Carcinoma of Bladder & Prostate BPH

Urinary Tract

Bladder Outflow Obstruction (BOO) A blockage at the base of the bladder that reduces or prevents the flow of urine into the urethra Most commonly caused by BPH or prostate cancer

Other causes Primary bladder neck obstruction young to middle aged men (rare in women) with bladder neck dysfunction Poorly understood Urethral stricture Catheterisation Previous transurethral surgery STIs e.g. gonorrhoea and syphilis Bladder calculi

Lower urinary tract symptoms Obstructive Irritative Poor stream Frequency Hesitancy Urgency Intermittent flow Nocturia Incomplete emptying Terminal dribbling Irritative sx may be secondary to BPH or intravesical pathology eg bladder cancer, uti and stones

Normal Prostate 4x3x2 cm 15g Exocrine gland Produces fluid portion of semen Role in controlling urine outflow Prostate normally 4x3x2 weighs ~ 15g

Zones of the Prostate

BPH History Symptoms as previously described Affect on QoL? Examination Abdomen (retention) PR = enlargement of the prostate with age

Investigations Urine dipstick and MC+S Bloods: U+E, PSA Urine flow test US of urinary tract Cystoscopy for urethral stricture/bladder calculus Urodynamics for complex cases

Management Conservative Medical Surgical

Medical Surgical α1 adrenoceptor blockers e.g. tamsulosin 5 α reductase inhibitors e.g. Finasteride TURP Surgical

Complications of TURP General and specific Early: septic shock, bleeding, transurethral syndrome Late: secondary haemorrhage, strictures, impotence, recurrent prostatic regrowth, recurrent symptoms, retrograde ejaculation (65-85%)

Prostate Cancer More common in men than women Most common male cancer (26% male cancer diagnoses in UK) Lifetime risk 1 in 9 for men in the UK Subclinical prostate cancer common in men over 50 Main risk factor increasing age- however ~25% of cases diagnosed in men <65

Presentation Symptoms as described previously or reflect local invasion/distant mets Role for screening? Examination Investigate as previously + Biopsy Further imaging

Stages T0: no primary tumour identifiable T1: tumour identified incidentally at TURP or with raised PSA T2: palpable tumour without extracapsular extension T3: spread beyond capsule; mobile tumour T4: fixed or locally invasive tumour

Gleason 10 Score for histological grading Prostate carcinomas often heterogenous and Gleason= sum of two most prominent grades 2= most well differentiated (best prognosis) 10= most poorly differentiated (worst prognosis) Gleeson 10

Prognosis Gleason 4 or less: 10 year risk of local progression 25% Gleason 5-7: 10 year risk of local progression 50% Gleason > 7: 10 year risk of local progression 75%

Management

Medical Gosrelin (Zoladex) (LHRH agonist) Flutamide (antiandrogens)

Prostate Cancer Screening Prostate cancer screening did not significantly decrease prostate cancer-specific mortality. Only one study reported a 21% significant reduction of prostate cancer-specific mortality in a pre-specified subgroup of men aged 55 to 69 years. There was no significant reduction in prostate cancer-specific and overall mortality. Harms associated with PSA-based screening and subsequent diagnostic evaluations are frequent, and moderate in severity. Overdiagnosis and over-treatment are common and are associated with treatment-related harms. Any reduction in prostate cancer-specific mortality may take up to 10 years to accrue. Therefore, men who have a life expectancy of less than 10 to 15 years should be informed that screening for prostate cancer is unlikely to be beneficial. No studies have examined the independent role of screening by digital rectal examination (DRE). From a Cochrane review of prostate cancer screening by PSA

Carcinomas of Bladder 98% Transitional Cell Carcinoma (remainder squamous cell carcinomas and adenocarcinomas)

Risk Factors Male > Female (3:1) Smokers > Non Smokers (4:1) Rubber and dye industries- 10 to 25 year delay Schistosomiasis

Presenting Symptoms Painless haematuria Recurrent UTIs Diagnosis on cystoscopy

Staging Ta: confined to mucosa T1: invading lamina propria T2: muscle involved T3: perivesical fat involved T4: invasion into adjacent organs/pelvic side wall Grade I to III

Superficial Bladder Cancer Ta or T1 ~80% of cases 15% will progress to invasive cancers over 10 years Treat by cystoscopy and endoscopic resection or diathermy Adjuvant intravesical chemotherapy (e.g. mitocin)

Invasive Bladder Cancer Radical cystectomy Formation of ileal conduit or creation of a neobladder out of small bowel

Haematuria Local vs Generalised? Local: infections, stones, trauma or tumours Renal diseases e.g. glomerulonephritis General (rarer): bleeding disorders, leukaemias, heamoglobinopathies and sickle cell disease

Microscopic vs Frank Painful vs Painless Beginning of otherwise clear stream vs throughout the stream History of risk factors

Investigations MSU: dipstick, MC+S, cytology for TCC Bloods: FBC (anaemia) U&E (renal function) Radiology: US of renal tract, CT, KUB, CTIVU Cystoscopy