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ICSM Year 6 > Surgery - Urology > Flashcards

Surgery - Urology Flashcards

1
Q

What is the best form of imaging for kidney stones?

A

CT KUB

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2
Q

Recall the 4 main types of kidney stone in order of highest to lowest radiointensity

A

Calcium phosphate
Calcium oxalate
Triple (struvite) stones
Uric acid (radiolucent)

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3
Q

Which type of kidney stone is associated with urease bacteria?

A

Triple (struvate) stones

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4
Q

Which type of kidney stone is associated with hypercalciuria?

A

Calcium oxalate

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5
Q

How should kidney stone pain be managed?

A

PR/IM diclofenac

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6
Q

Recall one contra-indication to diclofenac

A

CVS disease

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7
Q

How should kidney stones be managed depending on size?

A

Renal stones
Watchful waiting if < 5mm +/- tamsulosin (up to 1cm)
5-10mm shockwave lithotripsy
10-20 mm shockwave lithotripsy OR ureteroscopy
<2cm and pregnant: uteroscopy
> 20 mm percutaneous nephrolithotomy

Uretic stones
< 10mm shockwave lithotripsy +/- alpha blockers
10-20 mm ureteroscopy

If hydronephrosis/infection: percutaneous nephrostomy and antibiotics

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8
Q

Recall 2 options for medically managing BPH and some side effects of each

A
  • alpha-1 antagonists (tamsulosin): postural hypotension, dry mouth
  • 5 alpha reductase inhibitors (finasteride): ED, reduced libido, gynaecomastia, ejaculation problems
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9
Q

What is the main way in which BPH can be surgically managed?

A

TURP (transurethral resection of the prostate)

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10
Q

What is the main complication of TURP to be aware of?

A

TURP syndrome

Hyponatraemia, fluid overload and glycine toxicity caused by over-irrigation

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11
Q

When can PSA levels not be done?

A

Within:

  • 6 weeks of a prostate biopsy
  • 1 week of DRE
  • 4w following a proven UTI/prostatitis
  • 48 hours of vigorous exercise and/or ejaculation
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12
Q

When would a multi-parametric MRI be used to investigate possible prostate cancer?

A

If PSA is inappropriate or if high chance of Ca

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13
Q

What is the gold-standard investigation for prostate cancer?

A

Multiparametric MRI (this has replaced TRUS-guided biopsy)

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14
Q

Recall 3 options for managing localised prostate cancer (T1/T2)

A
  • Conservative with active monitoring
  • Radical prostatectomy
  • Radiotherapy (external beam and brachytherapy)
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15
Q

Recall 3 options for managing localised advaced prostate Ca

A
  • Hormonal therapy
  • Radical prostatectomy
  • Radiotherapy
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16
Q

How should metastatic prostate cancer disease be managed?

A

Hormonal therapy only

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17
Q

What are the options for hormone therapy in prostate cancer?

A

Synthetic GnRH agonist + 3w cover of anti-androgen

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18
Q

Recall 2 types of benign epithelial renal tumour

A

Papillary adenoma

Renal oncocytoma

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19
Q

What sort of tumour is an angiomyolipoma?

A

Benign mesenchymal renal tumour composed of thick-walled blood vessels, smooth muscle and fat

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20
Q

What is the maximum size for a papillary adenoma?

A

15mm

If more than this = malignant papillary renal cell carcinoma

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21
Q

What type of renal tumour can be seen in Birt-Hogg-Dube syndrome?

A

Renal oncocytoma

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22
Q

What type of renal tumour can be seen in tuberous sclerosis?

A

Angiomyolipoma

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23
Q

Which genetic syndrome predisposes to renal cell carcinoma?

A

Von Hippel Lindau

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24
Q

What are the 3 main subtypes of renal cell carcinoma, and which is most common

A

Clear cell (70%)
Papillary
Chromophobe

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25
Q

Which tumours are people with Von-Hippel-Lindau predisposed to?

A

Phaeochromocytoma
Neuroendocrine pancreatic
Clear cell renal

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26
Q

Which type of renal cell tumour is associated with loss of 3p?

