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yr3 revision > MET3 Revision: Urology II > Flashcards

MET3 Revision: Urology II Flashcards

1
Q
A
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2
Q

What are the 3 most common types of renal cell cancer? [3]

A

Clear cell (75%)
Papillary (10%)
Chromophobe (5%)

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3
Q

Clear cell renal cell cancer is commonly due to a mutation in which gene? [1]

A

VHL tumour supressor gene: occurs in Von Hippel-Lindau syndrome.

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4
Q

What are the classic triad of symptoms for renal cancer? [3]

Name two more important clinical signs [2]

A

Classic triad:
* Loin pain
* Haematuria
* Loin mass

Also important:

Scrotal varicocele: usually left sided due to obstruction of the left gonadal vein
Lower limb oedema: due to compression of the inferior vena cava
NB: 50% are asymptomatic

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5
Q

What investigations should you provide if suspect renal cancer? [4]

A

BP increased from increased renin

FBC:
- Polycythaemia from EPO secretion
- ESR
- U&E
- ALP
- LDH

Urine:
- RBC

Imaging:
- USS
- CT w contrast: definitive test
- MRI

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6
Q

Patients receiving which form of treatment increaese their risk of RCC? [1]

A

15% of haemodialysis patients develop RCC

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7
Q

What is the difference in renal cancer staging between 1-4? [4]

A

Stage 1: < 7cm; no spread
Stage 2: > 7cm; no spread
Stage 3: > 7cm; spread locally
Stage 4: Spread to abdomen; adrenal glands; lymph nodes

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8
Q

Treatment for localised renal cancer?: T1 [2] & T2 [1]

A

T1 tumours:
- < 3 cm: ablative therapies
- up to 7 cm: partial nephrectomy

T2:
Radical nephrectomy (open, laporoscopic, open)

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9
Q

Treatment for locally advanced disease: T3 & T4? [1]

A

Radical nephrectomy

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10
Q

Treatment for metastatic RCC? [6]

A

Debulking surgery
Adjuvent chemotherapy
Immunotherapy tyrosine kinase inhibitors:
* ipilimumab
* nivolumab
* Sunitinib: inhibitor of tyrosine kinase receptors
* Pazopanib: inhibitor of tyrosine kinase receptors
* Temsirolimus: inhibitor of the mammalian target of rapamycin (mTOR)
* Everolimus: inhibitor of the mammalian target of rapamycin (mTOR)

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11
Q

Where patients are not suitable for surgery, which les invasive procedures can be used to treat the RCC? [3]

A

Arterial embolisation,
- cutting off the blood supply to the affected kidney

Percutaneous cryotherapy,:
- injecting liquid nitrogen to freeze and kill the tumour cells

Radiofrequency ablation,
- putting a needle in the tumour and using an electrical current to kill the tumour cells

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12
Q

RCC is generally resistant to which treatment types? [2]

A

Radiotherapy and chemotherapy

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13
Q

What is the name of the score created to predict prognosis of RCC patients? [1]

A

Mayo prognostic risk score

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14
Q

Describe the spread of RCC [2]

A

Renal cell carcinoma tends to spread to the tissues around the kidney, within Gerota’s fascia. It often spreads to the renal vein, then to the inferior vena cava.

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15
Q

Describe characteristic finding of metastatic RCC on CXR [1]

A

Cannonball

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16
Q

Name 4 differential diagnosises of cannonball metastasis

A
  • renal
  • choriocarcinoma

less commonly, with prostate, bladder and endometrial cancer.

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17
Q

Explain why RCC causes each of the following cause of paraneoplastic syndrome

Polycythaemia
Hypercalcaemia
Hypertension
Stauffer’s syndrome

A

Polycythaemia:
- due to secretion of unregulated erythropoietin

Hypercalcaemia:
- due to secretion of a hormone that mimics the action of parathyroid hormone

Hypertension
- due to various factors, including increased renin secretion, polycythaemia and physical compression

Stauffer’s syndrome
- abnormal liver function tests (raised ALT, AST, ALP and bilirubin) without liver metastasis

