Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Surgery > Medbear Urology > Flashcards

Medbear Urology Flashcards

1
Q

What are the functions of the urinary system?

A
  • Storage and excretion of urine
  • Hormone production (e.g RENIN, ERYTHROPOIETIN, 1-25-DIHYDROXYCHOLECALCIFEROL)
  • Electrolyte maintenance
  • Acid-base maintenance
  • Fluid maintenance
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What are the benign causes of hematuria?

A
  • Menstruation
  • Exercise-induced myoglobinuria
  • Sexual intercourse
  • Trauma
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Classify hematuria based on when during urination does the blood appear?

A

Initial - Disease in the urethra, distal to UG diaphragm

Terminal - Disease near bladder neck or prostatic urethra

Throughout - Disease in the bladder or upper urinary tract

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

State the lower urinary tract symptoms (FUN DISH)

A

Storage problem - irritative symptoms
- Frequency
- Urgency
- Nocturia
Possibly -> UTI, stones, bladder tumor

Voiding problem - obstructive symptoms
- Terminal dribbling
- Intermittency
- Poor stream/straining to pass urine
- Hesitancy
Possibly -> BPH, prostate CA, urethral strictures

Others:
- Polyuria
- Oliguria
- Urethral discharge

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

State (5) red flags for malignancy

A
  • Male gender
  • Age (>35Y)
  • Past or current smoker
  • Occupational exposure - chemicals or dyes
  • History of exposure to carcinogenic agents
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Describe on urinalysis.

A
  1. Direct visual observation or inspection of urine
  2. Urine dipstick
    - GOLD STANDARD -> For detection of microscopic hematuria
    - If patient presents with red/brown urine, but negative on dipstick, consider other cause:
    a. Food dye
    b. Drugs
    c. Others - porphyria, alkaptonuria, bilirubinuria
  3. Urine Full Examination Microscopic Element (UFEME)
    - Confirms presence of RBC and cast
    - Absence of RBC/cast despite positive urine dipstick suggest HEMOGLOBINURIA, MYOGLOBINURIA
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

State (5) risk factor of renal cell CA

A
  1. Smoking
  2. Industrial exposure
  3. Prior kidney irradiation
  4. Family history
    - Von Hippel Lindau syndrome due to mutation of VHL gene
    - Hereditary papillary RCC due to mutation of the MET proto-oncogene on chromosome 7q31 -> MULTIFOCAL PAPILLARY RENAL CELL CA
  5. Acquired polycystic kidney disease
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Classify the types of renal cell carcinoma based on the following parameters:
1. Accounts for
2. Arise from
3. Pathogenesis
4. Prognosis

A
  • Appears well-encapsulated with areas of hemorrhage/necrosis
  • Malignant tumor arising from RENAL TUBULAR EPITHELIUM
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Classify renal cyst based on Bosniak Classification
1. Type
2. Description
3. Features
4. Workup
5. Malignancy

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What are the local symptoms of renal cell carcinoma?

A
  • Painless gross hematuria (Only when tumor invades the collecting system) -> Severe bleeding can cause clots leading to colicky pain
  • Historical triad (FLANK PAIN, PAINLESS HEMATURIA, PALPABLE FLANK MASS)
  • Pathological fracture
  • Aching loin pain
  • Episodes of acute pain
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What are the regional symptoms of renal cell carcinoma?

A
  • Left varicocele -> due to invasion of the left renal vein with tumor -> Obstruction of the left testicular vein -> Can’t enter the renal vein -> Fail to empty when patient is in supine position
  • Extension into IVC causes:
    1. Lower limb edema
    2. Ascites
    3. Liver dysfunction
    3. Pulmonary embolism
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

State (6) paraneoplastic syndrome of renal cell carcinoma

A
  • Hypertension -> due to RENIN OVERPRODUCTION
  • Non-metastatic liver dysfunction -> Stauffer syndrome (Resolved after tumor removal) -> elevation of ALP
  • Hypercalcemia
  • Polycythemia -> due to production of erythropoietin by the tumor
  • Cushing syndrome -> due to corticosteroid synthesis
  • Feminization or Masculinization (gonadotropin release)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Describe how you would investigate on a case of renal cell carcinoma?

