1
Q
Haematuria causes
A
Renal: Congenital: PCKD Trauma Infection Neoplasm Immune: GN (HSP), TIN
Extra-renal:
Trauma: stones, catheter
Infection: Cystitis, prostatitis, urethritis
Neoplasm: Bladder/prostate
Bleeding diathesis
Drugs: NSAIDs, frusemide, cipro, cephalosporins
2
Q
Urological causes of haematuira
A
Cancer (TCC or RCC)
Stones - kidney, ureter, bladder
UTI: Cystitis, pylonephritis
Trauma
BPH or prostate cancer
Transient causes: UTI, exercise , menstruation, myoglobinuria
3
Q
When to Ix haematuria
A
Ix in pts with:
- Visible haematuria
- Symptomatic non-visible haematuria (in absence of UTIs or other transient causes
- Persistent asymptomatic NVH eg. 2 or 3 +ve dipstick readings in absence of UTIs or other transient causes
4
Q
Standard male size catheter?
A
Usual size used for males is 14 / 16 Fr
5
Q
Complications of catheterisation?
A
1) Local trauma
2) Introduction of infection
3) Urethritis
4) Stricture formation
6
Q
When would you use a suprapubic catheter?
A
1) Urethral cath. not possible (Urethral stricture)
2) Urethral cath inappropriate: Urethral tauma suspected eg. pelvic injury with a high riding prostate
(Prostate + Prosthatic urethra torn from urethra and pulled upwards, thus the prostate feels too far up on PR)
7
Q
What % of pts with frank haematuria have a urological malignancy?
A
35%
–> Suspect RCC or blader cancer
8
Q
Haematuria causes: Local vs General
A
Local: Bleeding anywhere along urinary tract: Kidneys, ureters, bladder, prostate or urethra
- infection (TB, schisto, UTI)
- Stones
- Trauma
- Tumours
- Renal disease eg. GN
General causes
- Bleeding disorders
- Leukaemias
- Over anti-coagulation
- Haemoglobinopathies
- SCD
9
Q
Haematuria History Questions?
A
1) Blood deffo in urine and not from vag/butt?
2) True Haematuria? other causes of red urine:
- Drugs (rifampicin, nitro)
- Foods : Beetroot
- Systemic disease: Porphyrias / rhabdo
3) Associated with loin pain or pain on passing urine?
- Pain = stone/infection
- Painless = !! ?malginancy
4) Nature of bleeding:
- Micro/macroscopic
- Clots
- Beginning of otherwise clear stream? (Suggestive of urethral/prostatic lesion
- Throughout stream? (suggestive of bladder, ureter, kidney lesion)
- Bleeding at end of stream - Schisto
10
Q
Haematuria Ix?
A
One stop Haematuria clinic
- Urine test: MSU Dipstick, MC+S, Cytology
- Haematological tests: FBC (Anaemia), U+E (renal function)
- Radiological: USS of renal tract. If mass, CT.
X-ray KUB = IVU (Intravenous urogram)/ CT IVU
Special investigatinos:
- Cystoscopy : usually LA + Flexi, but sometimes rigid needed
- Consider Early morning urine samples for TB culture
11
Q
In which pts would haematuria always be investigated, and how?
A
For pts with Macroscopic haematuria and persistent microscopic haematuria
- US + cystoscopy should ALWAYS be performed.
If these are normal, then an IVU or CT IVU should be requested, particularly in pts > 50
12
Q
Bladder outflow obstruction causes
A
Most common:
- BPH
- Prostate cancer
Other:
- Bladder neck obstruction
- Urethral stricture
- Bladder calculi
13
Q
Bladder neck obstruction?
A
Affects young to middle aged men
Due to bladder neck dysfunction
Tx:
Medical (Drugs)
Surgical: Bladder neck incision
14
Q
Urethral stricture - Causes and treatment
A
Causes: Urethral trauma Catheterisation Previous transurethral surgery STI eg. gonorrhoea/chlamydia
Tx:
Urethrotomy
Dilators
15
Q
LUTS - Symptoms?
