Urology.pdf

Urological urgencies and emergencies List the urgencies Urgency is defined as a non life threatening condition but with a possibility of organ damage followed by ischemia. In urology the urgencies are divided by two as non traumatic and traumatic. Non Traumatic urgencies are: 1. acute urina...

Urological urgencies and emergencies List the urgencies Urgency is defined as a non life threatening condition but with a possibility of organ damage followed by ischemia. In urology the urgencies are divided by two as non traumatic and traumatic. Non Traumatic urgencies are: 1. acute urinary retention, 2. renal colic, 3. spermatic cord torsion, 4. priapism, 5. hematuria, 6. phimosis/paraphimosis Traumatic: Renal trauma, ureteral injury, bladder trauma, urethral injury What Is the Only Emergency in urology? Emergency is defined as life threatening and immediate medical intervention is required. The only medical emergency in urology is rupture/lesion of renal vessels that causes bleeding and kidney damage Hemorrhage of the renal artery What is nocturia? Nocturia is the need for the pts to wake up during the night frequently. main causes of acute urinary retention and treatment Acute urinary retention is due to urine not being able to leave the bladder thus it is not anuria (which is kidney related). The main etiology for Acute urinary retention is: - Benign Prostatic Hypertrophy - Urethral Stenosis - Phimosis - Spinal Cord Injury - UTI - Prostate cancer (T4) The treatment is: Bladder catheterization & treating the underlying cause (suprapubic cystostomy can be also used if catheterization is not possible)  Clinical features and Diagnosis of acute urinary retention Sudden and painful inability to empty the bladder, Suprapubic pain/discomfort , Palpable bladder (bladder globe) Diagnosis is made by physical examination (bladder globe palpation and percussion will have a dull sound), along with ultrasound that will show the blessed is full. The levels of Serum creatinine remains normal as the problem is not related to kidneys. Complications of acute urinary retention It can complicate into post-renal AKI DDx acute urinary retention and anuria BUN, creatinine, US, no pain present in anuria and no bladder globe. Urinary Retention and Cystotomy Cystotomy can be used as a treatment option in case the catheterization is not possible (urethral stenosis condition) Renal colic- causes, symptoms It is the most common urgency in Urology and presents with severe intense pain in the flank It is most commonly caused by ureteral stones (Blood clots (renal bleeding), Malformations, Neoplasms, Trauma) It creates a dynamic obstruction: as the urethra pushes against an obstruction the patient will feel the spasm. Symptoms: - Pain (Severe unilateral and colicky flank pain, Radiates anteriorly to the lower abdomen, groin, labia, testicles, or perineum, Paroxysmal or progressively worsening) - Hematuria (micro) - Nausea and vomiting - Urine frequency and urgency  Diagnosis & treatment Diagnosis is made by history, US (if the stone is in the kidney, Spiral CT without contrast when in ureters or MRI with contrast). Urinalysis will show hematuria, crystals and leukocytes Treatment: Medical: Painkillers (NSAIDs), antispasmodics (debatable, spasms are needed for the stone to leave), Myorelaxants Agressive: Extracorporeal lithotripsy (in order to break the stone by US waves), Urethral Catheterization Surgery: Endoscopic ureteral-lithotripsy (minimally invasive, breaks and vacuums the stone), Ureterolithotomy, Percutaneous nephrolithotomy (minimally invasive to remove big stones), Simple nephrectomy (in case of kidney failure) Small stones ( sudden contraction --> brings testicles too high --> twists the spermatic cord --> consequently causes ischemia (arterial and venous) Spermatophore torsion: why is it an urgency and what are the different subtypes of torsion Spermatic Cord Torsion untwisting direction Orchiopexy  prehn’s sign Negative cremaster reflex sign Toggle Priapism types Priapism is a prolonged and painful erection that lasts more than 3 hours and is not accompanied by sexual desire nor followed by ejaculation. The corpora cavernosa becomes engorged with blood. It can be low flow/venous priapism: occlusion of the deep dorsal vein of the penis (usually thrombosis) High flow/ arterial priapism: abnormal amount of blood reaches corpora cavernosa Etiology for low: Idiopathic, Hematologic