Surgical questions

Question 1

What investigations would you organise for someone with symptoms of benign prostatic hypertrophy?

Answer 1

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.

Question 2

What are the management options for BPH?

Answer 2

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

Question 3

What are the complications of TURP?

Answer 3

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%)

Question 4

What are the treatment options for prostate cancer?

Answer 4

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

Question 5

How should bladder cancer be managed?

Answer 5

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.

Question 6

What are the risk factors for testicular malignancies?

Answer 6

Undescended and ectopic testes

Increased incidence in males who are infertile and who have had a previous contralateral testicular malignancy

Question 7

What is the commonest type of testicular tumour?

Answer 7

Seminoma

Question 8

What investigations would you do if you suspected a patient had testicular cancer?

Answer 8

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.

Question 9

Where do testicular cancers tend to spread?

Answer 9

Para-aortic nodes, liver, lung, bone, brain

Question 10

What are renal calculi made of? Which type is associated with Proteus infection?

Answer 10

Mostly calcium stones (80%), complexed with oxalate, phosphate or mixed
Struvite (magnesium ammonium phosphate) associated with Proteus UTIs
Cysteine
Urate
Xanthine

Question 11

What differentials should you consider for renal colic?

Answer 11

Renal calculus
AAA
Appendicitis
Diverticulitis
Pyelonephritis
Gynaecological causes

Question 12

What investigations should you do for suspected renal calculi?

Answer 12

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

Question 13

How should an uncomplicated kidney stone be managed?

Answer 13

Analgesia - NSAIDs and opiates
Small stones tend to pass spontaneously. Stones >7mm tend to require intervention e.g. ESWL, percutaneous removal or urethroscopy.

Question 14

How should a kidney stone causing obstruction be managed?

Answer 14

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.

Question 15

What are haemorrhoids?

Answer 15

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.

Question 16

What are the causes of haemorrhoids?

Answer 16

Constipation and prolonged straining
Pelvic tumour
Pregnancy
CCF
Portal hypertension

Question 17

How would you classify haemorrhoids?

Answer 17

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

Question 18

How should you investigate rectal bleeding that sounds like haemorrhoids?

Answer 18

Never ascribe rectal bleeding to piles without adequate examination and investigation
Abdominal examination
PR
Proctoscopy
Sigmoidoscopy

Question 19

What are the treatments for haemorrhoids?

Answer 19

Conservative - high fibre diet, laxatvies e.g. lactulose and fibrogel, and topical analgesics

Rubber band ligation
Infra-red coagulation
Sclerosant
Cryotherapy
Haemorrhoidectomy

Question 20

How do you manage an anal fissure?

Answer 20

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

Question 21

Define fistula

Answer 21

An abnormal connection between two epithelial surfaces

Question 22

Define sinus

Answer 22

A blind-ending tract joining an epithelial surface to a cavity lined by granulation tissue

Question 23

How would you manage an anal fistula?

Answer 23

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.

Question 24

Most rectal prolapses reduce spontaneously or by manual reduction. When is a prolapse an emergency?

Answer 24

If it becomes oedematous and ulcerated and is irreducible, producing pain and bleeding.

Question 25

What are the management options for rectal prolapse?

Answer 25

Abdominal approach or perineal (Delorme’s procedure)

Question 26

How would you manage an anorectal abscess?

Answer 26

Incision and surgical drainage

Review for fistula in ano

Question 27

What are the management options for Barrett’s oesophagus?

Answer 27

If high grade dysplasia, oesophageal resection or eradication mucosectomy if young and fit. Can also use targeted mucosectomy or mucosal ablation by epithelial laser, radio frequency (HALO) or photodynamic ablation.

If no premalignant changes are found, regular endoscopy and biopsy and high dose PPI are used.

Question 28

Which investigations would you do to stage a colorectal cancer?

Answer 28

CT - mets
MR - local invasion
PET - lymph nodes and micromets
Rectal ultrasound for early tumours - depth of invasion

Question 29

What is a Hartmann’s procedure?

Answer 29

Resection of the recto-sigmoid colon with closure of the rectal stump and formation of an end colostomy.

Currently, its use is limited to emergency surgery when immediate anastomosis is not possible, or more rarely, it is used palliatively in patients with colorectal tumours.

Question 30

When do you use neoadjuvant chemo/radiotherapy in colorectal cancer?

Answer 30

Any T3 tumour, or critical tumour (near sphincter, prostate, nodes, mesorectal plane)

Only used in rectum, not colon.

After neoadjuvant therapy, 15% CPR and 50% downsized.

Question 31

How would you investigate a possible anastomotic leak?

Answer 31

CT (and rectal contrast)

Question 32

Tell me about screening for colorectal cancer.

Answer 32

Offered originally to those between 60 and 69, now extending to 70-75 too.
Given 6 test cards for faecal occult bloods at home.
Repeated every 2 years.
If positive test, or considered high risk (e.g. strong family history, FAP, anyone with previous polyps or cancer, IBD etc), offer a colonoscopy.

For every 1000 screened, 20 will have a positive test. Of these, 16 will have a colonoscopy, 8 will be normal, 6 will have polyps and the remaining 2 will have cancer.

Question 33

What are the risk factors for kidney cancer?

Answer 33

Obesity, smoking, von Hippel Lindau.

Question 34

Where do kidney tumours normally metastasise?

Answer 34

Bone
Adrenals
Lung
Brain

Also locally invasive

Question 35

What are the management options of renal cell carcinoma?

Answer 35

Active surveillance if unfit

Nephrectomy/ partial nephrectomy, laparoscopic nephrectomy, cryotherapy

Chemo/immunotherapy - 5FU etc
Cryotherapy
High intensity frequency ultrasound

Question 36

What paraneoplastic phenomena can occur with renal cell carcinoma?

Answer 36

EPO (polycythaemia)
Renin (hypertension)
PTHrP (hypercalcaemia)

Question 37

How is kidney cancer usually diagnosed?

Answer 37

CT urography

Question 38

How is bladder cancer usually treated?

Answer 38

Superficial - TURBT/cystodiathermy and intravesical chemo e.g. mitomycin C

Invasive - radical cystectomy with formation of ileal conduit or neobladder, radical radiotherapy and IV chemotherapy.

Carcinoma in situ is treated as invasive disease and therefore treated aggressively with intravesical BCG (SE: cystitis, genitourinary TB, systemic TB).

Question 39

How is testicular cancer managed?

Answer 39

Radical orchidectomy - check tumour markers for residual disease
Chemotherapy
Radiotherapy
Para-aortic lymph node dissection

Nearly everyone is cured, even with metastases.