Nephrolithiasis & Neoplasm

Clinical Medicine IPA-522Spring 2009

Types of Urology Lectures

Infectious diseases / bacterial infections

”….itis”, STD's

bugs and drugs

Everything else

calculus

neoplasms

prostate disease

Objectives

Describe the ROS associated with a GU complaint

Describe the key symptoms associated GU complaints

Describe the presentation, evaluation and treatments of renal calculus

Describe the presentation, evaluation and treatment options associated with kidney, bladder, testis and prostate cancer

Review of Systems

Frequency day and night

Urgency

Hesitancy

Force of stream

Incontinence pad use

Hematuria gross or microscopic

Pain with urination

Previous history GU surgery, UTIs, STDs,

kidney stones

Family h/o cancer

PSA status

LMP

Sexual complaints

Key Symptoms

Dysuria

Pain

Hematuria

Dysuria

Related to acute inflammation of the bladder, urethra, or prostate

The first symptom suggesting urinary infection originating from a stone, contaminant, prostate

Described as a “burning” while voiding with discomfort located in the urethra

Often associated with frequency and urgency

Don’t forget STD’s

Pain

Two types Local

which is felt in or near the involved organ

Referred originates in a diseased organ but is felt elsewhere

Kidney Prostate

Ureter Testicular

Bladder Epididymal

Bone / leg

Hematuria

Creates a wide variety of diagnostic possibilities

Differential diagnosis may include:

Infection

Renal calculus

Cancer

Trauma

Renal parenchymal disease

Hematuria

Hematuria without other symptoms must be regarded as a tumor of the bladder or kidney until proved otherwise.

Hematuria

High power field (HPF)

0 - 3 RBC/HPF accepted as normal

> than 3 requires

follow-up studies

UA

C&S

Cytology

Hematuria

Hematuria

Changing the focus causes RBC’s to appear as black circles

Hematuria timing

Partial

initial

suggests an anterior urethral lesion

terminal

suggests posterior urethral, trigone, or

bladder neck lesion

Total

present throughout urination

Topics to Cover

Nephrolithiasis

renal and ureteral calculus

Neoplasms

kidney, bladder, prostate, testis

Nephrolithiasis

Occur throughout the urinary tract

pain, infection, obstruction

Incidence

typical age range between 30 - 50 years

sex: male predominance

race: rare in African Americans

geographics: “stone belts” and developed countries

recurrences are common: 50% in 5 years

Caused by saturation and crystallization of stone-forming

salts in the urine

Etiology

Varies with different types of stones

calcium stones

hypercalciuria (50% of stone formers)

Idiopathic (95%) or 1 hyperparathyroidism (5%)

uric acid stones

volume depletion, acidic urine

struvite stones

form in high urinary pH (Proteus spp.)

cystine stones

Defect in the renal tubular absorption of cystine

Types of Calculus

Calcium 75 - 85% radiopaque

Uric acid 5 - 8% radiolucent

Cystine 1% radiolucent

Struvite 10 - 15% radiopaque

McPhee, 2003, p. 468

Etiology

Varies with different types of stones

calcium stones

hypercalciuria (50% of stone formers)

Idiopathic (95%) or 1 hyperparathyroidism (5%)

uric acid stones

volume depletion, acidic urine

struvite stones

form in high urinary pH (Proteus spp.)

cystine stones

Defect in the renal tubular absorption of cystine

Radiography

Radiopaque

applies to substances that absorb x-rays

representative areas appear white on the exposed

x-ray film

Radiolucent

applies to substances that penetrate x-rays

representative areas appear dark or black on the film

Radiography

Types of Calculus

Calcium 75 - 85% radiopaque

Uric acid 5 - 8% radiolucent

Cystine 1% radiolucent

Struvite 10 - 15% radiopaque

McPhee, 2003, p. 468

Presentation

Asymptomatic patients

Symptomatic / acute presentations

back pain or flank pain that waxes and wanes

pain can radiate to the groin, testicles, labia

hematuria

nausea/vomiting

dysuria

Flank Pain

Pertinent Labs and Studies

Urinalysis

Urine culture

Plain film of the abdomen

KUB

identifies radiopaque stones only (85%)

Renal U/S

Intravenous pyelogram (IVP)

CT (Spiral or Helical)

Urinalysis

Dipstick

Microscopic

IVP

A series of contrast films of the kidneys, ureters, and bladder taken at timed intervals after the IV injection of an iodine containing contrast medium.

A plain film of the abdomen is taken initially.

Serial films taken at 5, 15, 30, 60, 180 minutes.

