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ICSM Year 6 + edits > 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

<5mm: expectant treatment +/- tamsulosin

<20mm: shockwave lithotripsy

<20mm and pregnant: uteroscopy

> 20mm (eg staghorn calculi): extracorporeal shock wave percutaneous nephrolithotomy

If hydronephrosis/infection: percutaneous nephrostomy and antibiotics

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8
Q

Risk factors for shock wave lithotripsy

A

solid organ injury
ureteric obstruction
can’t be done for pregnant ladies
neither for vascular calcification

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9
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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10
Q

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

A

TURP (transurethral resection of the prostate)

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11
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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12
Q

When can PSA levels not be done?

A

Within:

  • 6 weeks of a prostate biopsy
  • 1 week of DRE
  • Male with regular anal intercourse
  • 4w following a proven UTI/prostatitis
  • 48 hours of vigorous exercise and/or ejaculation
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13
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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14
Q

What is the gold-standard investigation for prostate cancer?

A

Multiparametric MRI (this has replaced TRUS-guided biopsy) - produces a more detailed picture of the prostate gland

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15
Q

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

A
  • Conservative with active monitoring
  • Radical prostatectomy
  • Radiotherapy (external beam and brachytherapy - bead with radioactive material inserted near radiographic source)
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16
Q

Recall 3 options for managing localised advanced prostate Ca

A
  • Hormonal therapy
  • Radical prostatectomy
  • Radiotherapy
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17
Q

How should metastatic prostate cancer disease be managed?

A

Hormonal therapy only

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18
Q

What are the options for hormone therapy in prostate cancer?

A

Synthetic GnRH agonist + 3w cover of anti-androgen

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19
Q

Recall 2 types of benign epithelial renal tumour

A

Papillary adenoma

Renal oncocytoma

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20
Q

What sort of tumour is an angiomyolipoma?

A

Benign mesenchymal (type of stem cells able to differentiate into anything) renal tumour composed of thick-walled blood vessels, smooth muscle and fat

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21
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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22
Q

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

A

Renal oncocytoma

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23
Q

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

A

Angiomyolipoma

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24
Q

Which genetic syndrome predisposes to renal cell carcinoma?

A

Von Hippel Lindau

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25
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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26
Q

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

A

Phaeochromocytoma
Neuroendocrine pancreatic
Clear cell renal

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27
Q

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

A

Clear cell renal

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28
Q

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

A

Papillary renal cell carcinoma

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29
Q

What is Wilm’s tumour?

A

Nephroblastoma

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30
Q

How should high-grade transitional cell carcinomas be managed?

A

1st: intravesical immunotherapy
2nd: radical cystectomy

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31
Q

How should traumatic urethral injuries be investigated and managed?

A

Ix: ascending urethrogram
Mx: suprapubic catheter

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32
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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33
Q

What proportion of testicular tumours are germ cell tumours?

A

95%

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34
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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35
Q

What is the biggest risk factor for testicular seminoma?

A

Cryptochidism

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36
Q

What are the signs and symptoms of testicular cancer?

A

Painless lump +/- hydrocele, gynaecomastia

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37
Q

How should testicular cancer be investigated?

A

1st = USS
2nd = AFP , hCG (seminoma), LDH (teratoma) - higher = worse prognosis
3rd = CT TAP (thoracic, abdomen, pelvis)
NO biopsy

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38
Q

How can testicular cancer be managed?

A

Orchidectomy +/- chemotherapy +/- radiotherapy

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39
Q

Is the cremasteric reflex pos or neg in testicular torsion?

A

Neg

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40
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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41
Q

What is Prehn’s test?

A

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

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42
Q

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

A

Neg

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43
Q

What condition is Prehn’s test positive in?

A

Epididymitis

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44
Q

How should testicular torsion be managed?

A

Surgical exploration + BL orchidopexy

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45
Q

What is an orchidopexy

A

Surgical procedure that moves undescended testicle into the scrotum

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46
Q

What are the main RFs for ED?

A

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

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47
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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48
Q

How can ED be managed?

A

1st: PDE4 inhibitors (sildenafil)

2nd line: vacuum devices

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49
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

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50
Q

How should UTIs in men be managed?

A

7 days trimethoprim/nitrufurantoin

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51
Q

When should men be referred to urology for UTI?

A

If 2 or more uncomplicated UTIs

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52
Q

How should catheterised patients with asymptomatic bacteriuria be managed?

A

No treatment needed

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53
Q

How should catheterised patients with symptomatic UTI be managed?

A

7 days trimethoprim/nitrofurantoin

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54
Q

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

A

E coli

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55
Q

What are the signs and symptoms of prostatitis?

A

Referred pain
Obstructive voiding symptoms
Fever and rigors may be present

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56
Q

How should prostatitis be investigated?

A

DRE –> tender, boggy prostate gland

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57
Q

How should prostatitis be managed?

A

Quinolone 14/7

STI screening

58
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)

59
Q

What is measured by urodynamic testing?

A

3 pressures measured from inside rectum and urethra:

  • bladder
  • detrusor
  • IAP
60
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

61
Q

How should pelvic floor exercises be done for stress incontinence?

