Surgery - Urology Flashcards
What is the best form of imaging for kidney stones?
CT KUB
Recall the 4 main types of kidney stone in order of highest to lowest radiointensity
Calcium phosphate
Calcium oxalate
Triple (struvite) stones
Uric acid (radiolucent)
Which type of kidney stone is associated with urease bacteria?
Triple (struvate) stones
Which type of kidney stone is associated with hypercalciuria?
Calcium oxalate
How should kidney stone pain be managed?
PR/ IM diclofenac
Recall one contra-indication to diclofenacin renal colic. What should be used instead?
CVS disease
IV Paracetamol
What initial investigations should be performed for renal colic?
Urine dipstick + culture
Serum creatinine + electrolytes: ?renal function
FBC/ CRP: ?associated infection
Calcium/ Urate: ?underlying causes
Clotting if percutaneous intervention planned
Blood cultures if pyrexial/ signs of sepsis
What imaging should be performed for suspected renal stones?
non-contrast CT KUB
How should kidney stones be managed depending on size?
<0.5cm: expectant Tx +/- tamsulosin
<2cm: ESWL
<2cm + pregnant: uteroscopy
> 2cm (inc. staghorn calculi): percutaneous nephrolithotomy
If hydronephrosis/ infection: nephrostomy tube/ ureteric stent + abx
Give 4 causes of unilateral hydronephrosis
PACT
Pelvic-ureteric obstruction: congenital/ acquired
Aberrant renal vessels
Calculi
Tumours of renal pelvis
Give 5 causes of bilateral hydronephrosis
SUPER
Stenosis of the urethra
Urethral valve
Prostatic enlargement
Extensive bladder tumour
Retro-peritoneal fibrosis
How is hydronephrosis investigated?
USS: identifies presence of hydronephrosis + assess kidneys
IV Urography: assess position of obstruction
Antegrade or retrograde pyelography: allows Tx
If suspect renal colic: CT scan
Describe management of hydronephrosis
Remove obstruction + drain of urine
Acute upper urinary tract obstruction: nephrostomy tube
Chronic upper urinary tract obstruction: ureteric stent or a pyeloplasty
2 RFs for BPH
Age
Black > White > Asian
What does BPH present with?
LUTS-
Obstructive Sx: Hesitancy, Incomplete emptying, Poor flow, Straining
Irritative Sx: Frequency, Urgency, Nocturne, Incontinence
Terminal dribbling
Investigations for BPH
Urine dipstick
U+Es: esp. if chronic retention suspected
PSA: if obstructive Sx or if patient is worried about prostate cancer
Urinary frequency-volume chart for at least 3 days
IPSS
Name 2 alpha-1 antagonists
Tamsulosin
Alfuzosin
Recall 2 options for medically managing BPH
Alpha-1 antagonist: 1st line for mod-sev voiding Sx (IPSS >,8)
5 Alpha reductase inhibitors: indicated if significantly enlarged prostate + high risk of progression
Describe the MOA of alpha-1 antagonists in BPH
Decrease smooth muscle tone of prostate + bladder
Improves urine flow + reduces Sx
List 4 side effects of alpha-1 antagonists used in BPH
Dizziness
Postural hypotension (systemic vasodilation)
Dry mouth
Depression
Describe the MOA of 5 Alpha-reductase inhibitors in BPH
Block conversion of testosterone to dihydrotestosterone (DHT) which is known to induce BPH
Reduce prostate volume, may slow progression
May decrease PSA conc.
Describe 1 drawback of 5 Alpha-reductase inhibitors
Reducing prostate volume takes time, Sx may not improve for 6 months
Give 4 side effects of 5 Alpha-reductase innhibitors
ED
Reduced libido
Gynaecomastia
Ejaculation problems
What is the main way in which BPH can be surgically managed?
TURP (transurethral resection of the prostate)
What is the main complication of TURP to be aware of?
TURP syndrome: irrigation fluid enters systemic circulation
* Hyponatraemia: dilutional
* Fluid overload
* Glycine toxicity
List 4 complications of transurethral resection
TURP
Turp syndrome
Urethral stricture/ UTI
Retrograde ejaculation
Perforation of the prostate
When can PSA levels not be done?
Within:
- 6w of a prostate biopsy
- 1w of DRE
- 4w following a proven UTI/ prostatitis
- 48h of vigorous exercise +/or ejaculation
- Urinary retention
- Instrumentation of urinary tract
When would a multi-parametric MRI be used to investigate possible prostate cancer?
