Surgery - Urology Flashcards
1
Q
What is the pathophysiology of renal stones, what are they made of?
A
- Can be renal stones or ureteric stones
- 80% are calcium (calcium oxolate, calcium phosphate, mixed oxolate and phosphate)
- The rest are struvite (staghorn calculi), urate (radiolucent) and cystine
Stones usually impact in narrowed points
- Pelviureteric Junction
- Crossing pelvic brin where iliac vessels travel across ureter
- Vesicoureteric Junction
Causes
- Urate stones = High purine (lots of red meat diet or myeloproliferative disease)
- Cystine stones = homocystinuria
- Oversaturation of urine basically causes the majority of them
2
Q
How do renal tract calculi present?
A
- Sudden onset severe pain radiating from flank to pelvis
- Nausea and vomiting
- Haematuria (typically microscopic)
3
Q
How would you investigate for renal tract calculi?
A
- Urine dip for haematuria and infection (send urine culture too)
- Routine bloods
- U&es for kidney function
- Urate and calcium levels too
- Gold standard = Non contrast CT of Renal tract (CTKUB)
- AXR sometimes however not all stones are radio-opaque
- USKUB for hydronephrosis if u&es deranged
4
Q
How would you manage renal tract calculi?
A
- Fluid resus as they are usually dehydrated
- If lower ureter or <5mm diameter = usually pass on their own with sufficient analgesia
- Opiate analgesia and NSAIDs per rectum are most effective
- >5mm stone or infected stone requires hospital admission
-
Obstructive nephropathy or significant infection = retrograde stent insertion or nephrostomy
- These are temporary measures
- You need to relieve the obstruction immediately to avoid kidney damage
- For stones that do not pass spontaneously
-
Extracorporeal Shock Wave lithotripsy
- For smaller ie <2cm stones
-
Percutaneous nephrolithotomy
- For renal stones only
- Preferred for large stones eg. staghorn calculi
- Flexible uretero-renosocpy
-
Extracorporeal Shock Wave lithotripsy
Recurrent stones
- Tell patients to stay hydrated
- Oxolate = avoid high purine foods and high oxolate foods (nuts, rhubarb, sesame)
- Calcium = check pth to exclude primary hyperparathyroidism, avoid excess salt
- Urate = avoid high purine foods (red meat, shellfish), give purine lowering meds (allopurinol)
- Cystine = genetic testing
5
Q
What are bladder stones?
A
- Form from urine stasis in the bladder so commonly seen in chronic urinary retention
- Also occur secondary to infections like schistosomiasis
- Present with LUTS
- Manage with cystoscopy or fragment them with lithotripsy
- Chronic irritation from bladder stones can cause SCC
6
Q
What is pyelonephritis?
A
- Inflammation of the kidney parenchyma and renal pelvis
- Uncomplicated = normal urinary tract in a non-immunocompromised host
- Complicated is the opposite
- Common organisms
- EColi, Klebsiella, Proteus, Enterococcus faecalis (catheter), S Aureus (catheters), Pseudomonas (catheters), Staph saprophyticus (commensal)
7
Q
What are some risk factors of pyelonephritis? (think about individual risk factors)
A
- Things that reduce antegrade flow of urine
- Neuropathic bladder from spinal cord injury
- Obstructed urinary tract eg bph
- Things that promote retrograde ascent of bacteria
- Female (short urethra)
- Indwelling catheter etc
- Structural abnormalities like vesico-ureteric reflux
- Factors causing infection/immunocompromise
- DM, corticosteroids, HIV
- Factors causing bacterial colonisation
- Renal calculi, sex, oestrogen depletion (menopause)
8
Q
How does pyelonephritis present?
A
- Triad = fever, unilateral loin pain, N&V
- Perhaps also Lower UTI symptoms = dysuria, freq, urgency
- Haematuria
- o/e pyrexial, features of sepsis
- unilateral or bilateral costovertebral angle tenderness +/- suprapubic tenderness
9
Q
How would you investigate and manage pyelonephritis?
