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Urology Part II. CF Ng. Tumour. Tumour. General Aetiology / Risk factors Intrinsic: age / sex / race /inherited dx or FH Extrinsic: biological (virus) / chemical / physical Presentation Asymptomatic Local Metastatic General Para-neoplastic. Tumour. Treatment Curative OT RT
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Urology Part II CF Ng
Tumour General • Aetiology / Risk factors • Intrinsic: age / sex / race /inherited dx or FH • Extrinsic: biological (virus) / chemical / physical • Presentation • Asymptomatic • Local • Metastatic • General • Para-neoplastic
Tumour Treatment • Curative • OT • RT • +/- neoadjuvant / adjuvant therapy • Palliative • RT / ChemoT / Hormonal (CaP) / ImmunoT (RCC) • Drug • OT
Haematuria • Characteristics • Gross / microscopic • Painful / Painless • Relationship with steams (only for men) • Any associated symptoms • LUTS • UTI symptoms • Loin pain • Generalized bleeding tendency • Precipitating events – trauma, jogging, menstruation etc
Haematuria • Gross / macroscopic reddish discoloration due to red blood cells (drugs, vegetables, haemoglobin, myoglobin) • Microscopic normal people losing 0.5 to 1 million RBC per day detection by centrifugation method – standard for decades 3 – 5 RBC/HPF dipstix method– high false positive rate
Gross Haematuria • Painful vs painless • Inflammation / infection • Relationship to the steam • Early steam, whole steam, end steam
Differential Diagnoses for Haematuria • Urinary tract infections 50-60% • Tumours 10% • Stones 10-15% • Glomerulonephritis 5-10% • Trauma 1% • Bleeding problems 1% • BPH 2% • Idiopathic 5-10% • Miscellaneous
Investigations for Haematuria (1) • Cancer until prove otherwise • Haematuria work up – first line investigations • midstream urine for microscopy, culture & sensitivity test • abnormal RBC count confirmed bleeding • abnormal WBC count suggested infection • bacterial growth indicated urinary tract infection • urine cytology x 3 • optimal sensitivity 70-80% • cystoscopy – lower urinary tract endoscopy • intravenous urography – upper urinary tract imaging (problems) • early morning urine for AFB x 3 • not commonly done because of decrease occurrence • Blood • not cost-effective for cause, unless clinical or drug history suggestive • Even deranged clotting etc still need work up
Investigations for Haematuria (2) Second line investigations Ultrasound + KUB cystoscopy + retrograde pyelogram upper tract not well shown up computerised tomography to diagnose upper tract tumour ureterorenoscopy endoscopy of upper urinary tract renal arteriography or venography suspected vascular abnormalities
Bladder Cancer • Risk factors Instrinsic – elderly, males Extrinsic chemical carcinogens - petroleum, rubber, printing industry smoking Physical - chronic irritation – stone / neurogenic bladder / parasites/ cyclophosphamide
Pathology of Bladder Cancer • 95% urothelial 80-90% transitional cell carcinoma 5-10% adenocarcinoma uncommonly squamous cell carcinoma (HK) small cell carcinoma undifferentiated carcinoma • Transitional cell carcinoma 70-80% papillary 20-30% nodular or sessile
Presentation of Bladder Cancer • Local symptoms: • 85 – 90% with macroscopic haematuria • >95% with macroscopic or microscopic haematuria • Irritative bladder symptoms • Renal failure due to ureteric obstruction • Metastatic symptoms bone pain, weight loss • On first presentation 70 – 80% are early superficial cancers
Investigations for Bladder Cancer • Haematuria work up cystoscopy + bladder biopsy IVU • Chest X-ray • Computerised tomography of abdomen and pelvis • Bone scan
Staging of Bladder Cancer • Superficial disease Tis Ta T1 • Muscle invasive disease T2 T3 T4
