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Surgery - Year 3 > Surgery - Urology > Flashcards

Surgery - Urology Flashcards

1
Q

Define the Bladder Cancer referral criteria for all age groups

A

> 45 and visible haematuria
45 and visible haematuria persists even after UTI treatment
60 with unexplained non-visible haematuria and dysuria/raised WBC

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2
Q

Name 2 benign renal tumours

A
  • Angiomyolipoma

- Renal oncocytomas

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3
Q 
Renal cancer
Pathophysiology:
Spread locations:
Subtypes of RCC:
Symptoms:
Signs:
Risk factors:
Investigations:
Management:
Complications:
A

Pathophysiology: RCC mostly.

Spread locations: Pre-aortic and hilar lymph nodes. Perinephric tissues eg. adrenal glands/renal vein

RCC subtypes: Clear cell (most aggressive), papillary cell

Symptoms: Incidental finding usually
Triad: Loin pain, palpable mass, haematuria

Signs: Left-sided varicocoele

Risk factors: Smoking, Obesity, Hypertension, FH, Dialysis, Carcinogens

Investigations: Urine dipstick/cytology, Bloods, USS, Triple Phase CT - gold standard, Bone scan for mets

Management: Surgical usually - Lap radical nephrectomy (kidney, perinephric fat, ureters, adrenal gland)
Immunotherapy used if mets, as chemo resistant

Complications: Polycythaemia vera, hypertension from excess renin, Stauffer syndrome (deranged LFTs)

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4
Q 
Urothelial cancers
Pathophysiology:
Causes:
Symptoms:
Risk factors:
Investigations:
Management:
A

Pathophysiology: TCCs

Causes:

Symptoms: Painless haematuria, LUTS eg. recurrent UTIs, upper tract obstruction in advanced disease

Risk factors: Smoking, increasing age, occupational hazards eg. b-naphthalene, arsenic

Investigations: Urgent cystoscopy with biopsy, urine tests (haematuria/cytology), USS and staging CT (triple phase)

Management: TURBT + intravesical adjuvants given eg. BCG

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5
Q 
Stress Incontinence
Definition:
Risk factors:
Investigations:
Management (conservative and surgical):
A

Definition: Leakage when intra-abdominal pressure increases eg. lifting/coughing, usually due to weakened pelvic floor muscles

Risk factors: Post-partum, Post-menopause, Obesity, Constipation, After Surgery eg. TURP

Investigations: MSU dipstick, post-void bladder scan, bladder diaries, cystoscopy, outflow urodynamics (measures detrusor pressure)

Management:
Conservative: Pelvic floor muscle exercises, SNRI (duloxetine)
Reduce weight, reduce caffeine intake, smoking cessation, reduce fluid intake
Surgical: Pubovaginal sling, open colposuspension

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6
Q 
Urge incontinence
Definition:
Risk factors:
Investigations:
Management (conservative and surgical):
A

Definition: Overactive detrusor leading to uninhibited bladder contraction and increased bladder pressure

Risk factors: Neurogenic eg. stroke, infection, malignancy, ACH inhibitors

Investigations: MSU, Post-void bladder scan, bladder diaries, cystoscopy, outflow urodynamics

Management (conservative and surgical):
Conservative: Anti-muscarinic (Oxybutinin), bladder training for 6 weeks minimum, Reduce weight, reduce caffeine, smoking cessation, reduce fluid intake
Surgical: Botulinum toxin A injection, sacral nerve stimulation

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7
Q

Overflow incontinence
Definition:
Risk factors:

A

Definition: Chronic urinary retention leading muscle stretching and weakness.

Risk factors: BPH - most common

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8
Q 
Prostate Cancer
Pathophysiology:
Types:
Symptoms:
Grading:
Risk factors:
Investigations:
Management:
A

Pathophysiology: Adenocarcinoma caused by testosterone. Arises in the peripheral zone.

Types: Acinar and ductal (ductal are worse)

Symptoms: LUTS (obstructive), UTIs, Haematuria, Weight loss, Bone pain - most identified from screening

Grading: Gleason grading - 0 - 10, minimum 6 for tumours, taken one sample from each side of prostate

Risk factors: Increasing age, genetics (BRCA1/2 or FH), excessive testosterone, obesity, diabetes (metformin)

Investigations: DRE (can refer just from craggy prostate), PSA, Histology from TRUS or TURP, Bone scan/CT for mets

Management: Most will be met by watchful waiting (older, symptom-based) or active surveillance (younger, do tests until worth doing treatment). TURP, then radical prostatectomy. Androgen deprivation therapy if metastatic.

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9
Q

What can PSA be raised by?

