Introductory lecture of Urology Med 2013 short - CUHK Surgery I-Prof CF... · – LUTS, BPH,...

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Urology CUHK 2013

Urology

Dr CF Ng

Urology CUHK 2013

Urology CUHK 2013

How important is Urology in real life?

Urology CUHK 2013

Urology •  Oncology

–  Ca kidney, bladder, prostate, testis etc •  Voiding problems

–  LUTS, BPH, overactive bladder, neurogenic problems •  Urolithiasis •  Andrology

–  Erectile dysfunction, Premature ejaculation, Infertility •  Urinary tract infection

–  Upper tract and lower tract •  Transplant •  Others

–  Reflux, Duplex, hydrocele etc

Urology CUHK 2013

The facts

•  Men ~ ½ populations •  Aging population

–  Men ~ 80 years old –  Women > 80 years old

•  Quality of life – getting more and more important –  Lower urinary tract symptoms –  Erectile dysfunction –  Premature ejaculation –  Female sexual dysfunction

Urology CUHK 2013

Other Specialties •  General Surgery:

–  DDx for right / left sided loin pain –  Colorectal surgery

•  Direct involvement of tumour to urinary tract •  Post-operative urinary retention or ED

•  Neuro-surgery and spinal surgery –  Voiding dysfunction / neurogenic bladder

•  Medicine –  DM – recurrent UTI, ED, LUTS –  Cardiac condition and ED –  Neurological dx and voiding

•  Paediatrics –  UTI and reflux

•  O&G –  Close relationship resulted into direct involvement by tumour or

complication of treatment •  Psychiatry

•  Also as common c.o. of the patients

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Urology CUHK 2013

Medical treatment

•  Manage in office level – LUTS / BPH – ED (PE) – UTIs

Urology CUHK 2013

Urology teaching

Urology CUHK 2013

Objectives

•  Approach to commonly encounter problems / complaints

•  Understand the pathology, clinical information and management of common urological diseases

•  Observe some of the basic urological procedures and operations – Understand the nature, indications,

complications of these procedures

Urology CUHK 2013

Summary

•  Introductory lecture •  1-week attachment

– Ward round – Outpatient clinic – Tutorial / bed side teaching – Operation and various procedures – Meetings

Urology CUHK 2013

Mon Tue Wed Thur Fri

0800 reporting Ward round

0830

Operation (even day)

& OPD

(Dr CF Ng / Dr

Flexible cystoscopy

(odd day) &

Opearation or

ESWL (Odd day)

Operation

& ESWL

& CMG (LUC)

GR

Operation &

Flexible cystoscopy &

IVBCG (SACC)

1000 OPD

(Dr CK Chan)

LUNCH

1300 CMG (LUC)

& Operation

(even day) Operation

TRUS + Bx (SACC)

Circumcision & minor OT

(LKS tx room) Stone clinic

1400

1600 Ward round

1700 CPC Oncology Meeting

Dept meeting

Urology CUHK 2013

Tutorial

•  Each week – One tutor – one tutorial at the end of week

•  Each big group – One big group tutorial by Dr CF Ng – Cover some of the questions of the ppt and

other questions

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Urology CUHK 2013

Procedures

•  Uroflowmetry and bladder scan •  Flexible cystoscopy •  Transrectal ultrasound guided prostatic

biopsy •  ESWL •  Urodynamics •  TURP +/- other transurethral surgery •  +/- Robotics surgery

Urology CUHK 2013

Others

•  Imaging – KUB –  IVU – US – NCHCT

Urology CUHK 2013

Topics •  LUTS Obstructive BPH •  LUTS Irritative Infection •  Haematuria Ca Bladder •  Elevated PSA / AbN DRE Ca Prostate •  Loin mass RCC •  IVU filling defects TCC •  Scrotal mass Ca Testis •  Loin pain / Hydronephrosis Stone •  Sexual dysfunction ED •  Other Trauma, transplant

Urology CUHK 2013

LUTS

•  No more prostatism •  Includes:

