Urology

Report
Urology
Hematuria
Stones
Tumours
Outline
• Hematuria
▫ DDx
▫ General Work up
• Renal Colic
▫ Stones
• Malignancy
▫ Renal
▫ Bladder
• Scrotal masses
Hematuria
• Objectives
▫ 1. Taking a Hx.
▫ 2. Lab & Radiologic Invx’s.
▫ 3. Which pt’s to refer to
Urologist.
Hematuria
Hematuria General Approach
Hematuria
Pre-renal
•Myo/hemoglobinuria
•Coagulation disorders
•Pseudohematuria
•(beets, dyes, laxatives)
Renal
•Glomerulonephritities
•AV Fistulas
•Vascular
Malformations
•Infection
•Tumor
Post Renal
• Stones
•Infection
• Trauma
•Tumors
•GU Endometriosis
Hematuria
• Etiology by Age
Age
Etiology in order of frequency
0-20
Glomerulonephritis, UTI, congenital
anomalies
20-40
UTI, stones, bladder tumor
40-60
Male: Bladder tumor, stones, UTI
Female: UTI, stones, bladder tumor
>60
Male: BPH, bladder tumor, UTI
Female: Bladder tumor, UTI
Hematuria General Approach
Hematuria
Pre-renal
•Myo/hemoglobinuria
•Coagulation disorders
•Pseudohematuria
•(beets, dyes, laxatives)
Renal
•Glomerulonephritities
•AV Fistulas
•Vascular
Malformations
•Infection
•Tumor
Post Renal
• Stones
•Infection
• Trauma
•Tumors
•GU Endometriosis
Hematuria DDx
▫
▫
▫
▫
Stones
Infections
Tumours
Trauma
Hematuria HPI
• Stones:
▫ Flank/Abdo pain, dysuria, PHx Stones.
• Infection:
▫ Suprapubic pain, dysuria, frequency, fever/chills +/flank pain.
• Malignancy
▫ Wt loss, night sweats, flank pain, voiding changes,
Occupational Hx (petroleum exposure), smoking Hx,
FMHx of Cancer
• Trauma
▫ Recent encounters with Chuck Norris.
Gross Hematuria Invx
• Laboratory Work up:
▫ 1. CBC
 Hgb - severity of blood loss.
 WBC – infection.
 Platelet loss/coagulopathy.
▫ 2. Cr
 Renal impairment.
▫ 3. INR/PTT
 Coagulopathy.
▫ 4. U/A
 Leukocytes, Nitrites – Infection.
 R&M – if dysmorphic RBC’s +/- Protein = Glomerular cause,
crystals stones.
 C&S – Infection.
Hematuria Invx
Radiology Investigations
• Painless Gross Hematuria
▫ Triphasic CT: arterial/venous/ureteric phases
• Microscopic Hematuria
▫ Start with Renal U/S.
• Flank Pain
▫ Plain film KUB, CT KUB (non con).
• Signs of infection
▫ Start with U/S, if findings  may consider CT with contrast
Imaging Modality
Pros
IVP
1. Good choice for suspected 1. Expensive.
stones or Transitional
2. Radiation.
tumors of bladder or ureter. 3. May miss small renal
Tumors.
4. Contrast allergies,
Nephrotoxic
Hematuria
Cons
U/S
1. No ionizing radiation.
2. Inexpensive.
3. Can identify tumor or
stone
1. May miss stones,
ureteric & bladder
tumors.
2. Unable to differentiate
tumors from blood clot.
CT non contrast
1. Used for Renal Colic –
1. Ionizing radiation
best at identifying stones
exposure.
2. Accurate staging of
2. Risk to fetus in
Malignancy if present
Pregnancy
CT contrast (triphasic)
1. Useful identifying
abscesses, fluid
collections.
2. Ureteric phase –
identifies filling defects.
1. Contrast allergy.
2. Contrast makes
visualizing stones
difficult
Hematuria Referral
• When to refer to Urologist?
▫ Gross hematuria NEED cystoscopy +/- Retrograde
Pyelogram!!
