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Year 3 > Week 18 - BPH, Bladder Cancer, Prostate Cancer > Flashcards

Week 18 - BPH, Bladder Cancer, Prostate Cancer Flashcards

1
Q

what are the lower urinary tract symptoms that occur with prostate pathology

A

hestitancy
weak flow
urgency
frequency
intermittency
straining
terminal dribbling
incomplete emptying
nocturia

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2
Q

what is the scoring system that can be used to assess the severity of lower urinary tract symptoms

A

international prostate symptom score (IPSS)

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3
Q

what does the initial assessment of men presenting with LUTS involve

A

DRE
abdominal examination
urinary frequency volume chart
urine dipstick
PSA

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4
Q

what does PSA test for

A

for prostate cancer, depending on the patient preference

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5
Q

what is the general consensus on PSA testing

A

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.

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6
Q

what are the common causes of a raised PSA

A

Prostate cancer
Benign prostatic hyperplasia
Prostatitis
Urinary tract infections
Vigorous exercise (notably cycling)
Recent ejaculation or prostate stimulation

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7
Q

what are the medical options for patients with mild and manageable symptoms of BPH

A

alpha blockers

5-alpha reductase inhibitors

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8
Q

what is an example of an alpha blocker and what is the mechanism of action

A

tamsulosin

relaxes smooth muscle, with rapid improvement of symptoms

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9
Q

what is an example of a 5-alpha reductase inhibitor and what is the mechanism of action

A

finasteride

gradually reduces the size of the prostate

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10
Q

what are alpha blockers usually used to treat

A

used to treat the immediate symptomsw

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11
Q

what are 5-alpha reductase inhibitors used to treat

A

the actual enlargement of the prostate

they may both be used together where patients have significant symptoms and enlargement of the prostate

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12
Q

what does 5=alpha reductase do

A

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

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13
Q

how long does treatment take before there is an improvement in symptoms

A

6 months

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14
Q

what are the surgical options for BPH

A

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

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15
Q

what is the most notable side effect of alpha-blockers such as tamsulosin

A

postural hypotension

if an older man presents with lightheadedness on standing or falls, check lying and standing BP

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16
Q

what is the most common side effect of finasteride

A

sexual dysfunction due to reduced testosterone

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17
Q

what is a TURP

A

is the most common surgical treatment of BPH

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18
Q

what does a TURP involve

A

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

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19
Q

what is the aim of a TURP

A

to create a more expansive space for urine to flow through, thereby improving symptoms

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20
Q

what are the major complications of a TURP

A

Bleeding
Infection
Urinary incontinence
Erectile dysfunction
Retrograde ejaculation (semen goes backwards and is not produced from the urethra)
Urethral strictures
Failure to resolve symptoms

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21
Q

what is a TEVAP/TUVP

A

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.

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22
Q

what is a HoLEP

A

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.

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23
Q

what is an open prostatectomy

A

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.

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24
Q

where does cancer in the bladder arise from

A

the endothelial lining (urothelium)

the majority are superficial and do not invade the muscle on presentation

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25
Q

what are the major main risk factors for bladder cancer

A

smoking and increased age

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26
Q

what are worth noting as a carcinogen that cause bladder cancer and what are they used in

A

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.

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27
Q

what causes squamous cell carcinoma of the bladder in countries with a high prevalence of the infection

A

Schistosomiasis causes squamous cell carcinoma of the bladder in countries with a high prevalence of the infection.

28
Q

what are the two types of bladder cancer

A

Transitional cell carcinoma (90%)

Squamous cell carcinoma (5% – higher in areas of schistosomiasis)

Rarer causes are adenocarcinoma (2%), sarcoma and small-cell carcinoma

29
Q

what is the symptom to rememeber for your exam

A

painless haematuria

30
Q

what is the NICE guidlines on two week referral for bladder cancer

A

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

31
Q

how is bladder cancer diagnosed

A

using cytoscopy - a camera through the bladder can be used to visualise bladder cancer

it can be rigid or flexible

32
Q

what is the staging system used for bladder cancer and what are the clear distinctions

A

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.

33
Q

what is the surgery that involves removing the bladder cancer

A

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.

34
Q

what is often used after a TURBT procedure to reduce the risk of recurrence

A

Intravesical chemotherapy (chemotherapy given into the bladder through a catheter) is often used after a TURBT procedure to reduce the risk of recurrence.

35
Q

what may be used as a form of immunotherapy for bladder cancer

A

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.

36
Q

what is removal of the entire bladder called

A

Radical cystectomy involves the removal of the entire bladder. Following removal of the bladder,

37
Q

what is urostomy

A

is used to drain urine from the kidney, bypassing the ureters, bladder and urethra

this is the most common and popular solution after cystectomy

38
Q

what does forming a urostomy involve

A

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.

38
Q

what is a neobladder reconstruction

A

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.

38
Q

what does continent urinary diversion involve

A

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.

39
Q

what does a Ureterosigmoidostomy
involve

A

attaching the ureters directly to the sigmoid volon.

urine drains into and collects in the sigmoid colon.

40
Q

what are the techniques used to prevent urine refluxing into the ureters or back through the large bowel in a Ureterosigmoidostomy

A

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.

41
Q

where do advanced prostate cancers spread to

A

Advanced prostate cancer most commonly spreads to the lymph nodes and bones.

42
Q

what do prostate cancers almost always rely on

A

Prostate cancer is almost always androgen-dependent, meaning they rely on androgen hormones (e.g., testosterone) to grow

43
Q

what are the majority of prostate cancers and where do they grow

A

The majority are adenocarcinomas and grow in the peripheral zone of the prostate.

44
Q

what are the key risk factors for prostate cancers

A

Increasing age
Family history
Black African or Caribbean origin
Tall stature
Anabolic steroids

45
Q

what is the common presentations of bladder cancer

A

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)

46
Q

what cells in the prostate produce PSA

A

epithelial cells

47
Q

what is PSA and what does it do

A

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

48
Q

what is first line investigation for suspected localised prostate cancer

A

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

49
Q

what is the next step after a MRI

A

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).

50
Q

what ae the two options for a prostate biopsy

A

Transrectal ultrasound-guided biopsy (TRUS)
Transperineal biopsy

51
Q

what does a transrectal ultrasound-guided biopsy involve

A

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

52
Q

what does a transperineal biopsy involve

A

Transperineal biopsy involves needles inserted through the perineum. It is usually under local anaesthetic.

53
Q

what are the main risks of a prostate biopsy

A

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)

54
Q

what can be used to look for bony metastasis

A

Isotope Bone Scan

55
Q

what is the grading system specific to prostate cancer and what is based on

A

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).

56
Q

how is the Gleason score calculated

A

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

57
Q

what are the 5 options for treatment of prostate cancer

A

Surveillance or watchful waiting in early prostate cancer
External beam radiotherapy directed at the prostate
Brachytherapy
Hormone therapy
Surgery

58
Q

what is a key complication of external beam radiotherapy

A

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.

59
Q

what does brachytherapy involve

A

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.

60
Q

what does hormone therapy in prostate cancer aim to do

A

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.

61
Q

what are the 3 options for hormone therapy in prostate cancer

A

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)

62
Q

what are the side effects of hormone therapy

A

Hot flushes
Sexual dysfunction
Gynaecomastia
Fatigue
Osteoporosis

63
Q

what is a radical prostatectomy and what is the aim and the complications

A

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.

64
Q
A

Year 3 (63 decks)

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