- •Hematuria II: causes and investigation
- •Hematospermia
- •Lower urinary tract symptoms (LUTS)
- •Nocturia and nocturnal polyuria
- •Flank pain
- •Urinary incontinence in adults
- •Genital symptoms
- •Abdominal examination in urological disease
- •Digital rectal examination (DRE)
- •Lumps in the groin
- •Lumps in the scrotum
- •2 Urological investigations
- •Urine examination
- •Urine cytology
- •Radiological imaging of the urinary tract
- •Uses of plain abdominal radiography (KUB X-ray—kidneys, ureters, bladder)
- •Intravenous pyelography (IVP)
- •Other urological contrast studies
- •Computed tomography (CT) and magnetic resonance imaging (MRI)
- •Radioisotope imaging
- •Post-void residual urine volume measurement
- •3 Bladder outlet obstruction
- •Regulation of prostate growth and development of benign prostatic hyperplasia (BPH)
- •Pathophysiology and causes of bladder outlet obstruction (BOO) and BPH
- •Benign prostatic obstruction (BPO): symptoms and signs
- •Diagnostic tests in men with LUTS thought to be due to BPH
- •Why do men seek treatment for their symptoms?
- •Watchful waiting for uncomplicated BPH
- •Medical management of BPH: combination therapy
- •Medical management of BPH: alternative drug therapy
- •Minimally invasive management of BPH: surgical alternatives to TURP
- •Invasive surgical alternatives to TURP
- •TURP and open prostatectomy
- •Indications for and technique of urethral catheterization
- •Indications for and technique of suprapubic catheterization
- •Management of nocturia and nocturnal polyuria
- •High-pressure chronic retention (HPCR)
- •Bladder outlet obstruction and retention in women
- •Urethral stricture disease
- •4 Incontinence
- •Causes and pathophysiology
- •Evaluation
- •Treatment of sphincter weakness incontinence: injection therapy
- •Treatment of sphincter weakness incontinence: retropubic suspension
- •Treatment of sphincter weakness incontinence: pubovaginal slings
- •Overactive bladder: conventional treatment
- •Overactive bladder: options for failed conventional therapy
- •“Mixed” incontinence
- •Post-prostatectomy incontinence
- •Incontinence in the elderly patient
- •Urinary tract infection: microbiology
- •Lower urinary tract infection
- •Recurrent urinary tract infection
- •Urinary tract infection: treatment
- •Acute pyelonephritis
- •Pyonephrosis and perinephric abscess
- •Other forms of pyelonephritis
- •Chronic pyelonephritis
- •Septicemia and urosepsis
- •Fournier gangrene
- •Epididymitis and orchitis
- •Periurethral abscess
- •Prostatitis: presentation, evaluation, and treatment
- •Other prostate infections
- •Interstitial cystitis
- •Tuberculosis
- •Parasitic infections
- •HIV in urological surgery
- •6 Urological neoplasia
- •Pathology and molecular biology
- •Prostate cancer: epidemiology and etiology
- •Prostate cancer: incidence, prevalence, and mortality
- •Prostate cancer pathology: premalignant lesions
- •Counseling before prostate cancer screening
- •Prostate cancer: clinical presentation
- •PSA and prostate cancer
- •PSA derivatives: free-to-total ratio, density, and velocity
- •Prostate cancer: transrectal ultrasonography and biopsies
- •Prostate cancer staging
- •Prostate cancer grading
- •General principles of management of localized prostate cancer
- •Management of localized prostate cancer: watchful waiting and active surveillance
- •Management of localized prostate cancer: radical prostatectomy
- •Postoperative course after radical prostatectomy
- •Prostate cancer control with radical prostatectomy
- •Management of localized prostate cancer: radical external beam radiotherapy (EBRT)
- •Management of localized prostate cancer: brachytherapy (BT)
- •Management of localized and radiorecurrent prostate cancer: cryotherapy and HIFU
- •Management of locally advanced nonmetastatic prostate cancer (T3–4 N0M0)
