Urology Flashcards
State 5 causes of Nephrolithiasis.
• Hyperparathyroidism
• Hypercalcemia
• Hypercalcuria
• Hypomagnesemia
• Hyperoxaluria
• Hypervitaminosis D
• Hyperuricemia/Hyperuricosuria
• Infection
• Inadequate urinary drainage (urine stasis)
• Immobilisation
• Indinavir
• Diet (Vitamin A deficiency)
• Dehydration
• Decreased urine citrate
• Distal RTA
• Drugs: Loop diuretics; Thiazide diuretics; Indinavir
• Endocrine (metabolism error) -> Cysteinuria
Which drugs may cause Nephrolithiasis.
Loop diuretics
Thiazide Diuretics
Indinavir
Excess Vitamin D
Which 3 stones are radiolucent on XRA?
Indinavir
Cysteine
Uric Acid
What is the gold-standard investigation for Nephrolithiasis?
CT-KUB
How do you manage nephrolithiasis?
Supportive: Analgesia; Fluids
Medical: Tamsulosin; ESWL; ABX
Surgical: PCNL
A 57 y/o F patient presenting with abdominal pain in a loin-to-groin distribution. Pain comes and goes, nothing makes it better, 8/10. Urinalysis shows blood.
Likely diagnosis?
Gold-standard investigation?
Other investigations?
Causes (5) of this condition.
Treatment?
Nephrolithiasis
CT-KUB
Other: Urinalysis; FBC; U+E; Pregnancy test
Hypercalcaemia; Hyperoxaluria; Hypervitaminosis D; Infection; Indinavir; Inadequate drainage; Diet (vitamin A deficiency); Dehydration; Drugs (loop diuretics); Endocrine (cysteinuria)
Depends on size of stone (10mm) for ureteric stones; (5mm) for renal stones
Ureteric stones <10mm
- ESWL
+
- Tamsulosin
Ureteric stones >10mm
- PCNL
What shape are calcium oxalate stones?
Biconcave/ Bipyramidal envelopes
What shape are uric acid stones?
Rhomboid/ Needle-shaped
What shape are Struvite stones?
Staghorn; Coffin-lid
What shape are Calcium Phosphate stones?
Wedge-shaped prisms
What shape are Cystine stones?
Hexagon-shaped crystals
Define an AKI.
Sudden-onset reduction in renal function measured by SCr or Urine output occurring hours-days
Outline the criteria for a Stage 1 AKI.
SCr increase of 1.5-1.9x ; increase by 26umol/L
Urine output of <0.5mL/kg/hour for 6-12 hours
Outline Stage 2 AKI
SCr increase of 2-2.9x
Urine output reduction of <0.5mL/kg/hr for 12h
What is stage 3 AKI?
3x or >354umol/L or RRT
<0.3mL/kg/h (24h)3x or >354umol/L or RRT
<0.3mL/kg/h (24h)
How may an AKI be categorised by cause(s)?
Pre-renal
Renal
Post-renal
Outline the general management of an AKI?
Consider the cause
Pre-renal AKI:
- Fluid resuscitation: 500mL STAT (max 2L)
Renal:
- Biopsy and referral
Post-renal:
- Decompression
Other sequelae:
Acidosis:
- Sodium bicarbonate
Hyperkalaemia: (10:10:10)
- Calcium gluconate (10%) 10mL over 10 minutes
- IV Insulin 10U in 25g glucose (50% in 50mL)
State 3 Nephrotoxic drugs.
O-DAMN
Opiates
Diuretics
ACEi/ARBs
Metformin
NSAIDs
Describe CKD.
Abnormal structure or function ≥ 3/12 characterised by reduced eGFR
What measurable components are used in the criteria for CKD?
eGFR
Albumin excretion
An eGFR of 120mL/min/1.73 is stage…
G1
An eGFR of 88mL/min/1.73m is stage…
Stage 2
An eGFR of 68mL/min/1.73m is stage…
Stage 2
An eGFR of 58mL/min/1.73m is stage…
Stage 3a
An eGFR of 58mL/min/1.73m is stage…
Stage 3a
An eGFR of 48mL/min/1.73m is stage…
Stage 3
An eGFR of 38mL/min/1.73m is stage…
Stage 3b
An eGFR of 42mL/min/1.73m is stage…
G3b
An eGFR of 18mL/min/1.73m is stage…
G4
An eGFR of 28mL/min/1.73m is stage…
Stage 4
An eGFR of 8mL/min/1.73m is stage…
Stage 5
An eGFR of 12mL/min/1.73m is stage…
Stage 5
What are the 3 categories for CKD regarding Albumin excretion?