Acute Stone Episode Tx

Often presents in the ER

After the HPI UA, C&S, CBC with diff, BUN, Creatinine

KUB / IVP / Spiral CT

Admission may be indicated high grade unilateral obstruction

bilateral obstruction

obstruction of a solitary kidney

severe pain not controlled by oral analgesics

Treatment

Dependant on the size of the stone

Treatment

Stones measuring < 5 mm

Most likely to pass spontaneously

“Trial of stone passage”

Drink plenty of fluids

Increase urinary output to 2L/day

Strain urine

Oral analgesics

NSAIDs or possibly narcotic (Darvocet)

Weekly follow-up, earlier if pt. develops fever

Treatment

Stones measuring 5 - 10 mm

Less likely to pass spontaneously

Elective early intervention likely

especially if infection, obstruction, or solitary kidney is present

Treat as 5mm stone

ESWL or ureteroscopy with stone extraction possible.

ESWL failure: stone burden, body habitus, impaction, stone composition

Treatment (5 – 10mm)

ureteroscopy

ESWL

Treatment

Stones measuring >10 mm Not likely to pass

Treatment will depend Symptoms of the patient

If Cystine or Uric acid stones then dissolution may be possible with alkalization (ie. Potassium citrate)

Open surgery or percutaneous endoscopic procedure may be warranted

Treatment (>10mm)

Prevention

Regular high fluid intake

Consider diet restrictions for salt and protein

Medications

Potassium citrate (Urocit-K)

Allopurinol (Zyloprim, Aloprim)

Neoplasms

Kidney

Bladder

Testis

Prostate

Renal Neoplasms

General Characteristics Cause unknown

# 9 of ten most common cancers

Male:Female ratio 2:1

Occurs most commonly in the fifth to sixth decade

RCC is the most common malignant primary renal mass in adults: 80%

Renal Tumor Presentation

Incidental / Asymptomatic presentation

50% found this way

When not found incidentally, 33% will have metastatic disease with initial presentation

Symptomatic presentation

Pain, hematuria, weight loss, flank mass

Classic triad of flank mass, hematuria, and pain occurs in 10% of patients

Evaluation

UA

Cytology

CT scan with contrast

tumor is staged with CT

Kidney Tumor Staging

2 systems

TNM (Tumor, Nodes, Metastasis)

Robson’s classification

simplified staging system but correlated poorly with prognosis

http://hopkins-gi.nts.jhu.edu/pages/latin/templates/index.cfm

Treatment

Surgery is treatment of choice Cure rate for confined local disease: 60 to 90%

RCC is relatively radioresistant

Chemotherapy trials have been disappointing

Immunotherapy trials in progress show promise

Bladder Cancer

Average age: 40 - 70 years

# 4 of ten most common cancers

3 times more common in men

3% of cancer related deaths in US

Risk Factors tobacco exposure occupational carcinogens

Rubber, dye, printing, chemical industries

Bladder Presentation

Hematuria

Gross

Microscopic

Bladder Cancer Studies

Urine for UA, C&S, cytology

IVP

Cystoscopy

TURBT

TURBT

Bladder Cancer Treatment

Stage Dependant

Superficial lesions

Resection and fulguration with f/u cystoscopy every 3 months

Treatment with BCG Decreases tumor recurrence and progression

Invasive or recurrent cancer

Radical cystectomy

BCG (Bacillus Calmette-Guerin)

Instillation into the bladder

Medication must remain for 2 hours in the bladder

Generally a series of 6 treatments

Temporary side effects

frequent urination dysuria flu-like symptoms

Possible systemic infection

BCG Sepsis Conversion to PPD positive

Bladder Cancer Treatment

Stage Dependant

Superficial lesions

Resection and fulguration with f/u cystoscopy every 3 months

Treatment with BCG

Decreases tumor recurrence and progression

Invasive or recurrent cancer

Radical cystectomy with conduit or neobladder

Ileal conduit

The most commonly

used method of

urinary diversion in

the USA

Neobladder / Pouch

A variety of neobladders exist

Neobladder / Pouch

Testicular Cancer

Most common malignancy in young men

average age at diagnosis: 32 years

Initial presentation

painless, solid testicular swelling

“heaviness” in testis

Differential diagnosis

orchitis, hydrocele, spermatocele, testicular torsion

Etiology

Cryptorchidism a condition in which a testicle is arrested at some point in

its normal descent anywhere between the renal and scrotal areas

unilateral arrest more common than bilateral arrest at birth the incidence of maldescent is 3.4% half of such testicles descend in the first month of life

Trauma is not a cause of tumor

Testis tumors do not appear to have a geneticpredisposition

Laboratory Studies

Blood work

AFP, B-HCG: will be elevated and are diagnostic for germ cell tumors

BUN and Creatinine: retroperitoneal disease can cause urinary obstruction

Radiologic studies Scrotal U/S

Treatment

Orchiectomy

with possible biopsy of the contralateral testis

Scrotal Masses

Hydrocele fluid filled mass around testicle transilluminates elective surgical repair possible

Varicocele a venous varicosity in the spermatic vein “bag of worms”, does not transilluminate, may decrease