If PSA is inappropriate or if high chance of Ca
What is the gold-standard investigation for prostate cancer?
Multiparametric MRI (this has replaced TRUS-guided biopsy)
Results compared to 5-point Likert scale
What scoring system is used for prostate cancer?
Grade group (new)
Gleason score (old)
How is the Gleason score determined?
Most common grade (1-5)
Highest grade (1-5)
Most common grade + highest grade = Gleason score
What does each Gleason score/ Grade Group indicate?
GS6, GG1: similar to normal cells, slow growing, low risk
GS7 (3+4), GG2: mostly similar to normal, slow growing, intermediate risk
GS7 (4+3), GG3: less like normal cells, moderate rate of growth, high risk
GS8, GG4: some abnormal cells, moderate-fast growing, high risk
GS9-10, GG5: very abnormal cells, fast growing
Recall 3 options for managing localised prostate cancer (T1/T2)
- Conservative with active monitoring
- Radical prostatectomy
- Radiotherapy (external beam + brachytherapy)
Name a complication of radiotherapy in prostate cancer
Proctitis
Inflammation of lining of rectum- rectal pain + bleeding
Recall 3 options for managing localised advaced prostate Ca
- Hormonal therapy
- Radical prostatectomy
- Radiotherapy
How should metastatic prostate cancer disease be managed?
Hormonal therapy only
What are the options for hormone therapy in prostate cancer?
Synthetic GnRH agonist + 3w cover of anti-androgen
Recall 2 types of benign epithelial renal tumour
Papillary adenoma
Renal oncocytoma
What sort of tumour is an angiomyolipoma?
Benign mesenchymal renal tumour composed of thick-walled blood vessels, smooth muscle + fat
What is the maximum size for a papillary adenoma?
15mm
If more than this = malignant papillary renal cell carcinoma
What type of renal tumour can be seen in Birt-Hogg-Dube syndrome?
Renal oncocytoma
What type of renal tumour can be seen in tuberous sclerosis?
Angiomyolipoma
Renal cell cancer accounts for … of primary renal neoplasms
85%
In which patients is renal cell carcinoma more common?
Middle-aged Men
List 5 RFs for renal cell carcinoma
Smoking
HTN
Obesity
Diabetes
FH
Name 2 genetic syndromes that predispose to renal cell carcinoma
Von Hippel Lindau
Tuberous sclerosis
What are the 3 main subtypes of renal cell carcinoma, and which is most common
Clear cell (75-85%)
Papillary (2nd)
Chromophobe (3rd)
Which tumours are people with Von-Hippel-Lindau predisposed to?
Phaeochromocytoma
Neuroendocrine pancreatic
Clear cell renal
Which type of renal cell tumour is associated with loss of 3p?
Clear cell renal
Which type of renal tumour is associated with long-term dialysis?
Papillary renal cell carcinoma
Classic triad of S/S in renal cell carcinoma
Haematuria
Loin pain
Abdominal mass
Rare to present with these (<10%)
How do renal cell carcinoma patients usually present?
Often asymptomatic until late stages
>50% detected incidentally on imaging
What percentage of symptomatic renal cell carcinomas present with neoplastic syndromes? What are these?
30%
EPO: Polycythaemia
Renin: HTN
Parathyroid like hormone: Hypercalcaemia
ACTH: Cushing’s
What features on examination may suggest renal cell carcinoma?
Varicocele (tumour compressing veins)
Bilateral lower limb oedema (venous involvement)
Pyrexia of unknown origin
What is Stauffer syndrome?
Paraneoplastic disorder a/w RCC
Presents as cholestasis/ hepatosplenomegaly
Due to increased levels IL-6
Give 2 indications for 2ww referral in potential RCC
Unexplained macroscopic haematuria w/o UTI
Persistent macroscopic haematuria despite successful UTI Tx
Investigations for RCC
CT CAP
MRI for small lesions/ vascular involvement
CT + MRI with contrast
Surgical management for local RCC
Partial nephrectomy (<7cm, confined to kidney)
Radical nephrectomy
Medical management for metastatic RCC
Alpha-interferon + IL2
VEGF receptor TK inhibitors: Sorafenib, Sunitinib
What is Wilm’s tumour?
Nephroblastoma
How should high-grade transitional cell carcinomas be managed?
1st: intravesical immunotherapy
2nd: radical cystectomy
How should traumatic urethral injuries be investigated and managed?
Ix: ascending urethrogram
Mx: suprapubic catheter
How should traumatic bladder injuries be investigated and managed?
