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UrologyPart2 DelivDr.Ashlin Nourolahi-OskouiDisclaimer BIDASWteachingis led bystudents withsupervisionofjuniordoctorsand consultantsacrosstheUK. Theseteachingsarecreated to support students’learningbut should not replaceyourlocalMedical School teachingmaterial.LearningOutcomes •Haematuria •BPH •Prostate Cancer •Renal Cancer •Bladder Cancer •Testicle Cancer •Penile Cancer •SBAs and questions Haematuria Visible Non-visible Asymptomatic SymptomaticCauses?Causes • UTI • Cancers - renal,bladder, prostate • BPH • Renal stones • Radiation cystitis • Schistosomiasis • Nephrological • PseudohaematuriaHistory • Pink (rose) vs Dark red (port) • Clots • Timing in stream oTotalvsterminal • LUTS • Drugs • Smoker • OccupationReferralCriteria?ReferralCriteria(2ww) • ≥45 yrs old + unexplained VH w/o UTI • ≥45 yrs old + VH after tx ofUTI • ≥60 yrs old + nVH + dysuria/raisedWCC • ≥60 yrs old + asymptomatic nVH on 2/3 tests Non-urgentreferral: • ≥60 yrs old + recurrent / persistent UTIInvestigations • Urine dip • Bloods - FBC UE Coags • ?PsA • ?Renal cause oA:Cr, P:Cr oReducedGFR, CKD,proteinuria, <40yrs + HTN • Flexible cystoscopy • USKUB • CT UrogramManagement • Treat underlying cause • Clot retention - 3-way-catheter, washout, irrigate • Transfusion • Rigidcystoscopyto stop bleeding atsourceBenignProstateHyperplasia • 30-40% men affected ≥50yrs old • 90% men atage 90 • Sub Saharan African men at most risk • DHT production increasesand transition zone of prostate proliferates, reducing urine flowBPHsymptoms?BPHsymptoms • Frequency • Nocturia • Incomplete emptying • Reducedflow • Terminaldribble • Hesitancy • RetentionInvestigate • PR • MSU • PVBS • FBC UE LFT • PSA • US • MRI Prostate • UrodynamicsPSAPSA • Enzyme secreted by prostate cells • When to consider: o?prostate canceron PR o>50 yrsold who ask • PSAabove age stratified levels get2ww referral • Other conditions that raise PSA: BPH, prostatitis, UTI • Before PSA patientshould not: oAnactiveurinary infectionorwithinprevious6 weeks. oEjaculated in previous 48 hours. oExercised vigorously,forexample cycling,inthe previous 48 hours. oHada urological interventionsuchasprostatebiopsy inprevious 6 weeks.BPHmx • Watchful wait if mild and symptomatic • LTC • Alpha blocker e.g.,tamsulosin oSE: ejaculationissues, dizziness oCautioninposturalhypotension, cataract surgery (riskofintra-operative floppy irissyndrome), concomitant antihypertensives, elderly • 5-alpha reductase inhibitor e.g., finasteride oSexual dysfunction, reducedlibido, ED • TURP • HoLEP • Prostatectomy Prostatecancer • 2wwreferral if: • Risk factors – age, African descent, FHx, obese oAbnormal prostate onDRE oIf PSAabovenormal rangeforage • Adenocarcinoma 95% - peripheral • Multparametric MRI 1st line zone oLikert score ≥3 --> Biopsy and MDT • Features oLikert 1or2 + raised PSA--> active oLUTS surveillance oHaematuria • Histological grading = Gleeson oAbnormal DRE • TNM for staging oHaematospermia oBone/back pain • Biopsyis either TRUS or oWeight loss transperineally. oanaemiaProstateCancerMx 1. Active surveillance oRegular PSA, DRE, MRIs 2.Radical prostatectomy oDefinitivelocal diseasemx 3.RadicalRadiotherapy oERBT andor brachytherapy 4.Hormone therapy oGnRHagonist e.g.,Goserelin 5.DocetaxelchemotherapyRenalCancer • Renal cellcarcinoma 80-85% oClear cell– most common.VonHippelLindaugene association oPapillary oChromophobe • TCC • Wilm's tumour oMost common intra-abdo paediatric tumour Risk factors: • age, smoker,obese, FHx, HTN,VHL, tuberous