– Obstructive / Voiding symptoms •  Hesitency / Intermittency / Weak steam /

Straining / Sense of incomplete emptying –  Irritative / Storage symptoms

•  Frequency / Urgency / Nocturia

Urology CUHK 2013

Causes

Urology CUHK 2013

Causes •  Voiding symptoms

–  Outflow problem •  Prostatic pathology •  Urethral stricture…

–  Bladder problem •  Hypocontractile bladder

–  Nerve –  Detrusor muscle

•  Storage symptoms –  Local

•  Decrease capacity –  Real –  Functional

•  Local pathology – stone, UTI, tumour etc

–  Regional •  Neurological problem à Detrusor instability

–  General •  Increase fluid intake •  Increase urine output

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Urology CUHK 2013

Typical vs atypical •  Age: 60-80 •  Symptoms:

–  Both obstructive and irritative symptoms

–  for few months or years

•  Other symptoms –  Not much

•  Past health: –  Unremarkable –  Usual ‘elderly dx’

Urology CUHK 2013

Typical vs atypical •  Age: 60-80 •  Symptoms:

–  Both obstructive and irritative symptoms

–  for few months or years

•  Other symptoms –  Not much

•  Past health: –  Unremarkable –  Usual ‘elderly dx’

•  Age: < 50 or >80 •  Symptoms:

–  Predominant irritative +/- haematuria

–  Pure nocturia –  Acute onset

•  Other symptoms –  Haematuria, loin pain

•  Past health: –  Neurological dx –  Long hx of DM –  Post-longed hospitalization

+ catheterization –  Trauma, STD

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Physical examination

•  General condition – Hint suggesting of neurological disease

•  Abdomen – Distended bladder

•  Genitalia – Phimosis

•  Rectal examination – Anal tone, prostate size

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Investigation

•  Basic –  IPSS – KUB, MSU – RFT, sugar, +/- PSA – Uroflowmetry + bladder scan

•  Other – Cystoscopy – Urodynamic study

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Question 1 What are these investigations? How to interpret them?

1A

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>150 ml

>15ml/s

Pattern 1 Pattern 2

Pattern 3 Pattern 4

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1B

Urology CUHK 2013

1C

Urology CUHK 2013 Urology CUHK 2013

1D


BPH

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Urology CUHK 2013

BPH

•  Benign Prostate Hyperplasia •  Unknown aetiology •  Pathophysiology

– Static and dynamic obstruction – Secondary change in detrusor muscle à

detrusor instability and later failure

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BPH

•  Aetiology not known •  After age of 40

–  Appearance of BPH tissue

–  Slowly increase in size

•  Symptomatic – usually above 60 –  in male at age of 60 years

old, 30-50% experience voiding problems

Urology CUHK 2013

Zonal anatomy of Prostate

Urology CUHK 2013

Pathophysiology of BPH

•  Primary events: – Obstruction – static and dynamic

•  Secondary changes in bladder: – Hypertrophy à overactive bladder (detrusor

instability) •  Complications:

–  Increase in residual urine à stone / infection / retention

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BPH

•  Making the diagnosis – Clinical diagnosis – Excluded other causes – Assessment

•  FR + BS

•  Assess the severity and decide treatment

Urology CUHK 2013

BPH

•  Making the diagnosis – Clinical diagnosis – Excluded other causes – Assessment

•  FR + BS

•  Assess the severity and decide treatment –  IPSS / Complications – Risk of Progression (?) – 5 alpha-reductase

inhibitiors

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Urology CUHK 2013

IPSS

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Indication of treatment •  Symptomatic

–  IPSS – moderate (8-19) or severe symptom (>20) •  Complications

–  Prostate level – bleeding –  Bladder level

•  Retention of urine – acute or chronic •  Recurrent cystitis / UTI •  bladder stone formation •  Diverticulum formation

–  Upper tract – hydronephrosis, obstructive uropathy and renal failure

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BPH •  Treatment

–  Conservatives –  Medical

•  Alpha-blocker / 5-alpha reductase inhibitors •  Phytotherapy / PDE5i etc

–  Minimally invasive therapy •  Thermotherapy – RF, HIFU, TUMT

–  Surgical •  Tissue ablasion – PVP, HoLRP •  TURP (Monopolar / Bipolar) / Open prostatectomy

–  Others •  Long term catheter (Urethral / Suprapubic) •  Stenting

Urology CUHK 2013

Urology CUHK 2013

Theory of using α-AR blocker •  Predominant component in BPH is stromal tissue with

39% of the hyperplasia tissue is smooth muscle Shapiro et al J Urol 1992; 147: 1293

Shapiro et al The Prostate 1992; 20: 259

•  Lepor and Shapiro reported that α1-AR are abundant in the prostate and bladder neck and sparse in the bladder body