▫ Pt’s with GU Malignancies, stones, trauma.
• What should be done prior to referral?
▫ Hx, PE, Lab Invx’s, Imaging
▫ Initial management and stabilization of pt.
Retrograde Pyelogram
Hematuria Acute Rx
• ABC’s.
▫ Stabilize Pt, Blood products if needed.
• Invx to determine cause
▫ Treat underlying cause.
• Continuous Bladder Irrigation
▫ Call Urology.
▫ Manually irrigate all clots out of bladder first!
• Surgical management
▫
▫
▫
▫
Cystoscopy + Fulgaration.
Hyperbaric Oxygen
IR embolization.
Cystectomy and Urinary diversion.
Hematuria Summary
1. Painless Gross Hematuria
▫
Malignancy until proven otherwise.
▫
Rarely asymptomatic  Hx.. Hx.. Hx..
▫
▫
▫
▫
Hx, PE
Lab: CBC, Cr, U/A C&S, INR/PTT
Imaging: CT or U/S
Referral to Urologist: cystoscopy +/- Retrograde
pyelogram
2. Stones, infections & trauma
3. Workup
4. Management
▫
Stabilize Pt, +/- CBI, +/- Surgical intervention
Hematuria Cases
• Geeyu Malignansey, a 67 yo female with 114 pk/yr
smoking hx presents with Gross Hematuria.
• Wazun Mi, 23 yo male minding his own business
gets stabbed to the flank, while voiding and notices
he urine becomes red…
• 24 yo Engineering student comes in with dysuria
after holding her urine for 14 hours playing ‘Call of
duty’, she has leuks, nitrites and RBC’s on U/A…
Outline
• Hematuria
▫ DDx
▫ General Work up
• Renal Colic
▫ Stones
• Malignancy
▫ Renal
▫ Bladder
• Scrotal masses
Stones
Renal Colic
Objectives;
1. Give a differential diagnosis for acute flank
pain including two life-threatening conditions
2. Describe the laboratory and radiologic
evaluation of a patient with renal colic
3. Know 4 different kinds of kidney stones and
the risk factors for stone formation
4. Know 3 indications for emergency drainage of
an obstructed kidney
Renal Colic DDx
• Life Threatening:
▫ Abdominal Aortic Dissection
▫ Abdominal Aortic Aneurysm
Rupture
▫ Appendicits
▫ Ectopic Pregnancy
▫ Septic Stone
• GI
▫
▫
▫
▫
▫
▫
▫
▫
Cholecystitis
Biliary Colic
Acute Pancreatitis
Diverticulitis
Duodenal Ulcer
Inflammatory Bowel Disease
Viral gastritis
Splenic Infarct
•Gyne
•Pelvic inflammatory Disease
•Ovarian Torsion/Rupture
•Endometriosis
•GU
•Renal/Ureteric Calculi
•Renal Abscess
•Pyelonephritis
•Renal Vein Thrombosis
•Acute Glomerulonephritis
•Other
•Acute lumber disc herniation
•Herpes Zoster
•Fitz-Hugh-Curtis Syndrome
Renal Colic Invx
• Rocky, a 32 yo Male comes to ED with
microscopic hematuria and is writhing with Lt
Flank pain.
• What Laboratory Invx’s do you order?
• What initial imaging do you order?
Stones – Acute Lab Invx’s
• CBC
▫ WBC – increased indicates inflammation or
infection.
• Creatinine
▫ Assess for impaired renal function (obstruction).
• Urine Microscopy
▫ Bacteriuria, pyuria, pH
Renal Colic – 1st Imaging Test
• Plain Film KUB!
▫ ~85% of stones are
Radio-opaque on
plain film.
▫ No info on degree of
obstruction though.
Renal Colic – Other imaging options
IVP
• Intravenous Pyelogram
• Visualizes most stones
(radiolucent stones will
appear as filling
defects)
• Excellent Functional
Study
• Requires IV contrast,
thus risk of allergic
reactions and
nephrotoxicity
Renal Colic – Radiologic Evaluation
• CT Scan, hold the
contrast.