Testicular torsion acute, tender, painful, scrotal swelling surgical emergency

Scrotal Masses

VARICOCELE HYDROCELE HYDROCELE

TRANSILLUMINATED

Prostate Cancer

The most common tumor in U.S. males: # 1 30 - 40% of men > 50 years of age have prostate

CA, although < 10% of those with prostate cancer will die from prostate cancer

Presentation is in men usually > 65 y

Risk factors: family history African American age

Screening for Prostate Cancer

Screening generally consists of an annual PSA and DRE

Methods

Digital rectal exam (DRE)

begin at age 40 years, earlier for those with family hx

Serum PSA level

DRE

70% of all

prostate cancer

originates in the

peripheral zone

DRE

PSA

Prostate specific antigen Nl value: 0 – 4 ng/dl

Relative risk assessment will likely supplant PSA

PSA is an enzyme made in the prostate gland and is found in the peripheral circulation Present in 2 forms

Bound

Free

PSA test is not diagnostic of prostate cancer

PSA – the good…

PSA has resulted in detecting more prostate cancers

Detects prostate cancers earlier

Will elevate with malignant conditions (cancer) as

well as infectious benign conditions (prostatitis)

Free PSA

PSA – the bad and the ugly

PSA test is not a foolproof test for prostate cancer A normal PSA does not rule out prostate cancer

Often used improperly Started younger than necessary

Continued later than necessary

Can be masked with patients using Finasteride up to 50%

PSA Value

Journal of the American Medical Association 2005;294:66-70

PSA Velocity

The rate of change in serum PSA

more than 0.75 ng/mL per year

the prostate cancer detection rate was 47% among men with a PSA "velocity" greater than 0.75 ng/mL per year versus 11% among men with a PSA velocity less than 0.75 ng/mL per year (Smith & Catalona, 1994)

Free PSA

Prostate Evaluation - TRUS

Prostate Tumor Staging

2 systems

TNM (Tumor, Nodes, Metastasis)

Gleason score

one of the best tools available for predicting the outcomes of men treated with radical prostatectomy or with radiation therapy

prostate cancers with Gleason scores of 8 to 10 are much more likely to recur after primary treatment than are prostate cancers with Gleason scores of 2 to 6

Tannenbaum, 1977

Treatment

Watchful Waiting

PCPT

Finasteride reduced the risk of developing prostate cancer by 25% in men 55y and older

Radical Prostatectomy

External Beam Radiation

Radioactive Seed Implant

Cryosurgery

Hormone Therapy

Watchful Waiting

One approach to managing prostate cancer

Unlike other cancers, the natural progression of prostate cancer is slow and unpredictable

Creating a difficulty in distinguishing clinically relevant disease in the patient

Active surveillance

Another option that aims to individualize therapy

Watchful Waiting

Parker, 2004

Contrasts between active surveillance and watchful waiting

Watchful waiting Active surveillance

Aim To avoid treatment To individualise treatment

Patient characteristicsAge >70 or

life expectancy <15 yrs

Fit for radical treatment

Age 50–80

Tumour characteristicsAny T stage GS ≤7

Any PSA

T1–T2 GS ≤7

Initial PSA <15

MonitoringPSA testing unimportant

No repeat biopsies

Frequent PSA testing

Repeat biopsies

Indications for treatment Symptomatic progressionShort PSADT

Upgrading on biopsy

Treatment timing Delayed Early

Treatment intent Palliative Radical

Treatment

Watchful Waiting

Radical Prostatectomy

External Beam Radiation

Radioactive Seed Implant

Cryosurgery

Hormone Therapy

Objectives

Describe the ROS associated with a GU complaint

Describe the key symptoms associated GU complaints

Describe the presentation, evaluation and treatments of renal calculus

Describe the presentation, evaluation and treatment options associated with kidney, bladder, testis and prostate cancer

References

Course TextLeibovich, B.C. et al. (2003). Current staging of renal cell carcinoma. Urologic Clinics

of North America, 30, 481-497.McPhee, S.J., Lingappa, V.R., & Ganong, W.F. (2003). Pathology of disease: An

introduction to clinical medicine (4th ed.). New York: McGraw-Hill.Parker, C. (2004). Active surveillance: towards a new paradigm in the management

of early prostate cancer. The Lancet Oncology, 5, 101-106.Smith, D.S., & Catalona, W.J. (1994). Rate of change in serum prostate specific

antigen levels as a method for prostate cancer detection. Journal of Urology, 152, 1163–1167.

Tanagho, E.A., & McAninch, J.W. (2004). Smith’s general urology (16th ed.). New York: McGraw-Hill.

Tannenbaum, M. (1977). Urologic pathology: The prostate. Philadelphia: Lea and Febiger.

Yun, E.J., Meng, M.V., & Carroll, P.R. (2004). Evaluation of the patient with hematuria. The Medical Clinics of North America, 88, 329-343.