Prostate cancer: management

Localised prostate cancer (T1/T2)

Treatment depends on life expectancy and patient choice. Options include:

 conservative: active monitoring & watchful waiting

 radical prostatectomy
 radiotherapy: external beam and brachytherapy

Localised advanced prostate cancer (T3/T4)

Options include:

 hormonal therapy: see below

 radical prostatectomy
 radiotherapy: external beam and brachytherapy

Metastatic prostate cancer disease - hormonal therapy

Synthetic GnRH agonist

 e.g. Goserelin (Zoladex)

 cover initially with anti-androgen to prevent rise in testosterone

Anti-androgen

 cyproterone acetate prevents DHT binding from intracytoplasmic protein

complexes

Orchidectomy
Prostate cancer: PSA testing

Prostate specific antigen (PSA) is a serine protease enzyme produced by normal and
malignant prostate epithelial cells. It has become an important tumour marker but much
controversy still exists regarding its usefulness as a screening tool.

The NHS Prostate Cancer Risk Management Programme (PCRMP) has published
updated guidelines in 2009 on how to handle requests for PSA testing in asymptomatic
men. A recent European trial (ERSPC) showed a statistically significant reduction in the
rate of death prostate cancer by 20% in men aged 55 to 69 years but this was associated
with a high risk of over-diagnosis and over-treatment. Having reviewed this and other
data the National Screening Committee have decided not to introduce a prostate cancer
screening programme yet but rather allow men to make an informed choice.

Age-adjusted upper limits for PSA were recommended by the PCRMP:

Age PSA level (ng/ml)

50-59 years 3.0
60-69 years 4.0
> 70 years 5.0

PSA levels may also be raised by*:

 benign prostatic hyperplasia (BPH)

 prostatitis and urinary tract infection (NICE recommend to postpone the PSA test
for at least 1 month after treatment)
 ejaculation (ideally not in the previous 48 hours)
 vigorous exercise (ideally not in the previous 48 hours)
 urinary retention
 instrumentation of the urinary tract

Poor specificity and sensitivity

 around 33% of men with a PSA of 4-10 ng/ml will be found to have prostate
cancer. With a PSA of 10-20 ng/ml this rises to 60% of men
 around 20% with prostate cancer have a normal PSA
  various methods are used to try and add greater meaning to a PSA level
including age-adjusted upper limits and monitoring change in PSA level with
time (PSA velocity or PSA doubling time)

*whether digital rectal examination actually causes a rise in PSA levels is a matter of
debate

Nephroblastoma

Nephroblastoma (Wilm's tumours)

 Usually present in first 4 years of life

 May often present as a mass associated with haematuria (pyrexia may occur in
50%)
 Often metastasise early (usually to lung)
 Treated by nephrectomy
 Younger children have better prognosis (<1 year of age =80% overall 5 year
survival)

Testicular disorders

Testicular cancer
Testicular cancer is the most common malignancy in men aged 20-30 years. Around
95% of cases of testicular cancer are germ-cell tumours. Germ cell tumours may
essentially be divided into:

Tumour type Key features Tumour markers Pathology

Seminoma  Commonest  AFP usually Sheet like lobular
subtype (50%) normal patterns of cells
 Average age at  HCG elevated with substantial
diagnosis = 40 in 10% fibrous
 Even advanced seminomas component.
disease  Lactate Fibrous septa
Tumour type Key features Tumour markers Pathology
associated with 5 dehydrogenase; contain
year survival of elevated in 10- lymphocytic
73% 20% seminomas inclusions and
(but also in many granulomas may
other conditions) be seen.
Non seminomatous germ  Younger age at  AFP elevated in Heterogenous
cell tumours (42%) presentation =20-30 up to 70% of texture with
years cases occasional
 Advanced disease  HCG elevated ectopic tissue
 Teratoma carries worse prognosis in up to 40% of such as hair
 Yolk sac tumour (48% at 5 years) cases
 Choriocarcinoma  Retroperitoneal  Other markers
 Mixed germ cell lymph node dissection rarely helpful
tumours (10%) may be needed for
residual disease after
chemotherapy

Image demonstrating a classical seminoma, these tumours are typically more uniform
than teratomas
 Image sourced from Wikipedia

Risk factors for testicular cancer

 Cryptorchidism
 Infertility
 Family history
 Klinefelter's syndrome
 Mumps orchitis
Features

 A painless lump is the most common presenting symptom

 Pain may also be present in a minority of men
 Other possible features include hydrocele, gynaecomastia

Diagnosis

 Ultrasound is first-line
 CT scanning of the chest/ abdomen and pelvis is used for staging
 Tumour markers (see above) should be measured

Management

 Orchidectomy (Inguinal approach)

 Chemotherapy and radiotherapy may be given depending on staging
 Abdominal lesions >1cm following chemotherapy may require retroperitoneal
lymph node dissection.

Prognosis is generally excellent

 5 year survival for seminomas is around 95% if Stage I

 5 year survival for teratomas is around 85% if Stage I

Benign disease

Epididymo-orchitis
Acute epididymitis is an acute inflammation of the epididymis, often involving the testis
and usually caused by bacterial infection.

 Infection spreads from the urethra or bladder. In men <35 years, gonorrhoea or
chlamydia are the usual infections.
  Amiodarone is a recognised non infective cause of epididymitis, which resolves
on stopping the drug.
 Tenderness is usually confined to the epididymis, which may facilitate
differentiating it from torsion where pain usually affects the entire testis.

