Urology, Uro emergencies and Urological malignancies Flashcards
RFs for prostate Ca?
INCREASING AGE
FH-1st degree relative diagnosed with the disease under the age of 60-increases risk by 4 times
ethnicity-blacks more than whites more than asians, blacks 2 times as likely than white men in the UK, blacks also more likely to have more aggressive disease.
genetics-BRCA-2, risk increased by 5-7 times, ? if their mother had breast Ca
?Lynch syndrome (HNPCC)
previous Ca-bladder, kidney, lung, thyroid, melanoma
?risk reduction with part. diets e.g. high in foods containing selenium-fish, vegetables and lycopene-tomatoes
what investigation is necessary for definitive diagnosis of prostate Ca?
transrectal US (TRUS) guided BIOPSY BUT in men with a raised PSA, 10-30% of clinically significant prostate Cas will be missed.
initial assessment of patients with LUTS?
frequency volume charts-voiding diaries and charts, bladder diary
what does increased urinary frequency but normal volumes suggest?
high fluid intake:
diabetes mellitus
diabetes insipidus
psychogenic polydipsa-can distinguish from diabetes insipidus via 8hr water deprivation test-increase in urine osmolality implies pt is just drinking too much.
what do reduced volumes of urine with variations in volume voided suggest?
underlying detrusor overactivity
bladder innervation?*
efferent:
parasympathetic-S2-S4 pelvic nerves
sympathetic-T10-L2-hypogastric plexus
somatic-pudendal nerve-S2-S4-external urethral sphincter-*levator ani striated muscle.
how common is bladder Ca?
excluding non-melanoma skin Ca it is the 7th most common Ca in the UK
4th most common Ca in males, following prostate, lung and CR, and 11th in women
RFs for bladder Ca?
increasing age
male-more than twice risk of females
SMOKER-4 times the risk of someone who has never smoked, thought more than 1/3 of all bladder Cas caused by smoking. arylamines (aromatic) in the smoke, renally excreted as are PAHs.
arylamine exposure in industry-aniline dyes, 2-naphthylamine. PAH (polycyclic aromatic hydrocarbon) exposure-combustion industries, crude oil, carbon.
other Ca treatment e.g. pelvis radiotherapy, cyclophosphamide.
type 2 diabetics treated with pioglitazone
women with systemic sclerosis-?tx with cyclophosphamide
?pts with crohn’s disease-higher incidence of bladder Ca
schistosomiasis-parasitic infection increasing risk of squamous cell Ca
chronic bladder stones-can cause chronic infection, increasing risk of squamous cell Ca bladder, as does chronic inflammation from other causes e.g. indwelling urinary catheter
previous transitional cell Ca
bladder extrophy
persistent urachus
epidemiology of bladder Ca?
males affected more commonly than females?relation to men smoking more in the past and their work in industries where exposure to carcinogenic chemicals e.g. rubber, dyes, plastics
typically over the age of 60yrs, disease takes a long time to develop
caucasians more commonly
most common type of bladder Ca?
transitional cell carcinoma (90% in developed countries)
rest=mainly squamous
sites that may be affected by transitional cell carcinoma in the renal tract?
renal pelvis
ureter
bladder
urethra
how many patients present with superficial bladder Ca (non muscle invasive)?
70%, of which 10% are carcinoma in situ
sites of metastasis of bladder Ca?
liver
lung
bone
CNS
bladder Ca presenting features?
PAINLESS haematuria-visible in 80-90%, can come and go
may be dysuria and frequency, voiding symptoms can be caused by advanced disease but also occur with CIS
criteria for GPs for 2ww r/f for suspected bladder Ca?
pt 45 and over with unexplained visible haematuria without UTI OR
visible haematuria that persists or recurs after successful UTI tment OR
pt 60 and over and unexplained non-visible haematuria and either dysuria or raised WCC on blood test
consider non-urgent r/f for pts aged 60 and over with recurrent or persistent unexplained UTI.
criteria for GPs for 2ww r/f for suspected renal Ca?
pt 45 and older with unexplained visible haematuria without UTI OR
visible haematuria that persists or recurs after successful treatment of UTI.
role of blood and urine tests in investigating likely bladder Ca px?
FBC-exclude anaemia, ?raised WCC-UTI
urinalysis including culture to exclude infection
Us+Es, eGFR, creatinine
urine cytology may be helpful, important in diagnosis and f/u of CIS
preferred tment for high grade non muscle invasive bladder Ca and CIS?
intravesical induction and maintenance immunotherapy with BCG
this reduces risk of both progression and recurrence.
for high grade NMI tumours, should f/u with 3mnthly cystoscopy for 1st 2 yrs, then 6 mnthly for next 2 yrs, and yrly thereafter.
management of bladder symptoms in those with advanced bladder Ca, e.g. haemturia, dysuria, frequency, nocturia?
palliative radiotherapy
treatment of pt with muscle invasive bladder Ca but without distant mets?
radical cystectomy or radical radiotherapy, preceded by neoadjuvant chemo-cisplatin combo regimen (NA chemo NOT if poor performance status or renal function)
most significant bladder Ca prognostic factors?
tumour grade
depth of invasion
presence of CIS-highly invasive flat tumour
TNM staging of bladder Ca?
performed via CT with contrast or MR, optimum staging for muscle invasive=CT chest, abdo, pelvis with CT urography.