A

Cancer
Inflammation
BPH
Physical touch/movement

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10
Q 
Testicular Cancer
Types and age of onset:
Risk factors:
Investigations:
Management:
A

Types and age of onset:
Germ-cell:
- Non-seminomatous - 30 years old - worse prognosis
- Seminoma - 40 years old

Risk factors: Testicular dysgenesis (eg. cryptorchidism, hypospadias, subfertility), FH, Klinefelter’s syndrome

Investigations: Physical examination (irregular, painless, unilateral, firm, fixed, transilluminescence), AFP (non-seminomatous), b-hCG, scrotal USS, CXR for cannonball sign, CT for staging, DO NOT BIOPSY

Management: Radical orchidectomy

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11
Q

Name 5 side-effects of chemo

A
  • Myelosuppression
  • Alopecia
  • Emesis
  • Ototoxicity
  • Reynaud’s
  • Kidney failure
  • Infertility
  • Secondary malignancy
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12
Q 
Penile cancer
Referral criteria:
Pathophysiology:
Symptoms:
Risk factors:
Investigations:
A

Referral criteria: Mass or ulcer, STI excluded, foreskin symptoms

Pathophysiology: SCC, strongly associated with HPV (16/18)

Symptoms: Ulcerating lesion on the penis, painless by may discharge, inguinal lymphadenopathy very common

Risk factors: HPV, Phimosis (cannot retract foreskin), Lichen sclerosis, Smoking, HIV

Investigations: Refer to regional speciality centre for biopsy

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13
Q 
BPH
Pathophysiology:
Causes:
Symptoms:
Signs:
Risk factors:
Investigations:
Management:
Complications:
A

Pathophysiology: Hyperplasia of the glandular-epithelial and stromal tissue of the prostate.

Causes:

Symptoms: LUTS (voiding) - Hesitancy, Weak stream, Terminal dribbling, incomplete voiding

Signs:

Risk factors: Age, FH, Afro-Caribbean, Obesity

Investigations: DRE, IPSS (international prostate symptom score), urinalysis, PSA, urodynamic studies

Management: Lifestyle (reduced caffeine, alcohol), a-blockers (Tamsulosin - can lead to retrograde ejaculation/postural hypotension) or Finasteride (blocks testosterone conversion), TURP or HoLEP (holmium laser enucleation of the prostate)

Complications: AKI from high pressure retention, UTIs, haematuria

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14
Q 
Renal/Ureteric stones
Types of stones:
Symptoms:
Risk factors:
Investigations:
In-patient admissions criteria:
Management:
A

Types of stones: Calcium oxalate, Calcium phosphate (check PTH), Struvite (urease producing bacteria), Urate - not all can be seen on X-ray, need CT

Symptoms: Loin to groin pain, non-visible haematuria (90%), nausea, vomiting, temperature

Risk factors: Male, 20s or 50s, FH, dehydration, hypertension, BMI, metabolic syndromes, anatomy

Investigations: CT KUB (gold standard - non contrast), urine dipstick for haematuria, USS for hydronephrosis assessment, stone forming bloods (calcium, phosphate, uric acid), stone analysis

In-patient admissions criteria: AKI, uncontrollable pain, infected stone, stone >0.5cm

Management: Diclofenac PR, Tamsulosin (helps), IVI, anti-emetics
Symptom management: Stent/Nephrostomy to reduce pressure
Curative: Ureteroscopy with stone fragmentation, Lithotripsy (EWSL), PCNL percutaneous lasering

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15
Q 
Pyelonephritis
Pathophysiology:
Organisms:
Symptoms:
Risk factors:
Investigations:
Management:
Complications:
A

Pathophysiology: Inflammation of the kidney parenchyma due to bacterial infection.

Organisms: E. coli (80%), Staph, pseudomonas

Symptoms: Triad: Fever, loin pain, nausea and vomiting + LUTS, haematuria

Risk factors: Obstructive factors eg, BPH/neurogenic bladder, female gender, indwelling catheter, HIV/diabetes, renal calculi

Investigations: Urinalysis, pregnancy test, urine culture, USS, CT urogram (non-contrast)

Management: Empirical antibiotics, IV fluids, HDU, diclofenac PR, early CT

Complications: Chronic pyelonephritis (scarring), Emphysematous pyelonephritis (diabetics)

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16
Q 
LUTS
Name the two classifications of LUTS:
Name the symptoms of both:
What are the risk factors for developing LUTS?
Name 5 causes in males and females
Investigations
A

Classifications: Voiding and Storage

  • Voiding - urethral problems - Hesitancy, Weak Flow, Dribbling/Incomplete voiding
  • Storage - Bladder problems - Frequency, Urgency, Nocturia, Urge incontinence

Risk factors: Age, Male, Infection, Stones, BPH, Congenital malformations

Male: BPH, UTI, Urological malignancy, Detrusor muscle weakness, Urethral stricture

Female: UTI, menopause, urological malignancy, detrusor muscle weakness, urethral stricture

Investigations: Urinalysis, post-void bladder scanning, urine culture, PSA, urodynamic studies, cystoscopy

17
Q

Pseudo-haematuria
Name 3 drugs that cause red urine
Name 2 compounds that can cause red urine

A

3 drugs: Rifampicin, Nitrofurantoin, Senna

2 compounds: Myoglobin, Bilirubin

18
Q 
Haematuria
Name 12 causes of Haematuria:
Name 2 false positives in women:
Investigations:
Management:
A

Causes: Excess anticoagulation, Sickle cell, Renal calculi, Pyelonephritis, RCC, Trauma, Bladder Cancer, UTI, Prostate Cancer, BPH

False positives in women: Ovarian cysts, Endometrial cancer

Investigations: Urinalysis, Flexible Cystoscopy (gold standard), PSA, DRE, USS, CT urogram/CT triple phase

Management: Bladder scan, cancer red flags, identify drugs, give 3 WAY catheter and do irrigation

19
Q

Testicular lumps - what Investigations would you order for a testicular lump?