J Urol 1984; 132: 1226

•  The area density of prostate smooth muscle measured from prostatic biopsy was shown to have direct relationship with the improvement of peak flow rate by terazosin

Shapiro et al The Prostate 1992; 21: 297

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Current α1-AR blocker

•  Non-selective: Phenoxybenzamine •  Selective:

– Prazosin (Minipress) – Terazosin (Hytrin) – Doxazosin (Cardura) – Alfuzosin (Xatral, Xatral SR, Xatral XL)

•  Subtype selective (1a) – Tamsulosin (Harnal) – Silodosin (Rapaflo)

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Urology CUHK 2013

Efficacy

•  Meta-analyzed data from the AUA Panel’s evidence-based review suggest that alfuzosin, doxazosin, tamsulosin, and terazosin are similarly effective in partially relieving symptoms, producing on average a 4-to-6 point improvement in the AUA Symptom Index

AUA guidelines 2003

Urology CUHK 2013

Side effects •  The primary adverse events reported with α1-AR blocker

are –  orthostatic hypotension –  dizziness –  tiredness (asthenia) –  nasal congestion –  ejaculatory problems

•  Discontinuation rate due to AE –  For Alfuzosin & Tamsulosin = 4 ~ 10% (similar to placebo) –  For Doxazosin & Terazosin = + 4 ~ 10%

•  Ejaculatory problems (retrograde / retraded) –  Tamsulosin = 4.5 ~10% (placebo 0 -1%)

Marberger et al Eur Urol 2004; 45: 411

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5-Alpha Reductase Inhibitors

Urology CUHK 2013

5α-reductase •  Dihydrotestosterone (DHT) is synthesized from

testosterone via the enzyme 5-α-reductase •  In the majority of androgen target tissues either

testosterone or DHT binds to a specific androgen receptor to form a complex that can regulate gene expression.

•  DHT is essential for prostate development and growth, the development of the external genitalia and male patterns of facial and body hair growth or male-pattern baldness.

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Mechanism

•  5α-RI is the sole hormonal therapy, to date, that demonstrates both efficacy and acceptable safety for treatment of BPH

•  Decrease the size of prostate •  The onset of maximal clinical effect 3~12

weeks •  Effects especially superior in glands >

40ml Boyle et al Urology 1996; 48: 398-405

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Decrease in volume

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Urology CUHK 2013

Mechanism

•  5α-RI is the sole hormonal therapy, to date, that demonstrates both efficacy and acceptable safety for treatment of BPH

•  Decrease the size of prostate •  The onset of maximal clinical effect 3~6

months •  Effects especially superior in glands >

40ml Boyle et al Urology 1996; 48: 398-405

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Precaution

•  Side effects: – 5% ED

•  Decrease in PSA level – ~ 50%

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Main indications

•  As second line alone – Not tolerate side effects or contra-indicated for α1-AR blocker

•  As combination – when demonstrated prostate enlargement

•  Prevention of progression

•  Other potential usages (not worldwide accepted yet) –  Prostate cancer prevention –  Improving the performance of PSA

Urology CUHK 2013

CombAT major entrance criteria

•  Male aged ≥50 years •  Diagnosis of BPH by History and DRE •  IPSS ≥12 (moderate to severe symptoms) •  Prostate volume ≥30 cc by TRUS •  Serum PSA ≥1.5 and ≤10.0 ng/mL •  Two voids at screening with Qmax >5 and

≤15 mL/sec (moderate to severe impairment) and minimum voided volume of ≥125 mL

Urology CUHK 2013 Roehrborn CG et al Eur Urol 2010; 57: 123-131

67%

58%

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Other drugs

•  Anticholinergic agents –  Irritative symptoms – Exclude large RU

•  PDE5 inhibitors – FDA approved – ED + BPH (Cialis OD)

•  Phytotherapy

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Urology CUHK 2013

TURP - Monopolar •  Lithotomy position •  Cystoscopic examination •  Transurethral resection •  1.5% glycine •  3 ways urethral catheter

•  Post-OP –  NS irrigation –  CBP, RFT

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TURP

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Complications of TURP •  General •  Specific

–  IntraOT complications •  Bleeding, TUR syndrome, perforation/injury

– Early complications •  Bleeding, clot retention, infection, TUR syndrome •  Clip retention, •  Urge incontinence

