Information for health professionals
This section is aimed to provide information for general practitioners (GPs), but may be of use to other health care professionals, including emergency physicians, nurses and physiotherapists
Referral and advice
Prof Sengupta is happy to help manage your patients with urological problems. Elective review can usually be arranged within a week or two, and emergency care can be organised immediately at a suitable hospital. You are welcome to contact Prof Sengupta for advice to help facilitate patient management.
For your patient's convenience, please ensure a current referral, including recent relevant results, is sent with the patient, by fax to (03) 95618629 or via Argus to Argus AT senguptaurology DOT com DOT au
What is the appropriate investigation for haematuria?
Most patients with haematuria need to be carefully evaluated to exclude serious pathology. Exceptions include low-risk patients with low-volume microscopic haematuria, or haematuria clearly associated with a UTI that disappears after successful treatment of the infection. Anti-coagulant associated haematuria
also deserves investigation, since it may still be a sign of serious underlying pathology.
In addition to a full clinical assessment, investigation of haemtauria needs to include urianry cytology, imaging of the upper urinary tract and visualisation of the lower urianry tract by cystoscopy. CT-IVP is the imaging study of choice for haematuria, and provides excellent sensitivity for small parenchymal or collecting system lesions. Ultrasound may be a reasonable alternative in low-risk patients (although it has lower sensitivity), since it avoids the cost and risk associated with CT.
What is the role for PSA screening?
PSA screening should be offered to individual patients after appropriate counselling. Current recommendations suggest that men over the age of 50, with at least 10 years life expectancy should undergo annual screening by measuring their serum PSA. For men at high risk of prostate cancer, for example those with a first degree relative with prostate cancer, the screening age should start at 40.
Recently published results from a large European randomised controlled trial show that PSA screening has the following effects:
Population-based PSA screening cannot yet be recommended, since concerns remain regarding over-diagnosis and over-treatment. The recent development of a set of multi-disciplinary consensus clinical practice guidelines provide a helpful resource and has been endorsed by peak professional bodies
- Greater number of cancers detected
- Higher proportion of cancers of earlier stage, and lower grade
- Lower prostate cancer related mortality
Which treatment is best for localised prostate cancer?
Localised prostate cancer is amenable to a wide range of treatment modalities, including:
Making an appropriate choice of treatment is not easy, and requires careful assessment of each patient, followed by detailed counselling. The factors which may influence the choice of treatment include:
- Surgery (radical prostatectomy) by robotic, laparoscopic or open approaches
- External beaam radiation
- Radioactive seed implant (brachytherapy)
- Active surveillance
- Newer techniques such as cryotherapy or high intensity focussed ultrasound (HIFU)
- Cancer-related factors, including stage, grade, PSA etc.
- Patient co-morbidities, e.g. inflammatory bowel disease
- Patient age and functional status
- Patient preferences, especially relating to potential treatment-related morbidity
When should hormonal therapy be used for prostate cancer?
Prostate cancer is highly sensitive to the effects of androgenic hormones, and thus may be treated by androgen withdrawal (by surgical or medical castration) or blockade. Patients with widespread or symptomatic metastases require urgent and immediate hormonal treatment. Other patients who are routinely treated hormonally include those with high-risk local cancers undergoing radiotherapy, where the two treatments are synergistic.
For other patient subgroups, the optimal timing of hormonal therapy is unknown. This includes patients with minimal metastatic burden or post-treatment biochemical relapse. On balance, given known adverse effects of hormonal treatment and lack of evidence for any advantage from early treatment, it is reasonable to carefully monitor the patient and introduce treatment at a pre-determined PSA threshold or if symptomatic metastases develop.
Recent clinical trials suggest that the early addition of chemotherapy or novel anti-androgens to standard hormonal therapy may be beneficial - this may lead to changes in the systemic management of prostate cancer
How should small renal masses be treated?
Small renal masses pose a management dilemma, since they include both renal cancers and other benign tumours (upto 50%, depending on size). Biopsy of the lesion may help decision-making, but can suffer from sampling error and difficulty in histologic interpretation.
For young and healthy patients, excision of the mass is usually preferred, and if possible, should be done in a nephron-sparing procedure (i.e. partial nephrectomy). Not all renal masses are amenable to partial nephrectomy, and of those which are, many may require an open approach. Laparoscopic partial nephrectomy is becoming more widely available and applicable, but remains a challenging surgical procedure. Laparoscopic radical nephrectomy is the gold-standard for treatment of renal cancer, but results in over-treatment and loss of a renal unit if the mass is benign.
For the elderly or infirm patient, a small renal mass may not pose a significant threat, and as such, may be safely kept under surveillance. If treatment is required, other than the surgical options listed above, percutaneous ablative techniques such as cryotherapy or radio-frequency ablation (RFA) are now available as a less invasive option.