Urology (2) (Cancer and stones) Flashcards
(52 cards)
1
Q
Testis cancer
A
Usually from germ cells (produce sperm) in the testes (can also be non-germ cell tumours and secondary metastases).
- Seminomas (slightly better prog)
- Non-seminomas (mostly teratomas)
In general good prognosis >90% cure rate.
2
Q
The common places for testicular cancer to metastasise to are:
A
- Lymphatics
- Lungs
- Liver
- Brain
3
Q
RF for testes cancer
A
- cryptorchidism- Undescended testes
- Male infertility
- Family history
- Increased height
4
Q
presentation of testis cancer
A
- Painless lump (occasionally pain)
- Arising from testicle
- Hard
- Irregular
- Non fluctuant
- No transillumination
- Rarely gynaecomastia- Leydig cell tumour
- Evidence of metastasis may present with weight loss, back pain (from retroperitoneal metastases), or dyspnoea (secondary to lung metastases).
- *Lymphatic drainage of the testes is to the para-aortic nodes, therefore localised lymphadenopathy may not be present, even in cases of metastatic disease
5
Q
investigations for testicular cancer
A
- Scrotal US
- Tumour markers
- Alpha-fetoprotein (teratomas)
- Beta-hCG- teratomas and seminomas
- Lactate dehydrogenase (LDH)- no specifc tumour marker
- Staging CT CAP
6
Q
tumour marker for teratoma (NSGCTs)
A
alpha-feto-protein
(AFP)
7
Q
seminoma tumour marker
A
beta-hCG
8
Q
LDH and testicular cancer
A
LDH can also be used as a surrogate marker for tumour volume and necrosis, as well as for tumour response to oncological treatment.
9
Q
staging system for testicular cancer
A
Royal Marsden
- Stage 1 – isolated to the testicle
- Stage 2 – spread to the retroperitoneal lymph nodes
- Stage 3 – spread to the lymph nodes above the diaphragm
- Stage 4 – metastasised to other organs
10
Q
management of testicular cancer
A
- Surgery to remove the affected testicle (radical orchidectomy) – a prosthesis can be inserted
- Chemotherapy
- Radiotherapy
- Sperm banking to save sperm for future use, as treatment may cause infertility
11
Q
long term side effects of testis cancer treatment
A
of treatment are particularly significant, as most patients are young and expected to live many years after treatment of testicular cancer. Side effects include:
- Infertility
- Hypogonadism (testosterone replacement may be required)
- Peripheral neuropathy
- Hearing loss
- Lasting kidney, liver or heart damage
- Increased risk of cancer in the future
12
Q
categorisation of testicular cancer
A
germ cell tumours (GCT)
non germ cell tumours (NSGCT)
13
Q
Germ cell tumours (GCT)-95%
A
-
Seminomas
- Remain localised- very good prognosis
-
Non-seminomatous GCTs (metastasise early)
- Yolk sac tumours
- Choriocarcinoma
- teratoma
14
Q
Non germ cell tumours (NSGCT)
A
- Usually benign
- Comprise
- Leydig cell tumour
- Sertoli cell tumours
15
Q
penile cancer
A
Most common is squamous cell carcinoma, arising from the epithelium of the inner prepuce or the glans- Rare
16
Q
RF for penile cancer
A
- HPV 6,16,18
- BXO
- Phimosis
- Smoking
- Lichen sclerosis
- Untreated HIV infection
- Previous Psoralen-UV-A photochemotherapy (PUVA)
- Treatment for psoriasis
17
Q
protective factors for penile cancer
A
circumcision
18
Q
presentation of penile cancer
A
- Palpable/ ulcerating lesions on the penis usually located on the glans
- Painless
- May discharge or bleed
- Inguinal lymphadneopathy (30-60%)
- Distant mets uncommon
19
Q
DD for penile cancer
A
- Herpes or syphilis
- Psoriasis
- Lichen planus
- Balanitis
- Premalignant -condyloma acuminatum (genital warts)
20
Q
investigations fo penile cancer
A
- Penile biopsy to confirm diagnosis
- PET-CT imaging to determine inguinal involvement
- If inguinal involvement- CT CAP
21
Q
staging of penile cancer
A
TNM
22
Q
penile cancer management aim
A
complete tumour removal and oncological control and organ preservation
23
Q
combination treatment of penile cancer
A
- Surgery (2cm tumour-free margin for resection)
- Organ sparing treatment
- Local excision
- Partial glansectomy
- Total glansectomy with reconstruction
- Radical circumcision if only foreskin tumours
- Invasive penile cancer
- Partial amputation with reconstruction
- Total penectomy
- If inguinal lymph node involvement- radical inguinal lymphadenectomy, neoadjuvant chemo or radio
- Radiotherapy
-
Chemotherapy
- If superficial- topical chemotherapy e.g. imiquimod or 5-fluorouracil (5-FU)- then repeat biopsy and long term surveillance
- Organ sparing treatment
24
Q
other options for penile cancer management
A
- Laser
-
Glands resurfacing
- consisting of complete removal of the glandular epithelium down to the corpus spongiosum, followed by reconstruction with a split skin or buccal mucosa graft
25
stone disease
They can form as both **renal stones** (within the kidney) or **ureteric stones** (within the ureter).
26
types of renal stone
* Calcium oxalate
* Calcium urate (uric acid)
* Calcium phosphate
* Struvite (UTI- infection) – ammonia, Mg2+, Phosphate
* Staghorn calculi
27
most common renal stone type
**calcium oxalate stones and calcium phosphate stones**
28
struvite stone
associated with infection e..g UTI **Proteus mirabilis**
containL NH3, Mg2+ and Phosphate
staghorn calculi
29
causes of renal stones
**Causes**
Mostly idiopathic.
