectomy if there’s a tumor thrombus
Involves removal of the kidney, adrenal gland, and peri-renal fat tissue
Extensive lymphadenectomy is not recommended for survival benefit but for staging
What approach is taken if RCC is <4 cm, present in both kidneys, or if the patient has a single working kidney?
Partial Nephrectomy
How does RCC respond to radiation and chemotherapy?
RCC is not radio-sensitive
Rarely responds to chemotherapy
What is the response rate and survival benefit of systemic immunotherapy for RCC with multiple metastases?
30% response rate
Slightly better survival if nephrectomy was already performed
What are the 5-year survival rates (5YSR) for RCC based on disease extent?
Organ-Confined Disease: 80%
Locally Advanced Disease: 60%
Lymph Node Involvement: 20%
Distant Metastases: 10%
B3. What is an angiomyolipoma?
A hamartoma (resembles a tumor but is not malignant)
Composed of cells normally found at the site but growing disorganized
Contains blood vessels (BVs), smooth muscle, and fat
In which patient population is angiomyolipoma most commonly seen?
Mostly in females
Also associated with Tuberous Sclerosis (TS)
What is Tuberous Sclerosis (TS)?
An autosomal dominant syndrome
Characterized by mental retardation, epilepsy
Features adenoma sebaceum (angiofibromas on the face) and other benign hamartomas
How is angiomyolipoma usually diagnosed?
Diagnosed incidentally by an US or CT scan
What are the treatment options for small angiomyolipomas?
Nephron-sparing surgery
Emergency nephrectomy if necessary
What percentage of renal tumors are oncocytomas?
3-5% of all renal tumors
With which other renal condition do oncocytomas commonly occur?
33% occur in tandem with Renal Cell Carcinoma (RCC)
Describe the typical characteristics of oncocytomas.
Well-circumscribed, encapsulated tumors with a central scar
Arise from the collecting ducts
Considered benign
How are oncocytomas distinguished from RCC?
They cannot be distinguished radiologically from RCC
What is the standard treatment for oncocytomas?
Partial or total nephrectomy
What percentage of renal tumors in children under 15 are Wilms’ tumors (Nephroblastoma)?
80% of all renal tumors in this age group
At what age does Wilms’ tumor typically develop?
Usually around 3 years old
From what embryonic tissue does Wilms’ tumor arise?
Arises from embryonic mesenchyme of the metanephric blastema
What are the components of Wilms’ tumor?
Composed of epithelial, blastemal, and connective tissue (CT) elements
What genetic abnormality is associated with Wilms’ tumor?
Deletion or mutation of both alleles of the Wilms Tumor gene leading to tumorigenesis
What is the most common presentation of Wilms’ tumor?
Palpable abdominal mass in 90% of cases
What other symptoms may be present in Wilms’ tumor?
Flank pain, hypertension, hematuria, or undescended testis in 1/3 of cases
What imaging is used for diagnosing Wilms’ tumor?
Ultrasound (US) for diagnosis
Chest X-ray and CT for additional information
What is the standard surgical treatment for Wilms’ tumor?
Radical nephrectomy, with or without pre-op and post-op chemotherapy
What is the typical prognosis for Wilms’ tumor?
Fairly good prognosis ranging from 55% to 95%
What factors influence the prognosis of Wilms’ tumor?
The prognosis depends on the histological subtype of the cancer
B4. What are some occupational carcinogens associated with bladder cancer?
Iron and aluminum processing
Gas and tar manufacturing
How does smoking impact the risk of bladder cancer?
Smoking increases the risk of bladder cancer by 3 times
In which gender is bladder cancer more common?
Bladder cancer is almost 3 times more common in men than in women
What are the different pathological types of bladder cancer?
Papillary
Sessile
Infiltrating
Nodular
Mixed
Flat intra-epithelial growths
What does carcinoma in situ look like and how does it relate to muscle-invading cancer?
Appears as a velvety patch of mucosa
Has a direct relationship to muscle-invading cancer
Describe the three grades of bladder tumors.
Grade 1 (Well-differentiated): Thin fibrovascular stalk, thickened urothelium
Grade 2 (Moderately differentiated): Wider stalk, greater cell maturation disturbances
Grade 3 (Poorly differentiated): Non-differentiated cells; different tumor types may coexist with metaplasia
What is the most common finding in bladder cancer?
Painless hematuria
Do superficial bladder tumors typically cause bladder pain or dysuria?
Superficial tumors do not usually cause bladder pain or irritation and rarely cause dysuria
What imaging techniques can be used to diagnose bladder cancer?
IV urography (shows large tumors as filling defects)
Ultrasound (shows filling defects)
Urinary cytology (useful for high-grade tumors or carcinoma-in-situ)
Cystoscopy (main diagnostic tool for visualization and biopsy)
How can we determine whether a bladder tumor is superficial or muscle-invasive?
