Sunday, January 29, 2012
Renal Mass腎臟問題
Large solid vascular renal masses are usually cancerous. Such patients may present with haematuria but many masses are picked up earlier at health screenings. There is however, no role for routine screening for renal masses except in those with such a strong family history or previous history. An incidental mass of the right kidney at the lower pole, 5 x 4 cm is such an example. The standard practice nowadays is to have another imaging modality to confirm the ultrasound findings, especially any tumour thrombus in the renal vein and IVC. The CT can also help to look for any para-aortic lymphadenopathy The commonest benign renal masses viz AML angiomyolipoma and oncytoma may exhibit characteristic lesions on CT. I will also do a chest x-ray at the same time.
One option is to do percutaneous ultrasound guided Trucut biopsies of the lesion. However, the limitation of this is that the biopsy may not be representative of the tumour as renal cell carcinoma is heterogenous. Biopsy can also cause bleeding and associated with the theoretical risk of biopsy tract seedling. One would also require a good uro-histopathologist to make a diagnosis. I would usually recommend a biopsy if we are thinking of systemic therapy without a nephrectomy, e.g. in the presence of metastatic disease.
One option is to remove the entire kidney with the tumour, for completeness of the surgery.
However, I would think the standard management would be a partial nephrectomy. Partial nephrectomy is more complicated than total nephrectomy. It requires control of the renal vein, renal artery and probably
the insertion of ureteric catheter so that methylene blue can be injected to detect any breach of the pelvi-calcyeal system which needs to be sutured. As the surgical margin is renal tissue, there is also an increased risk of secondary haemorrhage, in addition to urinary fistula. As with most surgeries, it can be done by three approaches: open, laparoscopic or robotic. The later two usually takes longer.
“Minimally” invasive therapy includes cryoablation and radiofrequency. These ablative energies may be applied percutanously under ultrasound guide or laparoscopically. Tumour destruction is still incomplete. However, I would recommend such “MIT” only to patients who are unfit for surgery or who has
multiple bilateral lesions where surgery is difficult.
The approach in small (<4cm) renal masses (SRM) is more conservative, which may include active surveillance in masses <3cm (incidence of primary metastatic disease 2.4 % compared to 8.4% if mass is 3-4cm)
Dr Clarence Lei Chang Moh, FRCS Urol
clarencelei@gmail.com
20 Jan 2012
One option is to do percutaneous ultrasound guided Trucut biopsies of the lesion. However, the limitation of this is that the biopsy may not be representative of the tumour as renal cell carcinoma is heterogenous. Biopsy can also cause bleeding and associated with the theoretical risk of biopsy tract seedling. One would also require a good uro-histopathologist to make a diagnosis. I would usually recommend a biopsy if we are thinking of systemic therapy without a nephrectomy, e.g. in the presence of metastatic disease.
One option is to remove the entire kidney with the tumour, for completeness of the surgery.
However, I would think the standard management would be a partial nephrectomy. Partial nephrectomy is more complicated than total nephrectomy. It requires control of the renal vein, renal artery and probably
the insertion of ureteric catheter so that methylene blue can be injected to detect any breach of the pelvi-calcyeal system which needs to be sutured. As the surgical margin is renal tissue, there is also an increased risk of secondary haemorrhage, in addition to urinary fistula. As with most surgeries, it can be done by three approaches: open, laparoscopic or robotic. The later two usually takes longer.
“Minimally” invasive therapy includes cryoablation and radiofrequency. These ablative energies may be applied percutanously under ultrasound guide or laparoscopically. Tumour destruction is still incomplete. However, I would recommend such “MIT” only to patients who are unfit for surgery or who has
multiple bilateral lesions where surgery is difficult.
The approach in small (<4cm) renal masses (SRM) is more conservative, which may include active surveillance in masses <3cm (incidence of primary metastatic disease 2.4 % compared to 8.4% if mass is 3-4cm)
Dr Clarence Lei Chang Moh, FRCS Urol
clarencelei@gmail.com
20 Jan 2012
Saturday, January 14, 2012
B P H , BENIGN PROSTATEHY PERPLASIA（良性前列腺增生症）
B P H , BENIGN PROSTATEHY PERPLASIA
BPH can cause obstructive urinary symptoms eg h e s i s t a n c y , p o o r a n d
i n t e r m i t t e n t u r i n e f l o w , t e r m i n a l d r i b b l i n g a n d r e t e n t i o n .
Modern practice would require that the urine flow be documented with a
uroflowmetry. A normal uroflowmetry is >15 ml/sec. The post void residue
should also be <100 mls for most patients and any post void residue >300 mls
would be considered as having chronic retention with a risk of
hydronephrosis.
TWO types pf medicatons are used to treat BPH.
For patients whose prostate are proven to be enlarged (> 40 cc on rectal
exam or ultrasound per abdomen or transrectal TRUS), they will require a
medication to reduce the size of the prostate gland. This is done by
decreasing the dihydro-testosterone inside the prostate with A v o d a r t
(Dutasteride) or Proscar (Finasteride) daily. It takes 6 months to show any
clinical benefit. He will have to take this on a long term basis, possibly for
many years, until a better agent comes along. This agents cost about RM7
per day.