A

Clear cell renal

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27
Q

Which type of renal tumour is associated with long-term dialysis?

A

Papillary renal cell carcinoma

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28
Q

What is Wilm’s tumour?

A

Nephroblastoma

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29
Q

How should high-grade transitional cell carcinomas be managed?

A

1st: intravesical immunotherapy
2nd: radical cystectomy

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30
Q

How should traumatic urethral injuries be investigated and managed?

A

Ix: ascending urethrogram
Mx: suprapubic catheter

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31
Q

How should traumatic bladder injuries be investigated and managed?

A

Ix: Intravenous urogram or cystogram
Mx: laparotomy if intraperitoneal, conservative if extraperitoneal

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32
Q

What proportion of testicular tumours are germ cell tumours?

A

95%

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33
Q

What are the subtypes of germ cell testicular tumours?

A

Seminomas (50%)

Non-seminoma (embryonal, yolk sac, teratoma an choriocarcinoma)

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34
Q

What is the biggest risk factor for testicular seminoma?

A

Cryptochidism

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35
Q

What are the signs and symptoms of testicular cancer?

A

Painless lump +/- hydrocele, gynaecomastia

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36
Q

How should testicular cancer be investigated?

A

1st = USS
2nd = AFP, hCG, LDH
3rd = CT TAP
NO biopsy

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37
Q

How can testicular cancer be managed?

A

Orchidectomy +/- chemotherapy +/- radiotherapy

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38
Q

Is the cremasteric reflex pos or neg in testicular torsion?

A

Neg

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39
Q

What is the cremasteric reflex?

A

Stroking of the skin of the inner thigh causes the cremaster muscle to contract and pull up the ipsilateral testicle toward the inguinal canal

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40
Q

What is Prehn’s test?

A

Elevating scrotum and assessing for difference of pain - positive if pain is relieved

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41
Q

Is Prehn’s test pos or neg in testicular torsion?

A

Neg

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42
Q

What condition is Prehn’s test positive in?

A

Epididymitis

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43
Q

How should testicular torsion be managed?

A

Surgical exploration + BL orchidopexy

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44
Q

What is an orchidopexy

A

Surgical procedure that moves undescended testicle into the scrotum, permanently fixing it there

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45
Q

What are the main RFs for ED?

A

EtOH
Drugs (beta-blockers, SSRI)
CVD RFs (metabolic syndrome, hyperlipidaemia etc)

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46
Q

How should ED be investigated?

A 
QRisk score 
Free testosterone (9-11am) --> if low, FSH, LH, prolactin --> if abnormal, refer to endo
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47
Q

How can ED be managed?

A

1st: PDE4 inhibitors (sildenafil)

2nd line: vacuum devices

48
Q

How should pregnant women with asymptomatic bacteriuria/UTI be managed?

A

MC&S –> Abx
7 days nitrofurantoin 100mg BD (AVOID AT TERM )
OR
Amoxicillin/cephalexin

49
Q

How should UTIs in men be managed?

A

7 days trimethoprim/nitrufurantoin

50
Q

When should men be referred to urology for UTI?

A

If 2 or more uncomplicated UTIs

51
Q

How should catheterised patients with asymptomatic bacteriuria be managed?

A

No treatment needed

52
Q

How should catheterised patients with symptomatic UTI be managed?

A

7 days trimethoprim/nitrofurantoin and change catheter

53
Q

What is the causative organism in 95% of cases of prostatitis?

54
Q

What are the signs and symptoms of prostatitis?

A

Referred pain to perineum, penis, rectum or back
Obstructive voiding symptoms
Fever and rigors may be present

55
Q

How should prostatitis be investigated?

A

DRE –> tender, boggy prostate gland

56
Q

How should prostatitis be managed?

A

Quinolone 14/7

STI screening

57
Q

How should urinary incontinence be investigated?

A

1st: speculum - exclude prolapse
2nd: Urine dip and MC&S (rule out DM and UTI)
3rd: Bladder diaries (minimum 3 days) - if inconclusive –>
4th: Urodynamic testing (if mixed incontinence)

58
Q

What is measured by urodynamic testing?