• Aka CT-KUB.
• Fast Inexpensive
• Imaging choice in
most emergency
rooms.
• Degree of obstruction
inferred by presence
of hydronephrosis.
Stones - Factoids
• They are common!
▫ Lifetime risk in North American Male is 1 in 8.
▫ M:F ratio is 3:1
• Presenting complaint
▫ Renal colic due to acute obstruction of ureter by stone.
• Initial Evaluation
▫ Focuses on excluding other potential causes of
abdominal or flank pain.
• Non-obstructing stones
▫ Should not cause pain unless they are associated with
Urinary tract infection.
Ureteric Stone
• 3 Common sites
of Obstruction
Ureteric Stones
• Spontaneous passage?
Size
Likelihood
4mm or less
90%
5-7mm
50%
8mm or larger
20%
• Pharmacologic aid in spontaneous passage?
▫ Alpha blockers! Flomax
Renal and Ureteric Stones
• So you have established that there is a stone.
▫ When is ‘immediate’ referral to a Urologist
Necessary?
Immediate Referral to Urology
• Obstructed ureter + Fevers/chills, bacteriuria or
elevated WBC
▫ Risk of Urosepsis - emergency
• Obstructed Ureter + Insulin dependent DM
▫ Risk of papillary necrosis or emphysematous
pyelonephritis
• Solitary Kidney
• Significant co-morbid conditions
▫ Eg. CHF, pregnancy etc.
Common Types of Stones
Renal Stones
Calcium
Oxalate
Calcium
Phosphate
Struvite
(infections
stones)
Uric Acid
Calcium Oxalate
• Most common type.
• Risk Factors:
▫ Dietary Hyperoxaluria: chocolate, nuts, tea,
strawberries, peanut butter, cabbage or excessive
restriction of dietary calcium.
• Hypercalciuria
▫ Inherited increased absorption, or incr PTH
• Dietary Hypercalciuria
Calcium Phosphate
• Second most common stone type.
• Often seen in pt’s with Metabolic Abnormalities:
▫ Primary Hyperparathyroidism.
▫ Distal Renal tubular acidosis.
▫ Hypercalcemia due to Malignancy or Sarcoid.
Uric Acid
• Radiolucent on Plain X-Rays, but is
visualized on CT scan
• Risk Factors:
▫ Persistent Acidic urine: ie l
 Low urine volumes
 Chronic diarrhea
 Excessive sweating
 Inadequate fluid intake
▫ Gout (Hyperuricemia)
▫ Excess dietary purine (Meataholics)
▫ Chemotherapy for lymphoma, leukemia
Struvite (Infection Stones)
• Composed of MAP
▫ Magnesium + Ammonium Phosphate & Calcium
• Can only form if urine pH >8.0!
▫ Thus: usually only in presence of urease +ve
bacteria
 Proteus, Klebsiella, Providentia, Pseudomonas,
Staph Aureus
 Note: E Coli does NOT produce urease
• Tend to form Staghorn stones
Relieving Obstruction
Obstructed
Stone
Retrograde
Ureteric
Stents
Percutaneous
Nephrostomy
Tubes
Remove stone
Ureteric Stents
• “Double J Stents”
▫ Stay in place b/c of
curled ends
▫ Can place these
Antegrade or Retrograde
▫ Typically requires
General Anesthetic.
▫ Low risk of bleeding.
Percutaneous Nephrostomy Tubes
• “Neph Tubes”
▫ Placed under local
anesthetic by
Interventional
Radiology
▫ Increased Risk of
Bleeding.
Treating/Removing Stones
• Ways to Treat stones.
▫ Conservative passage + Alpha Blocker (Flomax) +
Hydration + NSAID (if Normal GFR)
▫ Extracorporeal Shockwave Lithotripsy (ESWL)
▫ Ureteroscopy + Basket or Laser
▫ Percutaneous Nephrolithotomy
Treating Stones
• Conservative passage + Alpha Blocker (Flomax) +
Hydration + NSAID (if Normal GFR)
▫ Indications





Pain can be controlled with Ketorolac + Narcotic
No renal impairment
No Intractable Vomiting (aka pt not hypovolemic)
No sign of infection.
