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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3998_Библиотеки_им_академика_М_И_Перельмана
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Prostate cancer and PSA 257
There are currently no tests to identify patients that are more likely to progress once detected and
active surveillance with an intention to cure but offering deferred radical treatment at progression is a
reasonable option to minimize the problem of overtreatment/side effects related to radical therapy.
Downside of PSA testing
1. It can miss cancer and provide false reassurance.
2. It may lead to unnecessary anxiety and medical tests when no cancer is present.
3. It might detect slow-growing cancer that may never cause any symptoms or shorten life span.
4. The main treatments of prostate cancer have signicant side effects, and there is some
overtreatment of patients due to screening for prostate cancer. There was a 21 per cent mortality
reduction reported at 11 years of follow-up in the core age group of the European randomized
screening study for prostate cancer (ERSPC) that was achieved in men who entered at an age
between 55 and 69 years. The numbers needed to screen and then treat to avoid one prostate
cancer–related death were 837 and 29 at 10 years and 503 and 18 at 12 years, respectively.
Routine PSA screening is not currently recommended in the United Kingdom for asymptomatic
individuals. However, the PSA test may be performed in patients aged over 50 years who present with
lower urinary tract symptoms or who request it.
Those with a family history of prostate cancer and from an African-Caribbean origin should be
advised to be tested from the age of 40 years as a baseline value and if the level is <1 ng/mL then
further tests may be repeated in 8 years and if >1 ng/mL then may be repeated in 2 years.
OSCE COUNSELLING CASE 5.6 –
‘Will I be incontinent after my prostate
operation?’
Q1: What are the main complications of radical retropubic prostatectomy and will I be incontinent
after a prostate operation?
Surgery is commonly offered to patients with an expected survival of over 10 years and localized
prostate cancer.
Surgery may be performed by an open or laparoscopic/robotic route: the open approach may
be retropubic or perineal. A bilateral nerve-sparing approach may be considered if suitable; this is
more likely to preserve erectile function. A laparoscopic/robotic route has the advantage of minimum
morbidity with equivalent oncological outcomes.
Inpatient stay varies with the approach used: open operations require a stay of 4 to 7 days and the
laparoscopic route requires 2 to 4 days.
The following are the common complications:
Impotence: where bilateral nerve sparing is performed the return of erectile function is between 50
and 70 per cent. Bilateral nerve sparing is only safely offered to patients with early disease (i.e. screen
detected). Taking all types of radical prostatectomy together (i.e. nerve and non-nerve-sparing),
recent studies suggest that over 56 per cent of men will be completely impotent and a further 29 per
cent will have a reduced erection.
Incontinence: severe incontinence is noted in 1 to 3 per cent, and occasional loss of control in 10 to
20 per cent of patients.
Mortality: the mortality rate is 0.7 per cent.
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258 Urology
REVISION PANEL
PSA is prostate specic and not cancer specic, age-specic PSAs are currently used to dene
normal values. PSA increases with age and other variables like PSA density (PSA in comparison
to the volume of the prostate), PSA velocity (rise in PSA over time) and PSA doubling time (time
taken for PSA to double is a variable that helps in prostate cancer diagnosis and management of
patients with raised PSA).
Baseline values of PSA at the age of 40 years may help predict future risk of prostate cancer
diagnosis. A lower baseline value of <1 ng/mL may need to be repeated in 8 years, while a
baseline value at the age of 40 years of >1 ng/mL may need to be monitored more closely and
repeated in 2 years.
Widespread use of PSA has led to reduction in the incidence of metastatic prostate cancer, but
it has also led to the use of increased widespread use of radical treatments for prostate cancer,
often resulting in overtreatment.
Population-based screening for prostate cancer using PSA is not yet recommended as the benets
are not fully demonstrated. The screening has shown to reduce mortality but at the cost of
overtreatment.
Prostate cancer may present with lower urinary tract symptoms, symptoms of obstructive
uropathy by trigone involvement and also by metastatic cancer with bone pain and/or spinal cord
compression.
Localized prostate cancer is managed by radical treatment or surveillance with an intention for
deferred radical treatment with disease progression (active surveillance). Radical treatment may
involve either removing the prostate (radical prostatectomy) or radiotherapy to the prostate
(external beam radiotherapy or installation of radioactive seeds into the prostate – brachytherapy).
Locally advanced prostate cancer is often treated using radical radiotherapy with adjuvant
hormone treatment. Radical surgery may be offered in some cases of locally advanced disease but
is often supported by adjuvant radiotherapy for positive surgical margins.
Metastatic prostate cancer is treated by medical castration therapy and often responds by
demonstrating a PSA response and clinical response by reduction of pain. Following an initial
response the prostate cancer often progresses despite castration into a castrate-resistant prostate
cancer.