A

CT kidney (alternative US kidney)
- Renal parenchymal mass with thickened irregular walls and enhancement after contrast injection suggests MALIGNANCY
- CT kidney is triphasic
1. Staging
2. LN involvement, perinephric extension
3. Renal veins or IVU extension
- US -> to differentiate cystic from solid renal masses

MRI Kidneys
- Useful if CT is inconclusive or if contraindication to contrast
- Most effective in demonstrating presence and extent of renal vein or IVU tumor thrombus

Intravenous Urogram (IVU)
- Determine position, size and outline of kidneys
- CA -> MOTTLED CENTRAL CALCIFICATION (90% specificity), PERIPHERAL CALCIFICATION (associated with RCC)

Pathological diagnosis
- In resectable lesion, a partial or total nephrectomy is done and provides tissue diagnosis post-operatively
- In metastatic lesions, biopsy of metastatic site is performed

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

State 3 major criteria for diagnosing a classical cyst.

A
  • Round and sharply demarcated with smooth walls
  • Anechoic
  • Strong posterior acoustic enhancement (indicating good transmission through a cyst)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Elaborate on the staging of renal cell carcinoma

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What are the complications of nephrectomy?

A
  • GA -> Atelectasis, AMI, pulmonary embolism, CVA, pneumonia, thrombophlebitis
  • Operative mortality rate - 2%
    1. Bleeding/Infection
    2. Pleural injuries can result in pneumothorax
    3. Injury neighboring organs
    4. Temporary or permanent renal failure
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

State (4) modifiable risk factors for urolithiasis

A
  • Diet
  • Dehydration -> Low urine volume
  • Massive ingestion of vitamin D or vitamin C (calcium oxalate)
  • Milk Alkali Syndrome

Triad of milk alkali syndrome
- Hypercalcemia
- Metabolic alkalosis
- AKI

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

List 3 points of constriction for the ureter.

A
  1. Pelvic-ureteric junction (PUJ)
  2. Pelvic brim (near bifurcation of the common iliac arteries)
  3. vesicoureteric junction (VUJ) - entry into the bladder
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

State 2 types of stones that can cause STAGHORN CALCULI

A
  • Struvite stones
  • Cystine stones
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Mention the clinical manifestations of renal stones.

A
  • Mostly asymptomatic unless stone gets lodged in the pelvic-ureteric junction -> hydronephrosis -> infection -> pyonephrosis
  • Vague flank pain
  • Small stones (commonest) / large branched staghorn calculi
    -> If bilateral kidneys are affected -> lead to chronic renal failure
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

What are the causes of stone formation?

A
  • Super-saturation (Most common)
  • Infection -> STRUVITE STONES
    Proteus vulgaris infection (urea-splitting organism) -> Splits urea into ammonium -> Generating alkaline urine
    More common in women (More prone to UTI)
    Common organisms -> PROTEUS, PSEUDOMONAS, KLEBSIELLA
  • Drugs
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

State the clinical manifestation of ureteric stones

A
  • Even small stones can cause severe symptoms (Ureter is narrow)
  • Classic ureteric colic pain (SEVERE, INTERMITTENT LOIN-TO-GROIN PAIN)
  • Hematuria - gross or microscopic
  • Can cause upper UTI (e.g FEVER, PAIN)
  • Stone at VUJ - frequency, urgency, dysuria
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

State the clinical features of bladder stone

A
  • May be asymptomatic
  • Irritative urinary symptoms - FREQUENCY, URGENCY
  • Hematuria
  • If infection is present -> Dysuria, fever
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

State the principles of management of urolithiasis

A
  • Provision of effective pain control
  • Treatment of any suspected UTI - antibiotics
  • Allow for spontaneous passage of stones or decide on active stone removal
  • Treat underlying etiology of stone formation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

What are the conservative treatment indicated for urolithiasis?

