- •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
292 CHAPTER 6 Urological neoplasia
Renal cell carcinoma: management of metastatic disease
Surgery
Approximately 25–30%of patients with RCC exhibit metastatic disease at presentation; 20–30% progress subsequently to this stage following nephrectomy.
Metastatic RCC is defined as tumor spread to one regional lymph node <2 cm (N1), or more than a single regional lymph node (N2). Distant metastatic sites (M1) include lung, liver, bone subcutaneous sites, and central nervous system. The prognosis is poor, so despite the rare possibility of spontaneous metastatic regression following nephrectomy, it was not usually undertaken except to relieve local symptoms of pain or hematuria.
The case for nephrectomy in metastatic RCC has reopened, as discussed on p. 290. Metastasectomy may be of benefit to the 1.5–3% of patients who develop a solitary metastasis (particularly in lung, adrenal, or brain) following nephrectomy.
Hormone therapy and cytoxic chemotherapy have little role in RCC.
Radiotherapy is useful for palliation of metastatic lesions in bone and brain, and in combination with surgery for spinal cord compression.
Immunotherapy
Responses are more likely in patients with good performance status, prior nephrectomy, and small-volume metastatic burden.
IL-2 (Aldesleukin)
IL-2 is the only agent shown to produce complete and durable responses in 6–8% of patients, with partial responses in 10–15%. A typical high-dose (bolus) is 600,000–720,000 IU/kg IV q8h for 5 days. It is usually given as several cycles.
Significant toxicity includes fever, chills, nausea, vomiting, hypotension, arrhythmias, and metabolic acidosis. Low-dose IL-2 is an alternative regimen to reduce toxicity.
Varying regimens are reported, generally 10% of a high-dose regimen administered as an outpatient.
Interferon A-2b
This offers a complete response of 1% and a partial-response rate of 10–15%. Varying regimens are described.
The SWOG Intergroup regimen for interferon A-2b is induction of 1.25 million IU m2 to 5 million IU m2 over 3 days and continued at 5 million IU m2 Monday, Wednesday, and Friday until progression.
The dose is modified on the basis of toxicity, which can include hematological and hepatic symptoms, diarrhea, anorexia, and hypotension.
RENAL CELL CARCINOMA: MANAGEMENT OF METASTATIC DISEASE 293
Molecular targeted therapies
The model for molecular targeted therapy in urology is highlighted by the development of new targeted therapies based on the molecular biology of RCC.1
•Sunitinib targets VEGF receptor tyrosine kinase and other pathways and is FDA approved for treatment of metastatic clear cell carcinoma. In RCC, a 30% partial-response rate is noted, with a 6-month improvement in progression-free survival, although, no complete responses are reported. The dose is 50 mg PO qd x4 weeks of a 6-week cycle (4 weeks on, 2 weeks off). Noteworthy are reports
of microangiopathic hemolytic anemia (MAHA) when used with bevacizumab.
•Sorafenib targets multiple tryosine kinases (VEGF receptor PDGF) receptor, fibroblast growth factor receptor-1 [FGFR-1], others). It is FDA approved for metastatic clear cell RCC at a dose of 400 mg PO bid.
•Temsirolimus is FDA approved for first-line therapy in poor-risk patients and offers approximately a 3-month improvement in survival. It is a parenteral rapamycin analogue that inhibits mTOR kinase given at a dose 25 mg IV weekly (premedicate with diphenhydramine 25–50 mg IV).
•Everolimus is approved for advanced RCC after failure of sunitinib or sorafenib. It is an mTOR (mammalian target of rapamycin) inhibitor dosed at 10 mg PO daily.
•Bevacizumab is a VEGF inhibitor given at 10 mg/kg IV every 2 weeks. It is not currently FDA approved for RCC.
Palliative care
Medications such as megestrol acetate (40–320 mg/day divided dose) or steroids (e.g., dexamethasone 4 mg daily) improve appetite and mental state, but are unlikely to have an impact on tumor growth.
The involvement of multidisciplinary uro-oncology, palliative, and primary care teams is essential to support these patients and their relatives.
1 Basso M, Cassano A, Barone C (2010). A survey of therapy for advanced renal cell carcinoma. Urol Oncol. 28(2):121–133.
294 CHAPTER 6 Urological neoplasia
Testicular cancer: epidemiology and etiology
Incidence and mortality
Primary testicular cancer (TC) is the most common solid cancer in men ages 20–45 years; it is rare below age 15 years and above 60 years. Constituting 1–2% of all male cancers, the lifetime risk of developing testicular cancer is 1 in 500. It is also considered the most curable cancer.
There were 8400 U.S. cases in 2009 but only 380 deaths. It is apparently increasing in incidence; it is reported to affect 7 per 100,000 men.
Public health campaigns encouraging testicular self-examination (TSE) for young men are ongoing in countries such as England.
Epidemiology and etiology
•Age: the most commonly affected age group is 20–45 years, with germ cell tumors; teratomas are more common at ages 20–35, while seminoma is more common at ages 35–45 years. Rarely, infants and boys below age 10 years develop yolk sac tumors, and 50% of men >60 years with TC have lymphoma.
•Race: White people are three times more likely to develop TC than are Black people in the United States.
•Cryptorchidism: 10% of TC cases occur in undescended testes: the risk increases by 3–14 times compared to men with normally
descended testes. Ultrastructural changes are present in these testes by age 3 years, although earlier orchidopexy does not completely eliminate the risk of developing TC. 5–10% of patients with a cryptorchid testis develop malignancy in the normally descended contralateral testis.
•Intratubular germ cell neoplasia (IGCN) is synonymous with carcinoma in situ, although the disease arises from malignant change in spermatogonia. 50% of cases develop invasive germ cell TC within 5 years. The population incidence is 0.8%. Risk factors include cryptorchidism, extragonadal germ cell tumor, previous or
contralateral TC (5%), atrophic contralateral testis, 45XO karyotype, and infertility.
•Human immunodeficiency virus (HIV) patients infected with the HIV virus are developing seminoma more frequently than expected.
•Genetic factors appear to play a role, given that first-degree relatives are at higher risk, but a defined familial inheritance pattern is not apparent.
•Maternal estrogen ingestion during pregnancy increases the risk of cryptorchidism and TC in the male offspring.
Trauma and viral-induced atrophy have not been convincingly implicated as risk factors for TC.
Bilateral testicular cancer occurs in 1–2% of cases.
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