What are the 3 categories and their limits for CKD regarding ACR?
A1 = <30; <3
A2 = 30-300; 3-30
A3 = >300; >30
(Albumin; ACR)
What investigations may you order in a patient with a declining eGFR over time?
- Urinalysis: protein/blood/ leukocytes
- ACR
- Electrophoresis
- MSC: white casts/red casts/granular casts
- FBC: derangements - ?Hb
- U+Es: ∆s? - reduced Ca2+; elevated PO43- ; reduced EGFR; increased ACR
- Hormones: increased PTH (renal osteodystrophy)
- Abs
- Bone profile
- USS: size; corticomedullary differentiation
-> Offer in visible haematuria or persistent microscopic haematuria - Renal biopsy
How would you treat CKD?
- ACEi: Ramipril
or - ARB + Statin: Candesartan + Simvastatin
Consider:
- Diuretics
- Vitamin D
- Bisphosphonates
- Calcium acetate
- Quinine
- Ferrous fumarate
At what level of Pi do you consider medical management?
Pi > 1.5mmol/L
Calcium acetate
How would you treat cramps associated with CKD?
Quinine
When do you refer to nephrology in CKD?
- eGFR drop by 25% or drop by 15% over 12/12
- G4+G5 (≈ eGFR <30)
- Proteinuria = A3 (ACR >30) with haematuria
- Malignant hypertension (≥4 antihypertensive)
- Rare/genetic CKD cause
Compare and contrast the two types of RRT.
HD = blood via dialysis machine with dialysate on either side allowing diffusion
- 4-5 times a week
- AV fistula
- Anticoagulation required
- Risk of hypotension
PD = Tenckhoff catheter placed into peritoneal cavity in SC tunnel with dialysate connected to tunnel to push fluid into cavity
- 3-5 times a day
- Risk of infection
What opportunistic pathogen may enter via a Tenckhoff catheter?
S epidermidis
S aureus
State 3 complications of RRT
CVD: endothelial dysfunction; vascular stiffness
Renal bone disease
Infection (opportunistic; uraemia changes T cell and granulocyte function)
Amyloid accumulation
What are the donor options for a renal transplant?
- Living donor
- Donor after cardiac death (DCD)
- Donor after brain death (DBD)
What drugs may be used in a kidney transplant?
Monoclonal antibodies: Daclizumab; Alemtizumab
Calcineurin inhibitors: Tacrolimus; Ciclosporin
Antimetabolites: Mycophenolate; Azathioprine
Glucocorticoids
Which drugs are given as inducers at the time of renal transplantation?
Monoclonal antibodies:
Daclizumab (CD25 T cell blocker)
Alemtuzumab (T and B cell)
What drug is given as first line for acute renal transplant rejection?
Prednisolone
Describe Glomerulonephritis.
Diseases caused by pathology to the filtration unit of the kidney causing CKD which presents with proteinuria and/or haematuria, diagnosed by renal biopsy or urinalysis and can progress to kidney failure.
Outline the broad structure of a glomerulus.
- Afferent + Efferent arteriole
- Capillary plexus
- Fenestrated endothelium lines glomerular capillaries
- Basement membrane (GBM) supports endothelium
- Podocytes (foot processes) separated by filtration pores
Outline the broad structure of a glomerulus.
- Afferent + Efferent arteriole
- Capillary plexus
- Fenestrated endothelium lines glomerular capillaries
- Basement membrane (GBM) supports endothelium
- Podocytes (foot processes) separated by filtration pores
What is the gold-standard investigation to diagnose a glomerulonephritis?
- Renal biopsy
Which two syndromes may Glomerulonephritis be divided into?
Give the main features of each.