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18
Q

Name 4 paraneoplastic syndromes that RCC causes

A

Polycythaemia
Hypercalcaemia
Hypertension
Stauffer’s syndrome

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19
Q

Describe what is meant by Stauffer syndrome

A

Stauffer syndrome: RCC paraneoplastic syndrome

Hepatosplenomegaly
+
Cholestatic LFTs (elevated bilirubin; ALP and GGT)

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20
Q

Clinical features of bladder cancer? [4]

A

Painless haematuria: most common symptom
recurrent UTIs
Dysuria
Frequency
Urgency
Suprapubic pain

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21
Q

Risk factors for bladder cancer? [5]

A

Smoking
Aromatic amines (rubber industry)
Chronic cystitis
Schisosomiasis
Pelvic irradtion

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22
Q

Describe NICE guidelines regarding haematuria that determines investigating for bladder cancer [2]

A

Painless haematuria:

Aged over 45 with unexplained visible haematuria, either without a UTI or persisting after treatment for a UTI. 2/3 samples positive for blood require investigation

Aged over 60 with microscopic haematuria (not visible but positive on a urine dipstick) PLUS:
Dysuria or;
Raised white blood cells on a full blood count

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23
Q

What investigations would you conduct for bladder cancer:

  • All patients given? [1]
  • NVH v VH? [2]
A

All patients given cytoscopy (rigid or flexible) - with biospy: diagnostic

NVH: USS renal tract

VH: CT urogram

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24
Q

Staging for bladder cancer is initially determined via histological biopsies made using which sampling technique? [1]

Subsequent staging of bladder cancer is determined via which methods? [3]

A

TURBT (Transurethral resection of bladder tumour):
- Muscle invasive
- Non-muscle invasive

Staging investigations:
* CT or MRI of pelvis
* Chest x-ray
* Bone scan

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25
Q

The management of bladder cancer may be classified according to which stages of bladder cancer? [3]

A
  • Low risk non-muscle Invasive Bladder Cancer (NMIBC)
  • Moderate risk muscle Invasive Bladder Cancer (MIBC)
  • Metastatic Bladder Cancer
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26
Q

Describe the treatment for Mild [2], Intermediate [2] & High [3] risk patients of Non-Muscle Invasive Bladder Cancer (NMIBC)

A

Mild:
- Transurethral resection of bladder tumor (TURBT): provides diagnosis, staging, and initial treatment of diathermy
- Post TURBT - Intravesical chemotherapy (mitomycin or gemcitabine) given using a catheter: reduces risk of relapse

Moderate:
- Transurethral resection of bladder tumor (TURBT): provides diagnosis, staging, and initial treatment
- Post TURBT - Intravesical chemotherapy (mitomycin) given using a catheter; 6 doses - liquid place directly in bladder

High:
- Transurethral resection of bladder tumor (TURBT): X2
- BCG vaccine
- Cystectomy – totally remove the bladder

27
Q

State 4 AEs of BCG vaccine for bladder cancer treatment [4]

A
  • a frequent need to urinate
  • pain when urinating
  • blood in your urine (haematuria)
  • flu-like symptoms, such as tiredness, fever and aching
  • urinary tract infections
28
Q

Describe treatment for Muscle Invasive Bladder Cancer (MIBC) [3]

A

Radical cystectomy: - gold standatd
- Complete surgical removal of the bladder, prostate or uterus, and regional lymph nodes
- Requires urinary diversion

Radiotherapy:
- organ sparing

(Adjuvant &/OR) Chemotherapy:
- Cisplatin before radical cystectomy

29
Q

Describe the treatment for metastatic bladder cancer [3]

A

First-line therapy:
- platinum-based combination chemotherapy, such as gemcitabine-cisplatin or dose-dense methotrexate, vinblastine, doxorubicin, and cisplatin (MVAC).

Immune checkpoint inhibitors:
- For patients ineligible for cisplatin or after progression on first-line chemotherapy, pembrolizumab, atezolizumab, or nivolumab are options.

Targeted therapy:
- For patients with specific molecular alterations (e.g., FGFR3), targeted therapies like erdafitinib may be considered.

30
Q

What Tumour staging includes invasive bladder cancer? [1]

A

Invasive bladder cancer includes T2 – 4 and any lymph node or metastatic spread.

