Week 18 - Cases 1 and 2

Question 1

what radiological modality is more sensitive and specific for detecting urinary tract stones than US

Answer 1

A computed tomography (CT) scan of the kidneys, ureters and bladder (KUB) i.e. CT KUB uses X-rays to detect urinary tract stones that contain calcium. No radio-opaque contrast is given so that any stones will present will be more easily seen.

Contraindications: Pregnancy; Frequent imaging needed (cumulative radiation dose); Known radiolucent stones (such as uric acid).

Question 2

what are the NICE guidelines for haematuria investigation protocols

Answer 2

NICE guidelines, all patients aged 45 years old and over with visible haematuria, in the absence of proven urinary infection or other cause, should be investigated as a 2-week wait urgent referral. This involves blood tests for U+E, FBC and PSA (if male and over 50) as well as a flexible cystoscopy and a renal tract ultrasound or a CT urogram (the key to a urogram is that the contrast is given intravenously as normal, but the images are taken after a delay of 5-10 minutes to allow the contrast to be present in the renal collecting system and ureters).

Question 3

why are UTI’s more common post menopause

Answer 3

They are more common in post-menopausal than pre-menopausal women because the lower oestrogen state after the menopause reduces the lactobacilli or ‘good bacteria’ which help to compete with uropathogenic bacteria.

Question 4

what does the term ‘complicated UTI’ mean

Answer 4

that there is an anatomical or pathological abnormality in the urinary tract that predisposes the patient to developing UTI’s

Question 5

what are such abnormalities?

Answer 5

Such abnormalities might include vesico-ureteric reflux, urinary tract stones, urinary tract tumours or incomplete bladder emptying.

Question 6

how are recurrent UTI’s defined

Answer 6

by more than three episodes of infection per year

Question 7

when do stones in the kidney cause pain

Answer 7

when they are so big that they fill the renal pelvis (staghorn stones)

Question 8

what are the non-modifiable risk factors for getting urinary tract stones

Answer 8

Patient risk factors that are non-modifiable include being male (3:1 ratio), 40-60 years old, being Caucasian (then Hispanic, Black and Asian in decreasing order) and having bowel, calcium level or rare renal problems (which are often genetic).

Question 9

what are the modifiable risk factors for getting urinary tract stones

Answer 9

Modifiable patient risk factors include chronic dehydration, diets high in calcium/ oxalate/ uric acid, obesity (often related to diet but also purine breakdown, high urine calcium and low urine pH), taking certain medications and high ambient temperatures. Any abnormality of the urinary tract causing obstruction and hence stasis of urine also predisposes to stone formation.

Question 10

when are bladder tumours usually identified

Answer 10

Bladder tumours are usually identified at flexible cystoscopy, a procedure done under local anaesthetic, in the outpatient department

Question 11

what happens during a TURBT

Answer 11

URBT, or transurethral resection of bladder tumour. This scrapes the tumour out of the bladder (not going through the muscle layer but trying to get a sample from it to determine whether it is involved) and diathermy is used to stop any bleeding. Non-muscle invasive bladder cancer (NMIBC) is treated by performing this operation, whereas tumours that are T2, and so invade the muscle, need further treatment.

Question 12

what is the main issue with NMIBC and so once the TURBT has been done, what has to happen

Answer 12

NMIBC is that it can recur and so once the TURBT has been done, they have ’surveillance’ which is periodic flexible cystoscopies for a set time period. If there is a recurrence seen then another TURBT needs to be done although in some centres small recurrent tumours can be treated with lasers in the outpatient clinic. There is also a small risk that NMIBC can also progress and become muscle-invasive bladder cancer (MIBC).

Question 13

what are the chemotherapy agents used in NMIBC

Answer 13

Additional treatments are usually intravesical instillations of chemotherapy agents (such as mitomycin) or intravesical BCG (these help to reduce the rate of recurrence and BCG reduces progression to T2, muscle-invasive disease). The NMIBC that are most likely to recur and progress are large (>3cm), multi-focal, have previously recurred and are T1 and/ or G3.

Question 14

If patients are T2 (muscle invasive at diagnosis) or progress from Ta/1 to this during surveillance, what will they require

Answer 14

they will require radical treatment to the bladder as they cannot be cured by TURBT or BCG alone. They initially have staging CT and MRI scans to check the cancer has not spread elsewhere, or become metastatic. This is by total surgical removal of their bladder called a ‘radical cystectomy’ or by giving radiotherapy. Both of these are usually preceded by a course of chemotherapy as there is evidence this improves patient survival in the long term.

Question 15

what chemotherapy predisposes one to bladder cancer

Answer 15

Cyclophosphamide

Question 16

what causes squamous cell carcinoma

Answer 16

Schistosomiasis

Question 17

From seeing the presumed Bladder Cancer, how long does the Urology team have to treat it by performing the TURBT?

Answer 17

31 days

This mandate is based on the operation standards, which are set out in the ‘Handbook to the NHS Constitution for England’, and it is expected that Trusts in England meet this target 96% of the time.

Question 18

In the UK, what is the most common chemotherapy agent to be instilled into the bladder via a catheter after a TURBT?

