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115 Cards in this Set
- Front
- Back
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Is age a significant prognostic factor in prostate cancer?
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NO
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Aetioligical factors in prostate cvancer
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age- rare before age 40
genetics- similar heritability to breast cancer |
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Pathophysiology of prostate cancer
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Most tumours are adenocarcinomas
histologically hetrogenous- theregore Gleason scoring system used |
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Prognostic significance of gleason scoring system for prostate Ca?
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Low grade- similar survaval to age matched controls at 10 years, significant difference is 15 years
For higher gleason scores life expectaqncy is 5-10 years |
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What % of patients who have TURP for what is clinically BPH turn out to have carcinoma diagnosed in the resected specimen?
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10-15%
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Where do prostate cancers arise from?
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75% in peripheral zone
25% in transitional zone 5% in central zone |
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How often will somebody with prostate cancer have a raised PSA?
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raised PSA found in >90%
neither sensitive nor specific changes in the level can tell you about the activity of the tumour and the response to treatment |
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What can the ratio of free to total PSA tell you?
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lower free component in prostate cancer
Ejaculation may result in a temporary surge of free PSA into the serum |
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Risk of TRUS with biopsies
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septicaemia - pre procedural enema and antibiotic prophylaxis
hemospermia, blood on faeces, haematuria with difficulty voiding |
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What nodes does prostate cancer spread to?
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internal iliac and parasacral
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How does prostate cancer spread to the axial skeleton?
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venous spread- creates osteosclerotic metastases
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How often are occult metastases found when prostate cancer is throught to be locallised?
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25% of cases
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Can prostate cancer with lymph nose mets be cured?
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no
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Is there a rolev for chemo in the management of prostate ca?
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no
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wHAT IS THE ESTIMATED DOUBLING TIME OF A LOCALISED PROSTATE CANCER?
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2 YEARS
A watch and wait approach may be used in elderly patients with life expectancy less than 10 years- balance this against risk of painful death from metastases to the axial skeleton |
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10 yr disease specific survivaql rate for organ confined prostate cancer after radical prostatectomy?
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90%
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Impotence and incontinence rate after radical prostatectomy
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impotence 30%
incontinence 7%- also a problem with RT |
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Advantage of brachytherapy over conventional therapy for prostate cancer?
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irritative voiding and minor proctitis are common in the short term- long term effects such as rectal bleeding and fecal soiling are uncommon
potency difficulties still common More likely to be incontinent afterwards if have had a TURP |
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What % of patients respond to androgen therapy in metastatic prostate cancer?
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80% have durable response- median duration is 24-36m
The faster the PSA returns to the normal age the better the response and prognosis |
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Does commencing androgen suppression early improve survival in prostate ca?
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no
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Most important factors adversely affecting quality of life in men on androgen suppression?
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loss of sexual desire and impotence
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Is there any evidence for the use of intermittent/maximal aqndrogen blockage over conventional therapy?
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no- as not all unwanted effects are reversible
and maximal blockade does not improve tumour control but increases unwanted effects |
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Prognosis of renal cell carcinoma
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50% cured if early stage
poor for late stage- <15% response to chemotherapy; if lymphatic metastases <35% 5 yr survuval |
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Targeted therapy for renal cell carcinoma
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Immune modulators including IFN. BCG, IL2
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Which patients with renal cell carcinoma get surgical resection (radical nephrectomy with underlying fat and fascia)
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no metastatic disease at diagnosis
survival benefit of excision of primary tumour +/- solitary metastasis/ multiple mets of resectable |
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How does renal cancer like to spread?
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tumour thrombus propagates up the venous system
5-10% involves the IVC might extend into the right atrium |
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Does venous propagation of a renal cell carcinoma make it inoperable?
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no- as prognosis relates to the presence of lymphatic spread and other mets
however, the higher the tumour thrombus the worse the prognosis because of increasign likelyhood of systemic metastases |
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How do you detect metastatic renal cell carcinoma in bone?
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radioisotope bone scanning using a radiolabelled phosphate compound that concentrates in sites of increased phosphate metabolism
also take reference plain xrays to excluse false pos e.g. pagets and healing fractures |
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Epidemiology of RCC?
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60% diagnosed in men
incidence increases from mid 50's |
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Relationship between RCC and VHL?
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arise more commonly in pts with vin hippel lindau syndrome
VHL gene mutation rate of 33-770% |
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Most common subtype of RCC
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clear cell 75-85%
others: chromophilic (papillary, 15%), crhomophobic (5%), oncolytic (uncommon), collecting duct (rare) |
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Best prognostic indicator from histology of RCC?
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nuclear grading system of Fuhrman
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What does a varicocele that develops after early childhood indicate?