- •Management of advanced prostate cancer: hormone therapy I
- •Management of advanced prostate cancer: hormone therapy II
- •Management of advanced prostate cancer: hormone therapy III
- •Management of advanced prostate cancer: androgen-independent/ castration-resistant disease
- •Palliative management of prostate cancer
- •Prostate cancer: prevention; complementary and alternative therapies
- •Bladder cancer: epidemiology and etiology
- •Bladder cancer: pathology and staging
- •Bladder cancer: presentation
- •Bladder cancer: diagnosis and staging
- •Muscle-invasive bladder cancer: surgical management of localized (pT2/3a) disease
- •Muscle-invasive bladder cancer: radical and palliative radiotherapy
- •Muscle-invasive bladder cancer: management of locally advanced and metastatic disease
- •Bladder cancer: urinary diversion after cystectomy
- •Transitional cell carcinoma (UC) of the renal pelvis and ureter
- •Radiological assessment of renal masses
- •Benign renal masses
- •Renal cell carcinoma: epidemiology and etiology
- •Renal cell carcinoma: pathology, staging, and prognosis
- •Renal cell carcinoma: presentation and investigations
- •Renal cell carcinoma: active surveillance
- •Renal cell carcinoma: surgical treatment I
- •Renal cell carcinoma: surgical treatment II
- •Renal cell carcinoma: management of metastatic disease
- •Testicular cancer: epidemiology and etiology
- •Testicular cancer: clinical presentation
- •Testicular cancer: serum markers
- •Testicular cancer: pathology and staging
- •Testicular cancer: prognostic staging system for metastatic germ cell cancer
- •Testicular cancer: management of non-seminomatous germ cell tumors (NSGCT)
- •Testicular cancer: management of seminoma, IGCN, and lymphoma
- •Penile neoplasia: benign, viral-related, and premalignant lesions
- •Penile cancer: epidemiology, risk factors, and pathology
- •Squamous cell carcinoma of the penis: clinical management
- •Carcinoma of the scrotum
- •Tumors of the testicular adnexa
- •Urethral cancer
- •Wilms tumor and neuroblastoma
- •7 Miscellaneous urological diseases of the kidney
- •Cystic renal disease: simple cysts
- •Cystic renal disease: calyceal diverticulum
- •Cystic renal disease: medullary sponge kidney (MSK)
- •Acquired renal cystic disease (ARCD)
- •Autosomal dominant (adult) polycystic kidney disease (ADPKD)
- •Ureteropelvic junction (UPJ) obstruction in adults
- •Anomalies of renal ascent and fusion: horseshoe kidney, pelvic kidney, malrotation
- •Renal duplications
- •8 Stone disease
- •Kidney stones: epidemiology
- •Kidney stones: types and predisposing factors
- •Kidney stones: mechanisms of formation
- •Evaluation of the stone former
- •Kidney stones: presentation and diagnosis
- •Kidney stone treatment options: watchful waiting
- •Stone fragmentation techniques: extracorporeal lithotripsy (ESWL)
- •Intracorporeal techniques of stone fragmentation (fragmentation within the body)
- •Kidney stone treatment: percutaneous nephrolithotomy (PCNL)
- •Kidney stones: open stone surgery
- •Kidney stones: medical therapy (dissolution therapy)
- •Ureteric stones: presentation
- •Ureteric stones: diagnostic radiological imaging
- •Ureteric stones: acute management
- •Ureteric stones: indications for intervention to relieve obstruction and/or remove the stone
- •Ureteric stone treatment
- •Treatment options for ureteric stones
- •Prevention of calcium oxalate stone formation
- •Bladder stones
- •Management of ureteric stones in pregnancy
- •Hydronephrosis
- •Management of ureteric strictures (other than UPJ obstruction)
- •Pathophysiology of urinary tract obstruction
- •Ureter innervation
- •10 Trauma to the urinary tract and other urological emergencies
- •Renal trauma: clinical and radiological assessment
- •Renal trauma: treatment
- •Ureteral injuries: mechanisms and diagnosis
- •Ureteral injuries: management