sclerosisetc.RenalCancerFeaturesRenalCancerFeatures • Haematuria • Flankpain • Flankmass • Fever • Night sweat • Malaise • Reducedweight • Left side varicocoele • Bone pain • Paraneoplastic syndrome oFever, highcalcium, polycythaemia, Cushings, HTNRenalCancer • Referral o≥45 yrs+ VH w/o UTI o≥45 yrs+ recursafterUTI tx • Investigations oCTAP w/contrast oUS ABdo oFBC UELFT BP ESR oBonescanRenalcancermanagement • MDT - macmillan cancer nurses • Localdisease (T1) --> partialnephrectomy • T2 --> Radical nephrectomy • Advanced - tyrosine kinase inhibitors/Anti-VEGF e.g., sunitinib • Radiotherapy - e.g.,brain mets symptomrelief • Nephroureterectomyin TCC • Renalartery embolisation if unfit for operation or refractory haematuriaBladdercancer • TCC - smoker,age,occupation (dyes), meds (e.g., cyclophosphamide),Radiotherapy • SSC - schistosomiasis • Features - haematuria, dysuria, urgency, frequency • Advanced features - pelvic pain,flank pain, bone pain, peripheral oedema, anorexia, weight lossBladdercancer • Referral criteria o≥45 yrs old + unexplained VH w/o UTI o≥45 yrs old + VH after tx of UTI o≥60 yrs old + nVH + dysuria/raised WCC • Ix oBloods, urinalysis, MSU oFlexible cystoscopy - therapeutic and diagnostic oCT/MRIBladdercancermanagement • TURBT on flexible cystoscopy for non-muscle invasive oWillget intravesical BCG (immunotherapy) ormitomycinC(reduce rate of recurrence) • Radicalcystectomy - muscle invasive • Ilealconduit oCisplatin basedneoadjuvant chemo oNeobladder • Radicalradiotherapy • ChemotherapyBladdercancer-metastatic • Cisplatin basedchemotherapy • Palliative care • Intractable bleeds --> transfuse,Radiotherapy and embolisation • Ureter obstruction --> nephrostomy or stent • Pelvic pains --> radiotherapy, chemo, nerve blocksT esticlecancer • Risk factors oCryptorchidism oHypospadias oInfertility oKleinfelter's(XXY) oTall men • Referral 2ww oNon-painful enlarged orshape change ortexturechange of testis oUS Testes resultinunexplainedorpersisting testis symptoms • Mets - lungs, liver, brainTesticleCancer- TesticleCancer-Features classification • Germcell • Unilateralscrotal mass oSeminoma • Pain/discomfort oN▪ Yolk saca • Back/flankpain ▪ Choriocarcinoma • Lymphadenopathy ▪ Teratoma ▪ Embryonal • Gynaecomastia (NSGCT) • Sex cord stromal oLeydig cell oSertolicell oGranulosa oThecomaTesticleCancer Investigate Treatment • FBC UE LFT • Orchidectomy + histology • AFP – Yolk sac • Beta-HCG - choriocarcinoma • LDH - cellturnover • Sperm preservation • CT CAP • Bone scanPenileCancer • Risk factors •Non-invasive oPhimosis, lichen otopical chemoe.g., 5FU, repeat biopsy, sclerosus, balantitis, monitor smoker, PUVAtx for •Muscle invasive psoriasis, HIV oLocal excision, partial ortotal • Features glansectomy, partial amputation, total oPalpable ulcerating lesion, penectomy bleeds, discharge, inguinal •Mets lymphadenopathy, pain or oLymphaenectomy, chemo, painless radiotherapy • Investigate oBiopsy, PET CT, CTAP , TNM stagingSBA1 A 30-year-old male presentsto the GP with testicle lump.On examination younote the lumpis not painful. Which tumour marker is most likelyto be raisedin suspected testicular cancer? A) AFP B)Beta-HCG C) CEA D)CA125 E) CA19-9SBA1 A 30-year-old male presentsto the GP with testicle lump.On examination younote the lumpis not painful. Which tumour marker is most likelyto be raisedin suspected testicular cancer? A) AFP B)Beta-HCG C) CEA D)CA125 E) CA19-9SBA2 • 66 yr old female presents with painless haematuria atyour GP practice. You suspecta TCC and do a 2wwurology referral. What is the first line investigation