Ta=NMI papillary carcinoma
Tis-CIS, flat tumour
T1- invaded through LP
T2-invaded into muscle, 2a=superficial, b=deep
T3-full muscle thickness involving perivesical fat-a-microscopically
T4-local invasion-prostate, uterus, vagina, pelvic wall, abdominal wall.
N1=metastasis in single LN in true pelvis-hypogastric, obturator, external iliac, presacral.
2=multiple LNs
3=common iliac LNs
M1=distant met.
RFs for squamous cell carcinoma of the bladder?
chronic inflammation and infection-renal stones, recurrent UTIs, long term indwelling catheter, schistosomiasis.
define paraneoplastic syndrome?
group of signs and symptoms resulting from endocrine function of tumours
e.g. polycythaemia in renal cell carcinoma.
what investigation should be sought if renal tract US and flexible cystoscopy with EUA are suggestive of a muscle invasive bladder Ca?
CT with contrast BEFORE proceeding to TURBT with biopsies
?look for metastases
why might a pt with renal cell carcinoma present with pyrexia?
due to paraneoplastic syndrome of IL-6 secretion by the tumour.
why might urinary symptoms e.g. frequency, be persistent following radical radiotherapy (EBRT) for T1 prostate Ca?
urinary symptoms before Ca diagnosis likely due to BPH, and tment of the then diagnosed prostate Ca with radiotherapy will destroy the Ca cells but will not shrink the prostate so it can still cause compressive symptoms.
only chemotherapy agents shown to significantly prolong survival in pts with hormone resistant prostate Ca?
taxanes e.g. docetaxel
what is bichemical recurrence of prostate Ca?
rising PSA despite previous radical prostate Ca treatment e.g. radiotherapy.
what is meant by active surveillence in prostate Ca?
this is a form of treatment of low risk prostate Cas-gleason score 6 or less, T score less than T2b and PSA less than 10, where pt is monitored with 3 mnthly PSAs, MRIs (yrly/3?) and biopsies (diagnost, 1yr, 3yrs) to look for Ca progression and if becomes eivdence of Ca progression then will start active Ca treatment with curative intention.
if concern about changes clinically or with PSA at any time, should reassess with MRI and/or re-biopsy.
what is meant by deferred hormone treatment in managing prostate Ca?
for pts where the intent of treatment is not curative but cancer is progressing slowly, can continue to monitor the pt with PSA before deciding to start hormone tment, when PSA reaches a part. level, so way in which to treat pts with prostate Ca that is likely to progress very slowly; and therefore likely pt to die with it rather than from it, that gives the pt more time without drug ADRs and maximises time before pt becomes resistant to hormone treatment.
normal PSA level?
age adjusted
0-3 in men under 60 years
0-4 in men aged between 60 and 69
0-5 in men aged 70 and above
when should a biopsy of the prostatic urethra be taken in investigating bladder Ca?
recommended if bladder neck tumour, bladder CIS present or suspected, +ve cytology without evidence of bladder tumour or when visible abnormalities of prostatic urethra.
preferably fluorescence guided when CIS suspected.
how is non muscle invasive bladder Ca categorised to determine tment?
low, intermediate and high risk based on tumour grading, size and number of tumours.
how are low grade (G1, G2) non muscle invasive bladder cancers treated?
low risk tumours, can be managed with complete macroscopic TUR, and f/u pt with cystoscopies.
may give single dose of intravesical mitomycin C at same time as 1st TURBT, and can also give this if recurrences of the tumour.
should give at least 6 doses of intravesical mitomycin C if classified as intermediate risk NMI bladder Ca.
ADRs of intravesical BCG?
cystitis
arthralgia
TB
when is radical cystectomy considered in bladder Ca treatment?
preferred curative treatment for localised muscle invasive bladder Ca.
with an ileal conduit or can form an orthotopic bladder-new bladder reconstructed out of bowel tissue, 1 mnth to heal-need urinary catheter during this time, if no tumour in urethra and at level of urethral dissection.
can consider adjuvant cisplatin combo chemo when neoadjuvant was not suitable
external beam radiotherapy alone should only be considered in those unfit for cystectomy, or as a multimodality bladder preserving approach.
1st line tment for fit pts with metastatic bladder Ca?
cisplatin-containing combination chemo
what complication of an orthotopic bladder are pts at high risk of?
urinary incontinence
UK risk of prostate Ca in men?
1 in 8