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 diclofenac
CVS disease
How should kidney stones be managed depending on size?
<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
Risk factors for shock wave lithotripsy
solid organ injury
ureteric obstruction
can’t be done for pregnant ladies
neither for vascular calcification
Recall 2 options for medically managing BPH and some side effects of each
- alpha-1 antagonists (tamsulosin): postural hypotension, dry mouth
- 5 alpha reductase inhibitors (finasteride): 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
Hyponatraemia, fluid overload and glycine toxicity caused by over-irrigation
When can PSA levels not be done?
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
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) - produces a more detailed picture of the prostate gland
Recall 3 options for managing localised prostate cancer (T1/T2)
- Conservative with active monitoring
- Radical prostatectomy
- Radiotherapy (external beam and brachytherapy - bead with radioactive material inserted near radiographic source)
Recall 3 options for managing localised advanced 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 (type of stem cells able to differentiate into anything) renal tumour composed of thick-walled blood vessels, smooth muscle and 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
Which genetic syndrome predisposes to renal cell carcinoma?
Von Hippel Lindau
What are the 3 main subtypes of renal cell carcinoma, and which is most common
Clear cell (70%)
Papillary
Chromophobe
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
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 proportion of testicular tumours are germ cell tumours?
95%
What are the subtypes of germ cell testicular tumours?
Seminomas (50%)
Non-seminoma (embryonal, yolk sac, teratoma an choriocarcinoma)
What is the biggest risk factor for testicular seminoma?
Cryptochidism
What are the signs and symptoms of testicular cancer?
Painless lump +/- hydrocele, gynaecomastia
How should testicular cancer be investigated?
1st = USS
2nd = AFP , hCG (seminoma), LDH (teratoma) - higher = worse prognosis
3rd = CT TAP (thoracic, abdomen, pelvis)
NO biopsy
How can testicular cancer be managed?
Orchidectomy +/- chemotherapy +/- radiotherapy
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 and pull up the ipsilateral testicle toward the inguinal canal
What is Prehn’s test?
Elevating scrotum and 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 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 and MC&S (rule out DM and 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 and 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
How should hydrocele be managed?
- Watch and wait
- Aspiration for symptomatic relief
- Surgical = Lloyd’s repair/ 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
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 should be done before treatment with goserelin for prostate cancer?
Pretreatment with flutamide to avoid initial “flare effect” of goserelin
What is a Hydrocele?
Painless swelling, transilluminates, testis not palpable
Fluid within the tunica vaginalis
Diffuse lumpy swelling, not painful, feel separately, trouble conceiving
Varicocele
Pampiniform plexus, poor venous drainage of testicle
Pea sized lump, discrete soft mass posterior to right testicle
- Epididymal cyst - most common scrotal swelling in primary care
- USS
- Reassurance, if large / pain = surgical / sclerotherapy
Swelling, large non-tender, cannot palpate above swelling
- Inguinal hernia, indirect hernia - descends into scrotum
- Surgical repair - push back in elective, if incarnated then emergency surgical
Thailand, gradual onset right scrotal pain, tender, swelling, epididymal-orchitis, dysuria - how do you treat? Common organisms in different groups
- Cef IM single dose, po doxy for 10-14 days
- Gonorrhoea based organism (young)
- E. coli - older
- Mumps - young not SA
Swollen left testicle, drinking, sudden tender and dull ache
emergency admission
haematoma
blood in tunica vaginalis
Both RF for testicular cancer
Cryptorchidism, hernia in infancy
Where do seminoma’s originate from?
seminiferous tubules
Most common site for testicular cancer mets and signs
Lung and lymphatics
haematospermia and SOB
What are the percentage of testicular survival at different hours?
6 - 90
12 - 50
24 - 10
What be the difference in duplex USS in TT and epididymitis?
Flow would be present in e
What is TT
testis torted around the spermatic cord and necrosis of testis
Main differentials for renal colic and investigations
renal cyst rupture
constipation
urine dip, cultures, ct-kub
Main signs and results for renal colic
Male
cannot lie flat
urinary stasis
decreased urine volume
Most common spots for renal colic
PUJ
VUJ
Pelvic brim - iliac vessels crossover
What is hydronephrosis and what causes it?