A
Obstructive:
- Hesitancy
- Poor Stream
- Intermittent flow + terminal dribbling
- Incomplete emptying (Pis-en-deux)
Irritative symptoms:
- Frequency
- Urgency (+ Urge incontinence)
- Nocturia
16
Q
BOO complications?
A
UTI (due to urinary stasis)
Formation of bladder calculi
Hydronephrosis + Subsequent renal impairment
Acute (painful) / Chronic (painless) retention
17
Q
Prostate anatomy
A
capsulated fibromuscular gland, measuring 4x3x2cm, weighing 15g (walnut).
18
Q
Which zone enlarges in BPH vs prostate cancer
A
BPH: transitional zone
Prostate cancer: Peripheral zone
19
Q
BPH Sx + Cause?
A
Obstructive + Irritative symptoms
Ix:
1) Examination: Abdo to exclude retention. PR to check prostate (sulcus present + smooth surface but enlarged gland)
2) Urine: Dipstick, MC+S
3) PSA
4) IF PSA high when rechecked/suspicious prostate –> transrectal US + biopsy
5) Urine flow test
6) US of urinary tract to assess residual bladder volume and look for upper tract dilatation
? cystoscopy if stricutre/ bladder cacluli
? Urodynamic studies
? Voiding diary to see how much bother the symptoms cause the pt
20
Q
PSA
- Which cells produce
- Normal value?
A
Produced by prostatic acinar cells
- -> both normal + cancer, but cancer produce x10
- Levels increase as prostate size increases (including BPH)
- Increases with age : Normal value
21
Q
BPH Mx
A
Mild Sx: Watchful waiting + R/V in clinic. 65% will not progress
Medical:
1)A1 blockers eg. Tamsulosin, prazosin, alfuzosin
–> Relax prostate smooth muscle, increase urinary flow _ help obstructive Sx
SE: uncommon, but include hypotension
2) 5AR inhibitors: Finasteride
Surgical
1) TURP - Gold standard
Newer:
- Microwave therapy
- Laser prostatectomy
- Radiofrequency ablation
- Prostatic stents
22
Q
TURP: Procedure
A
Pt placed in lithotomy positon
Resectoscope passed through urethra, used under direct vision to remove prostate piece by piece, using cutting diathermy. Chippings sent for histology.
Diathermy can also stop bleeding.
3 way catheter inserted post-op to irrigate bladder until fluid no longer heavily blood stained. Stops clots forming + blocking catherer.
23
Q
TURP complications
A
Early:
- Septic shock
- bleeding
- Transurethral syndrome (uncommon, thought to be due to absorption of hypotonic irrigation fluids during TURP - Can’t use TURP because of diathermy). Problems include electrolyte imbalance (low Na+), haemolysis, fluid overload, cerebral oedema. Tx: Fluid restrict, diuretics + monitor
Late:
- Secondary haemorrhage
- Urethral strictures
- Impotence (?3-5%)
- recurrent prostatic regrowth
- Recurrent symptoms
- 65-85% will develop retrograde ejaculation - infertile
24
Q
Prostate cancer Sx? Ix?
A
Same symptoms as BPH - can be difficult to differentiate.
Diagnosed histologically after TURP for what was thought was benign disease.
- However now, most commonly PSA + prostate biopsy
PR: enlarged, ‘craggy’ prostate, hard nodule may be palpable. Midline sulcus may be lost.
If malignancy diagnosed, staging:
- Bone scan
- MRI abdopelvis
LFTs
25
Prostate cancer histology + area?
