Procedures (circumcision, dialysis, nephrostomy& ureteric stenting, orchidectomy, prostatectomy, transplant, TURBT, vasectomy)

Question 1

Define circumcision.

Answer 1

Removal of the penil prepuse (foreskin)

Question 2

What are the indications for circumcision?

Answer 2

• Phimosis/paraphimosis
• Balanitis and balanoposthitis
• Lichen sclerosis
• UTI and prostatitis
• Zoon balanitis
• Genital condyloma
• Malignant lesions of the foreskin
• Prevention of STI, HIV, penile carcinoma
• Personal preference - e.g. Judaism, Islam, sociocultural reasons

Question 3

What are the complications of circumcision?

Answer 3

Acute:

• Bleeding
• Infection
• Wound dehiscence - post-op erections may cause excessive strain on suture line
• Overzealous or incomplete circumcision - causes skin thethering, penile length loss and rarely buried penis

Long term:

• Glans hyperesthesia
• Skin bridges and meatal stenosis - more common in lichen sclerosus
• Patient dissatisfaction

NB: mostly done under local anaesthesia

Question 4

Define dialysis.

Answer 4

A type of renal replacement therapy in patients with AKI or CKS to prevent uraemia and death from adverse complication of kidney failure.

Question 5

What are the types of dialysis?

Answer 5

Peritoneal dialysis (Tenchhoff catheter) 3-5 fluid exchanges per day needed done by the patient.

Haemodialysis - Peripheral (AV fistula or graft) or Central (Tesio) access. 3 times a week for 3-5hrs per session.

Question 6

What are the indications for dialysis?

Answer 6

• intractable hyperkalaemia;
• acidosis;
• uraemic symptoms (nausea, pruritus, malaise);
• therapy-resistant fluid overload;
• chronic kidney disease (CKD) stage 5.

Question 7

What are the costs of dialysis vs kidney transplant?

Answer 7

Dialysis - £30,000 per patient per year
Transplant - £20,000 per patient per transplant with immunosuppression costs of £6,500 per year thereafter

Question 8

What is the overall mortality in dialysis patients?

Answer 8

20% anually
Commonest cause is CVD which is x30 more common in dialysis patients than age-matched controls

Question 9

What are the complications of dialysis?

Answer 9

Question 10

What are the complications with the different types of vascular access in dialysis?

Answer 10

AV graft - infection as prosthetic material
AV fistula - infection, thrombosis, bleeding, failure to mature, pseudoaneurysm, venous HTN, steal syndrome.
Central venous catheter - infection, SVC syndrome, failure

Question 11

Define nephrostomy and ureteric stenting.

Answer 11

Ureteral stents used to relieve ureteral obstruction.

Question 12

What are the indications for ureteral stenting/nephrostomy?

Answer 12

• Ureteral obstruction - e.g. stones, malignancy
• High stone burden or inability to place stent endoscopically -> nephrostomy tube
• Ureteral anastomosis - e.g. after renal transplant
• Prophylactic e.g. before ESWL if patient has large stones

Question 13

What are the complications of nephrostomy and ureteral stenting?

Answer 13

• Haematuria
• UTI - prosthetic so prone to infection
• Stent migration
• Stent encrustation

Question 14

Define orchidectomy.

Answer 14

Orchidectomy is the surgical removal of the testes.

Question 15

What are the indications for orchidectomy?

Answer 15

• Maligancy
• Treatment of prostatic cancer - considered a form of hormonal manipulation
• Gender reassignment surgery
• Necrosis after testicular torsion
• Wasting of testes after trauma

Question 16

How long after orchidectomy can the patient return to work?

Answer 16

2 weeks

Question 17

What are the complications of orchidectomy?

Answer 17

• Reduced fertility or infertility
• Scrotal haematoma
• Infection
• Post-operative pain
• Phantom testis syndrome - pain like from the trauma they had there before
• Inguinal hernia
• Ilioinguinal nerve injury
• Risks for complications with prostheses are low but include infection and rotation.
• Reduced testosterone levels (in bilateral orchidectomy onlu) -> ED, gynaecomastia, loss of muscle mass, osteoporosis

Question 18

Define prostatectomy.

Answer 18

Surgical removal of all or part of the prostate gland - subototal or radical prostatectomy.

Question 19

What are the methods for prostatectomy?

Answer 19

Question 20

What are the indications for prostatectomy?

Answer 20

Benign conditions: BPH, retention, recurrent UTI, uncontrollable haematuria, bladder stones from bladder outlet obstruction
Malignancy: intermediate and high risk prostate cancer

Question 21

What are the complications of prostatectomy?

Answer 21

Acute: bleeding, infection, damage to surrounding organs, VTE.
Long term:

• sexual dysfunction - may no longer be able to ejaculate semen; avioded in TURP
• retrograde ejaculation
• incontinence
• urethral stricture

Question 22

What are the types of transplant?

Answer 22

DBD - donation after brain death
DCD - donation after circulator death
Live donor

Question 23

What are the most important antigens that give rise to rejection?

Answer 23

ABO blood group - DR>B>A. Maximum is 2 mismatches in each = 6.
HLA - done with PCR
Minor histocompatibility antigens

Question 24

What are the types of organ rejection?

Answer 24

Hyperacute. This occurs immediately through presence of pre formed antibodies (such as ABO incompatibility).
Acute. Occurs during the first 6 months and is usually T cell mediated. Usually tissue infiltrates and vascular lesions.
Chronic. Occurs after the first 6 months. Vascular changes predominate.

Question 25

What type of incision may be used in renal transplants?

Answer 25

A Rutherford-Morrison incision is made on the preferred sid

Question 26

Define TURBT.

Answer 26

Transurethral resection of a bladder tumour

Question 27

What are the indications for TURBT?

Answer 27

Treatment and diagnosis of:

• Non-invasive papillary carcinoma (Ta)
• Urothelial carcinoma in situ (Tis)
• Tumour invading the lamina propria only (T1)

Radical cystectomy is used for muscle-invasive tumours.

Question 28

What are the complications of TURBT?

Answer 28

• Bleeding, infection, VTE, perforation of the bladder wall.
• Anaesthetic complications
• Haematuria
• Dysuria
• Recurrence of tumour

Question 29

Define vasectomy.

Answer 29

Interruption or occlusion of the vas deferens for permanent male contraception.

Question 30

Describe the process for vasectomy.

Answer 30

Done as an outpatient procedure
Puncture wound is made in the skin of the scrotum under local anaesthesia
Vas deferens is accessed, divided and occluded using cautery
Takes ~15mins and can be done in clinic, hospital or some GPs

Question 31

What follow up is needed post-vasectomy?

Answer 31

Postvasectomy semen analysis is conducted at 12 weeks to confirm absence of spermatozoa in the ejaculate

Alternative contraception is required until azoospermia is confirmed

Question 32

What are the complications of vasectomy?

Answer 32

• scrotal haematoma
• sperm granulomas - caused by sperm leaking from the tubes, may form a tender mass but usually asymptomatic
• infection
• epididymitis
• persistent post-vasectomy pain (may need further surgery to reverse vasectomy or complete epididymectomy
• failure