- •Bladder and urethral injuries associated with pelvic fractures
- •Bladder injuries
- •Posterior urethral injuries in males and urethral injuries in females
- •Anterior urethral injuries
- •Testicular injuries
- •Penile injuries
- •Torsion of the testis and testicular appendages
- •Paraphimosis
- •Malignant ureteral obstruction
- •Spinal cord and cauda equina compression
- •11 Infertility
- •Male reproductive physiology
- •Etiology and evaluation of male infertility
- •Lab investigation of male infertility
- •Oligospermia and azoospermia
- •Varicocele
- •Treatment options for male factor infertility
- •12 Disorders of erectile function, ejaculation, and seminal vesicles
- •Physiology of erection and ejaculation
- •Impotence: evaluation
- •Impotence: treatment
- •Retrograde ejaculation
- •Peyronie’s disease
- •Priapism
- •13 Neuropathic bladder
- •Innervation of the lower urinary tract (LUT)
- •Physiology of urine storage and micturition
- •Bladder and sphincter behavior in the patient with neurological disease
- •The neuropathic lower urinary tract: clinical consequences of storage and emptying problems
- •Bladder management techniques for the neuropathic patient
- •Catheters and sheaths and the neuropathic patient
- •Management of incontinence in the neuropathic patient
- •Management of recurrent urinary tract infections (UTIs) in the neuropathic patient
- •Management of hydronephrosis in the neuropathic patient
- •Bladder dysfunction in multiple sclerosis, in Parkinson disease, after stroke, and in other neurological disease
- •Neuromodulation in lower urinary tract dysfunction
- •14 Urological problems in pregnancy
- •Physiological and anatomical changes in the urinary tract
- •Urinary tract infection (UTI)
- •Hydronephrosis
- •15 Pediatric urology
- •Embryology: urinary tract
- •Undescended testes
- •Urinary tract infection (UTI)
- •Ectopic ureter
- •Ureterocele
- •Ureteropelvic junction (UPJ) obstruction
- •Hypospadias
- •Normal sexual differentiation
- •Abnormal sexual differentiation
- •Cystic kidney disease
- •Exstrophy
- •Epispadias
- •Posterior urethral valves
- •Non-neurogenic voiding dysfunction
- •Nocturnal enuresis
- •16 Urological surgery and equipment
- •Preparation of the patient for urological surgery
- •Antibiotic prophylaxis in urological surgery
- •Complications of surgery in general: DVT and PE
- •Fluid balance and management of shock in the surgical patient
- •Patient safety in the operating room
- •Transurethral resection (TUR) syndrome
- •Catheters and drains in urological surgery
- •Guide wires
- •JJ stents
- •Lasers in urological surgery
- •Diathermy
- •Sterilization of urological equipment
- •Telescopes and light sources in urological endoscopy
- •Consent: general principles
- •Cystoscopy
- •Transurethral resection of the prostate (TURP)
- •Transurethral resection of bladder tumor (TURBT)
- •Optical urethrotomy
- •Circumcision
- •Hydrocele and epididymal cyst removal
- •Nesbit procedure
- •Vasectomy and vasovasostomy
- •Orchiectomy
- •Urological incisions
- •JJ stent insertion
- •Nephrectomy and nephroureterectomy
- •Radical prostatectomy
- •Radical cystectomy
- •Ileal conduit
- •Percutaneous nephrolithotomy (PCNL)
- •Ureteroscopes and ureteroscopy
- •Pyeloplasty
- •Laparoscopic surgery
- •Endoscopic cystolitholapaxy and (open) cystolithotomy
- •Scrotal exploration for torsion and orchiopexy
- •17 Basic science of relevance to urological practice
- •Physiology of bladder and urethra
- •Renal anatomy: renal blood flow and renal function
- •Renal physiology: regulation of water balance
- •Renal physiology: regulation of sodium and potassium excretion
- •Renal physiology: acid–base balance
- •18 Urological eponyms
- •Index
Chapter 6 |
185 |
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Urological neoplasia
Pathology and molecular biology 188