– Late complications •  Stricture, stress incontinence, retrograde ejaculation

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Comparison

•  TURP

•  PVP (Photoselective vapourization of prostate / Green Laser)

•  Bipolar vapourization

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Question 2

•  History of RTA 3 years ago in China –  Intracerebral bleeding

and need evaculation –  Stay in ICU ½ month

•  C.o. LUTS for 2 years –  Slow steam, sense of

incomplete emptying

Urology CUHK 2013

Questions 2

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Urology CUHK 2013

Question 3 (Noctural enuresis) •  C.o LUTS for few years

–  Slow steam, frequency –  Noctural enuresis for 6/12

•  P/E distended bladder •  Admitted after OPD

(already 5pm) –  Urethral catheter inserted

à RU = 1.5L –  Cr 450

Urology CUHK 2013

Question 3

•  Why there is noctural enuresis? •  If you are the house-officer, what will be

your management order? •  Four hour later, the nurse calls you and

tells you there is some haematuria, what will you do and why?

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Irritative LUTS

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Causes •  Voiding symptoms

–  Outflow problem •  Prostatic pathology •  Urethral stricture…

–  Bladder problem •  Hypocontractile bladder

–  Nerve –  Detrusor muscle

•  Storage symptoms –  Local

•  Decrease capacity –  Real –  Functional

•  Local pathology – stone, UTI, tumour etc

–  Regional •  Neurological problem à Detrusor instability

–  General •  Increase fluid intake •  Increase urine output

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Infection

Highlight: diagnosis of UTI

Upper tract infection

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Types of infection

•  Upper tract –  Acute pyelonephritis –  Acute pyonephrosis –  Cortical abcess

–  Chronic pyelonephritis

•  Lower tract –  Cystitis –  Prostatitis

•  Acute •  Chronic

–  Epididymo-orchitis

•  STD

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Urology CUHK 2013

Diagnosis of UTI

•  Multistix •  Mircroscopy •  Culture

–  Methods of urine collection –  CFU/ml (MSU)

•  > 105

•  New approach –  Symptomatic female ≥102 E Coli CFU + ≥8 pus

cell/mm3 or ≥ 105 other organism

–  Symptomatic male ≥103 pathogenic organism

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Cystitis

•  Simple •  Recurrent

– Treatment failure – Relapsing vs re-infection – Other organisms – Documented?

•  Malignant cystitis…

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•  No à need •  Yes à pattern

– Re-infection

– Relapsing

Documented culture?

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Recurrent UTI

•  Treatment failure – Resistant strain or incorrect antibiotics – Failed compliance to treatment

•  Relapsing infection •  Re-infection

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Re-infection •  Failure of defence mechanism

–  Hygiene •  Post-coital etc

–  Voiding dysfunction •  Large residual urine etc

–  Diabetes •  Management

–  Imaging or cystoscopy usually no use –  Check Bladder scan / voiding –  Check habit –  Rule out DM

Urology CUHK 2013

Re-infection

•  Treatment – Correct predisposing cause

•  Voiding problems •  DM •  Hygiene

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Urology CUHK 2013

Medications

•  Drug –  Post-coital prophylactic

•  single dose of full strength

–  Long term suppressive antibiotics •  Septrim, nitrofurantoin for 6-12 months •  then see any breakthrough infection à may stop

–  Self-treatment by women who experience recurrent infection is also an effective strategy.

•  Useful for women with infrequent recurrences, or •  Who are concerned they may develop infection while

traveling or otherwise unable to access usual health care.

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Upper tract infection

•  Acute pyelonephritis –  Diagnosis –  Management

•  Rule out obstruction – history, KUB •  Antibiotics •  Unresolved à ultrasound

•  Acute pyonephrosis –  Urological emergency à required drainage

•  Renal abscess –  Underlying pathology – DM etc

Urology CUHK 2013

Approach to Irritative Symptoms / Nocturia

•  Daytime symptom? – No à pure nocturia – Yes à frequency

•  High urine output? –  Yes à polyuria à increase intake or increase output – No à true frequency

» Detrusor hypersensitivity – secondary to nerve local irritative causes de novo

» Capacity problem – decrease true capacity functional capacity

Urology CUHK 2013

Question 4 (Nocturia) •  Nocturia for 2 years •  Not much daytime

symptoms •  PMH: HT, DM, OSA •  DRE 30 gm prostate •  FR – Qmax – 18ml/L

•  What Ix? •  Why nocturia?