31
Q

Describe the therapy options provided post-radical cystectomy [4]

A

Ileal conduit:
- A section of the ileum (15 – 20cm) is removed, and end-to-end anastomosis is created so that the bowel is continuous.
- The ends of the ureters are anastomosed to the separated section of the ileum.
- The other end of this section of the ileum forms a stoma on the skin, draining urine into a urostomy bag

Continent urinary diversion:
- Create a pouch inside the abdomen from a section of the ileum, with the ureters connected and fills with urine
- A thin tube is connected between a stoma on the skin and the internal pouch
- Urine does not drain from the stoma (unlike a urostomy), and the patient needs to intermittently insert a catheter into the stoma to drain urine from the pouch.

Neobladder formation:
- Formed from ileum; connected to both ureters and urethra
- Functions as normal bladder

Ureterosigmoidostomy (rare)
- Attaching the ureters directly to the sigmoid colon.
- The rectum may be expanded to create a recto sigmoid pouch (called a Mainz II procedure) to create a larger space for urine to collect.
- The patient can then drain the urine by relaxing the anal sphincter in the same way they open their bowels.

32
Q

The majority (70-80%) of bladder cancers are non-muscle invasive at presentation, which includes Ta ([]), Tis ([]), and T1 ([]) stages.

A

The majority (70-80%) of bladder cancers are non-muscle invasive at presentation, which includes Ta (non-invasive papillary), Tis (carcinoma in situ), and T1 (invasion into the lamina propria) stages.

33
Q

What is the name for this operation? [1]

A

Continent urinary diversion

34
Q

Name this operation [1]

A

Ileal conduit

35
Q

State the following locations where bladder cancer may spread if its:

  • Local spread [1]
  • Lymphatic spread [1]
  • Haematogenous [1]
A
  • Local spread: pelvic structures
  • Lymphatic spread: iliac and para-aortic nodes
  • Haematogenous: liver and lungs
36
Q

Describe the difference classes of testicular cancer [4]

A

Germ cell tumours (95% of cancers):
- Seminomas
- Non-seminomas: including embryonal, yolk sac, teratoma and choriocarcinoma

Non-germ cell tumours:
- include Leydig cell tumours and sarcomas.

37
Q

Describe the difference in common age of patients between seminomas and teratomas [2]

Describe the difference in aggressiveness between seminomas and teratomas [2]

A

Seminomas: 35-40 year olds; less aggressive
Teratomas: 20-35 year olds; more aggressive

Teratoma: troops; seminoma: seargents

38
Q

Describe clinical presentation of testicular cancer [4]

A
  • A painless lump is the most common presenting symptom
  • Pain may also be present in a minority of men
  • Other possible features include hydrocele, gynaecomastia (drastic level of β-hCG)
  • Haematospermia
39
Q

Name 3 tumour serum markers used to investigate in testicular cancer [3]

A

AFP is elevated in around 60% of germ cell tumours
LDH is elevated in around 40% of germ cell tumours
Seminomas: hCG may be elevated in around 20%

40
Q

What is first line investigation for testicular cancer? [1]
What is second line investigation for testicular cancer used for staging? [1]

A

1st: USS
2nd: CT - staging

41
Q

Describe the managment for testicular cancer? [2]

A

Radical inguinal orchidectomy (remove testicle through inguinal canal; not through the scrotum; want to prevents letting cancer cells go into the para-aortic lymph nodes, which drain the testes)

Adjuvant chemotherapy

42
Q

Describe the treatment for metastatic testicular cancer [3]

A

Chemotherapy:
- Cisplatin & Etoposide (cornerstone)
- Bleomycin (added)

43
Q

Describe 4 different stages of testicular cancer [4]

A
44
Q

What is liquefaction time? [1]

How long should it normally take in men? []

A

Time taken for semen to liquify after ejacilation

Semen should liquefy within 20 to 30 minutes of ejaculation

45
Q

Why may an increased liquify time be problematic? [1]

A

If too high, it means the sperm may be unable to make the jump to the cervix. It can be caused by infection and dehydration.