disorders: thrombocytopenia, lymphomas, leukemia, sickle cell, altered blood hemostasis, Pharmacological: prostaglandins injection (people tried improving their performance by increasing injection --> priapism), Induced: sex toys etc., Etiology for high: Trauma: mechanical injury to corpora cavernosa --> arteriovenous fistula Which type is more dangerous and why Low is more dangerous as it leads to ischemia It is characterized by a prolonged, painful erection that is not caused by sexual stimulation and is often associated with sickle cell disease or other blood disorders. During an ischemic priapism, blood becomes trapped in the penis, causing a lack of oxygen to the tissues. If left untreated, this can lead to tissue damage, permanent erectile dysfunction, and other complications. Priapism treatment Ejaculation: patients is asked to try to ejaculate Excessive physical effort (to release epinephrine which is a vasoconstrictor) Ice packs Intracavernous vasoconstrictor injection Blood aspiration from C.C. Surgery (shunt between C.C. and corpus spongiosum) Pudendal artery embolization can be performed by interventional radiologists. (selective blockage of the vessel) Hematuria - why it is important Hematuria is an obvious sign of an underlying pathology that causes bleeding. Almost all urological disorders could cause hematuria this sign should always be investigated**, especially for cancer. What is the most common cause of hematuria Which cancers cause hematuria. Bladder neoplasms (most important) ureteral neoplasms renal malignancies and benign tumors prostatic neoplasm (not common) What do you suspect in a patient with hematuria? Which other exams do you perform? Suspect UTI, neoplasms, trauma, kidney injury, stones. cytology, US, urethroscopy Gross hematuria Macrohematuria: it appears as a reddish discoloration of urine, variable from dark to bright red. Blood clots in hematuria spindle-like if they come from ureters, or globose when they derive from bladder’s bleeding Renal trauma (how to diagnose it (US, blood exam, CT scan) First imaging to perform for renal trauma Urinary incontinence Etiology of urinary incontinence Urinary incontinence is the involuntary loss of urine from the urethral meatus DIAPPERS Delirium (confused mental state) Infection Atrophic vaginitis or urethritis Pharmaceuticals (diuretics- anticholinergics, antidepressants) Psychological disorders Endocrine disorders Restricted Mobility Stool Impaction Pelvic floor weakness, UTI, caffeine,alcohol, obesity Urinary incontinence and treatment Involuntary micturition due to: Overactive bladder - urge - bladder is uninhibited so it tries to contract - Treated by decreasing detrusor muscle hyperactivity - relaxation techniques and antimuscarinic meds Too much pressure - stress - pressure on the bladder (abdominal) that overcomes the sphincter muscles - Hypermobility of the bladder neck and the urethra (85% of cases). - treat - strengthen external sphincter with kegels Incomplete emptying - overflow - due to blockage in urine flow usually or ineffective detrusor muscle - when it fills up urine leaks through the sphincter → weak stream or hesitancy. - treat by establish a clear path - catheter, BPH (alphalytics, a-5 reductase blockers) Treatment of stress incontinence most common cause of incontinence in man Benign prostatic hypertrophy PSA in BPH PSA is an organ specific marker and can increase in case of BPH. It is important to check free BPH to total BPh ratio in order to follow the proper steps. If it is below 15% and more than 4 ng/mL prostate cancer can be suspected and further investigations are needed. BPH natural history 1st stage: histologic BPH → asymptomatic histological change without any issues 2nd stage: anatomic BPH → hypertrophy manifests anatomically, enlargement is felt during examination. Initial symptoms are present only (like difficulty initiating urine). Urinary flow is normal (detrusor can overcome obstruction) 3rd stage: clinical BPH → Important symptoms (LUTS) appear due to complete obstruction of the urethra and they can evolve to urinary retention. In terms of lower urinary tract symptoms(LUTS) - Irritative stage – obstruction of urine flow is compensated by forceful bladder contraction. Symptoms of filling: - Post-micturition residual is absent - Normal urine flow - Obstructive stage – bladder is unable to completely void. Symptoms of emptying: - Post-micturition residual is present - Reduced urine flow - Congestive stage – reduced detrusor contraction up to failure. Symptoms of congestion: - Very high post-micturition residual - Very reduced urine flow Diagnosis of BPH 1. Clinical History: typical in males > 50 years old with symptoms of pollakiuria and nocturia 2. DRE: Volume, Consistency, Margins, median, nodules (DDx prostate cancer) 3. Urine: analysis, culture, PSA 4. Uroflowmetry and PMR: Study the urinary flow - the quantity of urine excreted per unit of time (mL/sec). 