A
  • Stones <5mm can be treated conservatively as 70% will be passed out of urine
  • Spontaneous stone passage aided with prescription of NARCOTIC PAIN MEDICATIONS and DAILY ALPHA-BLOCKER THERAPY (TAMSULOSIN)
  • HIGH FLUID INTAKE (Drink about 2-3L of water/day)
  • Diet modifications
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

State the medical therapy for the following stones
1. Calcium stones
2. Struvite stones
3. Uric acid stones

A

Medical therapy is limited, and indicated to slow down the process
- Calcium stones - THIAZIDE (increase urinary calcium excretion)
- Struvite stones - eradications of underlying INFECTION
- Uric acid stones - Alkalinizing urine with BAKING SODA or POTASSIUM CITRATE, ALLOPURINOL

Urine should be strained with each void and
Radio-opaque stone tracked with KUB X-ray

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

State the indications for surgical intervention for urolithiasis

Hint: 7s

A
  • 7s - Size, Site, Symptoms, Stasis, Stuck, Sepsis, Social
  • Stone complications
  • Unlikely to resolve with conservative treatment
    Example: Does not pass after 1 month, too large to pass spontaneously
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

State the complications of urolithiasis if left untreated

A
  • Hematoma/Significant bleeding
  • UTI
  • Ureteric injury - perforation/ureteric avulsion
  • Failure of procedure -> Unable to assess stone with URS
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

State the MOST COMMON bladder CA

A

Transitional cell carcinoma

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

State 2 occupational risk factors for bladder CA

A
  • Exposure to aromatic amines (printing, textile) - due to 2-NAPHTHYLAMINE
  • Industrial chemicals
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

State (5) non-occupational risk factors for bladder CA

A
  • Cigarette smoking
  • Chronic analgesic abuse (PHENACETIN)
  • Chronic parasitic infection (SCHISTOSOMA HAEMATOBIUM -> Squamous metaplasia -> squamous cell CA)
  • Chemotherapy
  • Chronic cystitis (e.g pelvic radiation)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

What are the clinical presentations of bladder CA?

A
  • Persistent painless hematuria
  • Lower urinary tract symptoms (LUTS)
  • Pain (in locally advanced or metastatic tumour)
  • Loco-regional complications - extensions to other organs: FISTULA FORMATION
  • Metastatic complications
  • Constitutional symptoms - LOW, LOA, fatigue

LUTS
1. Irritative symptoms (frequency, dysuria, urgency) -> CARCINOMA IN SITU
2. Obstructive symptoms (decreased stream, intermittent voiding, feeling of incomplete voiding, strangury) -> tumor at bladder neck or prostatic urethra
3. Dysuria -> persistent pyuria

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

What investigations should be done to diagnose a case of bladder CA?

A
  • Baseline blood investigations
  • Urine cytology -> for malignant cells
  • Imaging (IVU/CT urogram or US KUB)
  • Flexible cystoscopy or rigid cystoscopy KIV transurethral resection of bladder tumor
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

List the staging of the bladder tumor.
Ta =
Tis =
T1 =
T2a =
T2b =
T3a =
T3b =
T4a =
T4b =

A

Ta = Superficial, DOES NOT involve lamina propria
Tis = CARCINOMA IN SITU
T1 = Superficial, INVOLVES lamina propria (up to muscularis propria)
T2a = Superficial involvement of muscularis propria - up to inner half of muscle
T2b = Deep involvement of muscularis propria
T3a = Microscopic extension outside bladder
T3b = Macroscopic extension outside bladder
T4a = Invasion of prostate, vagina, uterus
T4b = Invasion of lateral pelvic wall, abdominal wall

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

How would you manage a case of superficial tumour of bladder CA?

A
  • TURBT
  • Intravesical therapy
    1. BCG -> 1 instillation per week for 6 weeks
    2. Mitomycin C -> Single instillation within 24 hours of TURBT
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

How to manage a case of muscle-invasive bladder CA?

A

Radical cystectomy with urinary diversion
- MALE -> Radical cystoprostatectomy with pelvic lymphadenectomy
- FEMALE -> Anterior exenteration with pelvic lymphadenectomy

Ways of diverting urine output:
1. Cutaneous ureterostomy
2. Ileal conduit
3. Neobladder construction using ileum
4. Stoma with pouch construction

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

State (2) choice of chemotherapy in metastatic bladder CA

A
  • GC - Gemcitabine + Cisplatin
  • MVAC - MTX + Vinblastine + Doxorubicin + Cisplatin
38
Q

State (4) risk factors of prostate CA

A
  • Advanced age
  • Hormonal -> growth of tumor can be inhibited by ORCHIDECTOMY or administration of ESTROGENS
  • Genetic
  • Environmental - Industrial chemical exposure, diet containing high animal fat consumption, Vitamin E, Soy

*Low-fat diet lowers testosterone levels

39
Q

State the pathophysiology of prostate CA

A
  1. Prostatic Intraepithelial Neoplasia (Architecturally benign prostatic acini and ducts lined by atypical cells)
    - Low grade PIN (PIN 1): Mild dysplasia - No increase risk of prostate CA
    - High-grade PIN (PIN 2/3): Moderate and severe dysplasia - 30-40% chance of concurrent/subsequent invasive cancer
  2. Adenocarcinoma (95%)
    - Arise from outer parts of prostate
    - Thus palpable on DRE and not resectable by TURP
40
Q

What are the clinical (symptomatic) presentations of prostate CA?