Urology CUHK 2013

Question 4 (Nocturia)

•  Nocturnal polyuria – Why? – Disturbance of ADH production

– Dependent edema

– Obstructive sleep apnoea

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Question 5 (Frequency)

•  What is the implication of these voiding charts?

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Urology CUHK 2013 3800 Total 3450 Total

400 4:30 400 2:00 250 2:00

350 23:00 250 22:00 400 21:00 500 21:00 270 19:00 800 19:30 330 17:30 250 16:30 450 14:00 500 15:00 350 11:00 250 12:00 350 9:00 250 12:30 500 7:00 400 7:30

Volume (ml) Urine – time Volume (ml) Intake – time


300 4:30 300 2:00 250 1:00

250 23:30 300 22:00

400 21:00 500 21:00 200 19:00 800 19:30 200 14:00 100 15:00 350 9:00 250 12:00 300 7:00 400 7:30



100 22:00 50 21:30 100 20:00 150 19:00 50 16:30 200 14:00 300 22:00 100 13:00 500 19:30 200 12:00 250 15:00 120 10:00 400 12:00 150 9:00 200 10:00 500 7:00 400 7:30



100 4:30 150 2:00 200 0:30 100 22:30 200 21:00 200 19:00 300 22:00 200 14:00 200 21:00 50 13:00 400 19:30 130 12:00 100 15:00 100 10:30 250 12:00 150 9:00 200 10:30 200 7:00 400 7:30


Urology CUHK 2013

Overactive bladder

•  Symptom complex of urinary urgency (intense, sudden desire to void) +/- incontinence / urinary frequency / nocturia

•  Present in the absence of any pathological or metabolic disorders could cause them

•  Mx à exclude other causes •  Tx à beh training +/- anticholinergic agent •  Beta-3 antagonists

Urology CUHK 2013

Question 6 (Frequency) •  Chronic smoker •  Irritative LUTS for ½

year •  No haematuria •  Seen by GP

–  Repeated culture –ve –  KUB – no stone

•  PMH: unremarkable

•  What will you do?

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Urology CUHK 2013

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

Urology CUHK 2013

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

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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

Urology CUHK 2013

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 –  upper urinary tract imaging

•  intravenous urography or •  Contrast CT urogrm •  US (less optimal)

–  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 à still need work up

Urology CUHK 2013

Question 7

•  What are the advantages and disadvantages of – US –  IVU – CT Urogram

–  In assessing upper tract

Urology CUHK 2013

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 / SOL

– Ureterorenoscopy •  endoscopy of upper urinary tract / luminal lesion

–  renal arteriography or venography •  suspected vascular abnormalities

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Tumour - General General •  Aetiology / Risk factors

–  Intrinsic: age / sex / race /inherited dx or FH –  Extrinsic: biological (virus) / chemical / physical

•  Presentation –  Asymptomatic –  Local –  Metastatic –  General –  Para-neoplastic

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Tumour - General

Treatment – Curative

•  OT •  RT •  +/- neoadjuvant / adjuvant therapy

– Palliative •  RT / ChemoT / Hormonal (CaP) / ImmunoT (RCC) •  Drug •  OT

Urology CUHK 2013

Bladder Cancer

•  Risk factors –  Intrinsic – elderly, males – Extrinsic

•  Chemical carcinogens – –  petroleum, rubber, printing industry –  smoking

•  Physical - chronic irritation – –  stone / neurogenic bladder / parasites/

cyclophosphamide

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Pathology of Bladder Cancer

•  95% urothelial –  80-90% transitional cell carcinoma –  5-10% adenocarcinoma (primary or secondary) –  uncommonly squamous cell carcinoma (HK) –  small cell carcinoma –  undifferentiated carcinoma

•  Transitional cell carcinoma –  70-80% papillary –  20-30% nodular or sessile

Urology CUHK 2013

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

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Investigations for Bladder Cancer

•  Haematuria work up –  Cystoscopy + bladder biopsy –  IVU or other upper tract investigation

•  Chest X-ray •  CT abdomen and pelvis •  Bone scan

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Urology CUHK 2013

Staging of Bladder Cancer

•  Superficial disease Tis Ta T1

•  Muscle invasive disease T2 T3 T4

•  Metastatic disease

•  Treatment based on the staging of the disease Urology CUHK 2013

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 two 2 years at least

•  Active – intravesical chemotherapy or BCG (immunoT)