A

3 pressures measured from inside rectum and urethra:

  • bladder
  • detrusor
  • IAP
59
Q

How should stress incontinence be managed?

A

1st line: lifestyle advice, WL if BMI>30, pelvic floor exercises
2nd line: duloxetine or surgical treatment

60
Q

How should pelvic floor exercises be done for stress incontinence?

A

8 contractions, TDS, 3 months

61
Q

Recall some options for sugical management of stress incontinence

A
  • Burch colposuspension
  • Autologous rectus fascial sling
  • Bulking agents
62
Q

Recall some RFs for stress vs urge incontinence

A

Stress: age, children, traumatic delivery, pelvic surgery, obesity

Urge: age, obesity, smoking, FHx, DM

63
Q

What is the normal post-void volume for <65 vs >65ys?

A 
<65 = <50mLs
>65 = <100mLs
64
Q

How should urge incontinence be managed?

A

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

65
Q

Recall an important side effect of oxybutynin and an alternative option if there is concern

A

Falls

Can give mirabegron instead

66
Q

How can urge incontinence be managed surgically?

A

Botox injection, sacral nerve stimulation, urinary diversion

67
Q

How should overflow incontinence be managed?

A

Refer to specialist urogynaecologist

1st line = timed voiding

68
Q

How should hydrocele be managed?

A
  • Watch and wait
  • Aspiration for symptomatic relief
  • Surgical = Lloyd’s repair/ Jaboulay’s repair
69
Q

Why does varicocele affect the LHS more than the RHS?

A

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
70
Q

What is the best investigation for varicocele?

A

Doppler USS

71
Q

If varicocele has a sudden onset, what must be considered?

A

Renal cell carcinoma

72
Q

How should varicocele be managed?

A 
Conservative (scrotal support) 
or surgical (radiological embolisation or operation to expose and ligate vein)
73
Q

In a patient with hypercalciuria and recurrent calcium renal stones, what drug can be used as prevention?

A

Thiazide like diuretics (they decrease urinary calcium)

74
Q

What should be done before treatment with goserelin for prostate cancer?

A

Pretreatment with flutamide (anti-androgen) to avoid initial “flare effect” of goserelin

75
Q

If NSAIDs are contraindicated in a patient with renal colic, what is second line?

A

IV paracetamol

76
Q

When is vasectomy considered a valid form of contraception?

A

Once 2x semen analyses have been done to confirm azoospermia - patients should use contraception during this time

77
Q

When would you refer under 2ww pathway for non-visible haematuria?

A

If >60yo and no explanation for non-visible haematuria AND raised WCC/dysuria

78
Q

What is the management of intermittent testicular torsion?

A

Emergency bilateral ochidopexy (as there is still a high risk of re-torsion so should be done ASAP)

79
Q

Which urological condition is a contraindication to circumcision during infancy?

A

Hypospadias - as the foreskin can be used in repair surgeries

80
Q

Up to what size tumour is a partial nephrectomy offered?

81
Q

What can be prescribed to prevent calcium stones?

A

Potassium citrate

82
Q

What is the investigation of choice for epididymo-orchitis?

A

Younger adults: Urethral swab for NAAT
Older adults/low-risk sexual Hx: MSU

83
Q

When would percutaneous nephrolithotomy be used?

A

Stones > 20mm

84
Q

What is the best imaging modality for hydronephrosis?

85
Q

What is balantis xerotica obliterans?

A

The equivalent of lichen sclerosis in women, it is a chronic skin condition causing raised, white and sometimes itchy white plaques on the external genitalia

86
Q

What can BXO increase your risk of?

A

Squamous cell carcinoma + associated with phimosis

87
Q

What are the two types of urethral injury?

A
  • Bulbar
  • Membranous
88
Q

What is the most common type of urethral injury and what is the typical MoA?

A

Bulbar - usually saddle type injury e.g. bicycle

89
Q

What is the triad of symptoms in bulbar urethral damage?

A
  • Perianal haematoma
  • Urinary retention
  • Blood at the meatus
90
Q

What signs and symptoms would be present in membranous urethral damage?

A
  • Penile or perineal oedema or haematoma
  • Prostate gland displaced upwards (so often not palpable on DRE)
91
Q

What is the typical cause of membranous urethral damage?