To improve his uroflow quickly (days) , one can use an alpha-blocker to relax
the adrenergic nerves to the prostatic urethra. The available ones include
Harnal (Tamsulosin), X a t r a l (Alfuzosin), Hytrin (Terazosin), Cardura
(Doxazosin). The side effects are those of postural hypotension and
ejaculatory disturbance. The cost range from RM1 to RM4 per day.
Other symptoms may not due to the prostate but from an overactive bladder,
OAB. These symptoms include f r e q u e n c y , n o c t u r i a , a n d u r g e n c y. In
such cases, an anti-cholinergic would be more useful e.g. Detrusitol
(Tolterodine or V e s i c a r e (Solifenacin).
If there is pain,one should exclude an UTI or stones.
If there is gross hematuria one need to exclude a bladder or renal tumour.
Bladder outlet obstruction and overactive bladder may be associated with
erectile dysfunction, ED. Many of these patients would also benefit from
PDE-5 inhibitor (phosphodiiesterases type 5) e.g. Sildenafil (Viagra),
Vardenafil (Levitra) or Tadalafil (Cialis). Sildenafil is now available as a
generic from Ranbaxy at just over RM10/- per table when the original Viagra
is about RM45/-. US FDA also recent approved d a i l y d o s e o f T a d a l a f i l
5 mg to be used for both erectile dysfunction and bladder outlet obstruction.
A further factor to improve patients with lower urinary tract symptoms is the
possibility of adding on testosterone hormonal replacement. A clue to such a
disorder (TDS, Testosterone Deficiency Syndrome) is that the patient has
other aspects of the metabolic syndrome e.g. obesity, hypertension, diabetesas well as loss of libido, erectile dysfunction, general tiredness. The biochemical diagnosis of TDS is finding a total testosterone of <11 nmol/ml. They can now be very effectively treated by intramuscular injection of
N e b i d o 1 gm every 3 months.
Thank you very much for your attention.
Dr Clarence Lei Chang Moh
Consultant Urologist
e-mail: clarencelei@gmail.com
13 January 2012
Ref:
Benign prostatic hyperplasia
(Diagram taken from http://en.wikipedia.org/wiki/Benign_prostatic_hyperplasia
Diagram illustrating normal prostate (left) and benign prostatic hyperplasia (right).
BPH can cause obstructive urinary symptoms eg h e s i s t a n c y , p o o r a n d
i n t e r m i t t e n t u r i n e f l o w , t e r m i n a l d r i b b l i n g a n d r e t e n t i o n .
Modern practice would require that the urine flow be documented with a
uroflowmetry. A normal uroflowmetry is >15 ml/sec. The post void residue
should also be <100 mls for most patients and any post void residue >300 mls
would be considered as having chronic retention with a risk of
hydronephrosis.
TWO types pf medicatons are used to treat BPH.
For patients whose prostate are proven to be enlarged (> 40 cc on rectal
exam or ultrasound per abdomen or transrectal TRUS), they will require a
medication to reduce the size of the prostate gland. This is done by
decreasing the dihydro-testosterone inside the prostate with A v o d a r t
(Dutasteride) or Proscar (Finasteride) daily. It takes 6 months to show any
clinical benefit. He will have to take this on a long term basis, possibly for
many years, until a better agent comes along. This agents cost about RM7
per day.
To improve his uroflow quickly (days) , one can use an alpha-blocker to relax
the adrenergic nerves to the prostatic urethra. The available ones include
Harnal (Tamsulosin), X a t r a l (Alfuzosin), Hytrin (Terazosin), Cardura
(Doxazosin). The side effects are those of postural hypotension and
ejaculatory disturbance. The cost range from RM1 to RM4 per day.
Other symptoms may not due to the prostate but from an overactive bladder,
OAB. These symptoms include f r e q u e n c y , n o c t u r i a , a n d u r g e n c y. In
such cases, an anti-cholinergic would be more useful e.g. Detrusitol
(Tolterodine or V e s i c a r e (Solifenacin).
If there is pain,one should exclude an UTI or stones.
If there is gross hematuria one need to exclude a bladder or renal tumour.
Bladder outlet obstruction and overactive bladder may be associated with
erectile dysfunction, ED. Many of these patients would also benefit from
PDE-5 inhibitor (phosphodiiesterases type 5) e.g. Sildenafil (Viagra),
Vardenafil (Levitra) or Tadalafil (Cialis). Sildenafil is now available as a
generic from Ranbaxy at just over RM10/- per table when the original Viagra
is about RM45/-. US FDA also recent approved d a i l y d o s e o f T a d a l a f i l
5 mg to be used for both erectile dysfunction and bladder outlet obstruction.
A further factor to improve patients with lower urinary tract symptoms is the
possibility of adding on testosterone hormonal replacement. A clue to such a
disorder (TDS, Testosterone Deficiency Syndrome) is that the patient has
other aspects of the metabolic syndrome e.g. obesity, hypertension, diabetesas well as loss of libido, erectile dysfunction, general tiredness. The biochemical diagnosis of TDS is finding a total testosterone of <11 nmol/ml. They can now be very effectively treated by intramuscular injection of
N e b i d o 1 gm every 3 months.
Thank you very much for your attention.
Dr Clarence Lei Chang Moh
Consultant Urologist
e-mail: clarencelei@gmail.com
13 January 2012
Ref:
Benign prostatic hyperplasia
(Diagram taken from http://en.wikipedia.org/wiki/Benign_prostatic_hyperplasia
Diagram illustrating normal prostate (left) and benign prostatic hyperplasia (right).
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