- Dilation of renal pelvis & calyces due to obstruction to urine flow
- Strictures, babies, outer compression
- Renal damage
Main conservative and medical treatment for kidney stones
Analgesia, fluids, anti-emetics, alpha blocker, treatment
Indications for nephrostomy
septic
ureteric obstructions
horseshoe kidney
previous renal transplant
ureteric stent via cystoscopy and open surgery
If have infected obstructed system in kidneys
Pyelonephrosis behind the stone
surgical emergency
treat with cefuroxime - cef oral if upper tract
Other causes in kidneys needing ABs
Renal calyx rupture
urinoma
pyelonephritis
pyonephrosis
give cefuroxime
What medication is used to excrete potassium?
Calicum resonium 15g
What catheter is used for clots
3-way catheter, washout
Sign and causes of acute urinary retention
600ml < bladder scan
prostatic obstruction
urethral strictures
alcohol
Signs and causes of chronic urinary retention
insidious, bladder at 1.5L, malignancy, diabetes, MS
- Pain infection, renal impairment only catheterises
Problem with acutely emptying large bladder and how to deal with it
fluid shift - make too much urine from kidney, diuresis post catheter
- Micro tears - severe haematuria
- Intermittent self-catheterise
Conservative measures for BPH
Avoid caffeine / alcohol, bladder training
If a patient with BPH wants to maintain libido what should be done
TUIP - incision
Other measures other than TURP to deal with BPH
HLUP procedure - enucleation
urolift implants
Score to grade prostate cancer
Gleasons
Painless blood in urine, no pain and lifelong smoker
Bladder cancer - transitional cell carcinoma
Male
Bladder, but can be anywhere
amine exposure
How is bladder cancer investigated?
- Cystoscopy + biopsy
- USS / ct for invasion
How is bladder cancer graded and treated?
- TNM system of grading
- TURBT
- If in lamina propria add immunotherapy / CTX
- Then radical cystectomy
- Invasion beyond bladder - palliative CTX
Follow up for post bladder cancer
- Follow up cystoscopy every 3 months for 2 yrs then every 6 months
- Then next 9 month
If doing a radical cystectomy what also will be done
Ileal conduit
If have bilateral kidney tumours what should be done
Wedge resection
Examples of immunotherapy used during renal cancer
Checkpoint inhibitors and VEGF inhibitors
What is Goserelin
Synthetic GnRH agonist in prostate cancer
Everything needed to know about vasectomy
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
If Nsaids contraindicated in renal colic what should be given
paracetamol
what bladder cancer is schistosoma infection linked with
Squamous cell carcinoma
Common complication with radical prostatectomy
Ed
Factors favourable of organic cause of eD
gradual onset
lack of tumescence
normal libido
If somebody cycles more than 3 times a week
stop cycling
Methods to prevent calcium stones
high fluid intake
add lemon juice
avoid carbonated drinks
limit salt intake
potassium citrate
thiazide diuretics
What is tumour flare? How do you stop it
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
If a patient has a T1 renal tumour
Partial nephrectomy
What is priapism?
persistent painful erection lasting more than 4 hours
Causes of priapism
SCD
ED medication
trauma
Ix for Priapism
cavernosal blood gas pCO2 increase for ischamic
Mx for priapism
aspirate blood with saline flush injection - then phenylephrine if all else failures
Features of acute tubular necrosis
raised urea, creatinine, potassium
muddy brown casts in the urine
caused by ischaemia
nephrotoxxins - aminoglycosides, myoglobin in rhabdo
lead, radiocontrast agents
Most common renal cancer for lung mets
renal cell carcinoma
What stones are radio-lucent
uric acid and xanthine stones
What is flutamide?
synthetic anti-androgen
what is tolterodine
anti-muscarinic for immediate release in overactive bladder
Signs of bladder rupture
pelvic fracture, lower abdominal peritonism, cannot pass urine
Signs of membranous urethral rupture
pelvie fracture and highly displaced prostate
adult patients with hydrocele require what
uss to exclude underlying tumour
What other systems can renal cell carcinoma affect
cause liver dysfunction - cholestasis and hepatosplenomegaly
Following relief of outflow flow obstruction what needs monitoring and why
physiological diuresis
U&E
What are features of low testosterone
gynaecomastia, reduced body hair and hypogonadism
young patient always had difficulty - refer to urology
Unilateral hydronephrosis causes
PACT
pelvic ureteric obstruction
aberrant renal vessels
calculi
tumours of renal pelvis
Bilateral causes of hydronephrosis
SUPER
stenosis of urethra
urethral valve
prostatic enlargement
extensive bladder tumour
retro-peritoneal fibrosis
Ix and mx for hydronephrosis
USS first line, IVU assess position
remove obstruction and drain urine
acute - nephrostomy
chronic - ureteric stent / pyeloplasty
cause of urethral stricture
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
Features, investigations and management of urethral strictures
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