Adenocarcinoma arising in peripheral zone of gland (functional part)
26
Prostate carcinoma staging
T0: No primary tumour identifiable
T1: Tumour idenified incidentally at TURP or with raised PSA
T2: Palpable tumour without extracapsular extension
T3: Spread beyond capsule; mobile tumour
T4: Fixed/ locally invasive tumour
27
Prostate cancer Mx
Early Dx: Curative intent
- Radical prostatectomy (laparoscopic/ robotic assistance/ open surgery)
- Radical radiotherapy
- Brachytherapy
Metastatic/locally advanced disease:
- Driven by androgens, main aim is to decrease androgen activity
- Medical castration:
LHRH agonists (Goserelin)
Oral antiandrogens: Flutamide/cyproterone
TURP if obstructive symptoms
28
Bladder carcinoma types
In UK almost all 98% are TCC
- Remainder SCC or adenocarcinoma
IN countries with endemic schisto - SCC more common
29
Bladder cancer associations
TCC: Occupational exposure to aromatic amines/aniline dyes. Smoking (x4)
SCC: Calculi, infections (Schisto
Adeno: Persistent urachal remnants
30
Bladder Cancer pc + Ix
Usually painless haematuira
- 15% present with recurrent UTIs
- Urine cytology may identify abnormal cells in urine, but Dx usually made by cystoscopy
31
Bladder cancer staging
```
Ta: Confined to mucosa
T1: tumour invading lamina
T2: Muscle involved
T3: Perivesical fat involved
T4: invasion beyond bladder into adjacent organs/fixed to pelvic side wall
```
NB: also pathological grading I - III
Grade I = well differentiated
Grade III = poorly differentiated
32
Superficial bladder cancers
Low grade/ Ta/T1
- Usually exophytic papillary TCCs
- 15% will progress to invasive cancer over 10yrs
Tx:
- Cytstoscopy + endoscopic resection/diathermy
- If no obvious lesion seen on cystoscopy, multiple biopsies should be taken to exclude CIS..
High grade G3, T1 tumours are aggressive & need aggressive treatment
- -> Resection & Diathermy
- Intravesical chemo (mitomycin)
- F/U with regular cystoscopies
- Intravesicular immunotherapy with BCG?
33
Invasive bladder cancers Tx
Tx:
Radical cystectomy
Formation of ileal conduit (results in stoma)
OR creating a neobladder from small bowel --> Highly complex surgery, with high complication rate - reserved for young, motivated pts with high chance of cure.
34
Renal tumour types?
Usually primary
RCC (>50 yr olds, arise from kidney itself)
TCC (lining of collecting system)
Wilm's tumour (nephroblastoma)
Lymphomas
35
Most common renal tumour? Type
RCC - >80% of renal tumours
Renal adenocarcinoma (AKA Clear cell carcinoma)
- Increased incid. in smokers
- As they grow, become encapsulated by rim of normal kidney tissue
36
RCC PC + OE
PC:
Haematuria or pain (due to pressure effects on local structures and nerves)
Classic triad: Pain, haematuria + renal mass *Rare for all 3*
May produce hormones eg. EPO (polycythaemia)
- PtHLP - hypercalcaemia)
50% found incidentally in pts with US or CT
OE:
Mass palpable in loin
1% PC with varicocoele results on left
37
RCC common met sites
Grow along renal vein/ IVC therefore blood borne mets
- Lung (cannonball)
- Bone (Path #s)
- brain
38
How do you differentiate kidney from a spleen?
1) Kidney ballotable
2) Kidney moves vertically down on inspiration
3) Kidney resonant to percussion (overlying colon)
Spleen:
1) Notch
2) Moves towards RIF on inspiration
3) Dull to percussion
39
What may a left scrotal varicocoele indicate?
RCC: If a RCC obstructs renal vein
The testicular vein on the left drains into the renal vein (enters IVC directly on the right)
40
RCC Ix? Mx?
1) US - solid mass arising from kidney
2) CT scan - stage disease
Mx:
Radical nephrectomy (remove kidney, surrounding fat within Gerota's fascia +- adrenal gland)
- Partial nephrectomy if small tumour (
41
Pelviureteric tumours?
Same as TCC of bladder
PC: Haematuria
Dx: IVU showing filling defect/ CT IVU
Tx: Nephrectomy + removal of ureter (nephroureterectomy).
F/U with regular cystoscopies to look for tumours in bladder (50% will develop subsequent bladder tumour
42
Wilm's tumour?