5. US: suprapubic, transrectal 6. Urodynamic complete exam - gold standard - Uroflowmetry (linear line) normally a gaussian bell shaped curve - Cystomanometry (volume of first desire to urinate and first void time) - Pressure/flow study (pressure inside bladder normally: 25-30 cmHO) 7. Urethrocystoscopy – endoscopy Treatment of BPH Prevention: lifestyle changes, regular sexual activity, checkups after the age of 50 - Alpha blockers: leads to decreased smooth muscle tone of the bladder neck - Adverse: retrograde ejaculation - 5alpha-reductase inhibitors (reduce circulating DHT, help slowing down but no regression)  - can lead to decreased sexual desire - Phytotherapy drugs (anti inflammatory) - Endoscopic transurethral resection - open adenomectomy Indications for surgery: Urinary retentions, UTI, Hematuria, Bladder urolithiasis, Hydronephrosis, AKI Complications: Retrograde ejaculation, Impotence, Urinary Incontinence BPH, in comparison with prostatic cancer Male sexual Dysfunction Male infertility Male infertility is estimated to affect 3 to 7% of the males. Risk factors: age (older age correlates to increased risk), Increased prevalence of STDs, stress, diet, smoking, alcohol. Diagnosis is made through Seminal Fluid Examination Normal Parameters: - Volume: 2-4mL - pH: 7.2-7.8 - Sperm cell concentration > 20 million/mL (< Oligoozopermia, none: azoospermia) - Motility >50% (< asthenospermia) - Morphology >50% (< teratospermia) - Viability >50% Semen Culture can be performed if an infection is suspected. The Etiology can be: Pre-testicular (10%): ➔ Alteration of the deposition of the semen (erectile dysfunction, anejaculation, hypospadias) ➔ GnRH and gonadotropins deficiency (hypogonadotropic hypogonadism, anabolic steroids) Testicular (75%) ➔ Idiopathic ➔ Varicocele ➔ Microdeletions of the Y chromosome/ sex chromosome abnormalities ➔ Cryptorchidism (testes fail to descend) ➔ Cytotoxic Drugs, radiation, orchitis, torsion, surgery Post Testicular (15%) ➔ Obstruction of the epididymis ➔ Infection of the accessory gland ➔ Immunological Factors Erectile Disorders - causes, treatment the 3 erectile disorders are Erectile dysfunction: It is the inability to achieve or maintain a penile rigidity, the incidence increases with age. Risk factors: Cardiovascular diseases, Diabetes, Endocrine disorders, Nervous system disorders, Post pelvic surgery complications, Trauma, Drugs (diuretics, alcohol, cocaine), Psychologic (depression, stress) They all cause inadequate release of NO by the vascular epithelium Prolonged Erection (Priapism): abnormal duration of erection (more than 3 hours), accompanied by pain. This disorder is better identified as an urgency in some cases. A prolonged erection duration state (more than 4 hours) is known as priapism. Almost always it is drug-induced, Painful erection: Pain is an unspecified symptom, so there is a wide-range of causes potentially linked to it - inflammation, phimosis, paraphimosis, Peyronie’s disease Mechanism of erection ED The physiology of erection is a complex process involving various factors, including neural, vascular, and hormonal mechanisms. The following is a brief overview of the physiological process of erection: 1. Sexual stimulation: Erection begins with sexual stimulation, which can be initiated by visual, auditory, or physical stimulation. 2. Neural activation: The brain and spinal cord receive sensory signals from the sexual organs, which activate the parasympathetic nervous system. This leads to the release of nitric oxide (NO) in the penile tissues. 3. NO release: NO stimulates the production of cyclic guanosine monophosphate (cGMP), which relaxes the smooth muscles in the penile blood vessels. 4. Blood flow: The relaxation of the smooth muscles in the blood vessels increases blood flow to the penis, causing it to become engorged with blood and leading to an erection. 