Urological Oncology
This domain tests whether you can place a tumour into the correct stage, grade and risk group and then select the treatment that matches that risk. Prostate, bladder, kidney, testis, upper tract urothelial and penile cancer all appear, and the examiners reward precise numbers: PSA, ISUP grade groups, TNM and EAU risk categories.
Prostate cancer
- Diagnosis combines PSA, DRE and multiparametric MRI (PI-RADS), then targeted plus systematic biopsy; the transperineal route reduces sepsis compared with transrectal.
- ISUP grade groups: GG1 = Gleason 3+3, GG2 = 3+4, GG3 = 4+3, GG4 = Gleason 8, GG5 = 9-10. GG3 behaves worse than GG2 despite identical Gleason sums of 7.
- EAU risk groups: low (PSA <10, GG1, cT1-2a); intermediate (PSA 10-20, or GG2-3, or cT2b), split into favourable and unfavourable; high (PSA >20, or GG4-5, or cT2c-3); advanced (N1 or M1).
- Low risk: active surveillance. Intermediate unfavourable and high risk: radical prostatectomy with extended lymphadenectomy or radiotherapy plus androgen deprivation. Metastatic: ADT combined with docetaxel, abiraterone, enzalutamide or apalutamide; mCRPC adds cabazitaxel, radium-223 or Lu-PSMA.
Bladder, kidney and testis
- NMIBC: complete TURBT including detrusor muscle, re-TURBT for T1 or incomplete resection, single immediate mitomycin C instillation unless perforation, BCG induction plus maintenance for high risk and CIS, cystectomy when BCG-unresponsive.
- MIBC: neoadjuvant cisplatin-based chemotherapy then radical cystectomy with pelvic lymphadenectomy, or radiotherapy with radiosensitiser.
- RCC: partial nephrectomy for T1 where technically feasible; systemic immunotherapy plus tyrosine kinase inhibitor for metastatic disease, stratified by IMDC criteria.
- Germ cell tumour: inguinal orchidectomy, AFP/hCG/LDH, CT staging; stage I seminoma can be managed by surveillance.
- UTUC: nephroureterectomy with bladder cuff; organ-sparing for small low-grade lesions; adjuvant intravesical mitomycin.
Worked example
A 64-year-old has PSA 9 ng/mL, PI-RADS 4 MRI, biopsy GG2 (3+4) in 3 of 12 cores, cT2a. PSA 9 plus GG2 plus cT2a places him in intermediate risk; a Gleason 4 pattern of limited extent and PSA below 10 make this favourable rather than unfavourable intermediate risk. Active surveillance is not appropriate. Discuss radical prostatectomy with nerve sparing, or external beam radiotherapy with short-course ADT, and note that all active options carry a risk of erectile dysfunction and incontinence.
Traps that cost marks
Reporting a TURBT specimen without detrusor muscle; omitting re-TURBT for T1; instilling mitomycin after a perforation; giving BCG during gross haematuria or within two weeks of resection; forgetting neoadjuvant chemotherapy in MIBC; using a scrotal approach for a testis tumour; misreading 4+3 as favourable intermediate risk.