Nephroblastoma - derived from mesoderm therefore variety of components (kidney, fat, cartilage, bone)
Commonest intra-abdominal tumour in
43
Testicular tumour Types
GC (almost all tumours)
- Seminomas (40%)
- NSGCT (10%)
- Mixed (40%)
Also rarely choriocarcinoma/yolk sac tumours (Types of NSGCT)
Non GC
- Leydig cell tumours
- Sertoli cell tumours
- Lymphomas
44
Germ cell tumours? (Seminomas/ teratoma)
Peak incidence 20-40 yrs
2% bilateral
Signficantly increased risk in men with undescended testes
45
Seminomas
- Arise in epithelium of seminiferous tubules
- Grow slowly
- Metastasise to regional & para-aortioc lymph nodes--> testicular veins drain towards IVC, not groin
46
NSGCST
Teratoma
Arise from all 3 germ layers
More aggressive/poorer prognosis than seminomas
Subdivided histologically:
- Well / moderately or undifferentiated
Metastatise via blood & lymphatics
Most secrete B-HCG/ AFP - tumour markers
47
Testicular tumour markers
B-HCG
AFP
secreted by most NSGCST
48
Testicular tumour staging
Stage I - confined to tests
Stage II - Involvement of lymph nodes below diaphragm
Stage III - Lymph nodes above diaphragm
Stage IV - Extralymphatic spread
49
Testicular tumour PC + Ix
Painless testicular mass
Secondary hydrocoele
```
Painful lump (10%)
- May be misdiagnosed initially as epididymo-orchitis.
```
O/E Look for evidence of lymphatic spread (Abdominal, supraclavicular & Chest)
US - connected to testes? Solid/Cystic?
Blood for serum AFP (never raised in seminoma), B-HCG
CT Chest-abdo-Pelvis to stage
50
How do you examine a scrotum?
1) Can I get above it (you can get above test. lesion, but not hernia)
2) Is it a lump in the testes (hydrocoele- testes impalpable) or is it separate?
3) Does it Transilluminate? (Hydrocoele)
4) Is the testes tender?
--> Hard mass in the tests, which does not transilluminate is likely to represent a testicular tumour
51
Testicular tumour Mx.
| Why groin incision?
Orchidectomy via groin incision
1) Allow cord to be clamped before mobilising testicle
2) Prevent seeding the scrotal skin
3) Allow incision to be within the radiotherapy field
If lump appears malignant, excised together with spermatic cord.
Further Tx dependent on tumour type, stage and grade.
Tumour markers following surgery, if still high, suggests residual disease
- seminomas very radiosensitive
- Stage IV tumours given chemo initially
- Teratoma less radiosensitive - combination chemo (bleomycin, etoposide + cisplatin) given at start
- Recurrence likely to occur within first 18-24 mo therefore repeat CT / tumour markers initially every 6/52, then every 3/12
52
Hydrocoele:
- Definition
- Causes
Presence of fluid around testis between tunica vaginalis & tunica albuginea
Primary (idiopathic)
- Majority
- Develop slowly, can become large and tense
- Commonest in >40
- Caused by tunica vaginalis producing excessive fluid for unknown reasons
Infantile:
- Patent processus vaginalis allows peritoneal fluid to fill sac
Secondary:
- Trauma
- Infection
- Malignancy
- develop more rapidly
53
Hydrocoele Dx & Mx
O/E
- Can get above swelling (Which has a smooth surface)
- Tests impalpable
- Transilluminates brilliantly
- US should be performed to look at testes
Mx:
- Small/pt not bothered - conservative
- Larger - can be tapped but fluid usually returns
- Definitive surgical treatment: plicating tunica vaginalis (Lor'd repair) or inverting the sac (Jaboulay's repair)
54
Epipdidymo-orchitis causes? PC? O/E
Inflammation of tests / epipidymiss due to infection
- Young : Viral (eg. mumps)
- Old: Bacterial (E.coli following UTI
- Sexually active: Chlamydia / gonococcal
PC: Acute onset severe testicular pain
Pain may be referred to RIF
May have Fever, urethral discharge and symptoms of UTI
O/E: Tender, red, warm Testis
- May have markedly swollen epididymis separate from testicle
Place hand under scrotum & elevate - relieves pain of epididymo-orchitis but not torsion
55
Testicular torsion
Most common age 12-27
Higher rate in undescended testes
Testis twists within tunica vaginalis - blood supply compromised
PC: Severe pain of very sudden onset + o symptoms of UTI
O/E: testis lies horizontally/retracted relative to other side
Ix: MSU for MC+S
IF any doubt - surgical exploration essential - warn pt possibility of orchidectomy if testicle infarcted
- At time of surgery, both testicles fixed with suture to scrotal wall to prevent recurrence.