Metastatic prostate cancer with spinal cord compression is a common neurological complication
of advanced malignancy and should be considered an oncological emergency.
Patients present with back pain that precedes spinal cord compression, other features include
weakness and sensory loss in lower limbs and urinary retention/incontinence.
The gold standard investigation to identify spinal cord compression is MRI and aggressive
investigation of patients with suspected spinal cord compression and urgent treatment leads to
best outcomes.
Conrmation of diagnosis and dexamethasone to reduce oedema and decompression either
surgically or by radiotherapy of the lesion in the spine rapidly allow for improved outcomes.
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Incontinence 259
INCONTINENCE
Questions
Clinical cases
For each of the clinical case scenarios given
Q1: What is the likely differential diagnosis?
Q2: What issues in the given history support/refute a particular diagnosis?
Q3: What additional features would you seek to support a particular diagnosis?
Q4: What clinical examination would you perform and why?
Q5: What investigations would be most helpful and why?
Q6: What treatment options are appropriate?
CASE 5.13 –
‘I have a urinary leak every time I cough or strain’
A 48-year-old woman is postmenopausal and has a minor leak of urine every time she coughs and
sneezes. She has three children, the last one needing a forceps delivery.
CASE 5.14 –
‘I can’t get to the toilet in time’
A 24-year-old teacher notes frequency and urgency every 30 minutes and urge incontinence.
CASE 5.15 –
‘I have been leaking ever since the operation’
A 38-year-old woman has been continually wet after a vaginal hysterectomy. She did not have any
urinary symptoms before the operation.
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260 Urology
OSCE Counselling case
OSCE COUNSELLING CASE 5.7 –
‘I keep going to the toilet every 30
minutes!’
A 34-year-old solicitor has difculty coping with work because she has to go to the toilet every 30
minutes; she has daytime frequency and urgency and no nocturia. She has recurrent episodes of cystitis
although the urine tests do not grow any organisms. She takes 10 cups of tea every day and about three
to four cans of coke. She has no children. She had a normal bladder examination and biopsy.
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Incontinence 261
Key concepts
Urinary incontinence: involuntary leakage of urine
Urodynamic stress incontinence (USI), previously called genuine stress incontinence
USI is noted during lling cystometry, and is dened as the involuntary leakage of urine
during increased abdominal pressure in the absence of a detrusor contraction. This is
caused by a failure to maintain the normal retropubic position of the bladder neck and
posterior urethra during increases in abdominal pressure and/or impaired internal sphincter
mechanism.
Detrusor overactivity, previously called detrusor instability
Detrusor overactivity is a urodynamic observation characterized by involuntary detrusor
contractions during the lling phase which may be spontaneous or provoked.
An overactive bladder is a symptom complex that includes urinary urgency with or without urge
incontinence, urinary frequency (voiding eight or more times in a 24-hour period) and nocturia
(awakening two or more times at night to void). It is a syndrome with no precise cause and local
causes are excluded. The urodynamic evidence of detrusor overactivity is commonly noted in patients
with an overactive bladder.
Patients with symptoms of an overactive bladder with underlying mucosal (carcinoma
in situ, interstitial cystitis, cystitis, bladder stone) or neurological causes (Parkinson’s
disease, MS, spinal cord injury, diabetic neuropathy) and extrinsic causes (e.g. bladder
outlet obstruction) are excluded from the overactive bladder syndrome. The urodynamic
diagnosis is conrmed by detrusor overactivity in the lling phase of urodynamics.
Total incontinence may be a result of complete loss of sphincteric control or a stula (abnormal
communication between the urinary tract and the skin). The most common cause of stulae is
iatrogenic and may be ureterovaginal or vesicovaginal.
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262 Urology
Answers
Clinical cases
CASE 5.13 –
‘I have a urinary leak every time I cough or strain’
A1: What is the likely differential diagnosis?
USI, most likely
Detrusor overactivity (urge incontinence)
Mixed incontinence (USI and detrusor overactivity)
Overow incontinence resulting from neurological causes or anticholinergic effects of drugs
UTI
Atrophic vaginitis/menopausal symptoms
Acute confusional state
Increased urine output (e.g. heart failure, diuretics, hyperglycaemia)
A2: What issues in the given history support/refute a particular diagnosis?
Urodynamic stress incontinence is more common in patients who are post-menopausal or post-child-
bearing. This is commonly attributed to weakening of the pelvic oor muscles and loss of anterior
vaginal support of the urethra to allow optimal closure mechanism.
A3: What additional features would you seek to support a particular
diagnosis?
Lower urinary tract symptoms would be in keeping with an overactive bladder such as frequency,
urgency, nocturia or suprapubic discomfort.
Voiding diary would be used to identify the amount and type of uid intake and the frequency of
voiding with urinary leaks. The number of pads and pad weight (as a measure of severity of leakage)
could be assessed.