A

8 contractions, TDS, 3 months

62
Q

Recall some options for sugical management of stress incontinence

A
  • Burch colposuspension
  • Autologous rectus fascial sling
  • Bulking agents
63
Q

Recall some RFs for stress vs urge incontinence

A

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

Urge: age, obesity, smoking, FHx, DM

64
Q

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

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

66
Q

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

A

Falls

Can give mirabegron instead

67
Q

How can urge incontinence be managed surgically?

A

Botox injection, sacral nerve stimulation, urinary diversion

68
Q

How should overflow incontinence be managed?

A

Refer to specialist urogynaecologist

1st line = timed voiding

69
Q

How should hydrocele be managed?

A
  • Watch and wait
  • Aspiration for symptomatic relief
  • Surgical = Lloyd’s repair/ Jaboulay’s repair
70
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
71
Q

What is the best investigation for varicocele?

A

Doppler USS

72
Q

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

A

Renal cell carcinoma

73
Q

How should varicocele be managed?

A 
Conservative (scrotal support) 
or surgical (radiological embolisation or operation to expose and ligate vein)
74
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)

75
Q

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

A

Pretreatment with flutamide to avoid initial “flare effect” of goserelin

76
Q

What is a Hydrocele?

A

Painless swelling, transilluminates, testis not palpable

Fluid within the tunica vaginalis

77
Q

Diffuse lumpy swelling, not painful, feel separately, trouble conceiving

A

Varicocele

Pampiniform plexus, poor venous drainage of testicle

78
Q

Pea sized lump, discrete soft mass posterior to right testicle

A
  • Epididymal cyst - most common scrotal swelling in primary care
  • USS
  • Reassurance, if large / pain = surgical / sclerotherapy
79
Q

Swelling, large non-tender, cannot palpate above swelling

A
  • Inguinal hernia, indirect hernia - descends into scrotum
  • Surgical repair - push back in elective, if incarnated then emergency surgical
80
Q

Thailand, gradual onset right scrotal pain, tender, swelling, epididymal-orchitis, dysuria - how do you treat? Common organisms in different groups

A
  • Cef IM single dose, po doxy for 10-14 days
  • Gonorrhoea based organism (young)
  • E. coli - older
  • Mumps - young not SA
81
Q

Swollen left testicle, drinking, sudden tender and dull ache

A

emergency admission
haematoma
blood in tunica vaginalis

82
Q

Both RF for testicular cancer

A

Cryptorchidism, hernia in infancy

83
Q

Where do seminoma’s originate from?

A

seminiferous tubules

84
Q

Most common site for testicular cancer mets and signs

A

Lung and lymphatics

haematospermia and SOB

85
Q

What are the percentage of testicular survival at different hours?

A

6 - 90
12 - 50
24 - 10

86
Q

What be the difference in duplex USS in TT and epididymitis?

A

Flow would be present in e

87
Q

What is TT

A

testis torted around the spermatic cord and necrosis of testis

88
Q

Main differentials for renal colic and investigations

A

renal cyst rupture
constipation

urine dip, cultures, ct-kub

89
Q

Main signs and results for renal colic

A

Male
cannot lie flat
urinary stasis
decreased urine volume

90
Q

Most common spots for renal colic

A

PUJ
VUJ
Pelvic brim - iliac vessels crossover

91
Q

What is hydronephrosis and what causes it?

A
  • Dilation of renal pelvis & calyces due to obstruction to urine flow
  • Strictures, babies, outer compression
  • Renal damage
92
Q

Main conservative and medical treatment for kidney stones

A

Analgesia, fluids, anti-emetics, alpha blocker, treatment

93
Q

Indications for nephrostomy

A

septic
ureteric obstructions
horseshoe kidney
previous renal transplant

ureteric stent via cystoscopy and open surgery

94
Q

If have infected obstructed system in kidneys

A

Pyelonephrosis behind the stone
surgical emergency

treat with cefuroxime - cef oral if upper tract

95
Q

Other causes in kidneys needing ABs

A

Renal calyx rupture
urinoma
pyelonephritis
pyonephrosis

give cefuroxime

96
Q

What medication is used to excrete potassium?

A

Calicum resonium 15g

97
Q

What catheter is used for clots

A

3-way catheter, washout

98
Q

Sign and causes of acute urinary retention

A

600ml < bladder scan
prostatic obstruction
urethral strictures
alcohol

99
Q

Signs and causes of chronic urinary retention

A

insidious, bladder at 1.5L, malignancy, diabetes, MS
- Pain infection, renal impairment only catheterises

100
Q

Problem with acutely emptying large bladder and how to deal with it

A

fluid shift - make too much urine from kidney, diuresis post catheter
- Micro tears - severe haematuria
- Intermittent self-catheterise

101
Q

Conservative measures for BPH

A

Avoid caffeine / alcohol, bladder training

102
Q

If a patient with BPH wants to maintain libido what should be done

A

TUIP - incision

103
Q

Other measures other than TURP to deal with BPH

A

HLUP procedure - enucleation
urolift implants

104
Q

Score to grade prostate cancer

A

Gleasons

105
Q

Painless blood in urine, no pain and lifelong smoker

A

Bladder cancer - transitional cell carcinoma
Male
Bladder, but can be anywhere
amine exposure

106
Q

How is bladder cancer investigated?

