The Manual’s expert uro-oncologist and robotic surgeon Homi Zagar answers some of the most common questions GPs have about urology.

At what Prostate Specific Antigen (PSA) level should the patients be referred to specialists?
Prostate cancer can be present at any PSA level and, during screenings, physicians need to take note of the patient’s ethnicity, age and family history (regarding prostate, breast and ovarian cancer).
As a rule of thumb, a PSA level of greater than three nanograms per millilitre for men aged 40 to 69 requires urological assessment.
For men who are older, the presence of other comorbidities, PSA dynamics and history, PSA free to total ratio, age-adjusted PSA level should also be considered.
A PSA that rises on every measurement warrants further investigation.

What is the role of Multiparametric MRI in the general practice setting?
Multiparametric MRI (mpMRI) is an emerging technology that could be added to PSA-based prostate cancer screening to improve diagnosis and management. A well-performed mpMRI by an expert radiologist provides significant additional information to the treating physician.
By improving the accuracy of assessing the extent of cancer of the prostate, mpMRI helps to understand whether the cancer is through the capsule, if it has eaten into the seminal vesicles or spread into the lymph glands. It can then help target with the appropriate surgery, treatment and dosage of radiotherapy
mpMRI does not replace prostate biopsy, but it can serve as a guide for increasing the biopsy yield. A negative mpMRI, however, does not exclude prostate cancer and up to 15 percent of patients with significant prostate cancer can still have a completely normal mpMRI. In an ideal world, mpMRI would be performed in all men proceeding to biopsy.

Is there any value in performing a DRE?
In a nutshell, 10 to 15 percent of palpable prostate cancers do not produce enough PSA to be detected by PSA screen testing alone.
At the same time, a significant proportion of patients with such tumours still benefit from definitive therapy. In our experience at APCR, up to 10 percent of patients undergoing radical prostatectomy have had a normal or very low PSA. Their cancers were only detected based on a digital rectal exam (DRE), which triggered further investigations.
Based on this, we recommend DRE to accompany PSA testing in men who have been counselled about the risk and benefit of screening and have chosen to be screened for prostate cancer.

What is the best imaging modality for the investigation of haematuria?
In patients with haematuria, bleeding can be from any part of the urinary system. No imaging modality is sensitive enough for the assessment of the bladder, and a cystoscopy is still warranted. For the assessment of the upper tracts, ultrasound is cheap, accessible and has reasonable sensitivity for assessment of renal masses.
However, ultrasound does poorly for the assessment of the ureters. The ideal imaging modality for a patient with haematuria is a CT urogram. An MR urogram can be performed in patients with poor renal function, but if the glomerular filtration rate (GFR) is less than 30, this should be discussed with the radiologist.

I have a patient with a new diagnosis of bladder cancer needing cystectomy – is there any value in getting a second opinion?
Although radical cystectomy is the gold standard for the treatment of muscle invasive bladder cancer and selected patients with high-risk non-invasive bladder cancer, many aspects of care can be scrutinised when obtaining a second opinion in this setting. Trimodal therapy (radiation, chemotherapy and maximal endoscopic resection of bladder cancer) is increasingly utilised and may provide an alternative option for patients who are not fit for the surgery.
For patients undergoing cystectomy, the discussion regarding the need for neoadjuvant chemotherapy is of paramount importance, especially given this practice is not adopted by all urologists. The type of chemotherapy regimen is also worthy of discussion as the newer regimens seem to be better tolerated and may provide additional benefits to selected patients. The utility of an enhanced recovery program after surgery, robotic surgery, erectile function preservation and formation of neo-bladder are all other aspects of surgery that can be further discussed with patients wanting to consider alternative options.
At APCR, we offer all of these options, and our multidisciplinary team can provide second opinions for patients needing cystectomy.

How are renal tumours best managed? Is there any role for a biopsy?
The treatment options for small renal masses (less than four centimetres) include surveillance, ablation or surgery (partial or radical nephrectomy). Patient factors, including comorbidities, renal function and life expectancy, dictate what the most suitable treatment option would be.
Renal biopsy can further stratify patients according to their risk and can provide additional data aiding with selecting the most appropriate treatment. For patients suitable for surgery, it is ideal to perform nephron-sparing surgery where possible in order to maximise the preservation of renal function. The majority of nephron-preserving surgery for APCR patients is performed in a minimally invasive fashion (robotic) at the Royal Melbourne Hospital.
We also offer ablative therapy for small renal masses for selected patients at the Royal Melbourne Hospital. This method carries a lower complication rate and is associated with minimal damage to the surrounding normal renal parenchyma. The recurrence rate is higher than partial nephrectomy and is preserved for older patients with more comorbidities, who are not suitable for surgical approaches. This modality can be applied again in the cases of disease recurrence and provides an excellent alternative option for selected patients.

How should a patient post nephrectomy be managed?
From an oncological point of view, patients should have regular chest and abdominal imaging – the frequency dependent on the stage of renal cancer and the characteristics of the tumour.
From the renal function point of view, however, the contribution from the primary physician is of paramount importance. After surgical nephron loss, the remaining nephrons are always at risk of further injury, and all modifiable factors with potential deleterious impact on renal function should be addressed. The patient should have regular assessments of his renal function (three to four times per year) as well as his blood pressure by his primary physician and, in the case of hypertension, this needs to be promptly treated. Diabetes control, weight loss, avoidance of high protein and salt diet, cessation of smoking are all the steps that can prolong the life of the remaining nephrons and minimise the risk of renal failure later on in life.

Homi Zargar
Uro-oncologust and robotic surgeon
Royal Melbourne Hospital

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