A

Pelvic fracture

92
Q

What would periureteric fat ‘stranding’ suggest?

A

Recently passed ureteric calculus (in the absence of visible calculus)

93
Q

What is decompression haematuria?

A

Haematuria can commonly occur after catheterisation for chronic urinary retention due to the rapid decrease in pressure in the bladder - it does not require any management apart from monitoring

94
Q

What are some causes of unilateral hydronephrosis?

A

Pelvic-ureteric obstruction (congenital or acquired)
Aberrant renal vessels
Calculi
Tumours of renal pelvis

95
Q

What are some causes of bilateral hydronephrosis?

A

Aberrant renal vessels
Calculi
Tumours of renal pelvis
Stenosis of the urethra
Urethral valve
Prostatic enlargement
Extensive bladder tumour
Retro-peritoneal fibrosis

96
Q

What is the management of hydronephrosis?

A
  • Remove the obstruction and drainage of urine
  • Acute upper urinary tract obstruction: nephrostomy tube
  • Chronic upper urinary tract obstruction: ureteric stent or a pyeloplasty
97
Q

What is first line for BPH?

A

Alpha-1 antagonists (e.g. tamsulosin) for mdoerate-severe symptoms (IPSS > 8)

98
Q

When are 5-a-reductase inhibitors indicated?

A

When the patient has a significantly enlarged prostate or considered to be at high risk of progression

99
Q

What is the IPSS and the different scores?

A

A tool for classifying the severity of lower urinary tract symptoms (LUTS) and assessing the impact of LUTS on quality of life

  • Score 20–35: severely symptomatic
  • Score 8–19: moderately symptomatic
  • Score 0–7: mildly symptomatic
100
Q

How do 5-a-reductase inhibitors work?

A

Prevent the conversion of testosterone to dihydrotestosterone, which is known to induce BPH. Therefore, they can actually reduce the size of the prostate and slow progression.

101
Q

How long can it take 5-a-reductase inhibitors to have an effect on prostate size?

102
Q

What tumour marker is associated with seminomas?

A

hCG (20% cases)

103
Q

What tumour marker is associated with non-seminomas?

A

AFP and/or hCG are raised in 80-85% cases

104
Q

How should post-obstructive diuresis be avoided?

A

Patients producing >200ml/hr urine output should have around 50% of their urine output replaced with intravenous fluids to avoid any worsening AKI.

105
Q

What is the first line investigation for priaprism?

A

Cavernosal blood gas sample (differentiates between ischaemic and non-ischaemic, which guides Mx)

106
Q

What symptoms can result of the goserelin ‘flare’ after initiating treatment?

A
  • Bone pain
  • Bladder obstruction
107
Q

What is the top differential for a scrotal lump that is separate to the testicle but cannot be palpated above it?

A

Inguinalscrotal hernia

108
Q

Which urothelial cancer does schistosomiasis increase the risk of?

A

Squamous cell cancer of the bladder

109
Q

What test should always be offered for men presenting with ED?

A

AM testosterone

110
Q

What stage tumour do patients typically present with symptomatic renal cell carcinoma?

111
Q

What is the first line investigation for suspected bladder cancer?

A

Flexible cystoscopy

112
Q

What are some side effects of prostate radiotherapy?

A
  • Proctitis - can cause bloody diarrhoea
  • Increased risk of bladder, colon, and rectal cancer
113
Q

What are some long term complications of a radical prostatectomy?

A
  • Erectile dysfunction
  • Urethral stenosis
  • Urinary incontinence
114
Q

What can cause retrograde ejaculation?

A
  • Alpha blockers
  • TURP surgery
115
Q

What is the Mx of bladder carcinoma in situ (CIS)?

A

Due to the early, but high-grade nature of such cancer, patients are managed by trans-urethral removal of bladder tumour (TURBT) with adjunctive intravesiclar chemotherapy to reduce the risk of recurrence

116
Q

What is the next step in management if an irregular, craggy and hard prostate is felt on DRE?

A

Immediate referral via 2ww pathway (irrespective of a normal PSA)

ICSM Year 6 (21 decks)

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