A

USS - first line
Do not biopsy due to testicular cancer seeding risk
Blood tests - bHCG, LDH, AFP

20
Q

Hydrocoele
Pathophysiology:
Description:
Management:

A

Patho: Abnormal collection of peritoneal fluid between the parietal and visceral layers of the tunica vaginalis

Description: Painless, motile lump that transilluminates (fluid-filled)

Management: USS scan, most resolve spontaneously

21
Q 
Varicocoele
Pathophysiology:
Description:
Investigations:
Management:
Complications:
A

Patho: Abnormal dilatation of the pampiniform plexus within the spermatic cord

Description: “Bag of worms” with a “dragging sensation” - disappears when lying flat. 90% on the left side due to drainage into renal vein as opposed to IVC

Investigations: USS and renal USS (for renal cancer)

Management: Embolisation or ligation of the spermatic veins

Complications: Infertility and testicular atrophy

22
Q

Epidydimal Cyst
Pathophysiology:
Description:
Management:

A

Patho: Benign, fluid-filled sac from the epididymis

Description: Smooth, fluctuant, transilluminates

Management: No treatment required

23
Q

Epididymitis
Pathophysiology:
Description:
Management:

A

Patho: Inflammation of the epididymis - usually bacterial or STI in origin

Description: Unilateral, acute onset pain (most common in adults), redness, swelling, systemic fever, relieved on elevation of the testes

Management: Oral antibiotics and analgesia

24
Q 
Testicular Torsion
Pathophysiology:
Symptoms:
Risk factors:
Management:
A

Pathophysiology: Spermatic cord twists within the tunica vaginalis due to testis rotating, compromising the blood supply to the testes - surgical emergency - oedema and infarct

Symptoms: Sudden onset severe unilateral pain, n+v, swollen, hard high-position testes, no cremasteric reflex, Prehn’s sign - pain continues on testicular elevation

Risk factors: 12-25 age, bell-clapper deformity, previous torsion, FH, undescended testes (cryptorchidism)

Management: Clinical diagnosis - can do doppler. Urgent scrotal exploration needed. Bilateral orchidopexy - fix testicles to scrotum.

25
Q 
Acute Urinary Retention
Pathophysiology:
Causes:
Symptoms:
Investigations:
Management:
Complications:
A

Pathophysiology: Acute onset large volume retention - pain

Causes: BPH, UTI, Constipation (urethral impingement), Severe pain, Medications eg. anti-muscarinics, neuropathic (MS)

Symptoms: Acute suprapubic pain, inability to micturate, palpable bladder

Investigations: DRE for prostate, Post-void bladder scan (gold-standard), Catheterise and get catheter specimen, USS for hydronephrosis

Management: Catheterisation and treat cause, TWOC

Complications: Hydronephrosis, Post-Obstructive diuresis (kidneys can over-diurese, causing AKI)

26
Q 
Chronic Urinary Retention
Pathophysiology:
Causes:
Symptoms:
Investigations:
Management:
Complications:
A

Pathophysiology: Painless inability to pass urine - significant bladder distension and desensitisation.

Causes: BPH, Urethral strictures, prostate cancer, pelvic prolapse eg. cystocele, pelvic masses eg. fibroids, neurological eg. MS/Parkinson’s

Symptoms: Painless urinary retention, overflow incontinence (constant dribbling of urine), LUTS (storage - frequency, urgency, nocturia, urge incontinence)

Investigations: DRE, post-void bladder scan, USS for hydronephrosis

Management: Long-term catheter, NO TWOC, intermittent self-catheterisation

Complications: CKD/hydronephrosis

27
Q

Catheters
Name 5 indications for a catheter:
Name 5 contra-indications for a catheter:
Complications of catheters:

A

Indications: Acute urinary retention, chronic urinary retention, end of life, neurogenic bladder, sepsis, post-operative

Contra-indications: patient refusal, urethral strictures, trauma to the meatus/urethra, scrotal haematoma, paediatrics

Catheters: Bladder stones, UTI, Pain, Traumatic hypospadias, Bladder Cancer

28
Q

Define TURP syndrome

A

Caused by non-electrolyte (hypo-osmolar) irrigation during surgery -> hypoosmolar

29
Q

Name 4 side-effects of a-blockers eg. Tamsulosin used in BPH treatment

A

Reduced libido
Erectile dysfunction
Postural hypotension/dizziness
Gynaecomastia

Surgery - Year 3 (6 decks)

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