5. Hormonal regulation: The release of testosterone, a male sex hormone, also plays a role in the physiology of erection. 6. Sustaining erection: Erection is sustained by a balance between the sympathetic and parasympathetic nervous systems, which regulate the contraction and relaxation of the penile blood vessels. Disruption of any of these physiological processes can lead to erectile dysfunction (ED), a common condition in which a man is unable to achieve or maintain an erection sufficient for sexual intercourse. Drugs that cause ED Antidepressants: Selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs) are commonly associated with ED. Antihypertensives: Certain blood pressure medications, such as beta-blockers, diuretics, and calcium channel blockers, can cause ED. Antipsychotics: Some antipsychotic medications, such as haloperidol and risperidone, can cause ED. Hormonal medications: Androgen deprivation therapy (ADT), used to treat prostate cancer, can cause ED by reducing testosterone levels. Chemotherapy drugs: Chemotherapy drugs, such as methotrexate and vincristine, can cause ED by damaging blood vessels and nerves in the penis. Recreational drugs/ substance abuse: Recreational drugs, such as cocaine and marijuana, can cause ED by affecting blood flow and nervous system function. ++alcohol (reduced blood flow, hormonal, nervous system damage, psychological, performance anxiety) Varicocele - symptoms, diagnosis, treatment Abnormal enlargement of the pampiniform venous plexus → swelling, elongation, abnormal tortuosity of the spermatic cord Symptoms: - Asymptomatic - Dull ache of the left hemi-scrotum in a lying supine position - Valsalva maneuver causes heaviness and pain (it is a congenital defect → hereditary chromosomal abnormality or mother using drugs during gestation) Diagnosis: history and physical examination, spermiogram and spermiocultura Scrotal duplex scan Treatment: Surgical, Sclero-embolization, Laparoscopic Spermiogram Normal Parameters: - Volume: 2-4mL - pH: 7.2-7.8 - Sperm cell concentration > 20 million/mL (< Oligoozopermia, none: azoospermia) - Motility >50% (< asthenospermia) - Morphology >50% (< teratospermia) - Viability >50% Most common anomaly at spermiogram Low sperm mobility precocious ejaculation The exact cause of premature ejaculation is not well understood, but it may be related to psychological factors such as anxiety, depression, or stress. It may also be caused by physical factors such as an underlying medical condition, certain medications, or an abnormality in the reflex that controls ejaculation. peyronie’s disease formation of fibrotic plaques in the tunica albuginea around corpora cavernosa. Micro-traumatic injuries in the elastic connective tissue, evolves in scarification, thereby a thickening and a retraction of the tunica albuginea. This situation will result in a pathological curvature of the penis. Pain is present only at the beginning due to inflammation. Urinary Tract Infections Cystitis, who would you expect to have cystitis, what should you do? Meares and stamey test Classification of prostatitis Pyelonephritis ; symptoms and diagnosis Urethritis ; pathogens and treatment symptoms, diagnosis, the gold standard in the diagnosis of obstruction of the urinary flow and then therapy Most common causative bacteria Prostate Cancer Markers in prostate cancer PSA is a marker PSA - what is it, relevancy to prostate cancer, values. PSA is “prostate specific antigen” produced only by prostate in the body. It is an organ specific marker and increase of it is not always linked to the prostate cancer. A suspicion should arise if the PSA levels are more than 4 ng/mL or free PSA/total PSA is more than less than 15%. It can increase in BPH, inflammation (prostatitis), riding bike, stimulation of prostate, sexual activity Lower levels of PSA does not exclude prostate cancer and further tests should be done in case of positive DRE At what age PSA screening should be performed in population? PSA screening should start around the age 50 along with DRE every 2 years. Patients in risk also should be in screening (BRCA2 gene, family history) Gleason Score Gleason score is a prognostic score produced with predominant primary tumor pattern and secondary tumor patter. In prostate cancer there are usually mor ethan one pattern present histologically, in gleason score thoose patterns are given a score and the scores are added together to have an overall prognostic score. The numbers range