Week 18 - BPH, Bladder Cancer, Prostate Cancer Flashcards
what are the lower urinary tract symptoms that occur with prostate pathology
hestitancy
weak flow
urgency
frequency
intermittency
straining
terminal dribbling
incomplete emptying
nocturia
what is the scoring system that can be used to assess the severity of lower urinary tract symptoms
international prostate symptom score (IPSS)
what does the initial assessment of men presenting with LUTS involve
DRE
abdominal examination
urinary frequency volume chart
urine dipstick
PSA
what does PSA test for
for prostate cancer, depending on the patient preference
what is the general consensus on PSA testing
is known to be unreliable, with a high rate of false positives (75%) and false negatives (15%). False positive results may lead to further investigations, including invasive prostate biopsies, which have complications and may be unnecessary. False negatives may lead to false reassurance. Therefore, it is essential to counsel patients to make an informed decision about whether to have the test.
what are the common causes of a raised PSA
Prostate cancer
Benign prostatic hyperplasia
Prostatitis
Urinary tract infections
Vigorous exercise (notably cycling)
Recent ejaculation or prostate stimulation
what are the medical options for patients with mild and manageable symptoms of BPH
alpha blockers
5-alpha reductase inhibitors
what is an example of an alpha blocker and what is the mechanism of action
tamsulosin
relaxes smooth muscle, with rapid improvement of symptoms
what is an example of a 5-alpha reductase inhibitor and what is the mechanism of action
finasteride
gradually reduces the size of the prostate
what are alpha blockers usually used to treat
used to treat the immediate symptomsw
what are 5-alpha reductase inhibitors used to treat
the actual enlargement of the prostate
they may both be used together where patients have significant symptoms and enlargement of the prostate
what does 5=alpha reductase do
converts testosterone to dihydrotestosterone which is a more potent androgen hormone
they reduce DHT in the tissues, including the prostate, leading to a reduction in prostate size
how long does treatment take before there is an improvement in symptoms
6 months
what are the surgical options for BPH
Transurethral resection of the prostate (TURP)
Transurethral electrovaporisation of the prostate (TEVAP/TUVP)
Holmium laser enucleation of the prostate (HoLEP)
Open prostatectomy via an abdominal or perineal incision
what is the most notable side effect of alpha-blockers such as tamsulosin
postural hypotension
if an older man presents with lightheadedness on standing or falls, check lying and standing BP
what is the most common side effect of finasteride
sexual dysfunction due to reduced testosterone
what is a TURP
is the most common surgical treatment of BPH
what does a TURP involve
removing part of the prostate from inside the urethra
a resectoscope is inserted into the urethra, and prostate tissue is removed using a diathermy loop
what is the aim of a TURP
to create a more expansive space for urine to flow through, thereby improving symptoms
what are the major complications of a TURP
Bleeding
Infection
Urinary incontinence
Erectile dysfunction
Retrograde ejaculation (semen goes backwards and is not produced from the urethra)
Urethral strictures
Failure to resolve symptoms
what is a TEVAP/TUVP
Transurethral electrovaporisation of the prostate (TEVAP / TUVP) involves inserting a resectoscope into the urethra. A rollerball electrode is then rolled across the prostate, vaporising prostate tissue and creating a more expansive space for urine flow.
what is a HoLEP
Holmium laser enucleation of the prostate (HoLEP) also involves inserting a resectoscope into the urethra. A laser is then used to remove prostate tissue, creating a more expansive space for urine flow.
what is an open prostatectomy
Open prostatectomy involves an open procedure to remove the prostate. An abdominal or perineal incision can be used to access the prostate. Open surgery is less commonly used as it carries an increased risk of complications, a more extended hospital stay and longer recovery than other surgical procedures.
where does cancer in the bladder arise from
the endothelial lining (urothelium)
the majority are superficial and do not invade the muscle on presentation
what are the major main risk factors for bladder cancer
smoking and increased age
what are worth noting as a carcinogen that cause bladder cancer and what are they used in
Aromatic amines are worth noting as a carcinogen that causes bladder cancer. Aromatic amines were used in dye and rubber industries but have been heavily regulated or banned for many years. They are also found in cigarette smoke and seem to be the reason smoking causes bladder cancer.
what causes squamous cell carcinoma of the bladder in countries with a high prevalence of the infection
Schistosomiasis causes squamous cell carcinoma of the bladder in countries with a high prevalence of the infection.