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left testicular veing obstruction from a propagated renal tumour thrombus
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Systemic effects of RCC
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20% fever
erythrocutosis ectopic renin high output heart failure due to shunting through pathologic vascular channels |
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Diagnostic algorithm for RCC?
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ultrasound showing non-simple cyst--> CT with contrast (contrast enhance in the post-injection phase)
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What % of testicular cancers are bilateral?
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1-3%
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What % of testicular cancer is accounted for by cryptorchidism?
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7-10% of cancer, 5-10% get cancer in other testis
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What can you take during pregnancy to increase the change of your child getting testicular cancer?
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exogenous oestrogen
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What is the most common type of testicular Ca
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75% are germ cell- 35% of these are seminomas
Most common non-seminoma germ cell cancer is embryonal cell 5% are non-germ cekk |
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Management of low stage Non-seminoma germ cell Ca
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75% of low stage are cured by orchidectomy alone
if fails do retroperitoneal lymph node dissection and chemo- excellent prognosis (95%) |
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Management of high stage NSGCT?
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platinum based chemotherapy
If does not respond on imaging: 20% still have cancer, 40% turn out to have a mature teratoma and 40% just have fibrosis Diagnose via RPLND 50-90% survive |
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Management of low stage seminoma germ cell tumor?
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radiosensitive
95% cured with 25-30Gy Prognosis 95% 5 yr |
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Management of high stage seminoma germ cell tumour?
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platinum based chemo
90% respons 90% of residual masses are fibrosis if well circumscribed and ?3cm - resect otherwise radiotherapy |
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What is the most common testicular tumour in patients > 50?
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lymphoma
5% of all testicular tumours 50% bilateral but usually asynchronous manage with chemo- get 50% 5 year survival |
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What is the most common non-germ cell tumour?
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Leydig cell tumour
3% of all testicular masses peaks age 7, 30 10% are malignant- poor prognosis (manage RPLND) may produce estrogens, 17OH steroids |
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Manage of perinephric abscess
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Drain and correct underlying infective cause- abdominal ultrasound for diagnosis
usually staph/ extension of pyelonephritis from infective stone leads to crhonic ill health and anemia |
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Do you manage asymptomatic bacteriuria in healthy young women
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usuallu not as self limiting
manage if young (kids), pregnant If due to IDC: take out IDC rather than giving antibiotics |
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Gender distribution of UTI in children?
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neonates : girls = boys (haematogenous spread)
Childhood: girls > boys 5% schoolgirls ascending > haematogenous, e.coli in 80% |
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Findings on DRE in acute bacterial prostatitis?
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tender, hot, swollen prostate
Be very gentle as risk of sending odd septic emboli |
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Management of acute bacterial prostatitis
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IV amp and gent while unwell then 8 weeks of trimethoprum or a flouroquinolone
If urinary obstruction is present add a suprapubic catheter |
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Clinical picture f chronic prostatitis?
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urethral burning, perineal pain. suprapubic discomfort and frequency, normal prostate on DRE
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Management of chronic prostatitis?
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trimethoprim for chronic bacterial
antibiotics/dietary for abacterial |
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What is the lymphatic drainage of the scrotum and the testis?
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scrotum --> superficial inguinal lymph nodes of ipsi side
testis--> para-aortic lymph nodes via the spermatic cord |
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nerve supply to scrotal skin?
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genital branch of genitofemoral nerve
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nerve supply to the scrotal skin?
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genital branch of the genitofemoral nerve and peroneal branch of the posterior femoral cutaneous nerve
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Management of scrotal haematomas post hernia repair?
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scrotal support may provide symptomatic relief
these are common after bilateral hernia repair large haematomas may require operative drainage |
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Role of alpha adrenergic agonist in management of BPH
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provide immeadiate therapeutic benefits
mild-moderate symptoms that have significant effects on quality of life |
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Infication for finasteride in BPH
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severe symptoms
Large prostate (>40g) Do not get an adequate response to minimal dose monotherapy with alpha blocker- add to alpha blocker Side effects include decreased libido and erectile dysfunction |
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Which alpha blockers do you chose?
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Depends on how much you want to lower blood pressure
Tamsulosin has less effect than terazoson, doxazocin |
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Management of overactive bladder symptoms that don't improve when you improve obstruction (with alpha blockers/5ARI's)
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Antimuscarinic drugs - add to alpha adrenergic as long as they have low post-void residual volumes
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Indication for surgical management of BPH
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Men who develop upper tract injuiry (hydronephrosis, renal dysfunction) or lower tract injuiry (urinary retention, recurrent infection, bladder decompensation)
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Causes of overactive bladder
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may be neurogenic (ie, secondary to stroke, or other neurologic condition), or may be caused by chronic obstruction.
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Who gets IVU and ultrasound after a UTI
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all men with UTI
all women with complicated UTI (according to tjandra) |
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Most common urologic emergency?