Nephrotic syndrome: hypoalbuminaemia + proteinuria + peripheral oedema
Nephritic syndrome: haematuria + oedema + hypertension
What 3 features are present in a nephrotic syndrome?
Hypoalbuminaemia (<30g/L)
Proteinuria (>3g/day)
Oedema
Give 3 examples of primary renal nephrotic syndrome and 3 examples of secondary renal nephrotic syndrome.
Primary:
- Minimal Change Disease
- Focal Segmental Glomerulosclerosis
- Membranoproliferative Glomerulonephritis
Secondary:
- Diabetes Mellitus
- SLE
- Myeloma
- Amyloid
- Pre-eclampsia
How would you manage a nephrotic syndrome?
- Tx cause
+ - Renoprotection: reduce damage
+ - Reduce oedema: Diuretics
-> Aim for 0.5-1kg weight loss/day
+ - Tx complications: infection; VTE; hyperlipidaemia; electrolyte disturbances; metabolic changes
How much weight loss per day do you aim for when treating nephrotic syndrome with diuretics?
0.5-1kg/day
Why is minimal change disease named this?
On microscopy, nothing is observed and electron microscopy shows fusion of podocytes.
An 4 y/o M presents with ankle oedema which has occurred recently. He is systemically well and there is nothing he sees his doctor for usually. FH is unremarkable.
Urinalysis shows protein ++, no blood and is frothy.
What investigations would you run?
Differential?
Treatment?
Urinalysis: Protein
MS+C: hyaline casts
eGFR: reduced
Renal biopsy: no change
DDx: Minimal Change Disease
Prednisolone 1mg/kg for 16 weeks
What other features may occur in patients with nephrotic syndrome?
Deranged lipids
Hypertension
Hypercoagulability
Which patient group is Focal Segmental Glomerulosclerosis most likely to occur in?
Black Patients
What is the definition of Focal Segmental Glomerulosclerosis?
Disease which may be primary or secondary which results in reduction of kidney mass, featuring scarring at specific points in the glomeruli covering <50% of glomerulus resulting in nephrotic syndrome.
How do you treat Focal Segmental Glomerulosclerosis?
- Renoprotection: ARB/ACEi
± Primary (idiopathic) - Corticosteroids: 1mg/kg
The treatment of Wilson’s disease may cause which Glomerulonephritis?
Which drug is this?
Membranous Nephropathy
Penicillamine
What is membranous nephropathy?
Commonest cause of nephrotic syndrome in adults, usually idiopathic but may be secondary, resulting in IgG and C3 deposition along GBM resulting in resorption of deposits and structural change.
A patient is presenting with nephrotic syndrome. Upon biopsy, diffusely thickened GBM is identified, due to IgG deposits. Additionally, IgG is seen in the Ab screen.
Differential?
Treatment?
Membranous Nephropathy
- Renoprotection: ACEi/ARB and Anti-hypertensives
Refractory to Tx for 6/12 or increased SCr by 30%
+ Ponticelli regimen (Pred + Cyclophosphamide)
What is Membranoproliferative Glomerulonephritis?
Nephrotic syndrome caused by deposition of IgG or C3 with increased cell numbers in the membrane of the glomerulus
What is the difference between Membranous Nephropathy and Membranoproliferative Glomerulonephritis?
In membranoproliferative disease, the mesangium and the GBM is affected
A patient presents with frothy urine showing protein and blood. On renal biopsy, there is C3 present and proliferation of the basement membrane and mesangium.
Differential?
Membranoprolierative Glomerulonephritis
- Renoprotection: ACEi/ARB
Outline the key clinical features of nephritic syndrome.
Haematuria + Hypertension + Oedema
A 32 year old female presents with ankle oedema. She is usually well but has had a throat infection for the last 2 days. Urinalysis shows blood and protein.
A renal biopsy shows IgA deposited within the mesangium.
Differential?
Treatment?
IgA Nephropathy
- Renoprotection: ACEi/ARB
± Persistent proteinuria (>1g following 3/12) - Corticosteroids: Prednisolone at 1mg/kg
A 15 year old presents with ankle oedema and a purpuric rash on the buttocks. Additionally, he has had some tummy pain.