Testicular torsion

 Twist of the spermatic cord resulting in testicular ischaemia and necrosis.

 Most common in males aged between 10 and 30 (peak incidence 13-15 years)
 Pain is usually severe and of sudden onset.
 Cremasteric reflex is lost and elevation of the testis does not ease the pain.
 Treatment is with surgical exploration. If a torted testis is identified then both
testis should be fixed as the condition of bell clapper testis is often bilateral.

Hydrocele

 Presents as a mass that transilluminates, usually possible to 'get above' it on

examination.
 In younger men it should be investigated with USS to exclude tumour.
 In children it may occur as a result of a patent processus vaginalis.
 Treatment in adults is with a Lords or Jabouley procedure.
 Treatment in children is with trans inguinal ligation of PPV.

Renal tumours

Renal cell carcinoma

Renal cell carcinoma is an adenocarcinoma of the renal cortex and is believed to
arise from the proximal convoluted tubule. They are usually solid lesions, up to
20% may be multifocal, 20% may be calcified and 20% may have either a cystic
component or be wholly cystic. They are often circumscribed by a pseudocapsule
of compressed normal renal tissue. Spread may occur either by direct extension
into the adrenal gland, renal vein or surrounding fascia. More distant disease
usually occurs via the haematogenous route to lung, bone or brain.
Renal cell carcinoma comprise up to 85% of all renal malignancies. Males are more
commonly affected than females and sporadic tumours typically affect patients in
their sixth decade.
Patients may present with a variety of symptoms including; haematuria (50%), loin
pain (40%), mass (30%) and up to 25% may have symptoms of metastasis.Less
than 10% have the classic triad of haematuria, pain and mass.

Investigation
Many cases will present as haematuria and be discovered during diagnostic work
up. Benign renal tumours are rare, so renal masses should be investigated with
multislice CT scanning. Some units will add and arterial and venous phase to the
scan to demonstrate vascularity and evidence of caval ingrowth.

CT scanning of the chest and abdomen to detect distant disease should also be
undertaken.

Routine bone scanning is not indicated in the absence of symptoms.

Biopsy should not be performed when a nephrectomy is planned but is mandatory

before any ablative therapies are undertaken.

Assessment of the functioning of the contra lateral kidney.

Management
T1 lesions may be managed by partial nephrectomy and this gives equivalent
oncological results to total radical nephrectomy. Partial nephrectomy may also be
performed when there is inadequate reserve in the remaining kidney.

For T2 lesions and above a radical nephrectomy is standard practice and this may
be performed via a laparoscopic or open approach. Preoperative embolisation is
not indicated nor is resection of uninvolved adrenal glands. During surgery early
venous control is mandatory to avoid shedding of tumour cells into the
circulation.

Patients with completely resected disease do not benefit from adjuvant therapy with
either chemotherapy or biological agents. These should not be administered
outside the setting of clinical trials.

Patients with transitional cell cancer will require a nephroureterectomy with

disconnection of the ureter at the bladder.
Renal stones: imaging

The table below summarises the appearance of different types of renal stone on x-ray

Type Frequency Radiograph appearance

Calcium oxalate 40% Opaque

Mixed calcium oxalate/phosphate stones 25% Opaque

Triple phosphate stones* 10% Opaque

Calcium phosphate 10% Opaque

Urate stones 5-10% Radio-lucent

Cystine stones 1% Semi-opaque, 'ground-glass' appearance

Xanthine stones <1% Radio-lucent

*stag-horn calculi involve the renal pelvis and extend into at least 2 calyces. They develop in
alkaline urine and are composed of struvite (ammonium magnesium phosphate, triple
phosphate). Ureaplasma urealyticum and Proteus infections predispose to their formation

Bladder cancer: risk factors

Risk factors for transitional cell carcinoma of the bladder include:

 Smoking
 Exposure to aniline dyes in the printing and textile industry: examples are 2-
naphthylamine and benzidine
 Rubber manufacture
  Cyclophosphamide

Risk factors for squamous cell carcinoma of the bladder include:

 Schistosomiasis
 Calmette-Guérin (BCG) treatment
 Smoking

Lower genitourinary tract trauma

Basics

 Most bladder injuries occur due to blunt trauma

 85% associated with pelvic fractures
 Easily overlooked during assessment in trauma
 Up to 10% of male pelvic fractures are associated with urethral or bladder injuries

Types of injury

Urethral injury Basics

 Mainly in males
 Blood at the meatus (50% cases)
 There are 2 types:

Bulbar rupture

 most common
 straddle type injury e.g. bicycles
 triad signs: urinary retention, perineal haematoma,
 blood at the meatus

Membranous rupture

 can be extra or intraperitoneal

 commonly due to pelvic fracture
 Penile or perineal oedema/ hematoma
 PR: prostate displaced upwards (beware co-existing
retroperitoneal haematomas as they may make
examination difficult)

Investigation

 ascending urethrogram

Management

 suprapubic catheter (surgical placement, not

percutaneously)

External genitalia injuries Secondary to injuries caused by penetration, blunt trauma,

(i.e., the penis and the continence- or sexual pleasure-enhancing devices, and
scrotum) mutilation
Bladder injury Basics

 rupture is intra or extraperitoneal

 presents with haematuria or suprapubic pain
 history of pelvic fracture and inability to void: always
suspect bladder or urethral injury
 inability to retrieve all fluid used to irrigate the
bladder through a Foley catheter indicates bladder
injury

Investigation
  IVU or cystogram

Management

 laparotomy if intraperitoneal, conservative if

extraperitoneal