Prostate cancer: epidemiology and etiology 190
Prostate cancer: incidence, prevalence, and mortality 192
Prostate cancer pathology: premalignant lesions 193
Prostatic-specific antigen (PSA) and prostate cancer screening 194
Counseling before prostate cancer screening 195
Prostate cancer: clinical presentation 196
PSA and prostate cancer 198 PSA derivatives: free-to-total ratio,
density, and velocity 200 Prostate cancer: transrectal
ultrasonography and biopsies 202
Prostate cancer staging 206 Prostate cancer grading 212 Risk stratification in management
of prostate cancer 214 General principles of management
of localized prostate cancer 215 Management of localized prostate
cancer: watchful waiting and active surveillance 216
Management of localized prostate cancer: radical prostatectomy 218
Postoperative course after radical prostatectomy 222
Prostate cancer control with radical prostatectomy 224
Management of localized prostate cancer: radical external beam radiotherapy (EBRT) 226
Management of localized prostate cancer: brachytherapy (BT) 228
Management of localized and radiorecurrent prostate cancer: cryotherapy and HIFU 230
Management of locally advanced nonmetastatic prostate cancer (T3–4 N0M0) 232
Management of advanced prostate cancer: hormone therapy I 233 Management of advanced prostate cancer: hormone therapy II 234 Management of advanced prostate cancer: hormone therapy III 238 Management of advanced prostate
cancer: androgen-independent/ castration-resistant disease 240 Palliative management of prostate
cancer 242
Prostate cancer: prevention; complementary and alternative therapies 244
Bladder cancer: epidemiology and etiology 246
Bladder cancer: pathology and staging 248
Bladder cancer: presentation 252 Bladder cancer: diagnosis and
staging 254
Management of superficial UC: transurethral resection of bladder tumor (TURBT) 256
Management of superficial UC: adjuvant intravesical
chemotherapy and BCG 258 Muscle-invasive bladder cancer:
surgical management of localized (pT2/3a) disease 260
Muscle-invasive bladder cancer: radical and palliative radiotherapy 263
Muscle-invasive bladder cancer: management of locally advanced and metastatic disease 264
186 CHAPTER 6 Urological neoplasia
Bladder cancer: urinary diversion after cystectomy 266
Transitional cell carcinoma (UC) of the renal pelvis and ureter 270
Radiological assessment of renal masses 274
Benign renal masses 276 Renal cell carcinoma:
epidemiology and etiology 278 Renal cell carcinoma: pathology,
staging, and prognosis 280 Renal cell carcinoma: presentation
and investigations 284 Renal cell carcinoma: active
surveillance 286
Renal cell carcinoma: surgical treatment I 288
Renal cell carcinoma: surgical treatment II 290
Renal cell carcinoma: management of metastatic disease 292
Testicular cancer: epidemiology and etiology 294
Testicular cancer: clinical presentation 296
Testicular cancer: serum markers 299
Testicular cancer: pathology and staging 300
Testicular cancer: prognostic staging system for metastatic germ cell cancer 303
Testicular cancer: management of nonseminomatous germ
cell tumors (NSGCT) 304 Testicular cancer: management
of seminoma, IGCN, and lymphoma 308
Penile neoplasia: benign, viralrelated, and premalignant lesions 310
Penile cancer: epidemiology, risk factors, and pathology 314
Squamous cell carcinoma of the penis: clinical management 318
Carcinoma of the scrotum 320 Tumors of the testicular
adnexa 321 Urethral cancer 322
Retroperitoneal fibrosis 326 Wilms tumor and
neuroblastoma 328
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188 CHAPTER 6 Urological neoplasia
Pathology and molecular biology
Neoplasia may be benign or malignant. Malignant neoplasms, characterized by local invasion of normal tissue or distant spread (metastasis) via lymphatic or vascular channels, may be primary or secondary.
