Surgical questions Flashcards
What investigations would you organise for someone with symptoms of benign prostatic hypertrophy?
Urine dipstick, microscopy and culture
Blood - U&E, PSA. Check PSA again if high and if it remains high or the prostate is clinically suspicious, a transrectal ultrasound and biopsy of the prostate can be performed.
Urine flow test
USS of urinary tract to assess for residual volume and look for hydronephrosis.
If you are suspicious of a urethral stricture/bladder calculus due to irritative symptoms, consider cystoscopy, urodynamic studies and voiding studies.
What are the management options for BPH?
Conservative - if mild symptoms. Approx 65% of patients will not improve or get worse.
Medical - alpha-adrenergic blockers e.g. tamsulosin, and 5-alpha reductase inhibitors e.g. finasteride.
Surgical - Transurethral resection of prostate
What are the complications of TURP?
Early - septic shock, bleeding, transurethral syndrome (electrolyte imbalance, fluid overload and cerebral oedema due to absorption of hypotonic irrigation fluid)
Late - secondary haemorrhage, urethral strictures, impotence, recurrent growth, retrograde ejaculation (65-88%)
What are the treatment options for prostate cancer?
Early prostate cancer - treatment with curative intent: - Radical prostatectomy - Radical radiotherapy - Brachytherapy (Best treatment not established)
Metastatic or locally advanced disease - prostate ca is driven by androgens, therefore aim to reduce these by medical or chemical castration:
- Medical - LHRH agonists e.g. Zoladex, administered as a trimonthly SC injection
- TURP can be performed if obstructive symptoms are present
How should bladder cancer be managed?
Superficial low grade:
- cystoscopy and endoscopic resection and diathermy
Superficial high grade:
- resection and diathermy followed by intravesical chemotherapy e.g. mitomycin. Patients are followed up regularly with cystoscopies.
Invasive disease
- Radical cystectomy and formation of an ileal conduit, or creation of a neobladder out of small bowel.
What are the risk factors for testicular malignancies?
Undescended and ectopic testes
Increased incidence in males who are infertile and who have had a previous contralateral testicular malignancy
What is the commonest type of testicular tumour?
Seminoma
What investigations would you do if you suspected a patient had testicular cancer?
USS testis
Blood - AFP (never raised in seminoma) and BHCG
CT CAP - staging
Orchidectomy via a groin incision - the testis is brought out and examined. If the lump appears malignant, or a frozen section taken confirms the diagnosis histologically, then it is excised together with the spermatic cord.
Where do testicular cancers tend to spread?
Para-aortic nodes, liver, lung, bone, brain
What are renal calculi made of? Which type is associated with Proteus infection?
Mostly calcium stones (80%), complexed with oxalate, phosphate or mixed
Struvite (magnesium ammonium phosphate) associated with Proteus UTIs
Cysteine
Urate
Xanthine
What differentials should you consider for renal colic?
Renal calculus AAA Appendicitis Diverticulitis Pyelonephritis Gynaecological causes
What investigations should you do for suspected renal calculi?
Urine dipstick (>90% haematuria) and microscopy. The urine may be sieved to try and catch the stone and identify components which may be useful for directing treatment.
CTKUB (without contrast)
Bloods - U&E, FBC, calcium, phosphate, urate
How should an uncomplicated kidney stone be managed?
Analgesia - NSAIDs and opiates
Small stones tend to pass spontaneously. Stones >7mm tend to require intervention e.g. ESWL, percutaneous removal or urethroscopy.
How should a kidney stone causing obstruction be managed?
In the absence of sepsis - ureteric stent
Evidence of sepsis - urological emergency - damage to the kidney can occur if not drained urgently and sepsis can become overwhelming. Antibiotics should be started and urgent arrangements should be made to insert a nephrostomy tube percutaneously.
What are haemorrhoids?
Disrupted and dilated anal cushions covered in a layer of mucosa. They contain a branch of the superior rectal artery and a tributary of the superior rectal vein.
What are the causes of haemorrhoids?
Constipation and prolonged straining Pelvic tumour Pregnancy CCF Portal hypertension
How would you classify haemorrhoids?
1st degree - remain in the rectum
2nd degree - prolapse through the anus on defecation but spontaneously reduce
3rd degree - as for second degree but require digital reduction
4th degree - permanently prolapsed
How should you investigate rectal bleeding that sounds like haemorrhoids?
Never ascribe rectal bleeding to piles without adequate examination and investigation Abdominal examination PR Proctoscopy Sigmoidoscopy
What are the treatments for haemorrhoids?
Conservative - high fibre diet, laxatvies e.g. lactulose and fibrogel, and topical analgesics
Rubber band ligation Infra-red coagulation Sclerosant Cryotherapy Haemorrhoidectomy
How do you manage an anal fissure?
Conservative - avoid straining and use bulk laxatives
Medical - topical local anaesthetic creams. Can use topical agents to relax the internal sphincter e.g. nitrates and CCBs. Or inject botox
Surgical - lateral subcutaneous sphincterotomies
Define fistula
An abnormal connection between two epithelial surfaces
Define sinus
A blind-ending tract joining an epithelial surface to a cavity lined by granulation tissue
How would you manage an anal fistula?
Low fistula - does not cross the sphincter muscles above the dentate line and so are treated by being laid open so the wound heals from depth upwards
High fistula - treated with a seton as cannot be laid open otherwise sphincters would be damaged. The seton can be gradually tightened so that gradually it cuts through the surface with the fistula healing by scar tissue behind it.
Most rectal prolapses reduce spontaneously or by manual reduction. When is a prolapse an emergency?
If it becomes oedematous and ulcerated and is irreducible, producing pain and bleeding.
