Appointments in our practice are reviewed and prioritised according to clinical urgency. Often patients will be requested to provide details of their current investigations at the time of making an appointment to assist us.

Urgent patients, for example those with a likely cancer diagnosis or an obstructed urinary tract will usually be seen within a week. I can be contacted through my office to discuss urgent cases and assisting with further investigations or directing patients to a hospital emergency department if necessary.

Patients can be seen at either the Gosford or Kanwal consulting rooms although waiting times can differ. For some patients such as those with lower urinary tract symptoms, additional assessment with a urinary flow rate and post void residual is only possible through the Gosford consulting rooms.

Gross or Macroscopic Haematuria

The likelihood of malignant causes (eg urothelial cancer/TCC of kidney, ureter, bladder, urethra or renal cell carcinoma or locally advanced prostate cancer) vs benign causes (eg benign prostatic hyperplasia [BPH], UTIs, urinary stones) is dependent on patient risk factors and the following recommended investigations:

• Urine cytology X3 (consecutive 3 days NOT first morning sample)
• Abdominopelvic CT with delayed phase (CT IVP) or renal tract US if renal impairment or contrast allergy
• PSA in men aged >40
• Mid stream urine (MSU) – Microscopy/Culture/Sensitivity (MCS)

A cystoscopy will usually be warranted for all patients with macroscopic haematuria.

Microscopic Haematuria

The risk of significant pathology in asymptomatic patients with negative urine cytology X3, normal upper urinary tract imaging (CT IVP or renal tract US) and normal PSA in men aged >40 is low.

In younger non smoking patients, it is reasonable to repeat the urine microscopy (MSU) and if there is no blood then no further investigations are required. Otherwise, patients will usually be offered a diagnostic flexible cystoscopy under local anaesthetic.

All patients being assessed for upper urinary tract stones require a non contrast abdominopelvic CT scan (CT KUB) unless contraindications such as pregnancy exist.

Ultrasound can be inaccurate for assessing size of renal stones, missing ureteric stones and often misinterpret echogenic shadows-being stones that do not exist.

We would also recommend a plain KUB X-ray for any stone >10mm. If a large stone cannot be seen on a plain X-ray, it could be a radiolucent uric acid stone that is amenable to chemical dissolution without surgery (=5% cases).

We recommend the following baseline investigations:

• Renal tract US (which will include prostate size estimate and bladder post void residual)
• MSU – MCS
• PSA

If a patient has obstructive symptoms (weak stream, straining to void, dribbling, hesitancy, incomplete emptying) a trial of alpha blocker such as tamsulosin (flomaxtra) prior to their appointment would be reasonable if there are no contraindications (eg upcoming cataract surgery, postural hypotension).

More urgency is required for a patient with high post void residuals especially if this is associated with renal impairment (raised serum Creatinine or hydronephrosis on US/CT) ie obstructive nephropathy.

Most renal masses are detected incidentally (asymptomatic) with the increasing use of abdominal imaging (eg US and CT).

Most solid renal masses with vascularity (eg contrast enhancement on CT) will be malignant although a mass <4cm can be benign in up to 25% (depends on actual tumour size and rate of growth)

A triple phase renal (abdominopelvic) CT will be required to further characterise the mass and often a renal tract ultrasound to confirm it is not a cyst.

Simple cysts on ultrasound or abdominopelvic CT do not require further evaluation.

Treatment options of solid renal masses is dependent on tumour size, characteristics, growth rate, patient factors such as other comorbidities and anxiety and they include:

• Laparoscopic Radical nephrectomy (unless the mass is very large or locally advanced)
• Partial nephrectomy (usually laparoscopic for renal masses <4cm)
• Active surveillance (especially for small renal masses in older patients as masses <3cm have only a 1-2% risk of metastases)
• Ablative treatments (eg Radio Frequency Ablation) for frail patients unable to tolerate surgery can be considered

PSA screening remains controversial. The American Urological Association (AUA), European Association of Urology (EAU) and the Urological Society of Australia and New Zealand (USANZ) all recommend PSA testing after appropriate counselling especially in light of continuing evidence from one of the largest screening studies (European Randomised Study of Screening for Prostate Cancer – ERSPC) showing =30% reduction in prostate cancer mortality in the screening group.

Advocates of PSA screening believe that the large number of patients who die of the disease warrants screening programs, arguing that lives can be saved by early detection and treatment. Screening is most likely to benefit patients who have at least 10 years of life expectancy.

Critics of PSA screening argue that the associated treatment morbidity and costs are not sufficient to justify widespread implementation of aggressive screening programs. Furthermore, there is often detection of harmless tumours.

Who should have a PSA test?

Given prostate cancer is the most common malignancy in Australian men and is still a leading cause of cancer death, early detection and treatment is critical as the disease is typically without symptoms unless it is advanced and incurable.

Men should be counselled on the pros and cons of PSA testing including the need for a prostate needle biopsy and the consequences of a positive result including radical surgery and radiotherapy.

In general in accordance with the USANZ 2009 PSA Testing Policy,

• Men with NO family history should be tested with annual DRE and PSA from age 50-70
• Men with a family history (especially if first degree relative) should be tested from age 40
• A single PSA from age 40 can help stratify future risk based on median PSA levels

What we do with an elevated PSA (above age specified limit) reading?

PSA can be elevated due to noncancerous causes such as urinary tract infections, prostatitis, grossly enlarged prostate, recent urinary instrumentation and recent ejaculation.

We would recommend:

• Repeat PSA (with free/total ratio) and MSU with abstinence of ejaculation for 72 hours prior to testing
• If there is a UTI, 4-6 week treatment with a sensitive antibiotic (avoid quinolones if possible) prior to repeating PSA / MSU and also upper tract imaging (renal US)

If the PSA remains elevated, or if there is a PSA history and the PSA velocity or change over time is >0.75ng/ml/year on at least 3 PSA tests, referral to a Urologist is appropriate.

Patients with low volume low risk prostate cancer detected on a needle biopsy will usually be assessed to be placed on an active surveillance program to avoid overtreatment with surgery or radiotherapy of potentially insignificant disease. Dr Louie-Johnsun has presented and published one of Australia’s first series on Australian men living with prostate cancer on active surveillance with minimal anxiety and minimal effects on quality of life.

Patients who clearly have a life expectancy of <10 years and are asymptomatic(eg over the age of 75) will be counselled with regard to watchful waiting rather than proceeding to a prostate needle biopsy as it is more likely they will die of other causes than prostate cancer.