A
  • Cystoscopy + biopsy
  • USS / ct for invasion
107
Q

How is bladder cancer graded and treated?

A
  • TNM system of grading
  • TURBT
  • If in lamina propria add immunotherapy / CTX
  • Then radical cystectomy
  • Invasion beyond bladder - palliative CTX
108
Q

Follow up for post bladder cancer

A
  • Follow up cystoscopy every 3 months for 2 yrs then every 6 months
  • Then next 9 month
109
Q

If doing a radical cystectomy what also will be done

A

Ileal conduit

110
Q

If have bilateral kidney tumours what should be done

A

Wedge resection

111
Q

Examples of immunotherapy used during renal cancer

A

Checkpoint inhibitors and VEGF inhibitors

112
Q

What is Goserelin

A

Synthetic GnRH agonist in prostate cancer

113
Q

Everything needed to know about vasectomy

A

Male sterilisation more effective than contraception
12 week semen analysis afer
bruising, haematoma, infection,
use contraception until azoospermia and has been 12 weeks
sperm granuloma, chronic testicular pain 5-30%
success rate of reversal 55% in 10 yrs and 25% after

114
Q

If Nsaids contraindicated in renal colic what should be given

A

paracetamol

115
Q

what bladder cancer is schistosoma infection linked with

A

Squamous cell carcinoma

116
Q

Common complication with radical prostatectomy

A

Ed

117
Q

Factors favourable of organic cause of eD

A

gradual onset
lack of tumescence
normal libido

118
Q

If somebody cycles more than 3 times a week

A

stop cycling

119
Q

Methods to prevent calcium stones

A

high fluid intake
add lemon juice
avoid carbonated drinks
limit salt intake
potassium citrate
thiazide diuretics

120
Q

What is tumour flare? How do you stop it

A

GnRH agonists cause increase in bone pain, bladder obstruction - temporarily increase LH

anti-androgen such as cyproterone acetate block androgen receptors, preventing testosterone binding

can use the non-steroidal bicalutamide

121
Q

If a patient has a T1 renal tumour

A

Partial nephrectomy

122
Q

What is priapism?

A

persistent painful erection lasting more than 4 hours

123
Q

Causes of priapism

A

SCD
ED medication
trauma

124
Q

Ix for Priapism

A

cavernosal blood gas pCO2 increase for ischamic

125
Q

Mx for priapism

A

aspirate blood with saline flush injection - then phenylephrine if all else failures

126
Q

Features of acute tubular necrosis

A

raised urea, creatinine, potassium
muddy brown casts in the urine

caused by ischaemia
nephrotoxxins - aminoglycosides, myoglobin in rhabdo
lead, radiocontrast agents

127
Q

Most common renal cancer for lung mets

A

renal cell carcinoma

128
Q

What stones are radio-lucent

A

uric acid and xanthine stones

129
Q

What is flutamide?

A

synthetic anti-androgen

130
Q

what is tolterodine

A

anti-muscarinic for immediate release in overactive bladder

131
Q

Signs of bladder rupture

A

pelvic fracture, lower abdominal peritonism, cannot pass urine

132
Q

Signs of membranous urethral rupture

A

pelvie fracture and highly displaced prostate

133
Q

adult patients with hydrocele require what

A

uss to exclude underlying tumour

134
Q

What other systems can renal cell carcinoma affect

A

cause liver dysfunction - cholestasis and hepatosplenomegaly

135
Q

Following relief of outflow flow obstruction what needs monitoring and why

A

physiological diuresis
U&E

136
Q

What are features of low testosterone

A

gynaecomastia, reduced body hair and hypogonadism
young patient always had difficulty - refer to urology

137
Q

Unilateral hydronephrosis causes

A

PACT

pelvic ureteric obstruction
aberrant renal vessels
calculi
tumours of renal pelvis

138
Q

Bilateral causes of hydronephrosis

A

SUPER

stenosis of urethra
urethral valve
prostatic enlargement
extensive bladder tumour
retro-peritoneal fibrosis

139
Q

Ix and mx for hydronephrosis

A

USS first line, IVU assess position

remove obstruction and drain urine
acute - nephrostomy
chronic - ureteric stent / pyeloplasty

140
Q

cause of urethral stricture

A

idiopathic
iatrogenic e.g. traumatic placement of indwelling urinary catheters
sexually transmitted infections e.g. gonorrhoea
penile fractures e.g. secondary to sexual trauma
hypospadias
lichen sclerosus

141
Q

Features, investigations and management of urethral strictures

A

Features
decreased urinary stream
incomplete bladder emptying
less common symptoms including spraying of urinary stream and dysuria

Investigations
uroflowmetry
ultrasound postvoid residual (PVR) measurement

Management
dilation
endoscopic urethrotomy

142
Q
A

ICSM Year 6 + edits (28 decks)

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