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acute urinary retention
affects 1/10 men aged 70 or older BPH is the most common underlying condition overdistension, medications (opiates and anticholinergics postop) |
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Management of acute urinary retiention?
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bladder decompression with a foley urethral catheter: use suprapubic when obstruction precludes a urethral catheter
Complete drainage: haematuria, hypotension and postobstructive diuresis are common but rarely clinically sifnificant |
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When is the catheter removed after urethral obstruction
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trial of void after 2 weeks
ongoing treatment with alpha blocker and 5AR |
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Management of staghorn calculi
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Stone removal procedure is necessary: percutaneous nephrolithotomy is first line
Antibacterial therapy alone is ineffective |
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what % of stones are calcium containing?
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70-85%
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What organisms cause struvite stones?
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proteus, staph, klebsiekka
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How do you know that you are dealing with a uric acid stone?
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stone is radioluscent
Urinary pH <6.5 |
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characteristics of stones due to cysteinuria?
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hexagonal
3% of kidney stones: due to decreased tubular reabsorption resulting in increased cysteine excretion first stone early e.g. childhood/adolescence screen urine with cysteine nitroprusside test |
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Management of cysteine stones
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High fluid intake
Urine alkalization with potassium citrate/potassium bicarbonate sodium and protein restriction addition of cysteine binding drug ee.g. topronin |
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Epidemiology of ureteric calculi?
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2-5% of population
Majority of stones form between ages 20 and 50 M 3x Warmer climates Familial tendency Tend to recur: 36% 1yr, 50% 5yr |
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Where is the pain of urolithiasis felt?
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loin pain- stone in pelvoureteric junction
groin pain- stone at pelvic brin genital pain- stone at uretovesical junction there is often some tenderness in the groin along the line of the ureter |
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Best imaging of ureteric stones?
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Non-contrast CT
IVP is also very useful\ KUB: reasonable if past history of radio-opaque calculi and similar presentation (but cannotrule out) Ultrasound: little diagnostic value but do first in people who should avoid radiation (like pregnant women) |
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High versus low urinary pH in urolithiasis
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High- suggests urea splitting organisms such as proteus (>6)
If <5: suggests uric acid |
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Management of ureteric calculi?
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initial opioid analgesia then NSAID/paracetamol
Oral or IV hydration (but avoid diuresis as may make pain and obstruction worse) |
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Which ureteric calculi are likely to pass spontaneously?
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<4mm- almost always
4-10: decreased likelyhood as size increases >10mm- almost never do proximal ureteral- unlikely (tjandra says 6mm) 80% overall will pass spontaneously |
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Management of caliceal/upper ureteral stones?
Management of lower ureteral stones? |
Upper: ESWL
distal: ureteroscopy or eswl ESWL: 85% sucess rate. Do for stones <2cm in diameter. Procedure of choice in 75% of cases. |
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Long-term management of uric acid stones?
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potassium citrate
allopurinol |
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Indications for surgery/active management with urolithiasis
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stone to large to pass
complete obstruction persisting pain without indication of stone movement |
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Indications for percutaneous nephrolithotomy?
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stones too large or too hard for lithotripsy
procedure of choice for staghorn calculi |
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Indications for open surgery in nephrolithiasis
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if also need to correct anatomical abnormalities
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Indications for ureteric stent in nephrolithiasis?
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may be placed prophylactically prior to ESWL if the patient has large stones (>1.5cm) to prevent ureteral obstruction
Urolithiasis complicated by UTI/renal insufficiency or renal failure- take out once stone passes or will serve as nidus for new stones |
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Risk factors for uric acid stones
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low urinary pH, hypouricosemia is NOT always present in patients with pure uric acid stones
low urine volume and high uric acid contributes Manage medically "chemolysis" rather than surgically |
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Nerve supply to scrotum
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ilioinguinal
genital br of genitofemoral SNS originating in the deep neural plexysed in the renal and aortic area- rich innervation |
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Effect of severe and less severe testicular torsion on testicular blood supply
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severe: arterial occlusion
less severe: occlusion of testicular vein, increase in venous pressure and subsequent cessation of local supply of oxygen-rich arterial blood to the testis |
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Pathogenesis of neonatal testicular torsion?
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occurs before the posterior aspect of the testicle has had time to fuse to the inner layers of the scrotal wall
can occur before or after birth extra-caginal torsion (the whole cord and its investing layers twist) Hard to diagnose: only 1/3 salvage the testicle If missed: testicle atrophies either in the scrotum or along the line of descent |
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Pathogenesis of intra-vaginal testicular torsion?