Urinalysis shows blood ++ and protein ++. He his hypertensive. Furthermore, a renal biopsy shows IgA and C3 positive.
What is your diagnosis?
What is your treatment?
HSP
- Renoprotection: ACEi/ARB
± Persistent proteinuria (>1g following 3/12) - Corticosteroids: Prednisolone at 1mg/kg
A patient presents with periorbital and ankle oedema, oliguria and darker urine. They are usually well but had a throat infection 2 weeks ago.
Their ASO is raised. Furthermore, urinalysis shows protein ++, blood ++.
What is your differential?
Wat other Antibody may be present?
What is your management?
Post-streptococcal Glomerulonephritis
Anti-DNAse B
- Supportive: analgesia; antipyretics
+ - ABX: Penicillin
Which type of collagen are antibodies produced against in Anti-GBM Disease?
Type 4 collagen
A patient presents with haematuria, puffy ankles and productive cough in which blood is present.
Renal biopsy shows crescent formation with anti-GBM antibodies.
Differential?
Treatment?
Anti-GBM disease
- Corticosteroids: Prednisolone
+ - Immunosuppressants: Cyclophosphamide
+ - Plasma exchange
What is rapidly progressive glomerulonephritis?
Any aggressive GN progressing to renal failure over days/weeks
What pathogen is the most common cause of Pyonephrosis?
Give 3 other potential pathogens.
E. coli
Proteus
Klebsiella
S. saprophyticus
S. aureus
Candida
A patient presents with nausea, high temperatures and fishy urine following a few hours of severe pain in the side of her tummy.
What investigations would you order?
Differentials?
Treatment?
• Urinalysis: Haematuria/Proteinuria/Leukocytes/WBCs
• Renal function: Hypercreatinemia/Reduced eGFR; Hyponatremia/Hyperkalemia/Acidosis (low bicarbonate)
• Urine culture: Positive or sterile
• FBC: Anaemia/Leukocytosis
• US-renal: small, irregular, scarred kidneys; echogenic parenchyma (pus); hydronephrosis; renal stones; peri-renal fluid collections
• XR-KUB: Renal calculi/kidney size
Pyelonephritis
Pyonephrosis
• ABX: Ciprofloxacin (500mg PO BDS 7-14/7)
If stones:
- PCNL
If complicated disease:
- Admit + Ceftriaxone
How may you categories UTIs?
Uncomplicated: UTI in healthy individual
Complicated: drug-resistant or structural impairment
Acute: infection
Recurrent: 2 episodes within 6 mo
State 3 RFs for a UTI
PMHx UTI
Age > 50
F
Instrumentation of renal tract
Renal tract obstruction / Structural differences
Which is the most common cause of a UTI?
E. coli
A 27 year old male presents with painful urination, increased trips to the toilet to pee and pain in his lower tummy.
He has no discharge or pruritus. He has recently had sexual intercourse with his partner of ten years and they use barrier contraception.
What investigations would you run?
Treatment?
Urinalysis: Nitrite, Leukocytes
FPU: Leukocytes
Culture
Could order a CT-KUB
Nitrofurantoin; Ciprofloxacin
A 28 year old male presents with painful urination, green discharge and pruritus at the end of his penis.
What investigations would you order?
Differentials?
Management?
FPU + NAAT: gram negative, diplococci
Urinalysis: Leukocytes
Urethritis secondary to Gonorrhoea
Ceftriaxone (1g IM) and Azithromycin (1g PO)
AND
Test of cure in 5 weeks
A 28 year old male presents with painful urination, discharge and pruritus at the end of his penis. He also has some eye pain and joint pain.
What investigations would you order?
Differentials?
Management?
Urinalysis: Leukocytes
FPU + Microscopy: rod-shaped, gram negative bacterium
Urethritis secondary to Chlamydia infection (Reiter’s Syndrome)
Ceftriaxone (1g) + Azithromycin (1g PO)
Which organism is the commonest cause of Prostatitis?
E. coli
Describe Urinary Incontinence
Involuntary expulsion of urine occurring due to strenuous physical activity (stress incontinence) or increased urge (urgency incontinence) or both (mixed incontinence) characterised by polyuria, nocturia, lower abdominal (suprapubic) distension and enuresis (if no physical cause found).