46
Q

Name and explain which organ is responsible for liquefaction [2]

A

Prostate as it secretes a milky white fluid which contains prostate specific antigen (PSA). PSA is responsible for liquefaction

47
Q

Label the abnormality pictured in A [1]

A

Bell clapper: (horizontal testes that lie high in scrotum),

48
Q

Describe the presentation of testicular torsion [5]

A
  • bell clapper’ position
  • sudden-onset, sharp, severe, unilateral testicular pain
  • absent cremasteric reflex
  • negative Prehn’s sign (pain that is unrelieved by elevating the affected testis)
  • swollen, tender and erythematous scrotal skin, may also be seen on examination.
49
Q

The common places for testicular cancer to metastasise to are? [4]

A

The common places for testicular cancer to metastasise to are:

Lymphatics
Lungs
Liver
Brain

LLLBean

50
Q

Describe the pathophysiology of hydrocele [4]

A

collection of fluid within the tunica vaginalis that surrounds the testes due to patent processus vaginalis or secondary to trauma, torsion or infection

51
Q

Name this testicular abnormality and how it occurs [2]

A

Varicocele
- pampiniform plexus become swollen
- result of increased resistance in the testicular vein

52
Q

State 2 implications of variocele [2]

A

testicular atrophy, reducing the size and function of the testicle

Can lead to impaired fertility (probably due to disrupting the temperature in the affected testicle)

53
Q

Explain what indicates that a variocele warrants further investigation? [1]

A

Varicoceles that do not disappear when lying down raise concerns about retroperitoneal tumours obstructing the drainage of the renal vein.

54
Q

What does this image depict? [1]

A

Epididymal Cyst

55
Q

What is a positive Prehn’s sign? [1]
Which two pathologies does it help to distinguish between? [2]

A

+ve Prehn’s sign:
- the relief of pain on elevation of the testis

  • Positive: indicates epididymo-orchitis
  • Negative (i.e. the pain is not relieved) in cases of testicular torsion.
56
Q

Describe the management of testicular torsion [3]

A

Explore with surgial exploration: if positive undergo bilateral orchidopexy:

  • the cord and testis will be untwisted and both testicles fixed to the scrotum,
  • Occurs bilaterally even if presenting with one testicle torsion is because around 90% of cases are caused by a bell-clapper deformity and most of the patients with this deformity have it bilaterally. Bilateral fixation, therefore, reduces the risk of torsion in the other testis.
57
Q

The first-line investigation of a testicular mass is []

A

The first-line investigation of a testicular mass is an ultrasound

58
Q

Describe which parameters of varicoceles determine if treatment is given [2]

A

Grade II or III varicocoele Management:
* Asymptomatic AND normal semen parameters Semen analysis every 1-2yrs
* Symptomatic OR abnormal semen parameters: Surgery

59
Q

nvestigations for suspected epididymo-orchitis are guided by age:
sexually active younger adults: []
older adults with a low-risk sexual history: []

A

nvestigations for suspected epididymo-orchitis are guided by age:
sexually active younger adults: NAAT for STIs
older adults with a low-risk sexual history: MSSU

60
Q

Label the tumour marker for each type of testicular cancer [4]

A

A: hCG & AFP
B: AFP
C: hCG
D: no rise

61
Q

[] is the most common cause of primary hyperaldosteronism

A

Bilateral idiopathic adrenal hyperplasia is the most common cause of primary hyperaldosteronism

62
Q

A 28-year-old female presents to the gastroenterology clinic with a history of irritable bowel symptoms and weight loss. She undergoes upper endoscopy and colonoscopy. A terminal ileal biopsy shows transmural inflammation, non-caseating granulomas and skip-lesions. As a result, she is started on a short course of steroids to induce remission of her underlying condition.

Which medication would be most appropriate to maintain remission?

Ciclosporin

Low dose prednisone

Mercaptopurine

Mesalazine

Tacrolimus

A

A 28-year-old female presents to the gastroenterology clinic with a history of irritable bowel symptoms and weight loss. She undergoes upper endoscopy and colonoscopy. A terminal ileal biopsy shows transmural inflammation, non-caseating granulomas and skip-lesions. As a result, she is started on a short course of steroids to induce remission of her underlying condition.

Which medication would be most appropriate to maintain remission?

Ciclosporin

Low dose prednisone

Mercaptopurine

Mesalazine

Tacrolimus

Azathioprine or mercaptopurine is used first-line to maintain remission in patients with Crohn’s

63
Q
A

yr3 revision (37 decks)

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