Week 18 - BPH, Bladder Cancer, Prostate Cancer

Question 1

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

Answer 1

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

Question 2

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

Answer 2

international prostate symptom score (IPSS)

Question 3

what does the initial assessment of men presenting with LUTS involve

Answer 3

DRE
abdominal examination
urinary frequency volume chart
urine dipstick
PSA

Question 4

what does PSA test for

Answer 4

for prostate cancer, depending on the patient preference

Question 5

what is the general consensus on PSA testing

Answer 5

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.

Question 6

what are the common causes of a raised PSA

Answer 6

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

Question 7

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

Answer 7

alpha blockers

5-alpha reductase inhibitors

Question 8

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

Answer 8

tamsulosin

relaxes smooth muscle, with rapid improvement of symptoms

Question 9

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

Answer 9

finasteride

gradually reduces the size of the prostate

Question 10

what are alpha blockers usually used to treat

Answer 10

used to treat the immediate symptomsw

Question 11

what are 5-alpha reductase inhibitors used to treat

Answer 11

the actual enlargement of the prostate

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

Question 12

what does 5=alpha reductase do

Answer 12

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

Question 13

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

Answer 13

6 months

Question 14

what are the surgical options for BPH

Answer 14

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

Question 15

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

Answer 15

postural hypotension

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

Question 16

what is the most common side effect of finasteride

Answer 16

sexual dysfunction due to reduced testosterone

Question 17

what is a TURP

Answer 17

is the most common surgical treatment of BPH

Question 18

what does a TURP involve

Answer 18

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

Question 19

what is the aim of a TURP

Answer 19

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

Question 20

what are the major complications of a TURP

Answer 20

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

Question 21

what is a TEVAP/TUVP

Answer 21

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.

Question 22

what is a HoLEP

Answer 22

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.

Question 23

what is an open prostatectomy

Answer 23

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.

Question 24

where does cancer in the bladder arise from

Answer 24

the endothelial lining (urothelium)

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

Question 25

what are the major main risk factors for bladder cancer

Answer 25

smoking and increased age

Question 26

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

Answer 26

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.

Question 27

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

Answer 27

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

Question 28

what are the two types of bladder cancer

Answer 28

Transitional cell carcinoma (90%) Squamous cell carcinoma (5% – higher in areas of schistosomiasis) Rarer causes are adenocarcinoma (2%), sarcoma and small-cell carcinoma

Question 29

what is the symptom to rememeber for your exam

Answer 29

painless haematuria

Question 30

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

Answer 30

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

Question 31

how is bladder cancer diagnosed

Answer 31

using cytoscopy - a camera through the bladder can be used to visualise bladder cancer it can be rigid or flexible

Question 32

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

Answer 32

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.

Question 33

what is the surgery that involves removing the bladder cancer

Answer 33

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.

Question 34

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

Answer 34

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

Question 35

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

Answer 35

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.

Question 36

what is removal of the entire bladder called

Answer 36

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

Question 37

what is urostomy

Answer 37

is used to drain urine from the kidney, bypassing the ureters, bladder and urethra this is the most common and popular solution after cystectomy

Question 38

what does forming a urostomy involve

Answer 38

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.

Question 38

what is a neobladder reconstruction

Answer 38

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.

Question 38

what does continent urinary diversion involve

Answer 38

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.

Question 39

what does a Ureterosigmoidostomy involve

Answer 39

attaching the ureters directly to the sigmoid volon. urine drains into and collects in the sigmoid colon.

Question 40

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

Answer 40

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.

Question 41

where do advanced prostate cancers spread to

Answer 41

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

Question 42

what do prostate cancers almost always rely on

Answer 42

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

Question 43

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

Answer 43

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

Question 44

what are the key risk factors for prostate cancers

Answer 44

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

Question 45

what is the common presentations of bladder cancer

Answer 45

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)

Question 46

what cells in the prostate produce PSA

Answer 46

epithelial cells

Question 47

what is PSA and what does it do

Answer 47

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

Question 48

what is first line investigation for suspected localised prostate cancer

Answer 48

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

Question 49

what is the next step after a MRI

Answer 49

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).

Question 50

what ae the two options for a prostate biopsy

Answer 50

Transrectal ultrasound-guided biopsy (TRUS) Transperineal biopsy

Question 51

what does a transrectal ultrasound-guided biopsy involve

Answer 51

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

Question 52

what does a transperineal biopsy involve

Answer 52

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

Question 53

what are the main risks of a prostate biopsy

Answer 53

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)

Question 54

what can be used to look for bony metastasis

Answer 54

Isotope Bone Scan

Question 55

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

Answer 55

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).

Question 56

how is the Gleason score calculated

Answer 56

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

Question 57

what are the 5 options for treatment of prostate cancer

Answer 57

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

Question 58

what is a key complication of external beam radiotherapy

Answer 58

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.

Question 59

what does brachytherapy involve

Answer 59

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.

Question 60

what does hormone therapy in prostate cancer aim to do

Answer 60

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.

Question 61

what are the 3 options for hormone therapy in prostate cancer

Answer 61

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)

Question 62

what are the side effects of hormone therapy

Answer 62

Hot flushes Sexual dysfunction Gynaecomastia Fatigue Osteoporosis

Question 63

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

Answer 63

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.