what are the two types of bladder cancer
Transitional cell carcinoma (90%)
Squamous cell carcinoma (5% – higher in areas of schistosomiasis)
Rarer causes are adenocarcinoma (2%), sarcoma and small-cell carcinoma
what is the symptom to rememeber for your exam
painless haematuria
what is the NICE guidlines on two week referral for bladder cancer
Aged over 45 with unexplained visible haematuria, either without a UTI or persisting after treatment for a UTI
Aged over 60 with microscopic haematuria (not visible but positive on a urine dipstick) PLUS:
Dysuria or;
Raised white blood cells on a full blood count
how is bladder cancer diagnosed
using cytoscopy - a camera through the bladder can be used to visualise bladder cancer
it can be rigid or flexible
what is the staging system used for bladder cancer and what are the clear distinctions
TMN
There is a clear distinction between:
Non-muscle-invasive bladder cancer (not invading the muscle layer of the bladder)
Muscle-invasive bladder cancer (invading the muscle and beyond)
Non-muscle-invasive bladder cancer includes:
Tis/carcinoma in situ: cancer cells only affect the urothelium and are flat
Ta: cancer only affecting the urothelium and projecting into the bladder
T1: cancer invading the connective tissue layer beyond the urothelium, but not the muscle layer
Invasive bladder cancer includes T2 – 4 and any lymph node or metastatic spread.
what is the surgery that involves removing the bladder cancer
Transurethral resection of bladder tumour (TURBT) may be used for non-muscle-invasive bladder cancer. The involves removing the bladder tumour during a cystoscopy procedure.
what is often used after a TURBT procedure to reduce the risk of recurrence
Intravesical chemotherapy (chemotherapy given into the bladder through a catheter) is often used after a TURBT procedure to reduce the risk of recurrence.
what may be used as a form of immunotherapy for bladder cancer
Intravesical Bacillus Calmette-Guérin (BCG) may be used as a form of immunotherapy. Giving the BCG vaccine (the same one as for tuberculosis) into the bladder is thought to stimulate the immune system, which in turn attacks the bladder tumours.
what is removal of the entire bladder called
Radical cystectomy involves the removal of the entire bladder. Following removal of the bladder,
what is urostomy
is used to drain urine from the kidney, bypassing the ureters, bladder and urethra
this is the most common and popular solution after cystectomy
what does forming a urostomy involve
creating an ileal conduit
A section of the ileum (15 – 20cm) is removed, and end-to-end anastomosis is created so that the bowel is continuous. The ends of the ureters are anastomosed to the separated section of the ileum. The other end of this section of the ileum forms a stoma on the skin, draining urine into a urostomy bag. Urine drains from the kidneys to the ureters, then the separated section of ileum (the conduit), then out of the urostomy.
what is a neobladder reconstruction
A continent urinary diversion involves creating a pouch inside the abdomen from a section of the ileum, with the ureters connected. This pouch fills with urine. A thin tube is connected between a stoma on the skin and the internal pouch. Urine does not drain from the stoma (unlike a urostomy), and the patient needs to intermittently insert a catheter into the stoma to drain urine from the pouch.
what does continent urinary diversion involve
A continent urinary diversion involves creating a pouch inside the abdomen from a section of the ileum, with the ureters connected. This pouch fills with urine. A thin tube is connected between a stoma on the skin and the internal pouch. Urine does not drain from the stoma (unlike a urostomy), and the patient needs to intermittently insert a catheter into the stoma to drain urine from the pouch.
what does a Ureterosigmoidostomy
involve
attaching the ureters directly to the sigmoid volon.
urine drains into and collects in the sigmoid colon.
what are the techniques used to prevent urine refluxing into the ureters or back through the large bowel in a Ureterosigmoidostomy
Techniques are used to prevent urine refluxing into the ureters or back through the large bowel. The rectum may be expanded to create a recto sigmoid pouch (called a Mainz II procedure) to create a larger space for urine to collect. The patient can then drain the urine by relaxing the anal sphincter in the same way they open their bowels.
where do advanced prostate cancers spread to
Advanced prostate cancer most commonly spreads to the lymph nodes and bones.
what do prostate cancers almost always rely on
Prostate cancer is almost always androgen-dependent, meaning they rely on androgen hormones (e.g., testosterone) to grow
what are the majority of prostate cancers and where do they grow
The majority are adenocarcinomas and grow in the peripheral zone of the prostate.
what are the key risk factors for prostate cancers
Increasing age
Family history
Black African or Caribbean origin
Tall stature
Anabolic steroids
what is the common presentations of bladder cancer
It may also present with lower urinary tract symptoms (LUTS), similar to benign prostate hyperplasia. These symptoms include hesitancy, frequency, weak flow, terminal dribbling and nocturia.