TCC bladder • Treatment • Superficial TCC • Muscle invasive TCC • Metastatic TCC
Superficial TCC bladder • Superficial disease • Transurethral resection of bladder tumour (TURBT) • can eradicate the cancer because of early disease • Problem – recurrence • but 30 – 50 % new cancer formed in 1 year • and 70 – 80 % new cancer formed in 5 years • Passive – surveillance to look for recurrence • FC 3-monthly x 8 i.e. 2 years • Then lift long FU for symptoms and cyto • Active – intravesical chemotherapy or BCG (immunoT)
Muscle invasive TCC bladder • Radical cystectomy • What to cut
Muscle invasive TCC bladder • Radical cystectomy • What to cut • What to reconstruct • Ileal conduit • Continence diversion • Orthotropic bladder subsitution / catheterization pouch • Risk • Absorption of urine – acidosis, metabolites, drugs etc • GI tract malfunction – diarrhoea, malabsorption etc • Mechanical problem – no sensation, no contraction, mucus etc • who
Other Treatment of Bladder Cancer • Muscle invasive disease radiotherapy cure rate lower than surgery use in patients not fit for surgery adjuvant chemotherapy early result did not improve cure rate • Metastatic disease • Chemotherapy – MVAC etc
Serum Prostate Specific Antigen (PSA) • Enzyme secreted into prostatic secretion • Serine protease • Liquefied semen coagulum release sperm • Leakage into serum
Serum Prostate Specific Antigen (PSA) • Specific for prostate problems but not prostate cancer • Upper normal limit 4 ng/l Old study – 97.5% population < 4ng/L 20% early prostate cancers below 4 ng/l 20-30% BPH with PSA >4ng/l • other PSA reference Age specific range PSA density PSA velocity Free and Total PSA
Usage of PSA • Screening • Before PSA, 25-30% of prostate cancers diagnosed were organ confined • After PSA, 50-60% of prostate cancers diagnosed were organ confined • Staging implication • >100 ng/l bone secondary • Monitoring treatment response • Before clinically detectable • Histological diagnosis • Adenocarcinoma ?origin PSA strain
Presentation of Prostate Cancer • Incidental finding • Screening – DRE or serum PSA • TURP pathology – T1a/b • Local symptoms • Obstructive symptoms • Ureteric obstruction • Metastatic symptoms • Bone pain, pathological fracture • Spinal cord compression AROU • General symptoms
Diagnosis of Ca Prostate • TRUS + Bx • Indications • Abnormal DRE • Elevated PSA • Complications: • Sepsis • Bleeding • AROU
Histology • Gleason grading • Gleason score • 2 numbers • Most common one + second common one (> 5%)
Staging Tests for Prostate Cancer • Local • Computerised tomography of abdomen and pelvis • Magnetic Resonance Imaging of prostate • Metastatic • Chest X-ray • Bone scan
Ca Prostate • Treatment • Localized • Watchful waiting • Radical prostatectomy • Radical radiotherapy – Ext beam or brachytherapy • Metastatic • Hormonal therapy • RT – palliative • Chemotherapy
Radical prostatectomy • IntraOT / Early Complications • Bleeding • UTI • Late complication • Stress incontinence • Anastomotic stricture • ED
Ca Prostate • Hormonal therapy • Hormone axis • Orchidectomy • Medical castration • LHRH analogue • Estrogen • Antiandrogen
Loin / abdominal mass • Right – liver, colon, gall bladder etc • Left – spleen, colon etc • Kidney: • Benign • Hydronephrosis • Congenital • PUJO • Other causes • PCK • Benign tumour – Angiomyolipoma etc • Malignant • RCC • etc
RCC • Presentation • Asymptomatic / incidental findings – increase availability of imaging • Local symptoms: loin mass, loin pain and haematuria (classical triad 20% - old date) • Metastatic symptoms: bone pain, chest symptoms etc • General symptoms: weight loss etc • Paraneoplastic symptoms: …