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
how can the severity of urinary symptoms due to BPH be assessed?
International Prostate symptom score (I-PSS): 7 symptom qns and 1 QOL, 7 symptoms: frequency, urgency, straining, intermittency, weak stream, incomplete emptying, nocturia. max. score 35, 20-35=severe. QOL: how would they feel about life long continuation of current urinary symptoms?
symptoms of locally invasive prostate Ca (T3 or T4)?
haematuria dysuria incontinence haematospermia (blood in semen) suprapubic or perineal pain ureteric obstruction-loin pain, anuria, AKI, CKD impotence rectal symptoms e.g. tenesmus
features of metastatic prostate Ca?
bone pain-back pain, sciatica spinal cord compression-paraplegia LN enlargement loin pain or anuria secondary to ureteral obstruction by enlarged LNs weight loss cachexia lethargy-anaemia, uraemia
features on DRE of prostate Ca?
nodule in 1 lobe
gland asymmetry
induration
lack of mobility-adhesion to surrounding tissue
palpable seminal vesicles-*involvement in T3 prostate Ca
in testing a pt for PSA, how long should be left before testing if pt has current UTI?
at least 4weeks
how do we investigate pt for prostate Ca?
PSA blood test
Us and Es, creatinine, eGFR
PCA3 urine test-?may use if deciding if rpt biospy needed after initial -ve biopsy
urinalysis-urine microscopy, culture and sensitivity
TRUS prostate BIOPSIES-taken from prostate periphery, 2 from base, middle and apex from both lobes of the prostate.
transperineal template biopsy-part of active surveillence to reduce no. biospies, for determining focal tment of disease, if inconclusive rectal biopsies.
cystoscopy and upper UT imaging, uroflow measurement
multiparametric MRI
pelvic MRI
isotope bone scan-hot spots
T staging of prostate Ca?
Tx-primary tumour cannot be assessed
T0-no evidence of primary tumour
T1-tumour in 1 lobe of prostate, clinically inapparent-neither palpable nor visible by imaging, 1a=incidental histological finding in 5% or less of tissue resected, b=more than 5%, c=tumour identified by needle biospy
2-tumour confined within prostate, a=1 lobe, b=both*2b or less classed as low risk tumour
3-extension through prostate capsule, a=EC invasion, b=invades seminal vesicles
4-fixed or invades adjacent structures-bladder neck, external sphincter, rectum, levator muscles and/or pelvic wall.
what is pM1c for prostate cancer?
most advanced category of distant metastasis-spread to sites other than non-regional LNs and bone.
how is prostate Ca graded?
histologically classifed based on degree of differentiation at low magnification: Gleason grading: 2=most well differentiated tumour, 10=most poorly differentiated, score=sum of the 2 most prominent grades as the Ca often heterogenous.
6 or less*=low risk pt
4 or less= well differentiated
more than 7=poorly differentiated
features of prostate Ca that suggest low risk of recurrence after treatment of localised disease?
PSA less than 10 and
T stage 2a (half of 1 side of prostate) or less and
Gleason score 6 or less
what factors suggest intermediate risk of recurrence after tment of localised prostate Ca?
PSA 10-20 or
T stage 2b or
Gleason score 7
what must be excluded before PSA testing?
UTI
NICE r/f criteria for prostate Ca in relation to raised PSA?
urgent r/f (2ww) if age-specific PSA raised or rising in man with or without LUTS and prostate normal on DRE
if borderline PSA in asymptomatic man, rpt after 1-3mnths, and r/f urgently if suggest rising PSA.
treatment options for localised prostate Ca?
radical prostatectomy
external beam radiotherapy
brachytherapy-transperineal implantation of radioactive seeds into the prostate
active surveillence
watchful waiting
focal therapy
cryotherapy-can be used to treat local recurrence refractory to other tments
if locally advanced (T3/T4) evidence that adding androgen suppression to standard tments can prolong survival.
indications for hormonal treatment of prostate Ca?
symptomatic pts, extensive T3-T4 disease, PSA more than 25-50, PSA doubling time less than 1 yr, pt driven, unfit pts.
NOT as monotherapy in those fit enough for radiotherapy.
standard tment of metastatic prostate Ca?
hormonal therapy
combined with chemotherapy if performance status 0-2
chemo-docetaxel, for hormone resistant prostate Ca**
complications of ‘flare’ phenomenon in advanced prostate Ca tment with LHRH agonists?
bone pain
SC compression
acute bladder outlet obstruction and obstructive AKI
fatal CVS events due to hypercoagulation status
result of initial increase in testosterone over 1st 10 days of tment causing increase prostate Ca activity
what tment should be given to prostate Ca patients who start LT bicalutamide (anti androgen) monotherapy?
prophylactic radiotherapy to both breast buds to reduce risk of gynaecomastia
complications of prostate Ca and its treatment for patients?
mets-bony-pain, pathological fractures, SC compression
obstructive uropathy-AKI, CKD
sexual dysfunction-loss of libido, erectile dysfunction
hormonal therapy complications-hot flushes, gynaecomastia
example of maximal androgen blockage in metastatic prostate Ca treatment?