A
  • Incidentally picked up during DRE or due to elevated PSA level (>100 highly suggestive)
  • Urinary symptoms
    1. Dysuria
    2. Hematuria
    3. Hesitancy
    4. Dribbling
    5. Retension
    6. Incontinence

Upon examination,
Asymmetrical, hard, irregular, craggy enlargement of prostate

Metastasis -> BONE (Pain, pathological fractures, anemia)

41
Q

What are the (3) routes of metastasis for prostatic cancer?

A
  1. Direct -> Stromal invasion through the prostatic capsule, urethra, bladder base, seminal vesicle
  2. Lymphatics -> SACRAL, ILIAC, PARA-AORTIC
  3. Hematogenous -> LUNGS, LIVER, BONES
42
Q

State the complications from metastatic disease for prostatic cancer

A
  • Pathological fractures, spinal cord compression
  • Ureteral obstruction, urethral obstruction
  • Extra-skeletal metastasis
43
Q

What clinical investigations can be done to diagnose a case of prostatic CA?

A

Serum PSA levels
- >10ng/mL = Biopsy recommended as 67% of patients will have prostate CA
- 4-10ng/mL = Biopsy advised, though only 20% will have prostate CA
- <4ng/mL = Majority will have negative biopsies

Transurethral US with biopsy
- Histology of prostate CA is graded by GLEASON SCORE -> Looking at glandular architecture at low magnification
- Classically: HYPOECHOIC
- Procedure-related complications:
1. Risk of sedation
2. Bleeding
3. Infection
4. Urosepsis (GENTAMICIN - prophylactic antibiotics)

44
Q

How would you stage prostatic cancer?

A
  • Clinical examination (palpable tumor -> T2)
  • TRUS biopsy for staging purposes (GLEASON SCORE)
  • CT scan of abdomen and pelvis -> To assess the extent of tumor invasion and nodal status - PELVIC LYMPHADENOPATHY
  • Bone scan for metastasis

*Metastasis usually spread via BATSON VENOUS PLEXUS to VERTEBRAL COLUMN

45
Q

What is the difference between active surveillance and watchful waiting in prostatic cancer?

A
46
Q

What is the surgical intervention of prostate cancer?

A

Radical Prostatectomy KIV bilateral pelvic lymph node dissection
- Surgical procedure to remove the prostate, surrounding tissue and seminal vesicle
- For patient with life expectancy >10Y
- Lymph nodes are removed between external iliac vein and obturator vessels bilaterally
- Complications:
1. Urinary incontinence
2. Erectile dysfunction
3. Lymphocele
4. Rectal/urethral injury

47
Q

How would you treat a locally advanced disease (T3/T4) of prostate cancer?

A

Radiotherapy
- External beam radiotherapy
- Interstitial bradytherapy
- Alpha-emitter radiation - Radium-223

48
Q

If a prostate cancer patient presented with metastatic disease, how would you treat him?

A

Plan:
Androgen deprivation therapy -> Lower serum testosterone

  1. Surgical Orchidectomy (Remove testicle)
    - Rapid decrease serum testosterone -> Improvement in bone pain and disease related symptoms
  2. Medical orchidectomy
    - LHRH/GnRH agonist -> GOSERELIN, LEUPROLIDE
    - LHRH/GnRH antagonists -> DEGARELIX
  3. Anti-androgen -> BICALUTAMIDE
    - Combined androgen blockade: prevents disease flare during initiation of GnRH agonist
    - Steroidal anti-androgen - rarely used
49
Q

List 4 pathology for BPH.