for this patient? A) FBC B)Urine dip C) Flexible cystoscopy D) USKUB E) CT KUBSBA2 • 66 yr old female presents with painless haematuria atyour GP practice. You suspecta TCC and do a 2wwurology referral. What is the first line investigation for this patient? A) FBC B)Urine dip C) Flexible cystoscopy D) USKUB E) CT KUBSBA3 A 92-year-old manpresentswithweightloss,fatigue,nocturia,terminal dribbleandfeelslikehe doesn't completely void.Theprostatefeels grade this cancer?has araisedPSA. Whatscoringsystemis usedto A)Bosniak B)TNM C)Gleeson D)Duke's E) BlatchfordSBA3 A 92-year-old manpresentswithweightloss,fatigue,nocturia,terminal dribbleandfeelslikehe doesn't completely void.Theprostatefeels grade this cancer?has araisedPSA. Whatscoringsystemis usedto A)Bosniak B)TNM C)Gleeson D)Duke's E) BlatchfordSBA4 A79-year-old manpresentswitha 3-yearhistory ofvoiding LUTS (poorstream, incompleteemptying,hesitancy) anda 3-monthhistory of hipand lowerback painwhichis worseat night.His adjustedserum calcium is2.9 mmol/L (referencerange2.25–2.5 mmol/L). What isthemostlikely diagnosis? A)bladder B)testicle C)Prostate D)Penis E) RenalSBA4 A 79-year-old manpresentswitha3-year history of voiding LUTS (poor andlower backpainwhichisworseatnight.Hisadjustedserum calciumip is 2.9mmol/L(reference range 2.25–2.5 mmol/L).Whatisthe mostlikely diagnosis? A)bladder B)testicle C)Prostate D)Penis C)RenalSBA5 Which tumour is characterised byshiller duval bodies on histology? This tumour has a raised AF. A) Choriocarcinoma B)Yolk sac tumour C) Teratoma D)Embryonalcarcinoma E) sertoli tumourSBA5 histology?ur is characterised byschiller duval bodies on This tumour has a raised AF. A) Choriocarcinoma B)Yolk sac tumour C) Teratoma D)Embryonalcarcinoma E) sertoli tumourSBA6 A 19 year old male presentswith a painless lump in his testicle. The testicle is removedandthe histology showsa fried egg appearance of the cells. Which is most likely? A) Leydig cell B)seminoma C) choriocarcinoma D)Teratoma E) Yolk sac tumourSBA6 A 19 year old male presentswith a painless lump in his testicle. The testicle is removedandthe histology showsa fried egg appearance of the cells. Which is most likely? A) Leydig cell B)seminoma C) choriocarcinoma D)Teratoma E) Yolk sac tumourSBA7 A 64-year-old man presents with a 2-month history of painless visible haematuria,hypertension,weight loss, pyrexiaand anaemia. What is the most likelydiagnosis? A) AC bladder B)SSC bladder C) Prostate cancer D) RenalcancerSBA7 A 64-year-old man presents with a 2-month history of painless visible haematuria,hypertension,weight loss, pyrexiaand anaemia. What is the most likelydiagnosis? A) AC bladder B)SSC bladder C) Prostate cancer D) RenalcancerSBA8 A 64-year-old woman presents with a 1-week history ofvisible haematuria,dysuria and LUTS.What is the most likelydiagnosis? A) AC Bladder B)SCC Bladder C) upper tract TCC D) UTI E) Bladder stoneSBA8 A 64-year-old woman presents with a 1-week history ofvisible haematuria,dysuria and LUTS.What is the most likelydiagnosis? A) AC Bladder B)SCC Bladder C) upper tract TCC D) UTI E) Bladder stoneSBA9 71-year-old manpresents witha6-monthhistoryof visiblehaematuria history).Whatisthe mostlikelydiagnosis?ker (80-year pack A)ACbladder B)Upper tractTCC C)SSC bladder D)urothelialbladdercancer E) BladderstoneSBA9 71-year-old manpresents witha6-monthhistoryof visiblehaematuria history).Whatisthe mostlikelydiagnosis?ker (80-year pack A)ACbladder B)Upper tractTCC C)SSC bladder D)urothelialbladdercancer E) BladderstoneFOR FEEDBACK AND QUERIES: Email @info@bidasw.com