The causes of an abnormal urethral support mechanism include congenital weakness and shortness
of the vagina, difcult labour, multiparity and menopause. Iatrogenic causes include radical or simple
hysterectomy and other types of extensive pelvic surgery.
Oestrogen deciency plays a role in the maintenance of the pliability of the urethral mucosa and
submucosa and may also present with dyspareunia.
Chronic inammatory tissue from previous surgical procedures and radiotherapy also compromises
the urethral closure mechanism.
The sphincteric weakness resulting from damage to the innervation of the urethral musculature may
also lead to stress urinary leak: sensory loss and history of neurological dysfunction.
A4: What clinical examination would you perform and why?
A clinical diagnosis of stress incontinence is often made by good history and examination and further
testing with urodynamics is usually not necessary except for surgical considerations. The absence of
urgency symptoms and complete bladder emptying and demonstrable stress leak on straining often
help in diagnosis.
Focused neurological examination should be performed including examination of power and tendon
reexes of the legs and feet, and examination for loss of sensation in legs, feet and perineum.
Bulbocavernosus reex and anal tone are also performed.
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Incontinence 263
Descent of the pelvic oor and anterior vaginal wall is noted with a Valsalva manoeuvre. Loss of urine
when the bladder is partially full, and eradication of this leak when the urethra is supported by digital
elevation of the urethrovesical junction, suggest that surgical correction would be effective.
Assessment of the contraction of the pelvic oor muscles, pelvic prolapse and the oestrogen status
in the vagina should be assessed.
A5: What investigations would be most helpful and why?
Urine dipstick and urine culture should be performed to rule out urine infection.
Postvoid residual measurement helps to identify the treatment procedure and whether further
investigations are necessary.
Women with pure stress incontinence in the absence of storage voiding LUTS and good bladder
emptying often do not require further urodynamics. However, many women have mixed symptoms
with/or bladder emptying difculties and urodynamics helps dene bladder function in this situation.
Valsalva leak-point pressure and uoroscopy may rarely be performed and are useful for identifying
the anatomy of the bladder neck and urethra.
A6: What treatment options are appropriate?
Behaviour and physical therapy All patients benet from behavioural therapy which includes
education to understand their condition and develop strategies to reduce incontinence.
Fluid and dietary advice, smoking cessation, urge avoidance and reinforcement and timed voiding
and 3-day bladder diary.
Pelvic oor muscle training
Use of vaginal cones with weights, vaginal electrical stimulation and biofeedback
Pharmacotherapy α-Adrenergic agonists act on the bladder neck and proximal urethra and increase
the urethral closure pressure (e.g. ephedrine, phenylpropanolamine).
Another agent, duloxetine, which is a dual serotonin (5-HT)/noradrenaline (norepinephrine) re-uptake
blocker with antidepressant action, is also useful in stress incontinence but its use is restricted due to
side effects.
Tricyclic antidepressants, which inhibit the re-uptake of noradrenaline, and their anticholinergic
effects simultaneously inhibit bladder activity and are useful in mixed incontinence.
Surgery Urodynamic stress incontinence caused by urethral hypermobility and descent of the bladder
neck may be assessed clinically and correction of the abnormality is sufcient to improve symptoms.
Tension-free vaginal tape placement and colposuspension are useful in correcting urethral
hypermobility and have good long-term effects.
CASE 5.14 –
‘I can’t get to the toilet in time’
A1: What is the likely differential diagnosis?
Detrusor overactivity
Ingestion of bladder stimulants (e.g. caffeine, alcohol etc.)
Cystitis
Bladder abnormalities (e.g. bladder stone, interstitial cystitis, bladder cancer)
Obstruction (e.g. in men with prostate enlargement)
Neurological conditions: stroke, MS
Increased urine output (e.g. diabetes, cardiac failure)
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264 Urology
A2: What issues in the given history support/refute a particular diagnosis?
Increased uid intake and bladder stimulants are one of the most common causes of increased urinary
frequency and urgency. A bladder diary often helps to identify the volume of uid intake, type of uids
ingested and void volumes and intervals of voiding and incontinence episodes.
A3: What additional features would you seek to support a particular
diagnosis?
A voiding diary (frequency and volume of voiding including incontinence episodes) and uid volume
chart (record of the amount and type of uid intake) are crucial to the diagnosis.
An overactive bladder is usually urgency associated with urinary frequency and often nocturia with
or without urinary urge incontinence.
A4: What clinical examination would you perform and why?
Examination to rule out a palpable bladder, neurological examination
Assessment of the contraction of the pelvic oor muscles, pelvic prolapse and the vaginal oestrogen
status
Assessment of the prostate in men by DRE.
A5: What investigations would be most helpful and why?