A
  1. Stromal epithelial interaction theory
    - Proliferation of both epithelial and stromal components of the prostate with resultant enlargement of the gland
  2. Hormones
    - Major stimulus: DIHYDROTESTOSTERONE -> Stimulates prostate growth and maintenance of size
    - Age-related increases in estrogen levels may also contribute to BPH -> By increasing expression of dihydrotestosterone receptors on prostatic parenchymal cells
  3. Stem cell theory
    - Abnormal maturation and regulation of cell renewal process
    - Increase in size of prostate due to decrease in cell death
  4. Static and dynamic components of prostatic obstruction??
50
Q

State the clinical presentation of benign prostatic hyperplasia (BPH)

A
  • Lower urinary tract symptoms (obstructive predominate) -> Irritative symptoms
  • Irritative symptoms -> complications of urinary retention: UTI, stones
51
Q

What are the complications of obstructive uropathy?

A
  • Hydroureter with reflux of urine
  • Hydronephrosis
  • Pyonephrosis
  • Pyelonephrosis and impaired renal function
52
Q

State (5) other differentials for BPH

A
  • Stricture/bladder neck contracture
  • Drug causes: Codeine (Cough mixture), anti-cholinergic, TCAs, BB
  • Chronic constipation
  • CA bladder neck/CA prostate
  • Neurogenic bladder
53
Q

State (4) complications of BPH

A
  • Acute/chronic urinary retention, complicated by bladder stone and recurrent UTI
  • Gross hematuria
  • Renal impairment secondary to outflow obstruction
  • Co-existence of prostate cancer
54
Q

How would investigate a case of BPH?

A

Blood
- FBC -> anemia? Raised WBC?
- Urea/Electrolyte/Creatinine
- UFEME + Urine C&S
- +/- Urine cytology
- PSA

Imaging
- US Kidney -> Hydronephrosis, stones
- US bladder / prostate
- KUB for bladder stone
- Cystoscopy -> TRO stones, strictures/bladder neck obstruction or cancer
- Uroflowmetry

55
Q

How does a normal uroflowmetry look like?

A
  • Normal bell-shaped curve
  • Saw-tooth appearance
  • Normal peak flow rate (Qmax) >15mL/sec
  • Total duration: 30sec(male), 20sec(female)
  • Residual urine: 0mL (young adults), 100-200mL (elderly)
56
Q

What are the medical treatments available for BPH patient?

A
  1. Alpha-blockers (Prazosin, Terazosin, Tamsulosin)
    - 1st LINE
    - MOA: Block alpha-1 adrenergic receptors in bladder neck, prostate and urethra -> Decreased outflow resistance and decreased bladder instability
    - Increase successful trial off catheter (TOC) and continued use reduced need for BPH surgery (during 6 month treatment period)
    - Side effect: Postural hypotension, dizziness, lethargy, light-headedness
  2. 5-alpha reductase inhibitors (Finaseride, Dutasteride)
    - Reduce prostate size (20%), decreased need for surgery (10-15%)
    - Side effect (Finasteride) - Decreased libido (erectile dysfunction), Ejaculatory dysfunction, impotence, gynecomastia
57
Q

What surgery is done to treat BPH?

A

Transurethral resection of prostate (TURP) -> GOLD STANDARD -> Aim to widen bladder neck

Transurethral incision of the prostate (TIUP)
- Decision made during TURP when prostate does not appear to be enlarged
- Make small cuts around the bladder neck area to open it up

58
Q

What are the indications for surgery in BPH patients?

A
  • Failed medical treatment
  • Significant complications:
    1. Upper tract injury (e.g renal insufficiency, obstructive uropathy, hydronephrosis)
    2. Lower tract injury (e.g refractory urinary retention, recurrent UTI, bladder decompensation)
  • Recurrent/persistent gross hematuria
  • Bladder calculi - secondary to BPH

Caution: Prior to TURP -> do a urodynamic studies to rule out neurogenic bladder / detrusor hypotonia

59
Q

State the complications seen in BPH patients if it is left untreated.