NB. Doppler US may be useful in showing integrity of arterial blood flow to testis
56
Testicular lumps differential
Indirect inguinal hernia
Epididymal cyst
Hydrocoele
Varicoele
Epipdidymo-orchitis
57
Renal colic: classic presentation?
Sudden onset severe pain
Patient writhing in agony
Unable to get comfortable (cf. peritonismwhere pt lies still)
- Pt sweaty, N+V
Ureteric stoin: Loin --> Groin pain
- May also be pain in scrotum or labia
Midureteric pain - mimics appendicitis on right and diverticulitis on left
Pt may have tenderness in renal angle, especially on percussion - indicates retroperitoneal inflammation
Dipstick - haematuria >90%. Confirm with MC+S
58
Urinary tract calculi composition
Most are calcium (80%) complex with oxalate (35%)
- Hypercalciuric
- FH/hyperparathyroidism, RTA , medullary sponge kidney
Phosphate (3%)
Mixed oxalate + phosphate crystals (40%)
Struvite (Magnesium ammonium phosphate)
--> Associated with UTIs (Proteus)
Cystine
Urate (Radiolucent)
Xanthine (radio-lucent)
59
Renal stone: Radio-opaque?
90% are radio-opaque
--> Urate stones radiolucent
CF gallstones: 90% radiolucent
60
Which type of renal stone is associated with UTIs
Which are associated with acid urine
Triple phosphate (Struvite) - especially with Proteus which breaks down urea to form ammonia, resulting in alkaline urine which precipitates these stones
In contrast : acid urine tends to precipitate calcium oxalate and urate containing stones
61
Causes of renal colic?
Most common = stone
Other causes:
Aortic aneurysm
TCC of ureter
Retroperitoneal lymph nodes
Pain mimicking renal colic:
- AAA
- Appendicitis
- Pyelonephritis
- Diverticulitis
- Gynaecological causes
62
Renal colic Mx:
1) Analgesia : NSAIDs (Diclofenac)
2) Primary Ix iwth CT KUB or IVU
- If pain resolves/ kidney not obstructed/grossly dilated - home with oral analgesia/ stone clinic appt.
- Pain persists / kidney obstruction - admit
- If no evidence of sepsis - ureteric stent under GA
- If evidence of sepsis: Urological emergency as dmg to kidney can occur if not drained urgently. Start Abx + urgent nephrostomy to drain kidney percutaenously
63
Normal course of ureters?
- Start at renal plevis (L1/L2 --> Look for 12th rib which is T12, then go down 1 level)
- Travel down along line of transverse processes towards sacroiliac joint where they cross OVER iliac vessels
- At this point, they travel backwards towards the ischial spines, then forwards into bladder.
64
Common sites for ureteric obstruction
1) PUJ - Pelviureteric junction
2) SIJ - Sacroiliac joint - where ureters cross over iliac vessels
3) VUJ - Vesicouretereic junction
65
What is an IVU?
Intravenous urogram:
- Venflon inserted + radio-opaque contrast injected into arm
- Film taken after 5 mins and another post-micturation
- If any abnormality, another taken after 1h.
- Further films taken until contrast seen down in level of obstruction.