from 1 to 5 1 being the highly differentiated cells. Another important thing is primary tumor cells prognostic values are more important than secondary for example 3+4 will have better prognosis than 4+3 Well differentiated tumors are:2,3,4 Intermediate: 5,6,7 Poor prognosis; 8,9,10 Prostate cancer - comparison with breast cancer and BRCA gene In men, mutations in those genes mean a higher risk of developing prostate cancer, and a higher risk to develop prostate cancer at a younger age and have a more aggressive form of the disease. Diagnostic approach to prostate cancer After there is suspicion due to DRE or PSA scores further evaluations should be made. Some imaging techniques are used in order to evaluate the mass firstly: TRUS and MRI Later on a prostate needle biopsy is needed to confirm the diagnosis of cancer with US guidance (12-18 samples are taken) TRUS will show hypoechogenic area Staging of prostate cancer TNM stagin is used in order to Stage the prostate cancer T represents tumor size, N represents lymph node involvement and M represents metastasis Tx: tumor cannot be evaluated (lack of info) T0: Absence of primary tumor T1: incidental finding not clinically palpable or visible T2: tumor confined to prostate (1 or 2 lobules) T3: tumor infiltrated the capsule T4: tumor invading nearby structures (bladder neck, rectum, external urethral spincter) Nx: not evaluated N0: no lymph involvement N1: metastasis in region lymph nodes (iliac and obturator) M0: no peripheric metastasis M1: Presence of metastasis M1a: distant lymph nodes M1b: skeletal metastasis M1c: Distant metastasis Treatment of prostate cancer Watch and Wait 1. Radical prostatectomy Approaches: retropubic, transperineally, trans-coccygeal, laparoscopic, robotic (Da Vinci) 2. Androgen deprivation (GnRH agonist, anti androgens) 3. Radiotherapy (radioactive seed replacement) Gold standard diagnosis for prostate cancer Biopsy How is prostate needle biopsy performed With the help of TRUS 12-18 samples are collected Two samples are taken from each lobe, (two lobes divided to anterior, posterior, intermediate and peripheral zone) Biopsy is usually made transperineally (can also be transrectally) Possible complications include - hematuria, hematospermia (especially in central zone), Rectorrhagia, Infections/sepsis. clinical symptoms of prostate cancer It is usually an asymptomatic disease Symptoms apper when the disease is advanced or there is metastasis. Urinary symptoms include obstructive and irritative symptoms. - Bone metastasis - Bone pain (at metastatic site). - Pelvic lymph node metastases (compression): Lymph node metastases cause a blockage in lymph flow that leads to edema of lower limbs. Usually edema starts as monolateral; - Perineal pain due to regional infiltration. - Obstruction of the ejaculatory ducts causes hematospermia (blood in the semen). - Hematuria if the tumor develops towards the bladder neck and the urethra - Infiltration of the pelvic plexus (neurovascular bundle): erectile dysfunction. - Renal insufficiency can happen due to two factors: chronic urinary retention or prostate cancer spread. lymph nodes involved in prostate cancer Obturator and external/internal iliac  First site of metastasis of prostate cancer Lymph nodes - internal and external iliac and obturator. also bone metastasis are common Is PSA a tumor marker? Approach to a 70 yo male with PSA=8 - lthough PSA levels increase physiologically with age a PSA level of 8 rises a suspicion of cancer. - We need to take into consideration the possibility of BPH, or a BPH combined with other cause that might increased PSA - are there any symptoms present? obstructive or irritational? - The next step will be an NMR (MRI) to asses the presence of lesions and the size of the prostate - If there are lesions in the prostate we preform a needle biopsy followed by a pathological evaluation of the samples - The disease needs to be confirmed and graded - Treatment choice for a 70 years old male would be radical prostatectomy or radiation therapy - Considerations for treatment include - comorbidities, age, overall state of the patient, life expectancy. Life expectancy is a factor in deciding what treatment to chose - Radiotherapy has the same results as surgery in a 15 years time frame (according to recent studies) - so a younger patient will be a candidate for a prostatectomy rather than radiology, also as surgery involves a higher