A
  • Risk of GA/spinal analgesia
  • Bleeding, infection/urosepsis
  • Local injury causing incontinence (1%) / bladder neck stenosis
  • Perforation of the urethra or bladder dome -> can form FISTULA
  • RETROGRADE EJACULATION (40 - 60%) -> ejaculate volume decrease
  • TUR syndrome (<1%) -> HYPONATREMIA (pseudo-hyponatremia/isotonic hyponatremia)

*Hyponatremia due to constant irrigation during TURP (glycine 0.9% is used)

60
Q

Define testicular torsion

A
  • It is a surgical emergency
  • True urologic emergency where the testis is rotated on its vascular pedicle resulting in ischemia
  • Irreversible damage after 12 hours of ischemia
61
Q

State the clinical presentations and possible findings on physical examination for testicular torsion

A

Clinical presentations
- Acute abdomen (T10 innervations)
- Acute onset of testicular pain and swelling
- Associated with nausea and vomiting

*No history of voiding complains

Physical examination
- Swollen and tender scrotum
- High riding in scrotum with transverse lie
- ABSENT cremasteric reflex
- NEGATIVE prehn sign

62
Q

Give (3) differentials for testicular torsion

A
  • Epididymitis
  • Torsion of testicular appendage (pea colored lump through scrotum)
  • Strangulated inguinoscrotal hernia
63
Q

What (1) investigation you would do to confirm a diagnosis of testicular torsion?

A

COLOUR DOPPLER ULTRASOUND
- Help confirm or exclude diagnosis with 95% accuracy

64
Q

How you manage a case of testicular torsion?

A

Emergency exploration if DOPPLER US is negative for flow or high index of clinical suspicion
- Untwisting of affected testis and bilateral orchidopexy (Surgical procedure that moves undescended testis into the scrotum)
- Warm up with warm pad to see reperfusion or check with doppler after untwisting
- If dead, excise and replace with prosthesis

65
Q

How would you manage a case of scrotal abscess?

A
  • Analgesia + IV antibiotics (AUGMENTIN)
  • Incision and drainage with cavity left open and packed
66
Q

State the complications of scrotal abscess if not treated properly.

A
  • Incomplete drainage leading to persistence of abscess or repeat I&D
  • FOURNIER GANGRENE (necrotizing fasciitis due to synergistic poly-microbial infection)
67
Q

What are the (3) risk factors of Fournier gangrene?

A
  1. Diabetes
  2. Alcoholics
  3. Immunocompromised
68
Q

Name the source of infection to Fournier gangrene.

A
  • Genitourinary (19%) - urethral stone/stricture/fistulae
  • Colorectal (21%) - ruptured appendicitis, colonic CA, diverticulitis, perirectal abscess
  • Dermatological (24%)
  • Idiopathic (36%)
69
Q

What are the clinical presentations of Fournier gangrene?

A
  • Abrupt onset with pruritus, rapidly progressing to edema, erythema, and necrosis within hours
  • FEVER, perineal and scrotal pain associated with INDURATED TISSUE
  • May progress to FRANK NECROSIS of skin and subcutaneous tissue
  • Crepitus in tissue suggest the presence of GAS-FORMING ORGANISMS
70
Q

Describe the management of Fournier gangrene.

A
  • Broad-spectrum antibiotics cover (against aerobic and anaerobic organisms)
    e.g IV penicillin G, IV Clindamycin 900mg, IV ceftazidime 2g
  • Wide debridement with aggressive post-operative support (testes are often spared due to discrete blood supply)
  • If there is damage to external anal sphincter -> COLOSTOMY may be required
  • Tight glucose control and adequate nutrition
71
Q

What surgical complication could lead to EPIDIDYMAL CYST?

A

VASECTOMY (Spermatoceles)

72
Q

Define Varicocele

A

It is the dilatation of veins of the PAMPINIFORM PLEXUS of the spermatic cord

73
Q

Epidemiology and risk factors of varicocele

A
  • Present in 15-20% of post-pubertal males
  • Predominantly occurs in the LEFT HEMI-SCROTUM

Risk factors:
- Idiopathic in young males around puberty
- In older men, with retroperitoneal disease (Need to exclude RCC)

74
Q

State the clinical presentation of varicocele.

A
  • Dull aching, left scrotal pain
  • Testicular atrophy
  • Decreased fertility
75
Q

What is the possible findings on palpation in a case of varicocele?

A
  • Mass is separate from testis (Can get above it)
  • Feels like a BAG OF WORMS
  • Compressible mass above or surrounding the testis
  • NOT TRANSILLUMINABLE
76
Q

Describe the classification of varicocele.

A
77
Q

What surgical management can be done to treat a case of varicocele?

