Urological Surgery Flashcards
1
Q
What is obstructive uropathy?
A
- Obstructive uropathy is blockage of urinary flow, which can affect one or both kidneys depending on the level of obstruction.
- If only one kidney is affected, urinary output may be unchanged and serum creatinine can be normal.
- When kidney function is affected, this is termed obstructive nephropathy.
- Hydronephrosis refers to dilation of the renal pelvis and can be present with or without obstruction
2
Q
What are some of the symptoms of obstructive uropathy?
A
- Flank pain
- Fever
- Lower urinary tract symptoms
- Distended abdomen/palpable bladder
- Inability to urinate
- Enlarged or hard nodular prostate on rectal examination
- Costovertebral angle tenderness
3
Q
What are some of the causes of obstructive uropathy? How would these be classified?
A
- Luminal: stones, blood clot, sloughed papilla, tumour: renal, ureteric, or bladder
- Mural: congenital or acquired stricture, neuromuscular dysfunction, schistosomiasis
- Extra-mural: abdominal or pelvic mass/tumour, retroperitoneal fibrosis, or iatrogenic—eg post surgery
4
Q
What are some of the RFs for urological surgery?
A
- BPH
- Constipation
- Medication (anticholinergic agents, narcotic analgesia, alpha receptor agonists)
- Urolithiasis (ureteric calculi)
- Spinal cord injury, Parkinson’s disease, or multiple sclerosis
- Malignancy
5
Q
What investigations should be considered for obstructive uropathy?
A
- Bedside: urine dipstick, pregnancy for female, urine MC+S
- Bloods: FBC, UE, CRP, PSA, CK,
- Others to consider: tumour markers (CEA, CA125))
- Imaging: renal USS, CT (if there is hydronephrosis or hydroureter)
6
Q
How would you manage obstructive uropathy?
A
Upper Tract Obstruction
- 1st: analgesia (diclofenac) and rehydration (IV fluids)
- 2nd: ureteric stent or nephrostomy
- alpha blockers e.g. tamsulosin
- Abx (if needed) e,g, gentamycin
Lower Tract Obstruction
- Urethral or suprapubic catheter - Monitor weight, fluid balance, and u&e closely
- After 2-3 days TWOC
7
Q
What are renal stones and who do they affect?
A
- Renal stones (calculi) consist of crystal aggregates.
- Stones form in collecting ducts and may be deposited anywhere from the renal pelvis to the urethra
- 2-3% of the Western population.
- Males <65yrs
- They can form as both renal stones or ureteric stones
8
Q
Where do kidney stones commonly form?
A
- Pelviureteric junction
- Pelvic brim
- Vesicoureteric junction.
9
Q
What types of kidney stones do you get?
A
- Calcium oxalate (75%).
- Magnesium ammonium phosphate (struvite/triple phosphate; 15%).
- Also: urate (5%), hydroxyapatite (5%), brushite, cystine (1%), mixed.
10
Q
How do kidney stones present generally?
A
- Can be assymptomatic
- Pain: ‘loin to groin’ (or genitals/inner thigh), with
- Nausea/vomiting.
- Cannot lie still
- Haematuria
- Proteinuria
- Sterile pyuria
- Anuria
11
Q
Depending on where the stone is obstructed, what type of symptoms do you get?
A
- Obstruction of kidney: felt in the loin, between rib 12 and lateral edge of lumbar muscles (like intercostal nerve irritation pain; not colicky, worsened by specific movements/pressure on a trigger spot).
- Obstruction of mid-ureter: mimic appendicitis/diverticulitis.
- Obstruction of lower ureter: sx of bladder irritability. Pain in scrotum, penile tip, or labia majora.
- Obstruction in bladder or urethra: pelvic pain, dysuria, strangury (desire but inability to void) ± interrupted flow.
12
Q
How do the stones appear depending on their composition?
A
- Calcium (oxolate, phosphate) - radio-opaque (spikey, smooth)
- Magnesium ammonium phosphate (struvite) - stag horn calculi, radio-opaque
- Urate - radio lucent
13
Q
Why do kidney stones appear?
A
- Over-saturation of urine
- High levels of purine in the blood (diet, haematological disorders)
14
Q
What are some of the more specific reasons kidney stones appear?
