Urologic Oncology
Core concepts
Build the section around stage, grade and risk stratification, because almost every oncology question is really a question about which of these three drives the next decision.
Kidney: know the difference between clear cell, papillary (type 1 vs 2) and chromophobe histology, and the hereditary syndromes (VHL, HPRC, BHD, HLRCC, tuberous sclerosis). Understand that partial nephrectomy is preferred for T1 tumours when technically feasible, and that radical nephrectomy is the oncologically safer choice when partial would leave inadequate parenchyma. Trap: confusing Fuhrman/WHO ISUP grade with stage; and forgetting that tumour thrombus level (I-IV) is a staging, not a grading, issue.
Bladder: non-muscle-invasive risk stratification (EORTC/EAU) determines whether a patient gets a single post-operative instillation, induction BCG, or maintenance BCG. BCG-unresponsive disease has a defined meaning (recurrence within 6 months of adequate BCG, or T1 at 3 months). Muscle-invasive disease: neoadjuvant cisplatin-based chemotherapy then radical cystectomy is standard; trimodality therapy is an alternative in selected patients.
Prostate: PSA kinetics, Gleason/ISUP grade group, D'Amico/NCCN risk grouping, and the fact that grade group 1 (Gleason 3+3) is now often managed with active surveillance. Trap: quoting a single PSA value as diagnostic; or forgetting that bone scan is not indicated at low PSA.
Testis: seminoma vs non-seminoma, tumour markers (AFP rules out pure seminoma), and the retroperitoneal lymph node drainage pattern. Penile: HPV-related vs HPV-independent squamous carcinoma, inguinal nodal staging. Adrenal: functional vs non-functional, and the size threshold for resection.
Worked rule of thumb
A 58-year-old with a 3.5 cm enhancing renal mass and normal contralateral kidney: T1a, so partial nephrectomy is the default; the trap answer is "radical nephrectomy because it is safer oncologically" - reserve that for tumours where partial is not feasible.
Exam traps
- Stage vs grade confusion.
- Marker-positive "seminoma" is a non-seminoma.
- BCG failure vs BCG-unresponsive.
- Assuming all renal masses need biopsy.