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CHAPTER 10 Urology
372
Erectile dysfunction
Key facts
• Erectile dysfunction (ED) is the inability to achieve or maintain an
erection satisfactory for sexual intercourse.
• Distinct from premature, retrograde, or delayed ejaculation.
• Causes include:
Psychogenic. • Anxiety, depression.
Drugs.• Antihypertensives, recreational drugs, tobacco, alcohol.
Vascular. • Hypercholesterolaemia, atheroma, diabetes mellitus (DM).
Metabolic/endrocrine. • Azotaemia, hypercholesterolaemia,
hypogonadism, hyperthyroidism, hyperprolactinaemia, DM.
Neurological.• Parkinson’s disease, CVA, spinal injury, neurological
damage following pelvic surgery, pelvic fracture, autonomic
neuropathies.
Penile. • Cavernositis, Peyronie’s disease, previous priapism.
Clinical features
• Specifi c validated questionnaires have been developed as
investigational tools and can be used in practice.
• The presence of morning erections strongly suggests psychogenic
cause.
• Small testicles, lack of secondary sexual characteristics suggest an
endocrine cause.
• Lack of lower limb pulses suggests possible vascular cause.
• Neurological defi cits in S2, 3, 4 distributions suggest neurological
cause.
Investigations and diagnosis
• Check blood glucose, lipids and serum electrolytes, hormone profi les
(testosterone, FSH/LH, prolactin), thyroid function for underlying
cause.
• Dynamic cavernosometry confi rms if there is a true vasculogenic cause
(venous or arterial).
• Angiography demonstrates arterial anatomy if revascularization is
contemplated.
Treatment
• Psychotherapy or specialist sexual counselling for psychogenic causes.
• Oral phosphodiesterase-5 inhibitors—sildenafi l (Viagra
tadalafi l.
• Apomorphine sublingual.
• Intracavernosal—prostaglandins, A-blockers, papaverine.
• Intraurethral—prostaglandin.
• Vacuum devices-induced pseudoerection.
• Prosthesis.
TM
), vardenafi l,
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CHAPTER 10 Urology
374
Adenocarcinoma of the kidney
Key facts
• Accounts for 2% of all cancers.
• Incidence is 2–5 per 100 population.
• ♂:♀, 3:1.
Clinical features
• May be asymptomatic at presentation, the tumour being detected
during imaging of the abdomen for an unrelated condition (e.g. CT
scan or ultrasound scan).
• Symptoms include painless haematuria, groin pain, awareness of a mass
arising from the fl ank.
• Chest symptoms and bone pain may be present with metastases to
these sites.
• Positive family history or clinical evidence of neurological or ocular
disease should raise the possibility of von Hippel–Lindau disease (VHL).
• Renal carcinomas are often small and may be multiple.
• Local spread often includes spread via intravascular invasion into the
renal vein and inferior vena cava.
Diagnosis and investigations
• Blood tests. Hb and ferritin to check for anaemia (iron-defi cient);
electrolytes and Cr to check for overall renal function. Raised
corrected calcium and alkaline phosphatase suggest possible bony
metastases.
• Diagnostic and staging investigation of choice is a pre- and post-IV
contrast-enhanced CT scan of abdomen and chest (delineates size,
local extent, local invasion, likely sites of possible metastases).
• Isotope bone scan if there is clinical or biochemical evidence of bony
metastases.
Treatment
Surgery
• Recommended as the only curative treatment except in the very
elderly, extensive (inoperable) local invasion, and the presence of
metastases.
• May be via open or laparoscopic approach.
• Radical nephrectomy is recommended for large tumours.
• Partial nephrectomy may be suitable for peripheral tumours <4cm in size.
• Resection of the primary cancer is occasionally appropriate with
the presence of metastasis (the deposit must be solitary and itself
amenable to complete local resection, e.g. in the liver or lungs).
Medical therapy
• Used for metastatic disease.
• Biological therapy can be with immune modulators such as interferons
and interleukins. Partial response rates of 15–20% can be achieved, but
the treatment carries signifi cant morbidity. This is reserved for patients
with a good performance status.
ADENOCARCINOMA OF THE KIDNEY
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• Chemotherapy is rarely used as the tumours are not chemosensitive.
• Hormonal therapy (androgens and tamoxifen) may have some benefi t.
• Radiotherapy is useful to palliate painful bony metastases.
Prognosis
• The outcome following nephrectomy is unpredictable.
• Tumours that are pathologically confi ned to the kidney confer a good
prognosis. Adverse risk factors include extracapsular spread, invasion
of the renal vein, lymph node involvement.
• Cure is likely if the tumour is <4cm in diameter and if there are no
adverse pathological features.
• Periodic radiological follow-up is recommended in most cases so that
locally recurrent or metastatic disease can be detected at an early
stage.
Key revision points—anatomy of the kidney
Usually fi ve segments (apical, anterior superior, anterior inferior, posterior and inferior), each supplied by its own artery.
- Fascial coverings.
-
Perirenal, anterior and posterior layers, enclosing kidney and
perirenal fat.