No previous failed trials of conservative passage.
Treating Stones
• Extracorporeal
Shockwave lithotripsy
▫ Indication:
 <~1.5cm renal or
ureteric stone.
▫ Stone is localized by XRay.
▫ ~3000 Shocks targeted
to gradually fragment
stone.
▫ Fragments passed in
urine.
Treating Stones
• Ureteroscopy
▫ + Basket
 If stone is small enough to adequately remove by
basket.
▫ + Holmium Laser
 If stone is ‘impacted’ or cannot simply be basketed
out.
Treating Stones
• Percutaneous Nephrolithotomy
▫ Indications
 Large Proximal ureteric or Renal Calculi >~1-1.5cm
 Treatment of Staghorn Calculi
▫ Risks:
 Bleeding
 Renal Perforation or Avulsion
• http://www.youtube.com/watch?v=irKCgFrAO
RA
Outline
• Hematuria
▫ DDx
▫ General Work up
• Renal Colic
▫ Stones
• Malignancy
▫ Renal
▫ Bladder
• Scrotal masses
Renal Mass
Objectives:
1. Give a differential diagnosis for a solid mass in
the kidney.
2. Describe the evaluation of a patient with a
suspected renal cell carcinoma
3. Give three indications for a partial
nephrectomy rather than a radical
nephrectomy for renal cell carcinoma.
Renal Tumors
• Presentation:
▫ Incidental finding!
▫ Triad: Flank pain, hematuria, palpable mass (not
common)
• How do you ‘work-up’ a Renal mass?
Renal Mass Investigations
• Imaging
▫ CT Abdo pelvis + contrast
 Characterize Mass and assess for tumor extension, IVC thrombus,
Nodes, Mets, abnormalities to contralateral kidney.
▫ CXR
 Assess for mets
• Laboratory
▫ Alk Phos (bone mets)
▫ LE’s  hepatic/portal vein involvment
▫ Calcium 
• Biopsy?
▫ Recommended only when Dx is unclear.
Why Investigate Calcium?
• Bone Mets or Paraneoplastic syndrome!
▫ 20-30% of RCC have Paraneoplastic Syndrome









Increased ESR
Wt loss, cachexia
Fever
Anemia
Hypertension (incr Renin)
Hypercalcemia (PTH-like Substance)
Incr ALP
Polycythemia (incr EPO production)
Stauffer’s syndrome – reversible hepatitis
Renal Tumors
Renal Mass
(U/S or CT)
Benign
•Oncocytoma
•Angiomyolipoma
•Psuedotumour
•Dromedary Hump
•Hypertrophied column of Bertin
•Compensatory Hypertrophy etc
Malignant
•Renal Cell Carcinoma
•Transitional Cell Carcinoma
•Wilms Tumour (peds)
•Metastasis
•Lymphoma/leukemia
•Lung
•Breast
Benign Tumors
• Know that they exist.
• DDx:
• Oncocytoma, angiomyolipoma (1-2% malignant),
papillary adenoma, pseudotumors etc….
• Differentiating pseudotumors from real tumors.
▫ DMSA scan
 Pseudotumors will have normal uptake, tumors will be
decreased.
Benign Renal Masses
• Angiomyolipoma
▫ Diagnosed if any part
of renal mass consists
of adipose.
 Composed of Fat –
smooth muscle –
blood vessels
▫ Risk of hemorrhage
near 50% once size
>4cm
Malignant Renal Cell Carcinoma
• Accounts for 90% of solid renal masses.
• Several different subtypes
▫ Clear Cell is most common
• 25% present with Mets
Renal Cell Carcinoma
• Treatment
▫ Local confined mass
 Nephrectomy
 Partial Nephrectomy
▫
▫
▫
▫
Solitary kidney or significant renal impairment
Bilateral tumors
Von Hippel-Lindau Syndrome
Small tumor <4cm
▫ Metastatic RCC
 Combination of Nephrectomy + Chemo (Sunitinib)
Renal Cell Carcinoma
Five year disease-specific survival
(following most effective treatment)
T1
T2
T3a
T3b, c
T4
95%
90%
60%
25% (following complete removal of IVC
thrombus)
20%
N1, 2
10% – 20%
M1
0%
Other Malignant Renal Tumors
• Renal Transitional Cell Carcinoma
▫ Because Transitional cells line renal pelvis, ureters &
bladder, must perform nephroureterectomy to Rx.
• Wilm’s Tumor
▫ Peds
• Sarcoma
• Metastasis to Kidney
▫ Leukemia, lymphoma
▫ Lung
▫ Breast
Bladder Cancer
Objectives:
1.
State 3 risk factors for transitional cell
carcinoma of the bladder
2. State the treatment options for superficial and
invasive TCC of the bladder
Bladder Cancer
• Often presents as painless
gross hematuria!
▫ Recall workup for gross
hematuria:
 Upper tract imaging CT
Abdo/pelvis
 Cystoscopy
• Diagnosis
▫ Cystoscopy + Biopsy
 Transurethral resection of
lesion and underlying detrusor
muscle to stage tumor
▫ Urine Cytology
▫ Ct Abdo/pelvis for staging.
Bladder Cancer
• Risk Factors
▫ SMOKING (RR 4 vs non smokers)
▫ Occupational Exposure
 Aniline dyes, aromatic amines
 Ie. Textile manufacturing, dry cleaning, painting)
▫ Previous Cyclophosphamide
 (ie chemo for lymphoma)
▫ Previous Radiaiton Rx in pelvis
Bladder Cancer
• DDx
• Transitional Cell carcinoma
▫ Most common!
• Adenocarcinoma
▫ Dome of bladder, associated with Urachus.
• Squamous Cell Carcinoma
▫ Associated with chronic inflammation
 Indwelling foley’s, bladder stones.
Transitional Cell Carcinoma
• Staging
▫ Non-invasive
 Tis, Ta, T1 disease
▫ Invasive
 >T1 disease (muscle invasive
Treatment of Non-invasive TCC
• 1. Transurethral resection of lesion
• 2. PLUS intravesical chemotherapy IF:
▫
▫
▫
▫
▫
▫
Carcinoma in-situ
Multi focal tumors
Unable to completely resect transurethrally
Rapid recurrence after initial resection
Superficial, high grade tumor
Lamina propria invasion (Stage T1)
Treatment of Non-invasive TCC
• Intravesical Chemotherapeutic Agents:
▫
▫
▫
▫
Bacille Calmette-Guerin (BCG)
Mitomycin
Doxorubicin
Thiotepa
Treatment of Non-Invasive TCC
• But….IF:
▫ Persistent CIS after intravesical chemotherapy
▫ Extensive superficial tumors that cannot be
resected.
• Then Pt will require Radical Cystectomy and
Urinary diversion for curative intent.
Treatment of Invasive TCC
• Radical Cystectomy
• +/- Chemotherapy for metastatic disease
• If palliative, may still require cystectomy if
uncontrollable hematuria (requiring
transfusions etc)
Radical Cystectomy + Urinary Diversion
• Once Bladder is removed…
• Urinary diversion is needed
▫ Ileal Conduit
 Pros – simple, least complications
 Cons – abdominal stoma, no continence.
▫ Neobladder
 Pros – continent with use of catheters
 Cons – Increased surgical complications, increased
risk of metabolic derrangements.