Ix: Intravenous urogram or cystogram
Mx: laparotomy if intraperitoneal, conservative if extraperitoneal
What is the most common malignancy in men aged 20-30?
Testicular cancer
What proportion of testicular tumours are germ cell tumours?
95%
Name 2 non-germ cell testicular tumours
Leydig cell tumours
Sarcomas
List 5 risk factors for testicular cancer
Infertility
Cryptorchidism
FH
Klinefelter’s syndrome
Mumps orchitis
What are the subtypes of germ cell testicular tumours?
Seminomas (50%)
Non-seminoma (embryonal, yolk sac, teratoma, choriocarcinoma)
What are the signs and symptoms of testicular cancer?
Painless lump (most common)
Hydrocele
Gynaecomastia
Pain in minority
What causes gynaecomastia in testicular cancer?
Increased oestrogen:androgen ratio
Germ cell tumours: hCG causes leydig cell dysfunction, increases both oestradiol + testosterone production (oestradiol more)
Leydig cell tumours: directly secrete more oestradiol + convert additional androgen precursors to oestrogens
How should suspected testicular cancer be investigated?
1st = USS
2nd = AFP, hCG, LDH
3rd = CT CAP
NO biopsy
Biopsy can promote seeding. Histology performed after orchidectomy
Which tumour markers are associated with the different types of germ cell testicular cancer?
LDH elevated in 40% germ cell tumours
Seminomas: hCG in 20%
Non-seminomas: AFT +/- b-hCG in 80%
What are the stages of testicular cancer?
Stage 1: confined to testis
Stage 2: regional LN involvement
Stage 3: distant mets
How can testicular cancer be managed?
Orchidectomy via inguinal approach
+/- chemotherapy
+/- radiotherapy
Inguinal approach reduces risk of seeding
What is the prognosis for testicular cancer?
95% 5y survival
Describe testicular torsion
Twist of spermatic cord resulting in testicular ischaemia + necrosis
What are the 2 aetiological types of testicular torsion?
Intravaginal: due to ‘Bell Clapper Deformity’. Abnormal fixation of tunica vaginalis to testicle which allows testicle to rotate freely within tunica vaginalis
Extravaginal: mostly in neonates before gubernaculum has fixated testes to bottom of scrotum (Rare)
Give 4 risk factors for testicular torsion
FH
Undescended testicle
Testicular tumour
Testicles with horizontal lie
List 3 symptoms of testicular torsion
Acute onset severe unilateral testicular pain
N+V
Pain initially intermittent, becomes constant
Give 5 signs on examination of testicular torsion
Swelling + erythema
Testis sits higher than contralateral one (Deming’s sign)
Testis may have horizontal lie (Angel’s sign)
Pain not relieved by elevation (Prehn’s sign)
Absent cremasteric reflex
Describe investigations for testicular torsion
Urgent surgical exploration
Should NOT perform imaging as may delay Tx
Urine dip
Dx cant be excluded OE + imaging
Describe management of testicular torsion
Analgesia
If testis viable: fix both to tunica vaginalis
If non-viable: orchidectomy
Is the cremasteric reflex pos or neg in testicular torsion?
Neg
What is the cremasteric reflex?
Stroking of the skin of the inner thigh causes the cremaster muscle to contract + pull up the ipsilateral testicle toward the inguinal canal
What is Prehn’s test?
Elevating scrotum + assessing for difference of pain - positive if pain is relieved
Is Prehn’s test pos or neg in testicular torsion?
Neg
What condition is Prehn’s test positive in?
Epididymitis
How should testicular torsion be managed?
Surgical exploration + BL orchidopexy
What is an orchidopexy
Surgical procedure that moves undescended testicle into the scrotum
What are the main RFs for ED?
EtOH
Drugs (beta-blockers, SSRI)
CVD RFs (metabolic syndrome, hyperlipidaemia etc)
How should ED be investigated?
QRisk score Free testosterone (9-11am) --> if low, FSH, LH, prolactin --> if abnormal, refer to endo
How can ED be managed?
1st: PDE4 inhibitors (sildenafil)
2nd line: vacuum devices
How should pregnant women with asymptomatic bacteriuria? UTI be managed?
MC&S –> Abx
7 days nitrofurantoin 100mg BD (AVOID AT TERM )
OR
Amoxicillin/cephalexin
How should UTIs in men be managed?
7 days trimethoprim/nitrufurantoin
When should men be referred to urology for UTI?