How do they form:
* Supersaturation: Excess minerals in urines due to increased excretion in renal ducts (calcium, phosphate, oxalate)
* Urate- high levels of purine e.g. from diet or haematological disorders
* Cystine- homocystinuria
* Stasis in outflow – anatomical problem
* Dehydration
* Reduced inhibitors
30
RF for stone disease
* Race/genetics
* \<65yrs
* Anatomical
* Osteoporosis/osteopenia
* Gout
* Bowel surgery/IBD
* Polycystic kidney disease
* Chemotherapy
* Diabetes
* Diet
* Obesity
* Urinary
* Volume
* Calcium, urate, oxalate
* Urine pH – diff types of stones form at diff pH
* Alkaline- struvite
* Acidic- uric acid stones
* Inhibitors: Urine citrate and Urate magnesium
31
alkaline urine
struvite- ifnection
32
acidic urine
uric acid stone
33
inhibitors of stone formation
Urine citrate and Urate magnesium
e.g. **Prevention:** Potassium citrate- makes urine more alkaline- prevents stone formation
34
locaiton of ureteric stone
For stones that enter the drainage system of the urinary tract, there are **three natural narrowed points** where stones are likely to impact:
* **Pelviureteric Junction (PUJ**), where the renal pelvis becomes the ureter
* **Crossing the pelvic brim**, where the iliac vessels travel across the ureter in the pelvis
* **Vesicoureteric Junction** (VUJ), where the ureter enters the bladder
35
presentation of ureteric stone
* Loin to groin pain (referred pain)
* Colicky – due to increased peristalsis from site of obstruction
* Sudden onset, severe
* N and V
* Haematuria – typically non-visible
36
hisotry for stones
* SOCRATES
* Risk factors
* Family history
* Any previous history of stones
37
exmaintion ofr stones
abdominal and genital area
38
**Investigations**
* ABCDE
* Bloods (FBC, UandE’s. CRP)
* Urine dipstick – haematuria, WCC, leucocytes
* Urine culture
* Stone retrieval- Urate and calcium levels – send for analysis
* **Non-contrast CT scan of the renal tract (**gold standard) – high sensitivity and specificity
* **AXR** less useful- some stones not radio-opaque
* **US** used concurrently in cases of known stone disease to assess for hydronephrosis- no radiation risk
39
CT in cancer and stones
cancer- contrast
stone- non-contrast
40
intitial management of stones disease
* Adequate fluid resuscitation (reduced fluid intake +/- vomiting)
* Most stones will pass spontaneously without further intervention, esp if lower ureter or \<5mmm in diameter
* Analgesia - diclofenac
* Opiate and NSAIDs per rectum
* SEPSIS 6 if evidence of significant infection- IV Abx
41
analgesia of choice for stones
diclofenac
42
criteria for inpatient admission- stones
* Post-obstructive acute kidney injury- renal impairment
* Uncontrollable pain from simple analgesics
* Evidence of an infected stone(s)
* Large stones (\>5mm)
43
obstructive nephropathy e.g. if stone in ureter to stop hydronephrosis
* **JJ stent**
* Passed up urethra and up ureter à coiled at both ends to keep in placeà drain the kidney into the bladder
* **Nephrostomy**
* Drainage tube placed directly into the renal pelvis (percutaneous) and collecting system- relieving obstruction proximally.
44
definitive managemnt of renal stones
* Extracorporeal shock wave lithotripsy (ESWL)
* Targeted sonic waves to break up stone so they can pass
* \<2mm- radiologically guided
* Contraindication- pregnancy or stone position over a bony landmark
* Percutaneous nephrolithotomy
* For larger renal stone (e.g. staghorn calculi)
* Percutaneous access to kidney – nephoscope passed into renal pelvis and stone fragmented using forms of lithotripsy
* Flexible uretero-renoscopy (URS)
* Involves passing a scope retrograde up into the ureter- allows stones to be fragmented through laser lithotripsy and the fragments subsequently removed
45
complications of renal stones
* Infection- SEPSIS- commence SEPSIS 6
* Post renal acute kidney injury
* Recurrent kidney stones
* Steinstrasse- bigger stone broken down causes a line of smaller stones lower down in the ureter
46
causes of bladder stones
due to urine stasis in the bladder e.g. chronic urinary retention .
* May also occur secondary to infection (classically schistosomiasis) or passed ureteric stone
47
presentation of bladder stones
LUTS
48
investigations for bladder stones
* Same for renal and ureteric stone
49
management of cystoscopy
* Allowing stones to drain or fragmented through lithotripsy
50
DD for loin to groin pain
* Pyelonephritic
* Acute renal colic
* AAA if RF present
* Man
* Obese
* HT
* smoker
51
non-acute stone disease general management
Stay hydrated
52
non-acute stone disease specific management
Specific management options depend on the underlying stone composition:
* Oxalate stone formers should be advised to avoid high purine foods and high oxalate foods (such as nuts, rhubarb, and sesame)
* Calcium stone formers should have PTH levels checked to exclude any primary hyperparathyroidism and avoid excess salt in their diet
* Urate stone formers should be advised to avoid high purine foods (such as red meat and shellfish) and may need to be considered for urate-lowering medication (e.g. allopurinol)
* Cystine stone formers may warrant genetic testing for underlying familial disease (homocystinuria)