Ileal Conduits
Neobladders
Scrotal Mass
Objectives
• Differential diagnosis of a scrotal mass
• Know how to diagnose and treat testicular
torsion
• Classify testicular tumors
• Treatment of testicular malignancies
Approach to Scrotal Mass
Scrotal
Mass
Infectious
Anatomic
Malignant
•Epididymitis**
•Orchitis**
•Hydrocele
•Inguinal hernia
•Varicocele
•Spermatocele
•Testicular Torsion**
•Appendix Testi Torsion**
•Testicular tumor
•Paratesticular tumor
•Cystadenoma of
epididymis
** = painful
Approach to Scrotal Mass
• Hx
▫ Pain, onset, firmness, hx of undescended testis, STD’s,
LUTs, urethral discharge
• PE
▫ Location of mass (testis, epididymis, scrotum)
▫ Tenderness
▫ Transilluminance
• Invx’s
▫ U/A – pyuria with epididymitis
▫ U/S – ++ Sensitive and specific for testicular tumors
Approach to Scrotal Mass
Scrotal
Mass
Infectious
Anatomic
•Epididymitis
•Orchitis
•Hydrocele
•Inguinal hernia
•Varicocele
•Spermatocele
•Testicular Torsion
•Appendix Testi Torsion
Malignant
•Testicular tumor
•Paratesticular tumor
•Cystadenoma of
epididymis
Infectious Scrotal Mass
Epididymitis
▫ Young adults – often associated with STI,
chlamydia
▫ Older adults – often non-STI, E Coli.
▫ Tender, indurated epididymis
• Orchitis
▫ AKA Mumps virus.
▫ Swollen ++ tender testicles, often bilateral.
Approach to Scrotal Mass
Scrotal
Mass
Infectious
Anatomic
Malignant
•Epididymitis
•Orchitis
•Hydrocele
•Inguinal hernia
•Varicocele
•Spermatocele
•Testicular Torsion
•Appendix Testi Torsion
•Testicular tumor
•Paratesticular tumor
•Cystadenoma of
epididymis
Anatomic Scrotal Mass
• Hydrocele
• Fluid within tunica vaginalis
• Called “communicating
hydrocoele” if processus
vaginalis is patent
• Hx
• Typically painless
• PE
• Transilluminates
• Cannot palpate testicle
• Treatment
• No Rx required unless for
cosmetic reasons
Anatomic Scrotal Mass
Inguinal hernia Spermatocele
Anatomical Scrotal Mass
Spermatocele
• Cystic dilatation (aneurysm)
of epididymal tubule
• Hx
• Painless
• PE
• Transilluminates
• Can palpate body of testicle
separate from the mass
• Rx
• No treatment required
unless for cosmetic reasons
Anatomical Scrotal Mass
• Varicocele
Anatomical Scrotal Mass
• Varicocele
▫ Varicosities of pampiniform plexus
 90% on left side; seen in 15% of male population.
 Associated with male factor infertility but most men with
varicocoeles can expect normal fertility.
▫ Hx
 Typically asymptomatic, cosmetically “bag of worms”
 Increases in size with valsalva or standing position.
▫ PE
 Bag of Spaghetti in scrotum palpating cord.
▫ Rx
 Surgical or angiographic sclerosis
 Results in improvement in semen parameters (number,
motility, morphology) in 70% to 90% of cases
Torsion – it hurts!
Anatomical – Acute Scrotum
• Testicular torsion
▫ Surgical Emergency!!
▫ Only definitive Diagnosis is Surgical Scrotal
Exploration.
▫ Typically in 12-18yr olds
▫ 6 hr window prior to irreversible testicular
ischemia
▫ Associated with ‘Bell Clapper Deformity”
▫ Detort – “like opening a book”
Testicular Torsion
Anatomic Scrotal Mass/Pain
• Testicular Torsion
▫ PE
 High riding, horizontal testicle.
 Absent cremasteric reflex
 Prehn Sign – relief of pain when supporting the
scrotum suggests epidiymitis.
▫ Investigations
 U/A – R/O pyuria (epidiymitis)
 Doppler U/S
▫ Rx
 Surgical detorsion and Orchidopexy.
Acute Scrotum
• Epididymitis
▫ Infection of the epididymis
 <35yrs of age – Chlamydia, gonorrhea
 >35yrs of age – E. Coli
▫ Hx
 Pain, Swelling testicle +/- dysuria +/- fever
▫ PE
 Indurated, swollen and acutely painful epididymis, +/erythema
▫ Invx’s
 CBC, U/A +/- Doppler US of testis.
