Station 3 Flashcards
63 YO Female Recurrent NVH:
Assess
Haematuria is concerning for a urological cancer diagnosis therefore i would like to see this patient in a one stop haematuria clinic with a flexible cystoscopy if possible
History
- Duration
- Previous Episodes?
- Initiation, Throughout, Terminal Stream
- Associated Symptoms - Pain/Fever/Symptomatic Anaemia/LUTS/Bowel Function
Red Flag
- Leg Swelling - Lymphovascular obstruction
- Bone Pain, Weight Loss, Anorexia, Anuria
RFs
- Smoking, Occupation (Textile/Rubber/Chemical Work), Schistosomiasis (Travel/Place of origin), Radiotherapy, Chroinc Infection, Chemotherapy
PMH/PSH
**FH ** - Urological Ca
DH - Allergies. Anticoagulants.
63 YO Female Recurrent NVH:
Examine
Investigate
Examine
Abdominal - Abdominal Masses, Rectal/Vaginal Exam
Investigate
Urinalysis
Urine Cytology
Bloods - FBC, UE, CRP, PSA
Imaging - USS ( NVH), CTU (VH),
Cystoscopy - Flexi/Rigid
Sensitvity + Specificity of Cytology
Sensitvity - 30-50%
Specificity - 98%
What to do if you find a tumour on Flexi?
Stay Calm
Wait to finish cystoscopic examination
Ask them to empty bladder get comfortable and come back in with relative
Bring CNS into the room
Gently explain likely diagnosis and following steps
Explain will need histological confirmation before being sure
Provide Contact details for CNS and the Urology POD
Provide leaflets regarding procedure and bladder cancer
Explain results will be discussed in MDT a week after operation at which point we can discuss treatment going forwards
Ix:
CT Urogram
Book for TURBT
Consent for TURBT
Confirm patient details. Ensure comfortable.
Indication - Diagnostic/Treatment
Depending on size of resection - day case versus overnight stay
Risks:
Bleeding, Infection, Pain, Lower Urinary Tract Symptoms
Damage - Bladder perforation, Urethra
Urethral stricture in future
Will need a catheter after procedure - ?1 day ? 2 weeks if concerns of bladder perforation/ urethral trauma
May need further procedure - Re-do TURBT if incomplete resection, Surveillance cystoscopies in future
Anaesthetic Risk
Instillation of intravesical mitomycin post procedure - GIve mitomycin within 6 hours of operation (ideally within 60 minutes)
Risk Stratification for Bladder Ca
NICE NMIBC:
Low Risk
G1/G2 (LG) pTa <3cm
Intermediate
G1/G2 (LG) pTa >3cm
Multifocal G1/G2 (LG) pTa
HG G2pTA
Low risk NMIBC Recurring within 12 months
High
G3
G2/G3 pT1
CIS
Agressive variant - micropapillary/nested)
When do you offer early re-resection?
What are the benefits?
- G3 or T1 Disease regardless of margins
- Incomplete resection
- No Muscle in Sample
Benefits:
- Improved recurrence free survival
- Improved outcomes post BCG
- Provides further prognostic information
When tumour is on lateral wall?
Risk of obturator kick
Ask for paralysis
Bipolar Diathermy
Short Bursts with low Current
Don’t overinflate bladder
While resecting you see fat?
What to do
Stop - call for help (urology consultant/more experienced surgeon)
Inspect bladder - obtain haemostasis
If concerns regarding intraperitoneal perf - on table cystogram (300 ml 50/50 Contrast, AP and Oblique views firstly with the bladder distended and then once emptied)
If confirmed IP Perf - > Consider laparatomy and bladder repair
If EP perf haemostasis, large bore catheter for 2 weeks, no mitomycin
after the procedure
exercise duty of candour - inform patient, risk of seeding
catheter can be removed after cystogram (at least 2 weeks later)
Risk of progression to muscle invasive disease without treatment - CIS
Risk of progression to MIBC after BCG
54% risk of muscle invasive disease without treatment
BCG
Responders - 10-20% Progress to MIBC
Non-Responders - 66% Progress to MIBC
Beneefit of post TURBT mitomycin?
Meta Analysis demonstrated an
absolute risk reduction of recurrence - 12%
relative risk reduction of recurrence - 39%
Benefit of BCG in NMIBC
Absolute risk reduction of progression - 4%
Relative risk reduction of progression - 27% (effect only in patients on maintenance treatment)
What constitutes BCG Failure vs BCG Refractory Tumour?
BCG Failure - MIBC Detection During FU
BCG Refractory:
HG NMIBC present att 3 months (associated with increased risk of disease progression)
CIS Present at 3 + 6 months. (BCG can still induce complete response in >50%)
HG Tumour appears during BCG therapy
Non HG recurrence is not considered BCG Failure
What is the next step in management after BCG Failure
Optimal - Radical Cystectomy
TNM Bladder Cancer
Tx , T0
Ta - Non Invasive Papillary
Tis- CIS
T1 - Supepithelial connective tissue
T2 - Muscle (T2a (Supericial), T2b (Deep))
T3 - Perivesical fat
T4 - Locally invasive (T4a - Prostate, SV, Uterus, Vagina , T4b - Pelvic Wall/ Abdominal Wall)
Nx, N0
N1 - Single LN
N2- Multiple LN
N3 - Common iliac
M0
M1 - Present