Answer 18

Mitomycin
After the TURBT is performed, a urinary catheter is inserted to administer the mitomycin. Once any bleeding has settled, the mitomycin is flushed into the bladder via the catheter, and the drainage port is blocked off so it remains there (this process is called an ‘installation’). Mitomycin is an alkylating agent that crosslinks DNA and inhibits DNA synthesis, so it damages cells if they are reproducing (cancer cells reproduce faster and so are damaged more than regular cells). It is held in the bladder for an hour before the patient micturates, and expels the mitomycin. There is evidence that doing this within 6 hours of a TURBT can reduce recurrence rates of non-muscle-invasive bladder cancer (NMIBC). Mitomycin can also be given to patients who have an intermediate risk NMIBC during their surveillance period. This is administered as a course of 6 installations, once a week, as there is evidence this can reduce recurrence rates.

Question 19

According to the NICE guidelines for ‘low risk’ bladder cancer, how long is the surveillance period before he can be discharged back to the care of his GP?

Answer 19

One year
In the NICE ‘Bladder Cancer: Diagnosis and Management’ document, those in the low risk category for cancer recurrence and progression can have a flexible cystoscopy at 3 and 12 months post-TURBT and can be discharged following this period if there is no disease recurrence. Patients are safety netted in that if they experience any red flags such as visible haematuria or recurrent UTIs, they should be referred back urgently (as they would be with these symptoms according to the NICE Urological Cancers: Recognition and Referral document).

Question 20

what are the most common reasons for brown urine

Answer 20

The most common reason for brown urine is either renal stones, or renal inflammatory conditions (such as nephritis, or benign prostatic hyperplasia). Ultimately, the causes can be any of those suggested in the previous case (for visible or non-visible haematuria).

Question 21

what is the normal residual urine volume

Answer 21

<100ml

Question 22

what is a Contrast-induced nephropathy (CIN)

Answer 22

is an acute kidney injury caused by the nephrotoxic effects of intravenous contrast medium given to patients during radiological investigations, particularly iodine-based contrast agents, such as those used for CT scans.

Question 23

what is CIN defined as

Answer 23

CIN is defined as an elevation of serum creatinine of more than 50% of baseline within 48 hours, or a reduced urine output (<0.5ml/kg/hour) for at least 6 hours. Patient risk factors include pre-existing renal impairment, where the eGFR is less than 60ml/min, and diabetes.

Question 24

what is the treatment of CIN

Answer 24

Treatment for CIN is largely preventative measures, such as the risk-benefit of performing scans with contrast, as well as correction of reversible causes of pre-existing kidney injury (such as hypo-perfusion).

Question 25

What is the expected normal PSA for a 72 year old man?

Answer 25

<6.4 mcg/L

Question 26

what is a PIRADs system

Answer 26

a system that rates prostate tissue from a 1-5

Question 27

what does a PIRADS score of 5 suggest

Answer 27

means the presence of cancer is very likely.

Question 28

What are the other two options, apart from active surveillance, that are options for the patient from the MDT as part of ‘all treatment options’?

Answer 28

Radical radiotherapy and adjuvant hormone treatment:
Post-treatment complications include urinary incontinence, erectile dysfunction and bowel problems.
Should have been checked.

Radical prostatectomy:
This now most commonly done robotically. Post-operative complications include stress incontinence and erectile dysfunction.

Question 29

what are prostate cnacers

Answer 29

adenocarcinomas that arise from the epithelium of prostatic gland cells

Question 30

Use the NICE guidelines on Lower Urinary Tract Symptoms for Men to help you decide which would be the most appropriate medication/s to start?

Answer 30

Tamsulosin
According to NICE, a patient with voiding Lower Urinary Tract Symptoms (LUTS) and a small prostate (<30cc) should start on an alpha blocker.
[They should also have a PSA <1.5, but in the context of prostate cancer we cannot use the PSA as a marker of Benign Prostatic hyperplasia (BPH).]
These drugs work after two doses (taken daily), and can cause side effects of postural hypotension and retrograde ejaculation.
Prostate cancer and BPH frequently overlap. This patient has a small amount of low risk prostate cancer so it will not be causing him any symptoms; Patients with prostate cancer that is invading locally, outside the prostate into the bladder, and seminal vesicles, may get some related LUTS.

Question 31

A 64 year old man presents with reduced urinary flow. You examine his prostate and feel a firmness on the Left side. What investigation needs to be done for the referral to Urology?

Answer 31

Prostate Specific Antigen (PSA)

Question 32

A 75 year old man present to A+E with a 5 day history of visible haematuria and for the last 12 hours has been unable to pass urine. He has suprapubic pain and bladder scan shows 900ml. What is the most important intervention he needs?

Answer 32

Insertion of a 3-way catheter
This patient is likely in clot retention

Question 33

A 58 year old woman attends the Urology outpatient department for a flexible cystoscopy due to recurrent UTIs and persistent non-visible haematuria. The camera will look where?

Answer 33

Urethra and bladder

Question 34

A 35 year old woman rings the GP with new symptoms of dysuria and frequency for the past 24 hours. She feels otherwise well in herself but fears she may have a UTI. Which of the following signs and symptoms would most concern you that she may need admission to hospital?

Answer 34

Pyrexia of >38.2C
Correct answer.
This is a sign of sepsis

Question 35

In a 20 year old man diagnosed after a CT scan with a 2mm distal ureteric stone, which is the most appropriate management option?

Answer 35

Extracorporeal lithotripsy