Primary urological neoplasms most commonly arise from the lining epithelium of the genitourinary tract—benign (less commonly) or malignant. Neoplasms are considered to arise from a single abnormal cell, through successive aberrant divisions. This is called clonal expansion.
Malignant epithelial neoplasms are termed carcinomas; carcinomas may be further characterized histologically by prefixing either adenoif the neoplasm is glandular, or squamous cell or urothelial cell (formerly transitional cell) according to the epithelium from which it has arisen.
Benign epithelial neoplasms from glandular or transitional epithelium are respectively termed adenoma or papillary neoplasm of low malignant potential (PNLMP) (formerly papilloma).
Connective tissue neoplasms are described according to their components, adding benign (-oma) or malignant (-sarcoma) suffixes. For example, a benign neoplasm composed of blood vessels, fat, and smooth muscle is an angiomyolipoma; a malignant neoplasm composed of smooth muscle is a leiomyosarcoma. Sarcomas are rare in urological organs, constituting 1% of all neoplasms.
In the early stages of tumorigenesis, an identifiable precursor lesion may exist. Several invasive carcinomas are considered to arise from non-inva- sive epithelial lesions. As an example in the bladder it is known as carcinoma in situ (CIS) may progress and become muscle invasive and metastatic bladder cancer.
There are exceptions and rarities. The most common primary testicular neoplasms arise from testicular tubules and are collectively described as germ cell tumors. Rarely, primary malignant lymphoma can arise in the testis.
In the kidney, the childhood Wilms tumor arises from the embryonic mesenchyme of the metanephric blastema, while the relatively common benign oncocytoma is thought to arise from cells of the collecting ducts.
Secondary neoplasms within urological tissues are uncommon; they may arise by direct invasion from adjacent tissues (e.g., adenocarcinoma of the sigmoid colon may invade the bladder) or hematogenous spread from another site in the genitourinary (GU) system or more remote site such as breast cancer involving the kidney.
Like all neoplasia, urological neoplasia is a result of molecular genetic alterations. It may be hereditary or sporadic, depending on whether the genetic abnormalities are partly constitutional (germ-line) or wholly somatic (acquired).
Hereditary tumors tend to appear at a younger age than their sporadic counterparts and are often multifocal, due to an underlying constitutional genetic abnormality such as von Hipple–Lindau syndrome and renal cell carcinoma. Tumor formation results from loss of the balance between cell division and withdrawal from the cell cycle by differentiation or programmed cell death (apoptosis). Signals regulating cell proliferation and
PATHOLOGY AND MOLECULAR BIOLOGY 189
interactions come from proteins, encoded by messenger RNA that is in turn transcribed from genomic DNA.
Genetic abnormalities may promote tumor development or growth in a number of ways:
•Activation (overexpression) of oncogenes encoding transcription factors (e.g., c-myc)
•Inactivation (reduced expression) of tumor suppressor genes (e.g., pp. 190, 246, 279)
•Overexpression of peptide growth factors (e.g., insulin-like growth factor 1 [IGF-1])
•Overexpression of angiogenic factors (e.g., vascular endothelial growth factor [VEGF])
The diverse proteins encoded by tumor suppressor genes stabilize the cell, ensuring differentiation and a finite lifespan in which the cell performs its function. Inactivation of such genes by deletion or mutation may result in loss of this negative growth control.
For example, the gene for phosphatase and tensin homologue (PTEN) is a prostate tumor suppressor gene encoding a phosphatase that is active against protein and lipid substrates. It is present in normal epithelium but is commonly reduced in prostate cancer. It inhibits one of the intracellular signaling pathways, PI3 kinase-Akt, that is essential for cell cycle progression and cell survival. Inactivation of PTEN would therefore promote cell immortalization and proliferation.
Interest in the molecular genetics of urological neoplasia will lead to improved screening tests for hereditary diseases, enhanced diagnostic testing, and expanded choice for “targeted” treatment strategies. As an example, the newer multikinase receptor inhibitors such as sunitinib, sorafenib and temsirolimus are based on the latest understanding of the molecular biology of renal cell carcinoma.