A
- Urinalysis (nitrites and leucocytes) and send urine cultures
- Urinary bhcg for women
- Routine bloods
-
Renal Ultrasound scan (USKUB) to rule out obstruction
- Pyonephrosis would be an emergency
- If obstruction is suspected do a non contrast CTKUB
Management
- A-e resus
- Empirical antibiotics and iv fluids
- Analgesia and anti-emetics
10
Q
What kind of cancer is a renal cell carcinoma and what are some risk factors?
A
- It is an adenocarcinoma of the renal cortex
Risk factors = smoking, industrial exposure to lead/aromatic hydrocarbons/cadmium, dialysis, HTN, obesity, polycystic kidney disease, horseshoe kidneys
11
Q
How would RCC present?
A
- Haematuria
- Flank pain or flank mass
- Left sided masses also present with left varicocele sometimes due to compression of left testicular vein as it joins left renal vein
- Lethargy, weight loss etc
- Paraneoplastic syndromes = polycythaemia (erythropoietin), hypercalcaemia (pth), HTN (renin)
12
Q
How would you investigate and manage RCC?
A
Investigations
- Routine bloods
- Urinalysis and send for cytology
- USKUB as routine for haematuria
- CTCAP with iv contrast
- TNM staging of cancer from renal biopsy
Management
- Localised disease
- Partial nephrectomy for small, radical nephrectomy for large
- Unfit for surgery = Percutaneous radiofrequency ablation or lap/percutaneous cryotherapy
- Surveillance
- Mets disease
- Nephrectomy + Immunotherapy
- Biological agents like sunitinib or pazopanib
- Metastasectomy if disease is resectable
13
Q
What are renal cysts? How would you classify them?
A
- Fluid filled sacs in the kidney
- Cysts can be Simple or Complex and are classified using the Bosniak classification
14
Q
What are some risk factors of kidney cysts?
A
Risk factors = old age, smoking, htn, male gender, genetics (polycystic kidney disease, tuberous sclerosis, von hippel-lindau disease)
- ADPKD is a mutation of PKD1 and PKD2 genes resulting in multiple renal cysts forming. Also associated with berry aneurysm formation, mitral valve disease, liver cysts. Pt eventually develop end stage renal failure
15
Q
How do renal cysts present?
A
- Flank pain (if rupture of infection)
- Haematuria
- PKD = uncontrolled hypertension and a flank mass
16
Q
How would you investigate and manage renal cysts?
A
Investigations
- CT imaging with IV contrast
- Bosniak scoring for risk of malignancy
- Routine bloods like U&Es
Management
- Asymptomatic simple cysts you just leave
- Symptomatic simple cysts are manged with simple analgesia
- If significant impact to pt = needle aspiration or cyst deroofing
- Complex cysts = depends on their bosniak stage
- Continued surveillance or surgical intervention eg. nephrectomy
17
Q
Most of incontinence in Gynae…
How would you manage Stress and Urge incontinence?
A
- Lifestyle = weight loss, reduce caffeine, avoid excessive fluids, smoking cessation
Conservative
- Stress 1st line = pelvic floor muscle training for 3 months
- 2nd line = duloxetine (SNRI)
- Urge 1st line = bladder training for 6 weeks
- 2nd line = antimuscarinics like oxybutynin
- Mirabegron for older ladies
Surgical
- Stress = tension free vagina tape, open colposuspension, artificial urinary sphincter, intramural bulking agents
- Urge = botulinum toxin A injections, percutaneous sacral nerve stimulation, augmentation cystoplasty, urinary diversion via ileal conduit
18
Q
What kind of cancer is bladder cancer? Risk factors?
A
- Transitional Cell Carcinomas 80-90%
- Squamous Cell Carcinomas, adenocarcinomas, sarcomas
Risk factors = smoking, old age, aromatic hydrocarbons (industrial dyes or rubbers), schistosomiasis infection (risk for SCC), previous pelvic radiation
19
Q
How does bladder cancer present?