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Intravesical therapy for CaB

•  To decrease recurrence rate •  To decrease progression rate (BCG only)

•  Classification: –  Immediate post-surgery – chemotherapy (e.g.

mitromycin C) but NEVER BCG – Further course of chemotherapy / BCG

•  After final pathology •  Usually few weeks later, especially BCG

– NEVER write I.V. Urology CUHK 2013

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Muscle invasive TCC bladder

•  Radical cystectomy – What to cut

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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


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Urology CUHK 2013

Other Treatment of Bladder Cancer •  Muscle invasive disease

– ChemoRT – Radiotherapy cure rate lower than surgery

•  Use in patients not fit for surgery

– Adjuvant chemotherapy •  Early result did not improve cure rate

– Neoadjuvant chemotherapy before OT •  Probably improve outcome of surgery (but some drawback)

•  Metastatic disease –  Chemotherapy – MVAC, GC etc

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Serum Prostate Specific Antigen (PSA)

•  Enzyme secreted into prostatic secretion – Serine protease – Liquefied semen coagulum à release sperm

•  Leakage into serum

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Urology CUHK 2013

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 PSA doubling time

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Urology CUHK 2013

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 à bone secondary

•  Monitoring treatment response –  Before clinically detectable

•  Histological diagnosis –  Adenocarcinoma ?origin à PSA strain

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Many guidelines / recommendataions

•  Latest one – AUA guideline on Early Detection of Prostate Cancer – Released in May 2013

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Recommendation

•  < 40 years old – not recommended

•  40 – 55 years old – Not routinely recommended – However, if at high risk (e.g. Family history,

African race etc)

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Recommendation •  55-69 years old

– Strongly Recommended to discuss about it between doctor and subject for considering PSA testing

•  70 or above – Not recommended – With less than a 10-15 years life expectancy – But if > 70 years old are in excellent health may

still benefit from PSA testing

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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 à AROU

•  General symptoms


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Diagnosis of Ca Prostate •  TRUS + Bx •  Indications

–  Abnormal DRE –  Elevated PSA

•  Complications: –  Sepsis –  Bleeding –  AROU

•  Preparation

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Histology Gleason grading

Gleason score

- 2 numbers

- Most common one + second common one (> 5%)

- Biopsy – first (commonest) + second (highest)

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Staging Tests for Prostate Cancer

•  Local – Magnetic Resonance Imaging of prostate

•  Metastatic – Chest X-ray – Bone scan

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Ca Prostate

•  Treatment – Localized

•  Watchful waiting •  Radical prostatectomy •  Radical radiotherapy – Ext beam or brachytherapy

– Metastatic •  Hormonal therapy •  RT – palliative •  Chemotherapy

Urology CUHK 2013

Radical prostatectomy

•  IntraOT / Early Complications – Bleeding – UTI

•  Late complication – Stress incontinence – Anastomotic stricture – ED

Urology CUHK 2013

da Vinci robotic system

Urology CUHK 2013

Ca Prostate

•  Hormonal therapy – Hormone axis

•  Choice: – Orchidectomy – Medical castration

•  LHRH analogue •  LHRH antagonist (coming into market soon)

– Others: •  Antiandrogen •  Estrogen (first one, not using now)

Urology CUHK 2013

Time of onset Normal level 6.11+/-1.82 ng/ml Time

Castration level 5-10%

Orchidectomy 0.2 8.6 +/- 3.2hr

LHRH analogue 0.2-0.5 +/- 3 weeks

LHRH antagonist 0.2-0.5 Within 24hr

Antiandrogen + LHRN analogue

0.2-0.5 +/- 2 weeks

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Urology CUHK 2013

Case 8 •  Known hormonal refractory prostate cancer •  Currently on supportive care and pending

assessment for ? chemotherapy •  Presented with increase difficulty in passing

urine and then AROU –  RU 700ml and clear –  DRE 60 gm irregular prostate

•  So you are the on call HO, anything you want to rule out?