-
Lateral conal fascia, formed from anterior and posterior perirenal
fascia; fused with transversalis and iliac fascia laterally.
- Blood supply.
-
Arterial supply, direct from the aorta; renal arteries also give
supply to the renal pelvis and upper ureter and adrenal gland.
Venous drainage, direct to inferior vena cava; left renal vein also
-
drains the left gonadal vein.
- Common anatomical variants.
-
Unilaterally absent kidney (1 in 1200).
Pelvic kidney (1 in 2500).Joined (horseshoe) kidney (1 in 400).-
375
CHAPTER 10 Urology
376
Transitional cell tumours
Key facts
• Transitional cell tumours (TCT) may affect any part of the urinary
epithelium (renal pelvis, ureter, bladder, or very rarely, urethra).
• TCT have a spectrum of disease from benign superfi cial ‘papilliferous’
growths to frankly invasive transitional cell carcinoma (TCC);
progression may occur from benign to more malignant forms with
time.
• TCC of the bladder. Fifth commonest cause of cancer deaths and the
commonest form of bladder cancer in the UK; ♂:♀,, 3:1.
• TCC of the upper urinary tract is similar in spectrum of disease and
management to bladder tumours, but much less common.
• TCT is associated with:
Exposure to aromatic hydrocarbons, e.g. workers in the •
petrochemical, industrial dye, rubber industries, chimney sweeps.
Smoking (especially in women).•
• Risk is probably due to excretion of carcinogenic products excreted
and concentrated in the urine and tumours are more likely in locations
exposed to urine for the longest periods, i.e. bladder.
Pathological features
• The majority (70%) are superfi cial in nature at diagnosis, being
confi ned to the mucosa.
• Invasion into the lamina propria, muscle, and perivesical fat can occur
with lymphatic and distant spread occurring in advanced cases.
• TCC in situ is pre-invasive and associated with a high risk of muscle-
invasive disease if not adequately treated.
• TCC must be differentiated from other forms of bladder cancer.
Squamous cell carcinoma. • Usually caused by chronic irritation due to
schistosomiasis infestation (bilharzia), indwelling catheter, repeated
previous surgical interventions.
Adenocarcinoma. • Rare; presents in middle age and is usually located
in the dome of the bladder in association with the urachus.
Clinical features
• The majority of cases present with painless haematuria.
• Other features are painful micturition, renal colic due to blood clot,
disturbance of urinary stream, retention of urine.
Diagnosis and investigation
Urine cytology May reveal malignant cells; if there are malignant cells, TCC
or carcinoma in situ will probably be present.
Cystoscopy
• Usually carried out using a fi bre optic fl exible cystoscope and local
anaesthetic gel.
• Images the bladder and urethra; suspect lesions usually require
transurethral resection under GA for diagnosis.
TRANSITIONAL CELL TUMOURS
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Transurethral resection
• Usually carried out using a rigid endoresectoscope under GA.
• Permits resection of all or part of the tumour using a diathermy ‘loop’,
with the tumour resected piecemeal; resection may be carried out into
deep tissue (the muscle wall of the bladder beneath the tumour).
• Subsequent pathological examination will determine the histological
grade and the pathological stage, e.g. depth of invasion.
• Following resection, bimanual examination determines whether or not
a residual mass is present.
Upper tract imaging
• Used to identify and assess pelviureteric tumours.
• IVU or ultrasound scan.
• Ultrasound scan permits examination of the renal cortex and will
detect tumours of 1cm diameter in the pelvicalyceal system, ureter,
and bladder.
• Bladder tumour may show as a fi lling defect in the cystogram phase.
Local staging MRI and CT scanning to detect local or systemic spread.
Treatment
Superfi cial TCT
• Remove; completed by endoscopic resection.
• Recurrence is common and regular endoscopic surveillance with check
cystoscopy is performed.
• Intravesical chemotherapy reduces the risk of tumour recurrence
(single dose of mitomycin C instilled after resection of the tumour).
• For multiple or recurrent TCC, six intravesical treatments are given.
Carcinoma in situ
• Requires thorough therapy to prevent invasive TCC.
• Immunotherapy with intravesical BCG is effective in 60% of cases.
• Needs close endoscopic surveillance with regular bladder biopsy.
Invasive TCC
• Muscle-invasive tumours are of high grade and the prognosis is poor.
• Curative therapy can be offered with radical cystectomy (combined
with a urinary diversion via an ileal conduit) or radical radiotherapy.
Squamous cell and adenocarcinoma
• Radical cystectomy provided general condition allows.
• Usually resistant to radiotherapy and chemotherapy.
Prognosis
• Approximately 30% develop muscle-invasive disease.
• The 5y survival rate for muscle-invasive bladder cancer is 40–50%.
• Metastatic TCC is poor prognosis with a median survival of 13 months.
• Systemic chemotherapy with cis-platinum-containing regimes provides
a long-term response in 15% of cases.
377
CHAPTER 10 Urology
378
Adenocarcinoma of the prostate
Key facts
• Most commonly diagnosed cancer affecting men in the western world.