Other symptoms include:
Haematuria
Erectile dysfunction
Symptoms of advanced disease or metastasis (e.g., weight loss, bone pain or cauda equina syndrome)
what cells in the prostate produce PSA
epithelial cells
what is PSA and what does it do
PSA is a glycoprotein that is secreted in the semen, with a small amount entering the blood. Its enzymatic activity helps thin the thick semen into a liquid consistency after ejaculation. It is specific to the prostate, meaning it is not produced anywhere else in the body
what is first line investigation for suspected localised prostate cancer
Multiparametric MRI of the prostate is now the usual first-line investigation for suspected localised prostate cancer. The results are reported on a Likert scale, scored as:
1 – very low suspicion
2 – low suspicion
3 – equivocal
4 – probable cancer
5 – definite cancer
what is the next step after a MRI
Prostate biopsy is the next step in establishing a diagnosis. The decision to perform a biopsy depends on the MRI findings (e.g., Likert 3 or above) and the clinical suspicion (i.e. examination and PSA level).
what ae the two options for a prostate biopsy
Transrectal ultrasound-guided biopsy (TRUS)
Transperineal biopsy
what does a transrectal ultrasound-guided biopsy involve
involves an ultrasound probe inserted into the rectum, providing a good indicate of the size and shape of the prostate. Guided biopsies are taken through the wall of the rectum, into the prostate.w
what does a transperineal biopsy involve
Transperineal biopsy involves needles inserted through the perineum. It is usually under local anaesthetic.
what are the main risks of a prostate biopsy
Pain (particularly lower abdominal, rectal or perineal pain)
Bleeding (blood in the stools, urine or semen)
Infection
Urinary retention due to short term swelling of the prostate
Erectile dysfunction (rare)
what can be used to look for bony metastasis
Isotope Bone Scan
what is the grading system specific to prostate cancer and what is based on
The Gleason grading system is based on the histology from the prostate biopsies. It is specific to prostate cancer and helps to determine what treatment is most appropriate. The greater the Gleason score, the more poorly differentiated the tumour is (the cells have mutated further from normal prostate tissue) and the worse the prognosis is. The tissue samples are graded 1 (closest to normal) to 5 (most abnormal).
how is the Gleason score calculated
The Gleason score will be made up of two numbers added together for the total score (for example, 3 + 4 = 7):
The first number is the grade of the most prevalent pattern in the biopsy
The second number is the grade of the second most prevalent pattern in the biopsy
A Gleason score of:
6 is considered low risk
7 is intermediate risk (3 + 4 is lower risk than 4 + 3)
8 or above is deemed to be high risk
what are the 5 options for treatment of prostate cancer
Surveillance or watchful waiting in early prostate cancer
External beam radiotherapy directed at the prostate
Brachytherapy
Hormone therapy
Surgery
what is a key complication of external beam radiotherapy
proctitis (inflammation in the rectum) caused by radiation affecting the rectum. Proctitis can cause pain, altered bowel habit, rectal bleeding and discharge. Prednisolone suppositories can help reduce inflammation.
what does brachytherapy involve
implanting radioactive metal “seeds” into the prostate. This delivers continuous, targeted radiotherapy to the prostate. The radiation can cause inflammation in nearby organs, such as the bladder (cystitis) or rectum (proctitis). Other side effects include erectile dysfunction, incontinence and increased risk of bladder or rectal cancer.
what does hormone therapy in prostate cancer aim to do
Hormone therapy aims to reduce the level of androgens (e.g., testosterone) that stimulate the cancer to grow. They are usually either used in combination with radiotherapy, or alone in advanced disease where cure is not possible.
what are the 3 options for hormone therapy in prostate cancer
The options are:
Androgen-receptor blockers such as bicalutamide
GnRH agonists such as goserelin (Zoladex) or leuprorelin (Prostap)
Bilateral orchidectomy to remove the testicles (rarely used)
what are the side effects of hormone therapy
Hot flushes
Sexual dysfunction
Gynaecomastia
Fatigue
Osteoporosis
what is a radical prostatectomy and what is the aim and the complications
Radical prostatectomy involves a surgical operation to remove the entire prostate. The aim is to cure prostate cancer confined to the prostate. Key complications are erectile dysfunction and urinary incontinence.