- IF there is a block you see a standing column of contrast above the stone
- Renal pelvis may be dilated and there may be blunting of calyces.
- In complete obstruction - you may see a dense nephrogram (kidney outline visibily radio-iopaque), with no contrast entering the ureter
nb. Students often confused as they see some contrast in ureter with a stricture and assume its a block - actually represents a normal wave of peristalsis
66
IVU CI?
IVU may be CI in :
- Pregnant (US instead)
- Asthmatic (may be able to do with steroid cover)
- Atopy
- Pts allergic to iodine (use unenhanced CT)
- Pts on metformin should stop 24hr before
67
Renal stone Mx
1) Routine bloods to assess renal function, screening for Ca2+, urate + phosphate levels in case of recurrent episodes
2) 90% stones 7mm - tend not to pass. Options:
ESWL used for stones 2cm or there is calyceal obstruction: Percutaenous removal may be necessary.
Stones in upper or middle third - ESWL or Ureteroscopy
Stones in lower third: Ureteroscopy
Rare cases eg. Impacted ureteric stone - open/laparoscopic surgery
68
ESWL?
Extracorporeal shock wave lithrotripsy - Tx of choice for most renal and ureteric stones
- Day case or outpatients
- Lithotripters generate a shock wave using either electromagnet or piezoelectric energy to shatter stone under X-ray/ US control.
69
Ureteroscopy?
Renal stones visualisd by passing a fine endoscope up ureter + fragmented with a pneumatic instrument (Lithoclast) or holmium laser.
70
Percutaneous nephrolithotomy
Tx if stone in renal pelvis too large for lithotripsy
- Under US or fluoroscopic guidance, needle inserted into calyx of kidney
- Guide wire passed down needle into renal pelvis
- Series of dilators inserted over guide wire to create a track to renal place
- Stone fragmented under direct vision and fragments removed.
71
Epididymal Cysts:
- What are they
- OE
- DDx?
Common in middle aged/elderly men
Rare in children/younger men
May be multiple/bilateral and can occur in various sizes
Entirely benign - no specific Tx other than reassurance.
Occasionally large may be Tx with sclerotherapy (injecting sclerosant fluid eg. Tetracycline ) or removed surgery. Simple aspiration of fluid not useful
O/E
- Fluid filled, discrete, fluctuant and transilluminable.
- Arise from epididymis - will be palpable separate to testicle but be attached to it.
DDx
Spermatocoeles
Varicoeles
Other causes of scrotal masses eg. hydrocoele/testicular tumour
72
Varicoele?
- What are they?
- Which side are they more common on
Abnormal dilatation of the testicular veins (varicose veins of the balls) caused by venous reflex down the gonadal veins
- 80-90% occur on left side (left gonadal vein arises directly from the longer left renal vein)
- Asymptomatic 'bag of worms'
- More prominent on standing
- Thought to be associated with male infertility (? Due to chronic raised temp)
Mx:
- Most conservative
- Surgical ligation
- Radiologically intervention eg. embolisation
73
Phimosis?
Narrowing of opening of the foreskin
- can be due to recurrent balanitis
CF. paraphimosis - swelling of glands as a result of a tight foreskin being retracted/not replaced - Blocks venous return
Tx: Circumcision
74
Undescended tests:
- When do they usually descend
- How to manage and by what age
- After what age is there irrepairable dmg
- Usually descend week 28-34 of fetus
- 80% of undescended can be palpated in inguinal canal
- -> orchidoplexy + fixed in the scrotum by placing between dartos muscle and skin
Should be done by 18 month to prevent dmg to the testis (spontaneous descent rare after 1 year
After age 2, testis likely to be dmgd and may be incapable of spermatogenesis
75
Mx of Renal colic
Medication
the British Association of Urological Surgeons (BAUS) recommend diclofenac (intramuscular/oral) as the analgesia of choice for renal colic*
BAUS also endorse the widespread use of alpha-adrenergic blockers to aid ureteric stone passage
Imaging
patients presenting to the Emergency Department usually have a KUB x-ray (shows 60% of stones)
the imaging of choice is a non-contrast CT (NCCT). 99% of stones are identifiable on NCCT. Many GPs now have direct access to NCCT
Stones
76
PSA Ranges:
50-59
60-69
>70
Things that raise PSA
-59: 3
60-69: 4
>70: 5
```
Things that raise PSA:
- BPH
- Prostatitis/ UTI (1/12)
- Ejaculation (48hrs)
- Vigorous exercise (48hrs)
- Urinary retention
Instrumentation of urinary tract
```
77
Prostate cancer - which ethnicity is a risk factor?
