Urology Notes

Urology

Benign Prostatic hypertrophy

Common in men > 60 years

• Less common in Asians

Aetiology

• Unknown

• Microscopically, glandular and connective tissue hypertrophy occurs

• Enlargement of the gland stretches and distorts the urethra, obstructing bladder outflow

Clinical features

• Nocturia

• Frequency

• Difficulty/delay in initiating micturition (hesitancy)

• Variability and decreased forcefulness of stream

• Post-voiding dribbling

• Acute retention may occur

• Occasionally severe haematuria may occur from rupture of prostatic veins or as a consequence of bacteriuria or stone disease

• Patients can (rarely) present with severe renal failure

• Abdominal examination for bladder enlargement together with PR is essential

  • Benign prostate feels smooth

Management

• Assess severity of symptoms and their impact

• Management options include

  • Transrectal resection of the prostate (TURP)

  • Transurethral incision of the prostate (TUIP) – less destruction than TURP, less risk to sexual function, similar benefits – relieves pressure on the urethra

  • Retropubic prostatectomy (open op)

  • Transurethral laser induced prostatectomy (TUUP)

  • Medication e.g alpha blockers (tamsulosin) – decreases smooth muscle tone (prostate and bladder) S/E include drowsiness, hypotension, dry mouth, ejaculation failure

    • E.g 5 alpha reductase inhibitors (finastericle) = decreased testosterone’s conversion to dihydrotestosterone which is primarily responsible for prostate growth. Excreted in semen, therefore advised to use condoms

      • S/E = impotence, decreased libido

  • Watchful waiting – risk of incontinence, renal failure or retention

Prostate Cancer

Epidemiology

• Increased incidence

• Common in men > 70 years

Aetiology

• Age = greatest risk factor

• 5% of cases are related to BRCA-1 inheritence

• Growth of prostate cancer relies upon androgen stimulation and doesn’t occur in castrated males

Pathology

• Usually in adenocarcimona

• TCC can occur in ducts

• Mostly located in posterior or peripheral part of gland (therefore delayed presentation as compression of urethra occurs late)

Clinical features

• Often asymptomatic

• May have hesitancy, terminal dribbling

  • Urgency, nocturia, frequency

  • Obstruction

  • Urinary infections

  • Haemiaturia

  • Lower back pain (from bony mets)

• Firm irregular, enlarged glad found on PR examination

Grading

• Uses the Gleason system: gives two grades based on the two commonest types of histology

  • 1: well differentiated, normal glands

  • 2: well differentiated varying size and shape of glands

  • 3: Moderately differentiated

  • 4: Poorly differentiated, fused glands

  • 5: Very poorly differentiated no/minimal gland formation

Staging

• TNM

  • T0 - occult tumour

  • T1 – intracapsular

  • T2 – doesn’t breach capsule

  • T3 – extends outside prostate

  • T4 – involves adjacent organs

• Metastatic spread is commonly to bones and common to iliac and external iliac nodes

Investigations

• PR examination

• PSA

• Transrectal biopsy

• Bone scan

• CT scan

Management

• If confined to prostate

  • Consider radical localized therapy

    • E.g radical prostatectomy

    • Radiotherapy (brachytherapy)

  • Complications include impotence, incontinence or strictures/irritation

  • If > 70 years old with other co-morbidities watchful waiting acceptable

• If locally invasive

  • Neoadjuvant hormonal therapy (anti-androgen)

  • Radiotherapy

• If metastatic

  • Hormonal therapy/medical castration for symptom relief

    • Complications include decreased libido, impotence, osteoporosis

  • Palliative radiotherapy

Prognosis

• Factors affecting prognosis

  • Performance status at diagnosis

  • Initial PSA level

  • Gleason grade

  • TNM stage

Screening

• Not currently available in UK

• In USA

  • DRE

  • PSA

    • If either positive – TRUS

• Large number of false positives

• No clinically significant benefit proven from early treatment

NB GnRH analogues first stimulate but then inhibit pituitary gonadotrophin output

Testicular Cancer

Epidemiology

• Rare

• Commonest cancer in 20-40year old males

Pathology

• Majority are germ cell tumours

  • Seminomas

    • Present early, usually without metastases

    • Predictable spread (para-aortic – supradiaphragmatic nodes)

    • No markers available

  • Teratomas

    • Present later

    • Spread less predictably – blood bourne mets early

    • Produce tumour markers – hCG, alpha feta protein

Both can secrete LDH – doesn’t help with monitoring

Clinical features

• Lump in/on testes

• Usually painless

• Noticed after trauma/infection

• Metastases

  • Back pain

  • Chest symptoms

Investigations

• HcG, alpha feta protein, LDH

• USS

• CXR

• Bone scan

• CT for staging

Management

• Sperm count and storage should be offered at presentation (before treatment)

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