risk of complications. Bladder Tumor Bladder cancer risk factors Endogenous: male sex, age, race Exogenous: smoking (directly proportional), working with leather, iatrogenic, infectious (schistosomiasis), substances eliminated through urine Types of bladder cancer Form ○ Papillary - P-53 independent - pedunculate and sessile. ○ Non-papillary form P-53 dependent → more aggressive - solid exophytic and flat invasive carcinoma (CIS) Depth  ○ Superficial 80% - not involving the muscle tunica - better prognosis. ○ Infiltrating form 20% - penetrates muscle layer Clinically ○ Benign form 3% - benign papilloma. ○ Malignant 97% - Transitional cell carcinoma (>90%) Squamous cell carcinoma (5-6%) - schistomiasis Adenocarcinoma (3%) ○ Undifferentiated carcinoma (very rare) Most common symptom Hematuria present nearly in all cases starts as microhemturia and then becomes macrohematuria LUTS (pollakiuria, urgency, dysuria, tenesmus, burning) Hydronephrosis Urinary retention Markers in bladder cancers There are several different markers that can be used to help diagnose and monitor bladder cancer. Some of the most commonly used markers include: Cystoscopy: This is a procedure in which a small tube with a camera on the end is inserted into the bladder through the urethra. This allows the doctor to visualize the bladder and look for any abnormalities or signs of cancer. Urine cytology: This involves examining a sample of urine under a microscope to look for cancer cells. - Tumoral cells in urine (CTM, Cellule Tumorali Maligne) – performed on 3 voids that show the presence of dysplastic cells. NMP22: This is a protein that is often elevated in the urine of people with bladder cancer. Bladder tumor antigen (BTA): This is a protein that is often elevated in the urine of people with bladder cancer. In the presence of hematuria what should you do if you suspect bladder cancer Urethrocystoscopy (gold standard) – has light and camera, can take biopsy. You can also see the flat form with this exam. Bladder cancer - schistomiasis causes which type of bladder cancer Squamous cell carcinoma  Histology of bladder cancer (in situ, pedunculated, sessile) Papillary form characterized by pink-red papillae. These can be - Pedunculate: small base that enlarges - Sessile: large base, more compact aspect N.B. The larger the base, the more it affects the deeper portions of the bladder wall Benign form 3% - benign papilloma. Malignant 97% - - Transitional cell carcinoma (>90%) - Squamous cell carcinoma (5-6%) - schistosomiasis - Adenocarcinoma (3%) - Undifferentiated carcinoma (very rare) Bladder cancer: diagnosis, differences between stage t1 and t2, symptoms, treatment Diagnosis: urethrocytotoscopy T1 invades lamina propria (subendothelial) T2 there is invasion of the muscularis propria Treatment T1 superficial form: 1. Transurethral endoscopic resection 2. Followed by chemotherapy T2 invasive: 1. Partial cystectomy: not extensively used nowadays, the total resection is preferred. 2. Radical cystectomy: it is performed for more infiltrative forms, when the muscular layers are affected, usually associated to an intermediate- or high-grade malignancy. 3. Urinary derivation: formation of an anastomosis between the ureter and the abdomen 4. Orthotopic Neobladder: doctors can create a new bladder from tissue taken from the intestinal tract, this new organ is not innervated but it works as a type of reservoir for urine. Its shape is similar to that of the bladder. It is usually performed in young patients with no comorbidities. Diagnosis medical history, DRE on males lab - Cytological urine examination imaging - Echography, Urethroscopy, Xray urography, CT, MRI, TNM staging T tumor T0 no evidence Ta non invasive papillary Tis carcinoma in situ - flat tumor t1 tumor invade lamina propria t2 invades muscularis propria t3 invades perivascular tissue t4 invades any of the following - prostatic stroma, seminal vesicles, uterus, vagina pelvic or abdominal wall Between T1 and T2 the therapeutic approach changes: T1 only requires surgical resection of the tumor itself, whereas with a T2 tumor the muscle layer has been invaded so the entire bladder has to be removed. N lymph n0 no involvement n1 1 lymph node less than 2 cm n2 1 lymph node 2-5 cm or multiple lymph nodes less than 5 cm n3 involvement of 1 lymph node more than 5 cm M metastasis m0 absence m1 presence G histological differentiation g0 - no anaplasia g1 slight