How may Urinary Incontinence be classified?
• Stress: Urination on physical activity (e.g. cough, strain ): IA pressure raised > Urethral P
• Urgency: Increased desire: Overflow UI = male outflow obstruction thus oliguria + bladder distension
• Mixed: ∑ (Stress + Urgency)
The external urethral sphincter is controlled by which nerves?
Pudendal N. (S2-4)
Outline the two phases of the micturition cycle.
Filling phase in which urine enters, stretch receptors are stimulated and bladder relaxes with sphincter contracting (L1-L3 hypogastric plexus)
Voiding phase in which the bladder is 75% full thus the detrusor contracts and sphincters relax (S2-S4) with intravesical P > urethral P
State 5 RFs for urinary incontinence.
Stroke
Obesity
Pregnancy
Ageing
Parkinson’s
Dementia
Multiple Sclerosis
Radiotherapy
Iatrogenic
Faecal incontinence
What is the difference between urgency and voiding symptoms?
Urgency is suggestive of storage incontinence, whereby the bladder is weaker or overactive thus increased desire to micturate
Voiding is suggestive of stress incontinence, whereby there is improper expulsion of urine
State the urgency and voiding symptoms.
Frequency
Urgency
Nocturia
Weak stream
Intermittency
Straining
Emptying incomplete
What investigations may you order in a case of suspected urinary incontinence?
• Bladder diary
• Empty supine stress test (Valsalva manoeuver in dorsal lithotomy position after voiding): Positive (urine leakage)
• Cough stress test (300mL filling + Valsalva manoeuvre in dorsal lithotomy): Urine leakage if positive
• Post-void residual measurement (US following voiding): Elevated if ≥100mL OR ≥ 50% void volume
• Urinalysis: May show leukocytosis; RBC casts; Infection; Nitrites
• US-KUB
• Cystourethroscopy (bladder scope): Fistula/Foreign body/Tumour/Interstitial cystitis/Urethritis
How do you manage a stress UI?
1st line is Pelvic floor training
• Conservative: Pelvic floor training; Weight loss; Smoking cessation; Modify fluid intake; Penile sheath (M)
±
• SNRIs: Duloxetine
± (Failed conservative + medical thus 3rd line)
• Surgery: Suburethral sling/ Urethral bulking agent (Si microparticles; Coaptite)
OR (Urethral hypermobility or displacement)
• Surgery: Burch colposuspension/ Artificial sphincter
How do you manage an urgency UI?
• Conservative: Bladder training/Pelvic floor training/ Modify fluid intake
±
• Pharmacotherapy: Oxybutynin (anticholinergic)/ Tolterodine (anticholinergic)/ Mirabegron (ß3 agonist)/ Topical Oestrogen/ Botulinum toxin (Ives.)
± (Failed conservative + medical)
• Surgery: Sacral nerve stimulation (Neuromodulation)/Clam ileocystoplasty/Urinary diversion
What class of drug is Duloxetine?
SNRI
What class of drug is Mirabegron?
ß3 agonist
What class of drug is Oxybutynin?
Anticholinergic
What class of drug is Tolterodine?
Anticholinergic
What are the side effects of Oxybutynin?
Oxybutynin is an anticholinergic thus SLUDGE side effects
Salivation
Lacrimation
Urination
Defaecation
GI upset
Emesis
A patient presents with painful urination, increased need to urinate and a fever. He has not passed urine like usual for the last day. He feels like he needs to go but cannot.
O/E he has a distended bladder. He has a PMHx of retroperitoneal fibrosis.
What investigations will you order?
What are your differentials?
How will you manage this?
Urinalysis: positive nitrites and blood
FBC: Normal
U+Es: Normal
US-Renal: Hydronephrosis
CT-Pyelogram: Pyonephrosis and fibrosis of the ureters causing extraluminal obstruction.
Urinary Obstruction secondary to Pyonephrosis tertiary to Retroperitoneal Fibrosis
Catheterise
Analgesia
Antibiotics
Stenting
A 62 year old male presents with increased need to go to the bathroom to pass urine, passing urine 2-3 times per night. He says when he goes, he has to wait to get going and then it stops then starts again. At the end a few drops come out and he mus wait.