A
- Diet: chocolate, tea, rhubarb, strawberries, nuts, and spinach (↑oxalate)
- Season: variations in calcium and oxalate levels mediated by vitamin d synthesis
- Work: Water consumption (can they hydrate regularly)
- Medications: diuretics, antacids, acetazolamide, corticosteroids, theophylline, aspirin, allopurinol, vitamin c and d, indinavir.
15
Q
What are some of the predisposing factors to kidney stones?
A
- Recurrent UTIs (magnesium ammonium phosphate )
-
Metabolic abnormalities:
- Hypercalciuria/hypercalcaemia, hyperparathyroidism, neoplasia, sarcoidosis, hyperthyroidism, Addison’s, Cushing’s, lithium, vitamin d excess
- Hyperuricosuria/↑plasma urate: on its own, or with gout
- Cystinuria
- Renal tubular acidosis
- Urinary tract abnormalities: PUJ obstruction, hydronephrosis, horseshoe kidney, vesicoureteric reflux, ureteral stricture
- Foreign bodies: cathetar, stents
- FMH: ↑3-fold
16
Q
What investigations are needed for diagnosis of kidney stones?
A
- Urine dipstick: Usually +ve for blood (90%) (non visible haematuria)+ mc&s
- Bloods: fbc, u&e, Ca2+, po43−, glucose, bicarbonate, urate
- Urine pH; 24h urine for: calcium, oxalate, urate, citrate, sodium, creatinine; stone biochemistry (sieve urine & send stone)
-
Imaging:
- GOLD STANDARD: CT KUB (high sensitivity and specificity)
- AXR - sometimes used for initial assessment, - will only show radio opaque stones (80% but not all)
- USS (hydronephrosis)
17
Q
What would the initial management be for kidney stones?
A
- IV fluid resuscitation
- Analgesia: PR diclofenac 100mg
- If infection: Abx (eg piperacillin/tazobactam 4.5g/8h iv, or gentamicin)
- Anti emetic: ondansetron
- ↑Fluid intake
Renal stones will pass spontaneously if in the lower ureter or <5mm in diameter
Unless pregnant: remove stones via Ureteroscopy
18
Q
When should you admit a patient for kidney stones?
A
- Post-obstructive AKI
- Uncontrollable pain from simple analgesics
- Infected stone(s)
- Large stones (>5mm)
19
Q
What management is required for stones >5mm or pain not resolving?
A
Medical expulsive therapy:
- α-blockers (tamsulosin 0.4mg/d) - Most pass within 48h
- ESWL (extracorporeal shockwave lithotripsy) - US waves shatter stone. Small stones: <2cm, performed via radiological guidance (either X-ray or USS). SE: renal injury, may also cause ↑bp and dm
- PCNL (Percutaneous nephrolithotomy): Keyhole surgery to remove stones, when large, multiple, or complex. For: large renal stones (including staghorn calculi).
- URS (Flexible uretero-renoscopy) - passing a scope retrograde up into the ureter, allowing stones to be fragmented through laser lithotripsy and fragments removed
20
Q
How are kidney stones prevented generally and specifically?
A
Generally
- Drink plenty
- Normal dietary Ca2+ intake
Specifically:
- Calcium stones: thiazide diuretic to ↓Ca2+ excretion.
- Oxalate: ↓oxalate intake; pyridoxine
- Struvite (phosphate mineral): treat infection
- Urate: allopurinol (100–300mg/24h po)
- Cystine: vigorous hydration and urinary alkalinization
21
Q
How is obstructive nephropathy or significant infection secondary to renal stones managed?
A
- Retrograde stent insertion is the placement of a stent within the ureter, approaching from distal to proximal via cystoscopy
- Nephrostomy is a tube placed directly into the renal pelvis and collecting system, relieving the obstruction proximally
22
Q
What are the nice guidelines for urological referral (haematuria)?
A
- Aged ≥45yrs with either:
- Unexplained visible haematuria without urinary tract infection
- Visible haematuria that persists or recurs after successful treatment of urinary tract infection
- Aged 60yrs with have unexplained non‑visible haematuria and either dysuria or a raised white cell count on a blood test.