anaplasia, slow grade malignancy g2 intermediate anaplasia, average malignancy g3 severe, high grade malignancy stage T2 characteristics Invades muscularis propria Surgical treatment of superficial bladder cancer Transurethral endoscopic resection Testicular Tumors Testicular cancer Tumor of the testis is one of the most successfully treatable cancers (the rate is over 90%). It is common in younger men – the most common tumor in males under 40 (15-35). Risk factor include - Cryptorchidism and History (self or familial) being the two most relevant - and other risk factors - ***testicular atrophy, mother related. Cryptorchidism – incidence of 12% (mostly seminomas). The risk depends on the anatomic location of the testis - Intra-abdominal = high risk, Inguinal canal = low risk **The risk is reduced to zero if the surgery to make the testis descend occurs within 6 months natural history It originates from seminiferous tubule cells inside testicular parenchyma It has rapid development with doubling time=3 weeks Volume regression due to necrotic processes taking place in the tumor itself; it provokes pain. Early metastasis: even at a distance because of the rapid development. The dissemination is through the lymphatic spread to the retroperitoneal lymph node. Hematogenous dissemination occurs in later stages, except for choriocarcinoma. Metastases are present at diagnosis in 60-70% of the cases of non-seminomas (highly aggressive), and in 25% of seminomas Symptoms of testicular cancer Painless swelling or hard lump recognized by the patient incidentally during self-examination ○ Rapid increase in volume and uneven surface ○ Not positive for transillumination (light passing through an organ) Severe pain (20% of cases) – due to intra-tumoral hemorrhage Bilateral gynecomastia (5% of cases) In 10% of cases the first manifestation is due to metastasis ○ Cervical mass (supraclavicular lymph nodes) ○ Cough and dyspnea (lung metastasis) ○ Lower back pain (retroperitoneal lymph nodes) Testicular cancer (age of onset) It happens under 40 (15 to 35)  Types of testicular cancer with percentages, doubling time of testicular cancer Doubling time of 3 weeks Germinal = 95% or non-germinal =5% Germinal Seminomatous 40% - STAT: placental alkaline phosphatase (PLAP) Spermatocytic (elderly), Typical seminoma (most common), Anaplastic seminoma (aggressive) , Trophoblastic seminoma (secretes hCG→ gynecomastia). nonseminomatous 60% CYTE (alpha-fetoprotein (AFP), beta-hCG) Choriocarcinoma, Yolk sac tumor, Teratoma, Embryonic carcinoma Non germinal Specialized cells - Leydig, Sertoli, stromal cells non specialized - mesenchymal/ hematopoietic origins. Testis cancer treatment The gold standard is Radical inguinal orchiectomy of the affected testis and its related spermatic cord; it has to be performed in all cases, regardless of the stage Therapy for seminoma - If the cancer is in stage I and II the approach is to watch and wait, with regular US follow up. - If the tumor is in stage III or IV the treatment is chemotherapy and surgery. Therapy for non-seminoma - If the cancer is in stage I and II the approach can be: ○ (1) wait and watch plus retroperironeal lymph node dissection (RPLND), ○ (2) RPLND plus chemotherapy or ○ (3) only chemotherapy. - If the tumor is at the stage III and IV the treatment is chemotherapy and surgery (lymphadenectomy). Main complication is infertility alterations of spermatozoa formation (spermatogenesis) and of their emission (ejaculation) are not rare. Before the surgery patient should be informed Tumor markers of testicular cancer (not only the acronym but the whole name) for staging and prognosis. Positivity is always a sign of active disease Non-seminomatous: ○ AFP (alpha-fetoprotein), ○ beta subunit of human chorionic gonadotropin (βhCG)  Seminomatous: placental phosphatase (PLAP) Bulky tumors: Lactate dehydrogenase (LDH) How to diagnose testicular cancer Clinical + histology History, physical examination, tumor markers, US, surgical exploration, CT (to assess lymph nodes) DDx - Testicular torsion (which is painful) - Epididymo-orchitis (pain, fever) - Hydrocele (transillumination positive) - Inguinal-scrotal hernia (non-solid) Testicular cancer, staging, Tis - intralobular germ cell tumor T1 - limited to testicular parenchyma T2 - limited to testis and epididymis or infiltrate tunica albuginea T3 invades spermatic cord T4 invades scrotum N0 no lymph involved. N1 -