Afro-Carribean
78
Non-infective cause of epipdidymitis?
Amiodarone well recognised - resolves on stopping drug.
Commonest infective in men
79
Urethral Injury
```
Mainly in males
Blood at the meatus (50% cases)
There are 2 types:
i.Bulbar rupture
- most common
- straddle type injury e.g. bicycles
- triad signs: urinary retention, perineal haematoma, blood at the meatus
ii. Membranous rupture
- can be extra or intraperitoneal
- commonly due to pelvic fracture
- Penile or perineal oedema/ hematoma
- PR: prostate displaced upwards (beware co-existing retroperitoneal haematomas as they may make examination difficult)
```
- Investigation: ascending urethrogram
- Management: suprapubic catheter (surgical placement, not percutaneously)
80
Complications of TURP?
TURP
T ur syndrome
U rethral stricture/UTI
R etrograde ejaculation
P erforation of the prostate
81
What should be co-prescribed with goserelin?
Anti-androgen tx such as cypoterone acetate should be co-prescribed when starting GnRH analogues due to risk of tumour flare.
BNF recommends starting cypoterone 3 days before
82
Prostate Cancer Mx?
Localised prostate cancer (T1/T2)
Treatment depends on life expectancy and patient choice. Options include:
conservative: active monitoring & watchful waiting
radical prostatectomy
radiotherapy: external beam and brachytherapy
Localised advanced prostate cancer (T3/T4)
Options include:
hormonal therapy: see below
radical prostatectomy
radiotherapy: external beam and brachytherapy
Metastatic prostate cancer disease - hormonal therapy
Synthetic GnRH agonist
e.g. Goserelin (Zoladex)
cover initially with anti-androgen to prevent rise in testosterone
Anti-androgen
cyproterone acetate prevents DHT binding from intracytoplasmic protein complexes
Orchidectomy
Watch and wait- Elderly, multiple co-morbidities, low Gleason score
Radiotherapy (External)- Both potentially curative and palliative therapy possible. Similar survival figures to surgery. However, radiation proctitis and rectal malignancy are late problems. Brachytherapy is a modification allowing internal radiotherapy.
Surgery- Radical prostatectomy. Surgical removal of the prostate is the standard treatment for localised disease. The robot is being used increasingly for this procedure. As well as the prostate the obturator nodes are also removed to complement the staging process. Erectile dysfunction is a common side effect.
Hormonal therapy- Testosterone stimulates prostate tissue and prostatic cancers usually show some degree of testosterone dependence. 95% of testosterone is derived from the testis and bilateral orchidectomy may be used for this reason. Pharmacological alternatives include LHRH analogues and anti androgens (which may be given in combination).
In the UK the National Institute for Clinical Excellence (NICE) suggests that active surveillance is the preferred option for low risk men. It is particularly suitable for men with clinical stage T1c, Gleason score 3+3 and PSA density
83
Hydronephrosis causes?
Mx?
Unilateral: PACT
- Pelvi-ureteric obstruction (congenital/acquired)
- Aberrant renal vessels
- calculi
- Tumours of Renal pelvis
Bilateral: SUPER
- Stenosis of urethra
- Urethral valve
- Prostatic enlargement
- Extensive bladder tumour
- Retro-peritoneal fibrosis
Remove the obstruction and drainage of urine
Acute upper urinary tract obstruction: Nephrostomy tube
Chronic upper urinary tract obstruction: Ureteric stent or a pyeloplasty
5th year
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