What symptoms are he describing?
What investigations may you order?
O/E he has a smooth, nodular enlargement bilaterally of the prostate.
What are your differentials?
How may you manage this?
Frequency
Urgency
Nocturia
Waiting
Intermittency
Emptying incomplete (dribbling)
• Urinalysis: Normal (uncomplicated); Pyuria (Complicated); Haematuria (Ca)
• PSA: Elevated
• International Prostate Symptom Score (IPSS): Mild (0-7); Moderate (8-19); Severe (20-35)
• US: Hydronephrosis/Mass/Urolithiasis/Post-void residual
• CT-Abdo/Pelvis: Mass/Hydronephrosis/Urolithiasis
Benign Prostatic Hyperplasia
Want to rule out Prostate Adenocarcinoma
Medical: Tamsulosin or Finasteride
Volume >30g
Surgical: TURP
Volume >80g
Surgical: Open prostatectomy
How does Tamsulosin mediate its effects in BPH management?
alpha 1 antagonist thus smooth muscle relaxes in prostate and ureters with reduced resistance to urine flow
How does Tamsulosin mediate its effects in BPH management?
alpha 1 antagonist thus smooth muscle relaxes in prostate and ureters with reduced resistance to urine flow
What are the side effects of Tamsulosin?
Dizziness
Sexual dysfunction
What is the MOA of Finasteride in BPH?
5a reductase inhibitor therefore reduces production of testosterone which reduces the growth of the prostate
What is the main side effect of Finasteride?
Sexual dysfunction
Breast abnormalities
Skin reactions
Which grading system can be used for Prostate Cancer?
Gleason Score
TNM
How is a Gleason Score calculated?
Take the two biopsied areas with the most dysplasia and add the score up using the Gleason Pattern Scale (1-5) which gives a score from 2-10.
Low = <6
Intermediate = 7
High = 8
What DRE finding(s) may increase your suspicion of a Prostate Cancer?
Assymetrical, enlargement, rigid, nodular prostate
What is the PSA threshold which warrants further investigation?
> 4 ug/L
with LUTS and 50+ or FHx
Which cancers commonly metastasise to bone?
Prostate
Breast
Kidney
Lung
Thyroid
How do you manage prostate cancer?
Supportive: Active surveillance (6 mo. bloods; 12 mo. DRE); Smoking cessation; Diet
Medical: Brachytherapy; Radiotherapy; Bicalutamide/Flutamide + Gorserelin
Surgery: Radical prostatectomy
A 2 day old presents with frothy urine and clubbed feet. O/E he is breathing rapidly with shallow breaths, you note craniofacial abnormalities.
He was born by LUCS in a planned delivery. The mother reports that the health visitor said she had less amount of amniotic fluid than usual.
US-Kidney shows no kidneys present.
What is your differential?
What are the features of this disease?
How would you manage this?
Bilateral renal agenesis (Potters Syndrome)
Features:
Pulmonary Hypoplasia
Oligohydramnios
Twisted skin
Twisted face
Extremity Deformity
Renal agenesis
• RRT: Dialysis/Transplantation
• IV Fluids and electrolytes
• Diuretics: Thiazide diuretics (bendroflumethiazide/Indapamide); ARAs (Spironolactone/Eplerenone)
What is Polycystic Kidney Disease?
congenital disease which results in cysts developing in the kidneys, compromising renal function and predisposing to chronic renal disease
What are the associated extra-renal findings with PCKD?
Cerebral aneurysms
Pancreatic/Prostatic, Ovarian, Splenic, Hepatic (POSH) Cysts
Colonic diverticula
Cardiac valve disease (mitral regurgitation)
Aortic root dilatation
What are the associated extra-renal findings with PCKD?
Cerebral aneurysms
Pancreatic/Prostatic, Ovarian, Splenic, Hepatic (POSH) Cysts
Colonic diverticula
Cardiac valve disease (mitral regurgitation)
Aortic root dilatation
Which type of PCKD is more common?
Autosomal dominant (85%)
Where is PKD-1 found?