LHRH agonist e.g. goserelin, combined with an antiandrogen e.g. bicalutamide.
most common type of renal cancer?
renal cell carcinoma-of which the most common type is clear cell. arises from renal proximal tubular epithelium.
types of renal cell carcinoma?
clear cell (80-90%)
papillary
chromophobe
benign tumours of the kidneys?
oncocytoma
angiomyolipoma-very vascular, more common in middle aged females, associated with tuberous sclerosis, patients at risk of life threatening haemorrhage and kidney rupture.
most common kidney tumour in children?
wilm’s tumour
underlying genetic alteration in both hereditary and non-hereditary renal cell carcinoma?
structural alterations of short arm of chromosome 3 (3p)
most common hereditary syndrome associated with renal cell carcinoma?
von hippel lindau disease-inherited disorder result of mutation of VHL TSG on chromosome 3. autosomal dominant. causes both benign and malignant tumours, most common-CNS and retinal haemangioblastomas, clear cell renal carcinoma, renal cysts and phaeochromocytoma.
renal cancer risk factors?
smoking obesity long term renal dialysis tuberous sclerosis renal transplant recipient acquired renal cystic disease
presentation of renal cell carcinoma?
often detected when USS used to investigate non-specific features visible haematuria loin pain loin mass fatigue weight loss varciocele pyrexia of unknown origin HTN may be px with metastatic disease-haemoptysis (cannon ball lung mets), pathological fracture, bone pain-osteolytic lesions produced when renal cancer metastasises to bone.
paraneoplastic symptoms in renal cancer?
pyrexia anaemia polycythaemia hypercalcaemia-PTHrP production neuromyopathy amyloidosis raised ESR abnormal LFTs
most common site of renal cancer to metastasise to?
lungs
*cannon ball secondaries on CXR
why might renal function tests e.g. U+Es, eGFR, creatinine, NOT be useful in the investigation of renal cancer?
likely normal if 1 kidney is functioning well
investigations to be considered in possible renal cancer?
FBC-hypochromic microcytic anaemia due to Fe deficiency if significant haematuria, WCC-UTI, polycythaemia-EPO prod. by renal tumour, and raised haematocrit.
renal function tests
urine cytology, microscopy, culture and sensitivity
CT renal scanning before and after IV contrast
MRI
IV urogram to identify urinary obstruction-hydronephrosis
cystoscopy-exclude bladder tumour
renal biospy
renal angiogram
mets:
CXR/CT chest
bone scan/skeletal survery-series of plain X-rays
brain CT
T staging of renal cancer?
T1-tumour 7cm or less in greatest dimension
T2-tumour more than 7cm in greatest diameter, limited to kidney
T3-tumour extends into major veins or perinephric tissues, but NOT into the ipsilateral adrenal gland and not beyond Gerota’s fascia (renal fascia)
T4-tumour invades beyond renal fascia (Gerota’s fascia), including contiguous extension into ipsilateral adrenal.
treatment for localised renal cancer?
partial nephrectomy=treatment of choice for those with localised tumour less than 7cm in diameter (T1). may be with or without radiotherapy and/or chemotherapy.
for those with small peripheral tumours where open/lap surgery not an option, may consider minimally invasive surgery-percutaneous RF ablation, lap cryotherapy, perc cryotherapy.
treatment to consider in palliation of unresectable renal malignancy and for renal haemorrhage?
renal artery emolisation
treatment of advanced/metastatic renal cancer?
nephrectomy combined with interferon-alpha
IF-alpha or IL-2 can be considered in those with clear cell cancer
tyrosine kinase inhibtors e.g. sunitinib if suitable for immunotherapy, mobile and can do light work.
resection of metastases in otherwise fit patients
palliative radiotherapy for brain mets and bone lesions
bisphosphonates to reduce rates of skeletal events in those with bone mets
RFs for renal stones?
dehydration diuretics Ca2+/Vit D supplements HTN gout hyperparathyroidism renal anatomical anomalies chronic metabolic acidosis previous stone disease cystinuria (AR) deficiency of citrate in urine hot climates higher SE groups
symptoms of renal calculi?
colicky loin to groin pain haematuria dysuria N+V fevers/rigors pain radiating to scrotum/labia/A.thigh from flank
investigations in suspected renal stone presentation?