Urology CUHK 2013

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

Urology CUHK 2013

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: …

Urology CUHK 2013

Paraneoplastic symptoms •  Polycythaemia •  Hypertension •  Hypoglycaemia •  Cushing’s •  Hypercalcaemia

•  Gynaecomastia, amenorrhoea, reduced libido, baldness

•  Hepatic dysfunction •  Pyrexia (PUO) / night

sweats

•  Ectopic erythropoietin •  Ectopic renin •  Ectopic insulin •  Ectopic ACTH •  Ectopic PTH-like

substance •  Ectopic gonadotrophins

•  Unk •  Unk ?IL

Urology CUHK 2013

Investigations

•  Imaging – CT scan

•  Contrast enhancing mass •  DDx – not much •  Other mass – characteristics •  Local staging and venous involvement

•  Staging

Urology CUHK 2013

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Urology CUHK 2013

RCC •  Treatment

– Radical Nephrectomy •  Laparoscopic or open

– Small size (< 4cm) or tumour in single kidney or patient with poor renal function •  Nephron-sparing surgery (partial nephrectomy) •  Energy-based surgery – RF, Cryotherapy, HIFU

– No good adjuvant •  Immunotherapy

– New treatments

Urology CUHK 2013

Target therapy

Urology CUHK 2013

Everolimus Temsirolimus

Urology CUHK 2013

Filling defect in IVU

•  Stone •  Tumour •  Clot •  Fungal ball •  Dislodged papilla

•  CT scan

Urology CUHK 2013

TCC upper tract

•  Upper tract TCC à 70% lower tract TCC •  Lower tract TCC à 5% upper tract TCC

•  Nephroureterectomy

•  FC FU as superficial TCC

Urology CUHK 2013

Surgical Treatment of Upper TCC (nephroureterectomy)

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Urology CUHK 2013

Scrotal mass

•  Differential diagnosis –  Inguinal – Spermatic cord

•  Varicocle / hydrocele of the cord / lipoma of the cord

– Epididimus •  Cysts / infection (acute or chronic)

– Tunica vaginalis •  Hydrocele / haematocele

Urology CUHK 2013

Scrotal Examination

•  (standing) •  Cough impulse + get above or not •  If can get above

– Define the relationship of the mass to testicles •  Cannot felt it à hydrocele, haematocele etc •  Can felt testicle

– Related to cord, epididimus, testis

– also the texture, transillumination etc

Urology CUHK 2013

Ca testis

•  Testicular mass –  Infection

•  Acute (bacterial or mump) or chronic – Tumour

•  Benign •  Malignant

–  Primary » Non-germ cell » Germ cell – seminoma or nonseminomatous

–  Secondary »  lymphoma

Urology CUHK 2013

Ca testis

•  Treatment – Early diagnosis – Measurement of markers – AFP, βHCG – Staging

–  Inguinal orchidectomy – Stage 1

•  Seminoma – Classically “treat one step above” by RT –  But surveillance / chemoT also possible now

•  Non-seminomatous – chemoT or RPLND – Stage 2 or above – need adjuvant tx


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Urology CUHK 2013

Acute Scrotum

•  Most important – –  Infection (bacterial or viral) vs torsion – Other possibility

•  Trauma •  Acute bleeding of tumour •  Etc

– Explore if in doubt – Doppler US is also helpful

Urology CUHK 2013

Stone

•  Stone – 10% population – 50% recurrence if don’t do prevention

•  Composition – Calcium related stone – Uric acid stone –  Infective stone / Struvite / Staghorn stone – Cystine stone

Urology CUHK 2013

Stone

•  Pathophsiology – Formation of crystal

•  Supersaturation –  Solute and solvent

•  Inhibitor and promotor

– Retain and aggregation •  ?inflammation •  Randall’s Plaque – crystal first

formed in interstitial space of papillae

Urology CUHK 2013

Stone

•  Management – Acute – Definitive – Preventive

Urology CUHK 2013

Stone

•  Acute – Loin pain

•  Diagnosis –  Various imaging – pros and cons – NCHCT – gold standard

•  Treat sepsis à drainage •  Control pain à drain if not control by simple mean

– Haematuria – Urethal stone

Urology CUHK 2013

Stone

•  Definitive –  Weapons

•  Conservative •  Medical expulsive therapy •  ESWL •  Endoscopic

–  URS –  PCNL

•  Laparoscopic – ureterolithotomy •  Open •  Medical dissolution – uric acid stone