By performing a cystoscopy biopsy (trans-urethral resection; TUR)
What should be checked before starting treatment for bladder cancer?
Presence of distant metastases via chest X-rays, abdominal ultrasound, and sometimes bone scans
What are the most common metastatic sites for bladder cancer?
Lymph nodes
Bones
Lungs
What is the treatment for small bladder tumors?
Complete resection
Why is treatment of superficial bladder tumors challenging?
Superficial tumors have a high chance of recurring and can progress to muscle-invasive forms
What is an adjuvant chemotherapy used for in bladder cancer?
To lower the rate of recurrence in superficial bladder tumors
How effective is adjuvant chemotherapy in decreasing the risk of recurrence for bladder cancer?
It decreases the risk by about 40%
What should be done to monitor patients after adjuvant chemotherapy for bladder cancer?
Regular cystoscopies should be performed
Is adjuvant chemotherapy necessary for low-grade bladder tumors?
No, it is not needed for low-grade tumors
B5. What proportion of patients with transitional cell carcinoma have a muscle-invasive or metastatic tumor?
1/3
What percentage of patients with a superficial bladder tumor will develop into a muscle-invading tumor?
30%
What is the primary treatment for muscle-invasive or metastatic bladder tumors?
Radical cystectomy
What does a radical cystectomy involve?
Removal of the bladder, prostate, seminal vesicles (or uterus and adnexa in women), distal part of ureters, and regional lymph nodes
What are the four options for urine diversion after a radical cystectomy?
Ileal conduit
Continent pouch
Bladder reconstruction (using bowel segments)
Ureterosigmoidostomy
What is the main purpose of radiotherapy in bladder cancer treatment?
For patients who decline bladder removal or have major co-morbidities, or as a palliative measure for severe symptoms
How can radiotherapy be used palliatively in bladder cancer patients?
To alleviate severe symptoms such as hematuria, urgency, and pain
What percentage of patients may develop metastases after a cystectomy for muscle-invasive tumors?
Up to 50%
What is neo-adjuvant chemotherapy used for in the context of muscle-invasive bladder cancer?
To improve the 5-year survival rate (5YSR) for patients who have undergone a cystectomy
B6. What percentage of renal tumors are renal pelvis tumors?
About 10%
What is a common risk factor for renal pelvis tumors?
Similar to those of bladder cancer
What additional risk factor is associated with renal pelvis tumors in Balkan countries?
Degenerative interstitial nephropathy (unknown cause and mechanism)
Where are ureteral tumors most commonly located?
In the lower ureter
What is the most common sign of upper urothelial tumors?
Gross hematuria
What symptom occurs in 30% of patients with upper urothelial tumors?
Flank pain (typically due to obstruction by the tumor)
What diagnostic method can reveal upper tract tumors as filling defects?
Retrograde pyelography
What diagnostic method collects urine samples for cytology studies and helps with staging of urothelial tumors?
Retrograde urography catheterization
What instrument is used for diagnosis and allows biopsy forceps to be inserted for sampling?
Ureteroscope
How do transitional cell cancers typically appear on IV contrast imaging?
Hypovascular with little uptake of contrast
What is the general treatment for renal pelvis and ureteral tumors?
Radical nephro-ureterectomy (removal of the kidney and ureter, including its orifice entering the bladder)
What additional treatment may be used for high-grade tumors?
Systemic chemotherapy as an adjuvant treatment
B7. What percentage of malignancies in men are malignant tumors of the testes?
Only 2%
What age range is most commonly affected by testicular cancer?
Men between 20-45 years of age
What percentage of all testicular cancers are germ cell tumors?
90-95%
What is a known risk factor for higher prevalence of testicular cancer?
Cryptorchidism (undescended testis)
What are the two major divisions of germ cell tumors of the testis?
Seminomas
Non-seminomatous germ cell tumors
From where do seminomas originate?
Germinal epithelium of the seminiferous tubules
List the types of non-seminomatous germ cell tumors.
Embryonal carcinoma
Teratoma
Choriocarcinoma
Mixed cell type
Are non-germ cell or benign tumors of the testes common?
Very rare
How do testicular tumors typically present?
As a small, hard nodule or painless enlargement
What symptom may occur if a testicular tumor produces chorionic gonadotropins?
Gynecomastia (breast tissue enlargement)
What are the most common metastatic symptoms of testicular tumors?
Back pain
Coughing
Dyspnea
Lower extremity swelling
How is testicular cancer diagnosed?
Scrotal ultrasound (US)
CT of chest and abdomen for metastases
What are important biochemical markers for testicular cancer?
Alpha-fetoprotein (AFP)
Beta human chorionic gonadotropin (beta-hCG)
Which marker is seen in embryonal carcinomas but not in seminomas?