blds-FBC, U+Es, CRP, uric acid, Ca2+
urine dip-NV haematuria
urine M,C+S
urine preg test in females
X-ray KUB-75% stones visible(contain Ca2+-radio opaque)-calcium oxalate most common
CT KUB (non contrast)-gold standard (helical non contrast CT)
initial management of pt with renal colic?
analgesia-PR NSAIDs e.g. indomethacin
anti-emetics
IVI if insufficient oral intake
if suitable for d/c then need suitable analgesia prescribed for home, OP urology f/u in 2-4wks, and f/u imaging (usually X-ray KUB)
indications for urgent surgical intervention in renal colic px?
infection with urinary tract obstruction bilateral obstructing stones obstruction in solitary/transplanted kidney intractable pain/vomiting/both AKI social reason, pilot/submariner**
options for urgent surgical intervention in renal colic?
nephrostomy
cystoscopy and insertion of JJ stent
why might a patient with an ileostomy be at risk of renal colic?
loss of HCO3- and fluid causes acidic urine which causes the precipitation of uric acid
treatment of renal stones in the non emergency setting?
stones less than 5mm in size usually pass spontaneously
medically-use of alpha blockers e.g. tamsulosin, to help stone pass
extracorporeal shockwave lithotripsy
percutaneous nephrolithotomy
ureteroscopy-in preg females where lithotropsy CI, and in complex stone disease, stent in situ left for 4 wks post procedure
open surgery
what benefit do 5 alpha reductase inhibitors e.g. finasteride, have over alpha blockers in BPH treatment?
can slow disease progression by reducing prostate volume BUT this takes time
also adverse effects of erectile dysfunction, reduced libido, gynaecomastia, ejaculation problems.
what is a varciocele? what complications might it cause?
abnormal enlargement of testicular veins, feels like a bag of worms, more common on L side *Note more acute angle of L testicular vein drainage into L renal vein vs. IVC on R hand side
diagnosed using US with Doppler studies
important as associated with infertility
surgery may be required if pt troubled by pain.
causes of acute urinary retention?
obstructive: BPH urethral stricture bladder neck stenosis pelvic mass constipation/faecal impaction clot retention post urological surgery inflammatory: prostatitis-prostate tenderness on DRE, boogy prostate UTI drugs: opioids alcohol diuretics spinal/ED anaesthesia neurogenic: SC injury MS/Parkinsons pelvic injury/trauma pelvic surgery spinal/epidurals
what to examine for in suspected acute urinary retention?
abdo exam.
DRE-assess faecal loading, prostate size, consistency, tendernesss, look for malignancy, and any blood on glove.
full neuro. exam including asses. anal sphincter tone and saddle anaesthesia if suspicion of cauda equina syndrome.
investigations for acute urinary retention?
FBC, U+Es
USS of KUB if renal impairment
urinalysis, bladder scan
management of pt with acute urinary retention?
analgesia
neuro/oncolog/OP opinion if suspected CE syndrome
2 way catheter, 3 way if likely clot retention, document urine colour and residual volume
laxatives/enemas if constipation likely cause
Abx if UTI suspected
if normal renal function, trial tamsulosin (alpha blocker) 400mcg OD
monitor urine output-diuresis, rebound haematuria
replace fluid losses
pt can be d/c with catheter in situ and tamsulosin, consider TWOC in 1 wk for simple UTI.
indications for IP admission in acute urinary retention?
acute renal impairment
large post obstructive diuresis
haematuria with clots
social reasons
most common malignancy in men aged 20-30yrs?
testicular cancer
types of testicular cancer?
germ cell and non-germ cell
germ cell-seminoma, teratoma, choriocarcinoma, yolk sac tumour
non-germ cell-sertoli, leydig
commonest germ cell tumour in men?
seminoma
seminoma tumour markers?
AFP usually normal
hCG raised in 10%
LDH raised in 10-20%
AFP and hCG usually elevated in teratomas
1st line diagnostic investigation for testicular Ca?
scrotal USS
treatment-orchidectomy-inguinal approach
RFs for testicular Ca?
cryptorchidism infertility klinefelter's syndrome (47, XXY) -gynaecomastia mumps orchitis FH
Part of prostate affected by BPH?
transitional
complications of a TURP?
- T-TUR syndrome-salt deplete irrigation fluid enters the systemic circulation, causing dilutional hyponatraemia, fluid overload and glycine toxicity. must fluid restrict.
- U-UTI, urethral stricture
- R-retrograde ejaculation
- P-prostate perforation
how does management of a TCC of the kidney differ from that for a renal cell carcinoma?
TCC requires nephroureterectomy with disconnection of the ureter at the bladder
renal cell carcinoma-partial nephrectomy if T1 disease, otherwise radical nephrectomy
