- •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
200 CHAPTER 6 Urological neoplasia
PSA derivatives: free-to-total ratio, density, and velocity
Measurement of the free-to-total (F:T) PSA ratio can increase the specificity of total PSA because the ratio is lower in men with prostate cancer than in men with benign hyperplasia. Most urologists use this in deciding whether to rebiopsy a patient with previous benign biopsies, instead of using this to decide about the need for a first-time biopsy.
As an example, a man with a normal DRE and a PSA of 4–10 ng/mL has a 27% risk of prostate cancer. This risk rises to 60% if the F:T ratio is 10% and falls to 10% if his ratio is >25%. The F:T ratio is most useful in the total PSA range 2.5–10 ng/mL.
Consideration may be given to the prostate volume, since large benign prostates are the most common cause of mildly elevated PSA. Serum PSA/ prostate volume = PSA density, and serum PSA/prostate transition-zone volume = PSA-TZ density. Various cutoff densities have been proposed to raise the specificity of total PSA, possibly to reduce the need for prostatic biopsy, but the issue remains controversial.
Short-term variations in serum PSA occur in the presence or absence of cancer, the cause of which may be technical or physiological. Longer term, the PSA tends to rise slowly due to BPH and faster due to prostate cancer—PSA velocity.
A PSA velocity >0.75 ng/mL per year with at least three determinations over at least 18 months is suggestive of the presence of PC. Recent studies have lowered this threshold significantly and some authorities believe it should no longer be considered as an indication for biopsy. A high pretreatment PSA velocity (>2.0 ng/mL/year) has been shown to correlate with a worse prognosis after radiotherapy or radical surgery.
PSA doubling time (PSADT) is the time it takes for a PSA value to double, based on an exponential growth pattern. Pretreatment PSADT has little diagnostic value. PSADT is an important predictor of tumor progression, therapeutic outcome, and tumor-specific mortality. Following surgery or radiotherapy for prostate cancer, PSADT <6 months indicates distant disease progression, whereas a more delayed PSADT suggests local recurrence.
Other markers are being studied for the diagnosis of prostate cancer. Urine-based analysis of PCA3 is promising. The biomarker known as early prostate cancer antigen-2 (EPCA-2) is also showing promise in identifying which patients with an elevated PSA may have cancer.
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202 CHAPTER 6 Urological neoplasia
Prostate cancer: transrectal ultrasonography and biopsies
The most common diagnostic modality for prostate cancer is currently transrectal ultrasonography (TRUS) with guided biopsies (Fig. 6.1). TRUS provides imaging of the prostate and seminal vesicles using a 7.5 mHz biplane intrarectal probe measuring approximately 1.5 cm in diameter.
While TRUS imaging may be performed for other reasons (e.g., evaluation of infertility, sizing for treatment planning), a TRUS without biopsy is considered an inadequate way to evaluate for prostate cancer. Many advocate use of an enema before the biopsy to enhance visualization.
The ultrasound-guided periprostatic injection of local anesthetic (1% lidocaine) has become the standard in the United States when biopsy is planned. Rarely, general or regional anesthesia may be necessary, especially in the presence of anal stenosis or if saturation (>20) biopsies are planned.
A careful DRE precedes insertion of the probe. Broad-spectrum antimicrobials (e.g., quinolone antibiotic) are given before and after the procedure.
TRUS can image the outline of the prostate, cysts, abscesses, and calcifications within the prostate. Hypoechoic and hyperechoic lesions in the peripheral zone may be due to prostate cancer or inflammatory conditions, although most prostate cancers are in fact isoechoic and are not visualized on ultrasound.
Advanced biopsy techniques that use microbubble contrast agents with and without color Doppler are being actively investigated to improve yield. There are no convincing data that color Doppler alone can improve the yield of prostate biopsy over the standard grayscale biopsy.
Indications for TRUS without biopsy
•Accurate measurement of prostate volume for treatment planning (e.g., microwave, needle ablation, brachytherapy)
•Male infertility with azoospermia, to look for seminal vesicle and ejaculatory duct obstruction due to calculus or Müllerian cyst
•Suspected prostatic abscess (can be drained by needle aspiration)
•Investigation of chronic pelvic pain, looking for prostatic cyst or calculi
Indications for TRUS with biopsies
•An abnormal DRE and/or an elevated PSA (exceptions include very elderly men with massively elevated PSA and abnormal DRE, or those in whom a TURP is indicated for severe LUTS/retention where histology will be obtained). See Table 6.1 (p. 199).
•Previous biopsies showing multifocal high-grade PIN or ASAP
•Previous biopsies normal, but PSA rising or DRE abnormal
•To confirm viable prostate cancer following treatment if further treatment is being considered
PROSTATE CANCER: TRANSRECTAL ULTRASONOGRAPHY & BIOPSIES 203
|
Pubic |
Urethra |
Bladder |
symphysis |
|
|
|
Prostate |
Peritoneum |
|
gland |
|
|
|
|
|
Biopsy |
|
|
needle |
|
|
Spring-loaded |
|
|
biopsy needle |
|
|
‘gun’ |
Seminal |
Rectum |
Ultrasound |
vesicles |
|
probe |
Figure 6.1 Transrectal ultrasound scanning (TRUS). An ultrasound probe is inserted into the rectum to guide the biopsy needle into the correct position so that multiple core biopsies can be taken from different areas of the prostate.
Biopsy protocol
Ten to 12 18 French Tru-Cut needle biopsies are taken in a systematic fashion to include any palpable or sonographic target lesion. The traditional sextant protocol (a parasagittal base, mid-gland, and apex from each side) is no longer considered an adequate technique. To the 10–12 biopsy regimen, add samples from the far lateral peripheral zones (Fig. 6.2). Studies have demonstrated that these extra biopsies detect up to 15% more cancers.
Additional biopsies of each transition zone may be taken if a transition zone cancer is suspected or if a patient is undergoing repeat biopsies due to a rising PSA. Seminal vesicles biopsies occasionally add staging information if they appear abnormal on DRE, TRUS, or MRI.
Complications of prostatic biopsy
•Occasional vasovagal reaction (fainting) immediately after procedure
•Small risk of urinary tract infection and rarely urosepsis, which may be life threatening
•Small risk of significant rectal bleeding
•Mild hemospermia or hematuria, for several weeks after the procedure
Prostate cancer may also be diagnosed by transurethral resection of the prostate (TURP) histology or clinically (without histology) in certain circumstances. For example, it could be viewed as unnecessarily invasive to biopsy an elderly and frail symptomatic patient with a rock-hard prostate and a PSA of >100 ng/mL prior to commencing hormone therapy.
204 CHAPTER 6 Urological neoplasia
Box 6.2
It is not safe to biopsy a patient who is anticoagulated on warfarin; biopsying patients on low-dose aspirin remains controversial but is not considered unsafe by many. Other antiplatelet drugs (e.g., clopidogrel) are usually stopped for 7–10 days prior to biopsy.
It is important that the patient appreciates that negative biopsies do not exclude the possibility of prostate cancer, and that a positive result will not necessarily result in the recommendation of immediate treatment.
|
Seminal vesicles |
(a) |
|
|
Base |
Posterior |
Traditional |
surface of |
sextant |
prostate |
|
|
Apex |
(b)
8-core
(c)
12-core
Figure 6.2 Biopsy protocols. A 10to 12-core biopsy regimen is considered the standard of care today. Obtaining 4 apical cores can often be difficult.
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