• Approximately 30 000 new cases diagnosed annually in the UK with
10 000 deaths.
• Peak incidence in eighth decade.
• Approximately 40% of cases present with early disease; 20% of cases
have metastases at presentation.
Clinical features
• The majority of men present with LUTS (b p. 354).
• Bone pain, pathological factures, and features of hypercalcaemia are
occasional presenting features due to metastases.
• May be diagnosed by digital rectal examination; areas of fi rmness or
palpable nodules are suggestive of malignant change.
Diagnosis and investigations
• Serum PSA. Can be used as a screening test; high sensitivity, but low
specifi city; elevated age-specifi c levels are an indication to consider
prostate biopsy.
• Transrectal ultrasound (TRUS). Permits detailed imaging of the prostate.
Systematic needle biopsy is performed guided by the ultrasound
images with antibiotic prophylaxis; graded using the Gleason grading
system which assigns a numerical score to adverse features from a
minimum of 2 to a maximum of 10.
• Pelvic MRI. Used to detect the presence of extracapsular extension or
the presence of pelvic lymphadenopathy (suggests spread).
• Laparoscopic node biopsy. May be performed to sample enlarged nodes
prior to considering radical treatment.
• Isotope bone scan. Will detect the presence of bone metastases.
Treatment
Localized disease (confi ned to prostate)
Patients with a life expectancy of <10y
• Active monitoring with treatment deferred until there is evidence of
disease progression (rising serum PSA).
• Hormonal therapy or A-blocker treatment offered for troublesome
LUTS.
• TURP is considered for severe symptoms with features of obstruction.
Life expectancy of >10y
• Counselled in detail about radical treatment aimed at cure.
• The options are as follows:
Radical prostatectomy• . Operation to remove the prostate and
seminal vesicles; complications include incontinence (severe in 3%)
and ED (40–50% of cases).
External beam radiotherapy• . Radiation is delivered at a radical
dose of 55–70Gy in 20–25 fractions over a 4–5-week period;
complications include cystitis, proctitis, and ED.
ADENOCARCINOMA OF THE PROSTATE
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Brachytherapy• . Radioactive seeds placed into the prostate using
TRUS guidance; a relatively new technique and long-term follow-up
data are lacking.
Locally advanced disease (spread beyond the prostate)
• Incurable and treatment is therefore palliative.
• Eighty per cent are androgen-dependent. Hormone therapy reduces
androgenic drive to the prostate cancer cell using two methods:
Luteinizing hormone• -releasing hormone (LHRH) agonists. Given by
3-monthly depot injections, suppresses testosterone production by
the testes; side effects include hot fl ushes, lethargy, loss of sexual
function.
Anti-androgens• . Given orally, act as competitive inhibitors at the
level of the androgen receptor, reduce androgenic stimulus to the
prostate cancer cell without reducing serum testosterone levels;
side effects include gynaecomastia and nipple tenderness (60%),
potency is sometimes preserved.
Metastatic disease
Treated with hormonal therapy using LHRH analogues. Addition of an
anti-androgen provides a secondary response in some cases of PSA
relapse. Pain from bone metastases usually responds to radiotherapy.
Hormone-resistant disease
• All prostate cancers will eventually become hormone-resistant.
• Chemotherapy is appropriate for patients who have a good
performance status.
• Palliative radiotherapy and bisphosphonates are used for bony
metastases.
Prognosis
• Localized prostate cancer. Excellent prognosis with 70–90% 10y
disease-specifi c survival fi gures.
• Locally advanced, non-metastatic disease. Median survival of 7y.
• Metastatic disease. Median survival of 2–3y.
• Once the state of hormone-resistant disease has been reached, the
median survival is 6–12 months.
379
CHAPTER 10 Urology
380
Carcinoma of the penis
Key facts
• Rarest of the urological cancers.
• Occurs primarily in older men.
Clinicopathological features
• Over 95% are squamous cell carcinoma.
• Usually affects the glans, but may involve the shaft.
• Associated with chronic infection of the penis, particularly in the
presence of phimosis.
• Early cases present with a painless ulcer, nodule, or ‘warty’ outgrowth
on the penis that may also involve the foreskin.
• Advanced disease presents with a fungating mass, usually ulcerated.
Inguinal lymphadenopathy may be present on examination. Nodes are
often reactive rather than being metastatic and antibiotics should be
given prior to further assessment.
Diagnosis and investigations
• Biopsy lesion to confi rm the diagnosis.
• Pelvic and abdominal CT scanning provide further evidence of nodular
involvement in cases with positive inguinal nodes.
Treatment
• If primary tumour confi ned to glans, treatment involves either partial
amputation or radiotherapy.
• Superfi cial lesions can be treated by excision of the glans followed by
glans reconstruction.
• More advanced carcinomas require total penectomy. Inguinal and iliac
lymph node dissections are considered.
Prognosis
• Early stage penile cancer has a high cure rate with either surgery or
radiotherapy.
• Long-term survival is sometimes seen even in cases of lymph node
involvement.
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