Alpha-fetoprotein (AFP)
Which marker may be seen in seminomas?
Beta human chorionic gonadotropin (beta-hCG)
Why should scrotal approaches or testicular biopsies be avoided in suspected testicular cancer?
Risk of tumor seeding or spreading
What type of spread is characteristic of choriocarcinomas?
Early hematogenous spread
How do germ cell tumors typically spread?
Via lymphatics in the para-aortic area
What is the most commonly involved metastatic site for germ cell tumors?
Retroperitoneum
What is Stage 1 of testicular cancer staging?
Lesion confined to testis
What is Stage 2 of testicular cancer staging?
Retroperitoneal nodal involvement
What is Stage 3 of testicular cancer staging?
Supradiaphragmatic nodal involvement or visceral metastases present
What is the primary treatment for testicular cancer?
Inguinal exploration and radical orchidectomy (removal of testis and spermatic cord)
Which testicular tumors are radio-sensitive?
Seminomas
What is the treatment for tumors with vascular or lymphatic invasion?
Chemotherapy (adjuvant treatment after surgery)
What is the treatment for tumors resistant to both radiotherapy and chemotherapy?
Radical retroperitoneal node dissection
What is the survival rate for Stage 1-2 testicular cancers?
85-100%
B8. How common are carcinomas of the penis?
Very rare, affecting 1 in 100,000 males
Where is the incidence and prevalence of penile cancer significantly higher?
South-American and some African countries
At what age is penile cancer most commonly seen?
Around 60 years old
What are the most common causal factors for penile cancer?
Poor hygiene
Long-term phimosis
Accumulation of smegma
Viral infection (HPV types 16, 18, 31, 33)
What percentage of penile cancers are squamous cell carcinomas?
95%
Where are penile cancers most commonly found?
48% in the glans
21% in the prepuce
9% in both
6% in the sulcus coronarius
What must penile cancer be differentiated from?
Inflammatory penile skin lesions like balanoposthitis
What are some low-risk pre-cancerous dermatological lesions?
Balanitis xerotica
Cornu cutaneum
Bowenoid papulosis
What is Balanitis xerotica?
Atrophic white patches on the glans or prepuce
What is Cornu cutaneum?
Keratinous skin tumors that are usually benign but can be pre-malignant or malignant
What is Bowenoid papulosis?
Verrucous, pigmented papules on the body of the penis associated with HPV
What are some high-risk pre-cancerous dermatological lesions?
Lichen sclerosis
Buscheke-Lowenstein tumor
Erythroplasia glandis/Erythroplasia of Queryat
Zoon balanitis
Bowen disease
What is Lichen sclerosis?
A high-risk pre-cancerous lesion
What is the Buscheke-Lowenstein tumor?
A verrucous carcinoma associated with HPV
What is Erythroplasia glandis/Erythroplasia of Queryat?
Squamous cell carcinoma-in-situ of the glans penis associated with HPV 16
What is Bowen disease?
A skin disease of a squamous cell carcinoma-in-situ
What is the TNM classification for penile cancer?
T
T1: Invades subepithelial CT
T2: Invades corpora cavernosa or spongiosum
T3: Invades urethra or prostate
T4: Invades other adjacent structures
N
N0: No node involvement
N1: Unilateral, single inguino-femoral lymph node involvement
N2: Bilateral or multiple unilateral lymph node involvement
N3: Deep inguinal or pelvic lymph node involvement
M
M0: No metastases
M1: Metastases present
What is the most common complaint in penile cancer?
The lesion itself
What does the tumor in penile cancer look like at the skin level?
It may be ulcerated or show exophytic growth
Usually covered by erythema
What are some less common symptoms of penile cancer?
Bleeding
Pain
Discharge
Odor
What percentage of penile cancer cases show palpable inguinal lymph nodes?
58%
What is the primary diagnostic tool for evaluating the primary penile tumor?
Clinical evaluation
What imaging is used to check for metastases in penile cancer?
Pelvic CT
For advanced penile cancer, what additional imaging might be used?
Bone scans
Abdominal CT
Lung CT
Cranial CT
What is necessary for diagnosing penile cancer?
Biopsy of the lesion
What surgical approach is required if the lesion involves part of the glans or distal shaft?
Partial amputation
What are the options for treating high-risk penile cancer (T ≥ 2) surgically?
Partial amputation
Total amputation
Emasculation
What surgical procedure is done for patients with positive lymph nodes in penile cancer?
Inguinal lymphadenectomy
Why might inguinal lymphadenectomy not be performed in low-risk penile cancer?
High morbidity
Not needed for non-invasive verrucous carcinoma
When could lymphadenectomy be considered for intermediate-risk penile cancer (T=1)?
It could be considered based on clinical judgment
What types of therapy might be used for penile cancer with fixed inguinal lymph nodes?