If 2 or more uncomplicated UTIs
How should catheterised patients with asymptomatic bacteriuria be managed?
No treatment needed
How should catheterised patients with symptomatic UTI be managed?
7 days trimethoprim/nitrofurantoin
What are the most common cause of scrotal swelling seen in primary care?
Epididymal cysts
Give 3 features of epididymal cysts on examination
Tender
Separate from body of testicle
Posterior to testicle
List 3 conditions associated with epididymal cysts
Polycystic kidney disease
Cystic Fibrosis
von Hippel-Lindau syndrome
What are the most common causes of Epididymo-orchitis?
Chlamydia (1st) + Gonorrhoeae (2nd): Young sexually active men
E.coli: Older adults (>35) with low-risk sexual hx
Local spread of infection from genital tract or bladder
What is the causative organism in 95% of cases of prostatitis?
E coli
What are the signs and symptoms of prostatitis?
Referred pain
Obstructive voiding symptoms
Fever and rigors may be present
How should prostatitis be investigated?
DRE –> tender, boggy prostate gland
How should prostatitis be managed?
Quinolone 14/7
STI screening
How should urinary incontinence be investigated?
1st: speculum - exclude prolapse
2nd: Urine dip + MC&S (r/o DM + UTI)
3rd: Bladder diaries (minimum 3 days) - if inconclusive –>
4th: Urodynamic testing (if mixed incontinence)
What is measured by urodynamic testing?
3 pressures measured from inside rectum + urethra:
- bladder
- detrusor
- IAP
How should stress incontinence be managed?
1st line: lifestyle advice, WL if BMI>30, pelvic floor exercises
2nd line: duloxetine or surgical treatment
How should pelvic floor exercises be done for stress incontinence?
8 contractions, TDS, 3 months
Recall some options for sugical management of stress incontinence
- Burch colposuspension
- Autologous rectus fascial sling
- Bulking agents
Recall some RFs for stress vs urge incontinence
Stress: age, children, traumatic delivery, pelvic surgery, obesity
Urge: age, obesity, smoking, FHx, DM
What is the normal post-void volume for <65 vs >65ys?
<65 = <50mLs >65 = <100mLs
How should urge incontinence be managed?
1st line: lifestyle advice, bladder training, avoid fizzy drinks, DM control
2nd line: oxybutynin/tolterodine or desmopressin
3rd line: mirabegron (beta-3 agonist)
4th line: surgical
Recall an important side effect of oxybutynin and an alternative option if there is concern
Falls
Can give mirabegron instead
How can urge incontinence be managed surgically?
Botox injection, sacral nerve stimulation, urinary diversion
How should overflow incontinence be managed?
Refer to specialist urogynaecologist
1st line = timed voiding
What is a hydrocele?
Accumulation of fluid within tunica vaginalis
Communicating or non-communicating
What causes communicating hydroceles? In which patients are these mostly seen?
Patency of processus vaginalis allowing peritoneal fluid to drain down into scrotum
Newborn males
Usually resolve within months
How should an infantile communicating hydrocele be managed?
Reassurance
Surgical repair if not resolved by 1-2y to avoid complications e.g. incarcerated hernia
What causes non-communicating hydroceles?
Excessive fluid production within tunica vaginalis
Hydroceles may develop secondary to what 3 conditions?
Epididymo-orchitis
Testicular torsion
Testicular tumours
List 5 features of hydroceles
Soft, non-tender swelling of hemi-scrotum
Usually anterior to + below testicle
Confined to scrotum, can ‘get above’ mass OE
Transilluminates
Testis may be difficult to palpate if hydrocele large
Investigation for hydrocele
Clinical dx
USS if doubt in dx or underlying testis can’t be palpated
10% testicular malignancies present as hydrocele
How should hydrocele be managed in adults?
- Watch + wait
- Aspiration if surgery CI (often reaccumulates)
- Surgical: Lloyd’s Plication/ Jaboulay’s repair
Why does varicocele affect the LHS more than the RHS?
Left testicular vein:
- drains into renal vein at 90 degree angle
- is longer than right
- often lacks a terminal valve to prevent backflow
- can be compressed by renal and bowel pathology
>80% occur on left
What is the best investigation for varicocele?
Doppler USS
If varicocele has a sudden onset, what must be considered?
Renal cell carcinoma
How should varicocele be managed?
Conservative (scrotal support) or surgical (radiological embolisation or operation to expose and ligate vein)
In a patient with hypercalciuria and recurrent calcium renal stones, what drug can be used as prevention?