Urine dipstick and microscopy: exclude cystitis
Blood glucose and electrolytes: diabetes and renal impairment
Urine cytology: useful screen for bladder cancer
Cystoscopy and/or biopsy: interstitial cystitis and carcinoma in situ identied with a bladder biopsy
and appearance on cystoscopy
Ultrasonography and radiograph: postvoid residual volume, assessment of kidneys and screen for
bladder calculi
Flow rate (in men)
Urodynamics: diagnose detrusor overactivity
A6: What treatment options are appropriate?
Behavioural modication Weight reduction, uid advice (avoid bladder stimulants, moderate
intake), timid voiding and urge inhibition are encouraged.
Pelvic oor training has been shown to be effective in management of overactive bladder.
Biofeedback and electrical stimulation are also useful adjuncts to treatment.
Pharmacotherapy Anticholinergics acting on the muscarinic receptors are useful to suppress
involuntary bladder contractions. The common side effects include dry mouth, constipation and
blurred vision, which can be troublesome. Beta-3 agonists are the newest addition to the treatment of
overactive bladder.
Tricyclic antidepressants also have similar effects on the bladder and often a combination may be
required.
Surgery
Cystoscopy and biopsy are useful to rule out inammatory causes of overactive bladder
symptoms.
Cystoscopic injection of Botox
®
into the bladder has been shown to have signicantly improved
refractory overactive bladder.
Augmentation of the bladder using a patch of detubularized bowel or by a detrusor myomectomy
has been used.
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Incontinence 265
Extradural stimulation of the S3 nerve root exerts its effect by stimulating the sacral sensory bres,
which have the ability to inhibit the sacral parasympathetic neurons responsible for detrusor
contraction.
CASE 5.15 –
‘I have been leaking ever since the operation’
A1: What is the likely differential diagnosis?
Vesicovaginal stula/ureterovaginal stula
Urethral incontinence
A2: What issues in the given history support/refute a particular diagnosis?
History of operation, no urinary symptoms before surgery affect the diagnosis.
Iatrogenic trauma is the most common cause of stulae in developed countries. Obstructed labour is
the most common cause in the developing world.
A3: What additional features would you seek to support a particular
diagnosis?
The type of operation is important to the aetiology: abdominal hysterectomy, Wertheim’s
hysterectomy, anterior colporrhaphy or vaginal hysterectomy. The risk of ureteric injury after a
standard hysterectomy is 0.5 to 1.5 per cent and the risk of a stula is <1 per cent. The stula
develops soon after the procedure or may be delayed by 2 or more weeks if ischaemic necrosis of the
tissues is its cause.
History of irradiation is an important cause of genitourinary stulae. They are associated with bladder
pain and infection in 40 per cent of cases.
Direct invasion in late stages of cancer (e.g. cervical cancer) is seen.
The severity of urine loss by number of pads and pad weight is assessed.
A4: What clinical examination would you perform and why?
Examine the abdomen and genitalia and note radiation changes and dermatitis from urinary contact
of the skin.
Perform a three-pad test by inserting three dry cotton-wool swabs into the upper, middle and lower
thirds of the vagina. The bladder is adequately distended with methylene blue and any leakage
around the catheter is stopped. The swabs in the lower and middle third of the vagina soaking with
methylene blue would indicate a vesicovaginal stula. If the upper third vaginal swab is soaked with
clear urine it is likely to be a uretrovaginal stula (multiple stulae and vesicouretric reux may yield
false-positive results).
Directly inspect the vagina after instillation of dye into the bladder to see the size and site of the
stula.
A5: What investigations would be most helpful and why?
Biochemical analysis of the uid is conducted to conrm urine leak.
IVU: ureteric stula is associated with ureteric dilatation and/or hydronephrosis and extravasation
of contrast. To assist in delineating anatomy of the lower urinary tract MRI or CT urography may be
used.
Cystoscopy and examination under anaesthetic may be helpful to assess the pliability of the tissues
and dene the stula.
A6: What treatment options are appropriate?
Initially insert a catheter and often a small stula will heal in 3 to 4 weeks by conservative management.
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266 Urology
Surgical repair may become necessary and often the rst operation is the best chance to cure the
patient, so it must be done by an expert in a specialist centre with appropriate support.
Early repair is in favour because of the improvement in quality of life. If injury to the bladder or
ureter is noted intraoperatively, it must be repaired immediately. However, commonly the stula is not
obvious until 2 to 3 weeks after the procedure. The urine needs to be diverted with either a catheter or
a nephrostomy as necessary and the infection treated.
The basic principles of stula repair are as follows:
The stulous tract is excised to healthy, well-vascularized tissue.
The repair should be tension free and multilayered using absorbable sutures.
Techniques to improve the viability of the tissue by interposing well-vascularized tissues between the
bladder and vagina (e.g. a Martius ap using a ap of labial brofatty tissue and the omental ap)
are used.
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