A
- Painless haematuria
- Recurrent UTIs or LUTS
- Pelvic pain
20
Q
How would you investigate and manage bladder cancer?
A
Investigations
- TNM staging
- Urgent cystoscopy (flexible cystoscopy under LA)
- If suspicious lesion identified from initial cystoscopy then do a rigid cystoscopy under GA too
- Do a biopsy on rigid cystoscopy
- Also potentially do a Transurethral Resection of Bladder Tumour (TURBT) during rigid cystoscopy
- CT staging
- Urine cytology (not that sensitive though)
Management
- Non muscle invasive bladder cancer
- T1 = TURBT
- If higher risk, give adjuvant intravesicle therapy eg. Mitoycin C or BCG (Macille Calmette-Guerin)
- Radical Cystectomy can also be offered to high risk disease
- Regular surveillance via cytology and cystoscopy due to high risk of recurrence
- Muscle invasive bladder cancer
-
Radical cystectomy!!!
- Neoaduvant chemotherapy (cisplatin combo regimen)
- Need a urinary diversion following cystectomy through ileal conduit formation or bladder reconstruction
- Monitor b12 and folate annually as ileum is resected in urinary diversion procedures
- Regular follow up with CT imaging
-
Radical cystectomy!!!
- Metastatic or locally advanced cancer
- Chemotherapy
- MDT team, palliative team
21
Q
What is the first thing you would do if you had a scrotal lump?
A
1st line is ultrasound scan of scrotum
- No biopsy needed even to rule out testicular cancer as it can risk seeding cancer
- Do tumour markers = Lactate Dehydrogenase (LDH), Alpha-fetoprotein (AFP), B-hCG
22
Q
What are 5 extratesticular causes of a scrotal lump and 4 testicular causes?
A
Extratesticular
- hydrocoele
- varicocoele
- epididymal cysts (spermatocoele)
- epididymitis
- inguinal hernia
Testicular
- testicular tumour
- testicular torsion
- benign lesions = leydig cell tumours, sertoli cell tumours, lipomas, fibromas
- Orchitis
23
Q
What is a hydrocoele? (brief)
A
- Peritoneal fluid between parietal and visceral layers of tunica vaginalis
-
Painless fluctuant swelling that transilluminates
- Large epididymal cysts also transilluminate
- Can grow large and cause discomfort when sitting/walking
- Can occur congenitally in neonates where they regress spontaneously
- Can occur in infants due to patent processus vaginalis and need ligation
- In older males need urgent US
24
Q
What is a varicocoele? (brief)
A
- Abnormal dilation of pampiniform venous plexus within spermatic cord
- Feels like a bag of worms, there is a dragging sensation, disappears when lying flat
- Typically on L side as spermatic vein drains into left renal vein (R drains into inferior vena cava)
- Can cause infertility and testicular atrophy by increasing scrotal temp
- Undergo semen analysis
- Management = embolization or lap/open ligation of spermatic veins
25
Q
What is a spermatocoele? (brief)
A
- Benign fluid filled sacs arising from epididymis
- Smooth fluctuant nodules that are above and separate from tests and transilluminate
- Often there are multiple of them
- Typically do not need treatment
38
Q
What is epididymitis?
A
- Inflammation of the epididymis (orchitis is inflammation of the testes)
- Sometimes occur together = epididymo-orchitis
- But mainly epididymitis on its own
- Rarely orchitis on its own
- Bimodal age distribution = 15-30 years old and >60 years old.
Causes in <35 year olds is typically sexual transmission = N.Gonorrhoea and C trachomatis
Causes in >35 year olds is typically enteric organism from a UTI = E Coli, Proteus spp, Klebsiella pneumoniae, Pseudomonas aeruginosa
45
Q
What is torsion of hydatid of Morgagni?
A
- This is a remnant of the Mullerian duct that can become torted and present similarly
- More common in younger ages.
- Scrotum is usually less erythematous with a normal lie of testis.
- Blue dot sign may be present in the upper half of the hemiscrotum = visible infarcted hydatid