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abdominally high investment of spermatic cord by tunica vaginalis/lack of fixation of tunica vaginalis to posterior scrotum
frequently bilateral testicle lies transversely 'bell clapper' Usually occurs in adolescence (differential growth between testicle and adjacent structures) Narrow based vascular pedicle |
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Epidemiology of testicular torsion
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1/4000 males <25
16-40% of males presenting with an acute scrotum |
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Why does nausea and vomiting occur in testicular torsion?
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innervation of the testicle by fibres of the coeliac ganglion
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Examination in testicular torsion?
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boy in severe pain
testicle tense, tender, high in the scrotum if early: twist in the spermatic cord can be felt as a tight 'knot' as the cord exits the external inguinal ring Pain persistis on elevation of scrotum (unlike epidydimo orchitis_ |
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Examination in extravaginal torsion?
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hard, swollen testis
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Diagnosis of testicular torsion?
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doppler ultrasound can confirm but not rule out- should not delay the transfer of a patient to theatre if clinical diagnosis has been made
Other option: radionucleotide scintigraphy (blood flow)--> like U/s reserved for ambiguous cases MRI--> future |
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Management of testicular torsion?
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detorsion and orchidoplexy of both testicles
midline incision through medium raphe wrap affected testis in warm swabs- remove if necrotic fix other testis to muscular wall of scrotum- non- absorbable sutres in adults, absorbable in kids |
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When is manual detorsion recommended?
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If there is a delay in the availability of theatre
Opening of a book 28% have some degree of torsion after successful detorsion- so theatre should not be delayed after this |
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Can the contralateral testicle be affected by sympathetic atrophy?
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prob not
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What is the most important clinical appendage?
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hydatid of Morganini- remnant of mesonephric duct found in the sup. pole of the testis
90% of appendiceal torsions involve this 7% in head of epididymus |
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What is the mean age of presentation of torsion of testicular appendages?
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9-10
younger than the age of testicular torsion milder pain, fewer associated symptoms, later in the course |
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Classic presentation of testicular appendiceal torsion?
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blue dot on scrotal exam- esp obvious in children due to their thin scrotal skin
cremasteric reflex still present torted appendage often able to be identified on U/S or radionucleotide scintigraphy (68% at 5 hours) |
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Management of testicular appendiceal torsion?
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usually conservative if diagnosis can be made with certainty preoperatively: rest, analgesia and scrotal support
surgical excision: reserved for those whose pain is slow to settle |
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Pathogenesis of epidydimo orchitis?
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inflammatory, usually infective- more gradual onset of sx than torsion
infective process from GU tract- infects epididymus and testis--> pain as testis swells within taut tunica albiginea. Hx of dysuria/urethral d/c, systemic sx e.g. fever |
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Clinical features of epidydimoorchitis?
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swelling of hemiscrotum- often gradual onset
testis is swollen and tender, epididymus is engorged, swollen, tender (IMPORTANT differentiating factor) Often experience acute leukocytosis and pyrexia. |
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Management of epididymo- orchitis?
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antibiotics
NSAIDS scrotal support Urinalysis with culture and sensitivity and blood cultures |
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Incidence ofinfection in children presenting with acute scrotum?
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20-30%
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Aetiology of epididymo-orchitis by age?
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Infantile: high incidence of urogenital abnormalities so full urological eval
Older children: less abnormalities/more dysfunctional voiding Adolescents: STI's, coliform infection from penetrative anal intercourse Older: coliform infections due to bladder outlet obstruction, instrumentation, surgery, catheterisation Immunocompromised/travel: brucella, candida, TB |
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Which patients can be managed conservatively after testicular trauma?
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palpable testis, tunica albuginea intact with little to no significant haematocele
Penetrating injuries all require exploration |
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Management of haematocele/ruptured tunica albuginea?
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Surgical exploration: expose ruptured testis and excise devascularised portion
tunica is closed and scrotum is closed in layers aim: preserve as much testicular tissue as possible for testosterone production |
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Types of blunt testicular injuries?
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contusions and ruptures- due to impingement of the testis on the symphisis pubis
haematocele: large blue tender scrotal mass |
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Diagnosis of testicular rupture
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Ultrasound
abnormal echotexture of parenchyma |
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When do hydroceles cause paim?
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if rapidly forming
pain is unusual |
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What is a varicocele?
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dilatation of veins of panpiniform plexus- bag of worms surrounding the testis
Normally causes dragging sensation- pain if acutely thrombosed |
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Repir of a varicocele?
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surgical or radiological
repair if large Asymmetric or small testes If discovered during the pubertal years if subfertility is a problem- as associated with reduced production of viable spermatozooa |
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How can epididymal cysts/spermatoceles cause pain?
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enlarge quickly
haemorrhage |
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How do hydroceles develop in the elderly?
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slow accumulation of fluid- probably by impaired reabsorption
can be huge can also form in response to tumour (5-10% of testicular tumours associated with hydrocele) |