A
  • Trans-femoral angiographic embolization with coil or sclerosant
  • Surgical ligation (excise the surrounding dilated veins)
78
Q

Define hydrocele

A

Asymptomatic fluid collection around the testicles (processus vaginalis) that transilluminates

79
Q

State the clinical presentation of hydrocele.

A
  • Very swollen scrotum, uniformly enlarged
  • Cannot define testis well
  • Maybe firm, tense or lax
  • Maybe TRANSILLUMINABLE if acute (Less in chronic hydrocele)
  • Can get above the mass*****
80
Q

Classify hydrocele based on its anatomy.

A
  • Vaginal hydrocele
  • Hydrocele of the cord
  • Congenital hydrocele
  • Infantile hydrocele
81
Q

State (4) causes of secondary hydrocele.

A
  • From testicular tumour
  • From torsion/trauma
  • From orchitis (any inflammation)
  • Following inguinal hernia repair
82
Q

What are the (2) surgical procedures done to treat a case of hydrocele?

A
  1. Lord’s plication of the sac - for small sac with thin wall
  2. Jaboulay’s operation to evert the sac - for large sac with thick wall
83
Q

Describe the procedure steps for Lord’s plication of the sac in hydrocele.

A
  • Vertical paramedian incision is made
  • Layers of scrotum are divided along the incision to identify the tunica vaginalis sac - from superficial to deep: (Skin, Dartos, External spermatic fascia, Cremasteric fascia, Internal spermatic fascia)
  • TV sac is opened, draining the hydrocele fluid out
  • TV is bunched up by placing multiple plicating sutures, such that the TV becomes crumpled up around the testis
  • Secretions can then be absorbed by the lymphatics and venous system, avoiding reaccumulation of the hydrocele
  • Scrotal support to reduce edema
84
Q

Describe Jaboulay’s operation

A
  • It is similar to Lord’s plication
  • Except that there is SUBTOTAL EXCISION of TV sac
  • With the cut edge of the sac everted and sutured behind the testis, instead of plication
85
Q

State 3 complication of surgical management for hydrocele

A
  • Hematoma (higher risk for Jaboulay)
  • Wound infection -> pyelocele (purulent collections)
  • Injury to the spermatic cord
86
Q

State (3) risk factor for testicular tumour

A
  • Cryptorchidism
  • HIV infection
  • Gonadal dysgenesis (e.g KLINEFELTER SYNDROME)
87
Q

What are the positive findings on clinical examination of a case of testicular tumor?

A
  • Inseparable from the testis, distinct from superficial inguinal ring
  • Hard, nodular, irregular, non-tender
  • Not-transilluminable
88
Q

State 2 differential diagnosis for testicular tumor.

A
  1. Chronic infection with scarring (e.g Orchitis/TB)
  2. Long standing hydrocele with calcification
89
Q

What investigations can be done to diagnose a case of testicular tumor?

A

*No role for percutaneous biopsy -> risk of seeding, risk of changing lymphatic drainage

  • US scrotum
    Seminoma -> HYPOECHOIC INTRATESTICULAR MASS
    Non-seminoma -> INHOMOGENOUS LESIONS
  • Tumor markers
    LDH (Assess tumor burden)
    AFP
    B-HCG

Staging -> CT TAP (assess para-aortic lymph node involvement and distant metastasis)

90
Q

Stage testicular tumor based on CT TAP

A

Stage 1 = Testis lesion, no nodes involved
Stage 2 = Nodes below diaphragm
Stage 3 = Nodes above diaphragm
Stage 4 = Pulmonary and hepatic metastasis

91
Q

Classify testicular tumour.

A
  • Germ cell tumour (90-95%) -> most commonly seminomatous tumours
  • Sex cord stroma tumours (5-10%)

Secondary testicular tumor -> lymphoma, leukemia

92
Q

How would you manage a case of testicular tumor?

A
  • Fertility and sperm banking
  • Staging, radical orchidectomy via inguinal approach +/- retroperitoneal lymph node dissection with combination chemotherapy

*Not to violate scrotal skin -> risk of altering lymphatic drainage of testis

*Intra-op, perform early clamping of testicular artery and vein within the spermatic cord before testis is mobilized -> Prevent intra-operative seeding of tumor up the testicular vein

Surgery (13 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions