Urology

Question 1

Urological cancers

Answer 1

Prostate
Kidney
Bladder
Testis 
Penile

Question 2

Risk factors for prostate cancer

Answer 2

Age
FHx
BRCA2
Ethnicity - black African

Question 3

Presentation of prostate cancer

Answer 3

Asymptomatic - high PSA

LUTS

Suspicious DRE

Bone pain - bone mets

Rare - ejaculatory problems

Question 4

LUTS

Answer 4

Hesitancy
Weak stream
Frequency
Feeling of incomplete urination

Question 5

Investigations for prostate cancer

Answer 5

DRE

PSA - before DRE

MRI prostate/pelvis before biopsy

• helps decide biopsy technique
• may not need biopsy

Biopsy

Question 6

Methods of prostate biopsy

Answer 6

TRUS - transrectal ultrasound guided biopsy

Transperineal biopsy

Question 7

TRUS

Answer 7

Targets posterior area of the prostate

Local anaesthetic

Question 8

Transperineal biopsy

Answer 8

Targets whole area of prostate

General anaesthetic

Question 9

Common causes of raised PSA

Answer 9

Prostate cancer 
Urinary infection 
Prostatitis 
Enlarged prostate - BPH 
Acute urinary retention 
DRE 
Intercourse

Question 10

Problem with PSA

Answer 10

Poor sensitivity - false positives

May have prostate cancer but clinically insignificant

Question 11

Factors influencing prostate cancer treatment

Answer 11

Age 
DRE
Stage 
PSA - no robotic prostatectomies when > 20 
Biopsy result - Gleason grade 
MRI scan and bone scan - mets

Question 12

Gleason score and intervention

Answer 12

Intervention when 3 + 4 or > 8

Question 13

Castrate resistant prostate cancer

Answer 13

Metastatic prostate cancer

Androgen independent prostate cancer

Question 14

Metastatic prostate cancer

Answer 14

Bone metastasise - osteoblastic therefore sclerotic

Likely if PSA >20

Question 15

Treatment of prostate cancer

Answer 15

Hormones (medical castration) - LHRH agonists

Surgical castration

Question 16

LHRH agonists

Answer 16

LH normally has a pulsatile release

Initial LH flare - more symptomatic therefore give anti-androgen for first 28 days to prevent the flare

Then decreases as downregulated

Question 17

Palliative options for prostate cancer

Answer 17

Single dose radiotherapy

Bisphosphonates - zoledronic acid

Question 18

Caution with LHRH antagonists

Answer 18

Can cause anaphylaxis as similar structure to histamine

Question 19

Treatment of metastatic castration resistant prostate cancer

Answer 19

Add antiandrogen - bicalutamide

Consider prednisolone + docetaxel chemo if good performance status

Question 20

Locally advanced prostate cancer treatment (no mets)

Answer 20

Radical radiotherapy with adjuvant hormones

Question 21

Treatment of localised prostate cancer

Answer 21

Active surveillance
Radical prostatectomy - robotic
Radiotherapy - external beam or brachytherapy

Question 22

Palliative treatment for localised prostate cancer

Answer 22

Deferred hormones - watchful waiting

Question 23

Prostate screening

Answer 23

Opportunistic screening if patients are counselled

Question 24

Problems with prostate cancer screening

Answer 24

Lead time bias 
Length time bias
Overdiagnosis 
Over treatment  - side effects 
Not cost effective

Question 25

Lead time bias

Answer 25

Identifying the disease earlier does not affect the prognosis however it seems that there are more years of survival

Question 26

Length time bias

Answer 26

Overestimation of survival duration because prostate cancer can be asymptomatic and slowly progressing with a better prognosis. More aggressive diseases are asymptomatic for a shorter period and are detected after giving symptoms

Question 27

Haematuria types

Answer 27

Visible | Non visible - seen on dipstick

Question 28

When to refer haematuria

Answer 28

40+ with unexplained visible haematuria | 65+ with unexplained non visible haematuria

Question 29

Differentials for haematuria

Answer 29

Cancer: - RCC - TCC - Bladder carcinoma - Advanced prostate cancer Other: - renal stones - UTI - glomerulonephritis - pyelonephritis/ cystitis - BPH

Question 30

Investigations for haematuria in secondary care

Answer 30

Radiology - USS Urine - cytology Flexible cystoscopy

Question 31

Investigations for haematuria in primary care

Answer 31

Bloods - U+Es, albumin/creatinine ratio | MSU - dipstick

Question 32

Presentation of testicular cancer

Answer 32

Lump in body of testis | Painless

Question 33

When to refer for 2 ww for testicular cancer

Answer 33

Testicular lump

Question 34

What happens in a 2 ww referral

Answer 34

Urgent USS of scrotum | Testis tumour markers

Question 35

Testis tumour markers

Answer 35

AFP Beta - hCG LDH

Question 36

Risk factors for penile cancer

Answer 36

Risk factors for STIs | FHx

Question 37

When to suspect penile cancer

Answer 37

Excluded STI Lump/ulcer/lesion is persistent despite treatment Recurrent balanitis and phimosis

Question 38

Risk factors for bladder cancer

Answer 38

Persistent irritation - indwelling catheter, recurrent bladder stones Schistosomiasis Overflow incontinence Occupational exposure - rubber or plastic manufacture - arylamines - carbon/crude oil - polyaromatic hydrocarbons - painters, mechanics, hairdressers Smoking Male White

Question 39

Types of bladder cancer

Answer 39

TCC | Squamous cell carcinoma - schistosomiasis

Question 40

Treatment of bladder cancer

Answer 40

TURBT - transurethral resection of bladder cancer Single intravesical instillation of mitomycin

Question 41

Treatment of intermediate/high risk non muscle invasive TCC

Answer 41

Check cystoscopy | Intravesical chemotherapy/ immunotherapy

Question 42

Treatment of muscle invasive TCC

Answer 42

Potentially curative - neoadjuvant chemotherapy + radical cystectomy or radiotherapy Palliative chemotherapy or immunotherapy

Question 43

Treatment of metastatic TCC

Answer 43

Palliative chemotherapy (cisplatin) or immunotherapy

Question 44

Types of radical cystectomy

Answer 44

Ileal conduit Reconstruction - orthotopic Women - also remove fallopian tubes

Question 45

Standard treatment of upper urinary tract TCC

Answer 45

Nephro - ureterectomy

Question 46

Risk factors for RCC

Answer 46

White Male Smoking Obesity Dialysis

Question 47

Treatment for localised RCC

Answer 47

Active surveillance Excision - radical or partial nephrectomy

Question 48

Radical nephrectomy

Answer 48

Removal of kidney, adrenals, peri-nephritic and upper ureter

Question 49

Metastatic RCC treatment

Answer 49

Palliative biological targeted therapies - targeting angiogenesis

Question 50

Types of testicular cancer

Answer 50

Germ cell tumours - seminoma or teratoma | - usually in men < 45 yo

Question 51

Risk factors of testicular cancer

Answer 51

Undescended testis

Question 52

Treatment of testicular cancer

Answer 52

Inguinal orchidectomy

Question 53

Which lymph nodes does scrotal cancer spread to

Answer 53

Inguinal lymph nodes

Question 54

Which lymph nodes does testicular cancer spread to

Answer 54

Para - aortic

Question 55

What type of cancer is penile cancer

Answer 55

Squamous cell carcinoma

Question 56

Risk factors for penile cancer

Answer 56

Phimosis | HPV 16 and 18