▫ Rx
 Antibiotics x4 weeks + NSAIDS, and Ice PRN
Epididymitis
Acute Scrotum
• Torsed Appendix testi
▫ May mimic Testicular Torsion
▫ ?Blue Dot sign
▫ Testi may be inflamed/tender, point tenderness to
appendix testi.
▫ Not likely elevated, NO horizontal lie
• Invx
▫ Doppler US to assess testi perfusion
▫ U/A
• Rx
▫ Conservative, symptom management if confirmed
▫ Urological assessment.
Approach to Scrotal Mass
Scrotal
Mass
Infectious
Anatomic
Malignant
•Epididymitis
•Orchitis
•Hydrocele
•Inguinal hernia
•Varicocele
•Spermatocele
•Testicular Torsion
•Appendix Testi Torsion
•Testicular tumor
•Paratesticular tumor
•Cystadenoma of
epididymis
Testicular Cancer
• Typically occurs in
young healthy Men.
• Very good cure rates
Even for Metastatic
Disease!
Testicular Cancer
Testi Ca
Primary
Germ Cell Tumors
Nonseminomatous
Seminomatous
Secondary
Non-Germ Cell
Tumors
Testicular Cancer
Testi Ca
Primary
Germ Cell Tumors
Nonseminomatous
Seminomatous
Secondary
Non-Germ Cell
Tumors
Germ Cell Testicular Cancer
• Seminoma
• Non-Seminoma
▫ Embryonal Carcinoma
▫ Teratoma
▫ Teratocarcinoma (Teratoma +Embryonal
Carcinoma)
▫ Choriocarcinoma
▫ Yolk Sac Tumour (typically infants)
Testicular Cancer
Testi Ca
Primary
Germ Cell Tumors
Nonseminomatous
Seminomatous
Secondary
Non-Germ Cell
Tumors
Non-Germ Cell Testicular Cancer
• Leydig Cell Tumor
• Sertoli Cell Tumor
Testicular Cancer
Testi Ca
Primary
Germ Cell Tumors
Nonseminomatous
Seminomatous
Secondary
Non-Germ Cell
Tumors
Secondary Testicular Cancer
• Lymphoma
• Leukemia
Testicular Cancer
• Presentation
▫ Typically painless intratesticular mass discovered
on self examination
▫ Age 15-35
 Albeit some tumor subytpes cluster in infancy and
60’s
Testicular Cancer
• Investigations
▫ Lab
 B-HCG
 Produced by choriocarcinoma & in some Seminomas
 Alpha-fetoprotein
 Produced by Yolk Sac, Embryonal Carcinoma &
Teratocarcinoma
 LDH
 Correlates with tumor volume
▫ Imaging
 Scrotal U/S
 CT Abdo and Pelvis
 CXR
Testicular Cancer
• Treatment:
▫ Radical Orchiectomy
 ALWAYS Inguinal
approach
 NEVER scrotal
approach
▫ PLUS…
Testicular Cancer
• Treatment:
Rx Beyond
Radical
Orchiectomy
Seminoma
NonSeminoma
Testicular Cancer
• Seminoma Treatment:
▫ Negative CT scan or low volume retroperitoneal nodes
 Treated with external beam radiotherapy (2500 cGy) to the
retroperitoneum and ipsilateral pelvic nodes.
• Large volume retroperitoneal dz / Metastatic Dz
• Treated with chemotherapy; cis-platinum, bleomycin,
vinblastine is a typical regimen
Testicular Cancer
• Non-Seminoma Treatment:
▫ Negative CT scan & N tumour markers post
orchiectomy
 Surveillance.
 OR, Retroperitoneal lymph node dissection may be done
to determine the actual stage and potentially cure
patients with low volume nodal mets.
▫ Large volume retroperitoneal disease or mets
 Chemotherapy
 cisplatinum, VP-16, bleomycin.
 Residual teratoma may be seen after successful
chemotherapy and should be excised (RPLND).
Retroperitoneal Lymph Node Dissection

similar documents