Thiazide like diuretics (they decrease urinary calcium)
What can treatment of prostate cancer with GnRH agonists initially cause?
‘Tumour flare’
Paradoxical increase in Sx.
Describe the pathophysiology of tumour flare
GnRH temporarily causes pituitary to increase LH secretion before inhibiting LH release
Leads to increased stimulation of Leydig cells + production of more testosterone which stimulates survival + growth + Sx of prostate cancer
What are the symptoms of ‘tumour flare’?
Bone pain
Bladder obstruction
What should be done before treatment with goserelin (GnRH agonist) for prostate cancer?
Pre-Tx with anti-androgen to avoid initial “tumour flare effect”
e.g. Flutamide, Bicalutamide, Cyproterone acetate
What can occur as a complication of the scarring that occurs in balanitis xerotica oblilterans?
Phimosis
Give 4 medical indications for circumcision
Phimosis
Paraphimosis
Recurrent balanitis
Balanitis xerotica obliterans
What must be excluded prior to circumcision?
Hypospadias as foreskin may be used in surgical repair
What anaesthetic cover is circumcision performed under?
LA or GA
Describe the prevelance of bladder cancer
2nd most common urological cancer
M > F
50-80y
Give 4 risk factors for bladder cancer
Smoking (past or current)
Occupational exposure to aromatic amines + hydrocarbons
Pelvic radiotherapy
SCC RF: long term catheters + chronic inflammatino from schistosomiasis
What are the subtypes of bladder cancer?
> 90% Urothelial (transitional cell carcinoma)
5% SCC (higher in areas affected by schistosomiasis)
2% Adenocarcinoma
Give 3 ways in which bladder cancer may present
Painless macroscopic haematuria (most common)
Microscopic haematuria + LUTS (urgency, dysuria)
Pelvic pain + Sx of urinary tract obstruction (advanced)
What are the indications to make a 2ww referral for suspected bladder cancer?
> 45 with UE macroscopic haematuria or macroscopic haematuria that persits after UTI Tx
60 with UE microscopic haematuria + dysuria/ raised WCC
UE = unexplained
What investigations should be performed in suspected bladder cancer?
Urine dip + culture: r/o infection
1. Flexible cystoscopy OP
+/- urine cytology
2. Transurethral resection of bladder tumour (TURBT
3. CT CAP + CT urography for staging
Describe management of bladder cancer
Superficial lesions: TURBT
Recurrences/ high grade/ risk: Intravesical chemotherapy
> > ,T2: radical cystectomy + ileal conduit + neoadjuvant chemo
What does each tumour staging in bladder cancer indicate?
T1: superficial, confined to urothelium/ connective tissue
T2: muscle invasion
T3: through muscle to fat
T4: spread to other pelvic organs/ abdomen
Define acute urinary retention
Abrupt development of inability to pass urine (hours)
Give 7 causes of acute urinary retention
BPH (most common)
Urethral strictures
Prostate cancer
Calculi
Cystocele
Constipation
Neurological (less common)
List 5 drugs that can cause acute chronic urinary retention
Anticholinergics
TCAs
Antihistamines
Opioids
Benzodiazepines
In patients with predisposing causes, what can cause urinary retention?
UTI
Give 2 scenarios acute urinary retention is common in
Postoperatively
Postpartum
Give 4 S/S of acute urinary retention
Inability to pass urine
Lower abdo discomfort
Pain + distress
Acute confusional state (esp elderly)
How may acute urinary retention present on examination?
Palpable distended urinary bladder on abdo/ rectal exam
Lower abdo tenderness
What examinations should be performed in acute urinary retention?
Rectal + Neuro exam
Pelvic exam in females
Investigations for acute urinary retention
- Post-catheterisation urinalysis + culture
- Post-void bladder scan for residual vol
- Serum U+Es + creatinine
- FBC + CRP
Which investigation can confirm acute urinary retention?
Bladder USS Vol >300cc
Management for acute urinary retention
Catheterisation (decompress bladder)
Volume drained in 15 mins measured: >400cc, leave catheter in place
Give 1 complication of Tx of acute urinary retention
Post-obstructive diuresis
What is post-obstructive diuresis?
Kidneys increase diuresis due to loss of medullary conc. gradient. Can take time re-equilibrate
Can lead to volume depletion + worsening of any AKI
Some may require IV fluids to correct this temporary over-diuresis
Define chronic urinary retention
Gradual (months-years) development of inability to empty the bladder completely
Characterised by a residual volume >1L or a/w a distended/ palpable bladder