Chemotherapy (systemic adjuvant or neoadjuvant)
Radiotherapy
What are some complications of radiotherapy for penile cancer?
High local failure rate
Meatal stenosis
Urethral strictures
B7. Are carcinomas of the urethra common?
No, they are rare.
They are much more common in women (4x more likely).
What are common etiological factors for urethral tumors in males?
Chronic inflammation
STDs
Urethritis
HPV infection
Urethral strictures
What are common etiological factors for urethral tumors in females?
Chronic irritation
Lower UTI
Papillomas
Polyps
Leukoplakia of the urethra
What symptoms are commonly seen in patients with urethral tumors?
Urethral bleeding
Urinary frequency
Urethral obstruction
Strictures
Perineal pain
Palpable urethral mass
What is the likelihood of a transitional cell carcinoma in relation to the location of the urethral tumor?
Higher chance if the tumor is more proximal.
What is the likelihood of a squamous cell carcinoma in relation to the location of the urethral tumor?
Higher chance if the tumor is more distal.
How is a diagnosis of urethral carcinoma typically made?
Endoscopy
Bimanual palpation
Biopsy
What is the primary treatment for urethral tumors?
Radical excision with extended regional lymphadenectomy.
What is the recommended treatment for proximal urethral tumors in females?
Radical cystectomy.
What is the recommended treatment for proximal urethral tumors in males?
Radical prostatectomy.
Under what circumstances might a partial urethral resection be considered for urethral tumors?
If the tumor grade is low.
What is the most common benign lesion of the scrotum?
Sebaceous cyst.
What is the most common malignant tumor of the scrotum?
Squamous cell carcinoma
What are the risk factors for scrotal malignancies?
Chronic inflammation
Poor hygiene
What is the usual approach to diagnose scrotal tumors?
Biopsy.
What should be done if there is a local lesion in scrotal malignancy?
Complete excision of the lesion.
Do scrotal malignancies typically involve the inner contents of the scrotum?
No, usually they do not.
How do scrotal cancers typically metastasize?
In the same lymphatic way as penile cancer.
What is the recommended treatment if there are positive lymph nodes in scrotal cancer?
Inguinal lymphadenectomy.
B10. What is the second most common malignancy in males?
Prostate cancer.
At what age is prostate cancer most frequently diagnosed?
Between 65-75 years old.
What is the most common site for metastasis of prostate cancer?
Bones.
What is the Gleason score used for in prostate cancer?
It grades the tumor based on its microscopic appearance to assess aggressiveness.
What symptoms may indicate advanced metastatic prostate cancer?
Bone pain
Hematuria
Urinary retention
Weight loss and fatigue
Flank pain (if urine flow is obstructed)
What does a rectal-digital exam reveal in prostate cancer?
Stony hard nodules or an entirely hard prostate
If the tumor is small, no positive findings are present
What are normal serum PSA levels?
<4 ng/mL
What can cause elevated PSA levels other than prostate cancer?
Rectal-digital examinations
Prostatitis
Catheterization
Benign prostatic hyperplasia (BPH)
What is needed to confirm a prostate cancer diagnosis?
Biopsy (trans-rectally or through the perineum)
What imaging techniques are used to stage prostate cancer?
Bone scan
Chest X-ray
B11. What is the primary treatment for localized prostate cancer (T1-T2)?
Radical prostatectomy (removal of the prostate, seminal vesicles, and regional lymph nodes).
What are the common complications of a radical prostatectomy?
Incontinence
Impotence
What is the chance of incontinence and impotence following a radical prostatectomy?
Slight chance of incontinence
Fairly high chance of impotence (though these complications tend to improve after 1 year)
What is the next step if prostate cancer is locally advanced and surgery is performed?
The treatment involves a higher rate of complications and a high chance of recurrence.
What is the first choice of therapy for locally advanced prostate cancer?
Hormone therapy.
What types of hormone therapy are used for prostate cancer?
Castration (removal of testes)
Anti-androgens such as LH inhibitors
Estrogen
How long does hormone therapy typically delay prostate cancer progression?
About 2 years.
What happens after hormone therapy becomes ineffective in prostate cancer?
The cancer becomes hormone-resistant, PSA levels will elevate again, and hormone therapy will no longer work.
What is the next step after hormone therapy becomes ineffective for prostate cancer?
Chemotherapy combined with steroids.
What type of drug can be used to treat bone metastases in prostate cancer?
Bisphosphonates (prevent the loss of bone mass).
What are some treatments for advanced cancer patients with bone metastases?
Painkillers
Transfusions
TURP (Transurethral Resection of the Prostate) for high urinary retention
Percutaneous nephrectomy for a dilated kidney
What are some conditions that can cause “urge to urinate” symptoms?
Infections
Large bladder stones
Bladder tumor
Detrusor hyperactivity
Scarred bladder