–  Each pros and cons

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Urology CUHK 2013

PCNL – Percutaneous Nephrolithotomy

Urology CUHK 2013

URS Ureterorenoscopy

Urology CUHK 2013

Stone •  Definitive

–  Investigations •  IVU •  +/- DMSA , RFT etc

–  Factors to consider •  Stone factors

–  Site / Size / Composition / Complication •  Patient factors

–  General medical condition –  Body build –  Social status

•  Surgeon / institutional factors

Urology CUHK 2013

Stone

•  Preventive – Uric acid stone

•  Low purine diet, high fluid intake, alkalization of urine

–  Infective stone •  Treat infection and underlying cause

– Cystine stone •  High fluid intake •  Chelating agents

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Urology CUHK 2013

Stone

•  Preventive – Calcium stone

•  General –  Basic blood à hyperPTH –  Basic dietary advice

» High fluid, normal calcium diet, low salt, high citrous fruit

•  Specific – Metabolic work up

Urology CUHK 2013

Hydronephrosis

•  What? •  ≠ obstruction •  Types

– Obstructing – Refluxing – Non-obstructing and non-refluxing

Urology CUHK 2013

Obstructive hydronephrosis

•  Unilateral hydronephrosis –  Intraluminal – stone, clot, foreign body –  Wall – stricture (benign / malignant) –  Extraluminal – tumour, lymph node

•  Bilateral hydronephrosis –  Usually distal pathology –  Ca bladder –  Prostatic pathology, urethral pathology –  Ca Cervix, Uterine prolapse –  ** Bladder scan, PR, PV

Urology CUHK 2013

Hydronephrosis

•  Management – Urgent intervention

•  Sepsis •  Deranged RFT •  Symptomatic

– Otherwise – Investigate first •  DON’T PUNCTURE! •  IVU, CT, ascending ureterogram •  MCU

Urology CUHK 2013

Question 9

•  40 years old gentleman, known metastatic Ca sigmoid

•  Admitted to Oncology ward for work up of imparied RFT: Cr 80 à 400

•  US today at 4:30pm à bilateral hydronephrosis + empty bladder

•  Last US 6 months ago – mild left hydronephrosis •  You, as a uro trainee, are asked to see him

Urology CUHK 2013

Question 9

•  Do you need to do something tonight?

•  What will you do, PCN or JJ stent?

•  How many will you inserted?

•  If you insert one, which side?

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Urology CUHK 2013

Erectile dysfunction

•  Causes – Psychological – Organic

•  Systemic – Hormonal –  Systemic disease – Drug

•  Local – Neurological –  Arterial – Cavernosal / venous

Urology CUHK 2013

Erectile dysfunction •  Managements

–  History •  Clarify the c/o •  Precipitate events •  Variable symptoms •  Past medical disease / surgery / drug history

–  PE •  General exam – suggest endocrine problems •  Peripheral pulses

–  Investigation: •  Basic blood test •  Testosterone, LH, FSH, PRL, fasting sugar, Thyroxine

Urology CUHK 2013

Erectile dysfunction - Management •  Cause specific •  Other

–  Medical •  Systemic

–  Central acting – uprima (apomorphine) –  Local acting – viagra, cialis, levitra

•  Topical (PDE2 analogue and other) (intracarvonosal or transurethral or tropical)

–  Surgical •  Vascular surgery – arterial or venous •  Penile prosthesis

–  Others •  Vaccum pump / SW therapy •  Stenting (investigational)

Urology CUHK 2013

Drugs

Urology CUHK 2013

Local treatment

Urology CUHK 2013

Prosthesis

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Urology CUHK 2013

Vaccum pump

Urology CUHK 2013

SWT

Urology CUHK 2013

More important…

Men with moderate to severe ED à 65% increase risk for developing CAD in 10 years time Urology CUHK 2013

181

Urology CUHK 2013

Trauma

•  Kidney – blunt / penetrating –  Conservative most of the cases

•  Ureter – iatrogenic •  Bladder – extraperitoneal or intrapertoneal

•  Urethra injury –  Anatomy … –  Most imp – recognize it and do no harm à no urethral

catheterization in non-experienced hand

Urology CUHK 2013

Urethral anatomy •  Prostatic urethra •  Membranous urethra •  Bulbar urethra •  Penile urethra

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Urology CUHK 2013

Urethral anatomy

Urology CUHK 2013

Types of blushing

Urology CUHK 2013

Question 10 – what are the DDx

Urology CUHK 2013

Thank you and

see you in Urology ward

Introductory lecture of Urology Med 2013 short - CUHK Surgery I-Prof CF... · – LUTS, BPH,...

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Transcript of Introductory lecture of Urology Med 2013 short - CUHK Surgery I-Prof CF... · – LUTS, BPH,...