Urology Part II

1. Urology Part II CF Ng

2. Tumour

3. Tumour General • Aetiology / Risk factors • Intrinsic: age / sex / race /inherited dx or FH • Extrinsic: biological (virus) / chemical / physical • Presentation • Asymptomatic • Local • Metastatic • General • Para-neoplastic

4. Tumour Treatment • Curative • OT • RT • +/- neoadjuvant / adjuvant therapy • Palliative • RT / ChemoT / Hormonal (CaP) / ImmunoT (RCC) • Drug • OT

5. Haematuria • Characteristics • Gross / microscopic • Painful / Painless • Relationship with steams (only for men) • Any associated symptoms • LUTS • UTI symptoms • Loin pain • Generalized bleeding tendency • Precipitating events – trauma, jogging, menstruation etc

6. Haematuria • Gross / macroscopic reddish discoloration due to red blood cells (drugs, vegetables, haemoglobin, myoglobin) • Microscopic normal people losing 0.5 to 1 million RBC per day detection by centrifugation method – standard for decades 3 – 5 RBC/HPF dipstix method– high false positive rate

7. Gross Haematuria • Painful vs painless • Inflammation / infection • Relationship to the steam • Early steam, whole steam, end steam

8. Differential Diagnoses for Haematuria • Urinary tract infections 50-60% • Tumours 10% • Stones 10-15% • Glomerulonephritis 5-10% • Trauma 1% • Bleeding problems 1% • BPH 2% • Idiopathic 5-10% • Miscellaneous

9. Investigations for Haematuria (1) • Cancer until prove otherwise • Haematuria work up – first line investigations • midstream urine for microscopy, culture & sensitivity test • abnormal RBC count confirmed bleeding • abnormal WBC count suggested infection • bacterial growth indicated urinary tract infection • urine cytology x 3 • optimal sensitivity 70-80% • cystoscopy – lower urinary tract endoscopy • intravenous urography – upper urinary tract imaging (problems) • early morning urine for AFB x 3 • not commonly done because of decrease occurrence • Blood • not cost-effective for cause, unless clinical or drug history suggestive • Even deranged clotting etc  still need work up

10. Investigations for Haematuria (2) Second line investigations Ultrasound + KUB cystoscopy + retrograde pyelogram upper tract not well shown up computerised tomography to diagnose upper tract tumour ureterorenoscopy endoscopy of upper urinary tract renal arteriography or venography suspected vascular abnormalities

12. Bladder Cancer • Risk factors Instrinsic – elderly, males Extrinsic chemical carcinogens - petroleum, rubber, printing industry smoking Physical - chronic irritation – stone / neurogenic bladder / parasites/ cyclophosphamide

13. Pathology of Bladder Cancer • 95% urothelial 80-90% transitional cell carcinoma 5-10% adenocarcinoma uncommonly squamous cell carcinoma (HK) small cell carcinoma undifferentiated carcinoma • Transitional cell carcinoma 70-80% papillary 20-30% nodular or sessile

15. Presentation of Bladder Cancer • Local symptoms: • 85 – 90% with macroscopic haematuria • >95% with macroscopic or microscopic haematuria • Irritative bladder symptoms • Renal failure due to ureteric obstruction • Metastatic symptoms bone pain, weight loss • On first presentation 70 – 80% are early superficial cancers

16. Investigations for Bladder Cancer • Haematuria work up cystoscopy + bladder biopsy IVU • Chest X-ray • Computerised tomography of abdomen and pelvis • Bone scan

18. Staging of Bladder Cancer • Superficial disease Tis Ta T1 • Muscle invasive disease T2 T3 T4

19. TCC bladder • Treatment • Superficial TCC • Muscle invasive TCC • Metastatic TCC

20. Superficial TCC bladder • Superficial disease • Transurethral resection of bladder tumour (TURBT) • can eradicate the cancer because of early disease • Problem – recurrence • but 30 – 50 % new cancer formed in 1 year • and 70 – 80 % new cancer formed in 5 years • Passive – surveillance to look for recurrence • FC 3-monthly x 8 i.e. 2 years • Then lift long FU for symptoms and cyto • Active – intravesical chemotherapy or BCG (immunoT)

22. Muscle invasive TCC bladder • Radical cystectomy • What to cut

25. Muscle invasive TCC bladder • Radical cystectomy • What to cut • What to reconstruct • Ileal conduit • Continence diversion • Orthotropic bladder subsitution / catheterization pouch • Risk • Absorption of urine – acidosis, metabolites, drugs etc • GI tract malfunction – diarrhoea, malabsorption etc • Mechanical problem – no sensation, no contraction, mucus etc • who

32. Other Treatment of Bladder Cancer • Muscle invasive disease radiotherapy cure rate lower than surgery use in patients not fit for surgery adjuvant chemotherapy early result did not improve cure rate • Metastatic disease • Chemotherapy – MVAC etc

34. Serum Prostate Specific Antigen (PSA) • Enzyme secreted into prostatic secretion • Serine protease • Liquefied semen coagulum  release sperm • Leakage into serum

36. Serum Prostate Specific Antigen (PSA) • Specific for prostate problems but not prostate cancer • Upper normal limit 4 ng/l Old study – 97.5% population < 4ng/L 20% early prostate cancers below 4 ng/l 20-30% BPH with PSA >4ng/l • other PSA reference Age specific range PSA density PSA velocity Free and Total PSA

37. Usage of PSA • Screening • Before PSA, 25-30% of prostate cancers diagnosed were organ confined • After PSA, 50-60% of prostate cancers diagnosed were organ confined • Staging implication • >100 ng/l  bone secondary • Monitoring treatment response • Before clinically detectable • Histological diagnosis • Adenocarcinoma ?origin  PSA strain

39. Presentation of Prostate Cancer • Incidental finding • Screening – DRE or serum PSA • TURP pathology – T1a/b • Local symptoms • Obstructive symptoms • Ureteric obstruction • Metastatic symptoms • Bone pain, pathological fracture • Spinal cord compression  AROU • General symptoms

40. Diagnosis of Ca Prostate • TRUS + Bx • Indications • Abnormal DRE • Elevated PSA • Complications: • Sepsis • Bleeding • AROU

41. Histology • Gleason grading • Gleason score • 2 numbers • Most common one + second common one (> 5%)

42. Staging Tests for Prostate Cancer • Local • Computerised tomography of abdomen and pelvis • Magnetic Resonance Imaging of prostate • Metastatic • Chest X-ray • Bone scan

43. Ca Prostate • Treatment • Localized • Watchful waiting • Radical prostatectomy • Radical radiotherapy – Ext beam or brachytherapy • Metastatic • Hormonal therapy • RT – palliative • Chemotherapy

44. Radical prostatectomy • IntraOT / Early Complications • Bleeding • UTI • Late complication • Stress incontinence • Anastomotic stricture • ED

45. da Vinci robotic system

47. Ca Prostate • Hormonal therapy • Hormone axis • Orchidectomy • Medical castration • LHRH analogue • Estrogen • Antiandrogen

49. Loin / abdominal mass • Right – liver, colon, gall bladder etc • Left – spleen, colon etc • Kidney: • Benign • Hydronephrosis • Congenital • PUJO • Other causes • PCK • Benign tumour – Angiomyolipoma etc • Malignant • RCC • etc

50. RCC • Presentation • Asymptomatic / incidental findings – increase availability of imaging • Local symptoms: loin mass, loin pain and haematuria (classical triad 20% - old date) • Metastatic symptoms: bone pain, chest symptoms etc • General symptoms: weight loss etc • Paraneoplastic symptoms: …