Chromosome 16
Where is the PKD-2 gene found?
Chromosome 4
Which form of PCKD is more dangerous/sever?
Autosomal recessive
What investigation would you order and what would it show in PCKD?
US - enlarged bilaterally with echoic and anechoic masses (liquid-filled cysts)
U+Es
Genetic testing
IV Pyelogram
Liver biopsy
How would you manage PCKD?
• Supportive (delay progression): Monitoring/Avoid nephrotoxic substances/Treat arterial hypertension/Treat UTIs
• Vasopressin receptor analogue: Tolvaptan
• Treat liver failure
• Genetic counselling
• RRT: Dialysis/Kidney transplantation
What is Wilm’s Tumour?
WT1 TS gene ∆ in children with oncology referral (surgery, radio + chemo)
How do you treat a Wilm’s tumour?
• Surgery: Radical nephrectomy
• Post-operative chemotherapy: Dactinomycin + Vincristine
What are the renal phakomatoses?
broad group of neurocutaneous syndromes
A 34 year old male presents to the GP with recent personality change. He says that his wife has gradually reported a more fluctuant mood in himself. Furthermore, he said he has had some recent headaches. He recently had a cough which has been present for 6 months and he says he is regularly SOB.
O.E you notice some areas of hypopigmentationw which are flat. Furthermore, on his lower back there are some skin lesions with an orange-peel texture. His chest is clear; S1+S2 are pure but he has an irregular heart rate.
PMHx - pneumothorax
What tests would you order?
What is your differential diagnosis?
What are the clinical features (both observed) and seen in this condition?
How would you manage this condition? (Give the 3 main ones, and 2 further examples)
- FBC
- U+E
- PFTs
- ECG
- Echocardiogram
- EEG
- MRI-Brain
- CT-CAP
- Genetic testing: ∆TSC1/2
- Colonoscopy
- Renal biopsy
Tuberous Sclerosis
Ashleaf Spots
Shagreen’s patches
Heart rhabdomyomas
LAMs
Epilepsy
Angiomyolipoma
Facial angiofibroma
- mTOR1 inhibitor: Evrolimus
± Seizures
- Anticonvulsant: Lamotragine
Note: Ketogenic diet may reveal metabolic disorders via diet, levels of organic acids and carnitine w/ ECG
± Subependymal giant cell astrocytoma
- Active surveillance: Periodic neuroimaging
or
- Surgical resection
± Angiofibroma/collagen plaque (Shagreen patch)
- Laser therapy (<2mm)
or
- Dermabrasion (>2mm)
± HTN
- Antihypertensives: Amlodipine
Note: Do not use ACEi if patients Tx with mTOR inhibitor
± Angiomyolipomata
- Active surveillance
If >3-6cm
- Embolisation or Nephrectomy
± Lymphangioleiomyomatosis (LAM)
- Active surveillance
+
- mTORi: Evrolimus
±
- Oxygen therapy
± Renal Cell Carcinoma
- Total Nephrectomy
± Intracranial aneurysm
- Surgery: Intra-arterial coiling/ Craniotomy/ Clipping
What type of diet may reveal metabolic disorders?
Ketogenic diet
What is Von-Hippel Lindau Syndrome?
Autosomal dominant inheritance disease due to ∆VHL causing ∆VHLp resulting in tumour and cyst development affecting multiple systems
What are the clinical features of Von-Hippel Lindau Syndrome?
Haemangiomas
Increased risk of RCC
Phaeochromocytoma
Pancreatic lesions
Eye Lesions
What would you expect the plasma catecholamines to come back as in VHL Syndrome?
Elevated due to Phaeochromocytoma
How would you manage a patient with known Von-Hippel Lindau Disease?
Supportive: Annual review (surveillance)
Surgical: Nephrectomy; Resection of adrenal medulla; Resection of haemangioblastoma
Describe Alport Syndrome.
Inherited disease of glomerular basement membrane abnormalities – type IV collagen resulting in sensorineural hearing loss, lenticonus, retinal abnormalities and renal problems.
A 4 year old child is brought into GP by his mother due to noticing blood in his urine. The urine is described as frothy. In addition to this, she says she has to speak louder to him when communicating and that he does not listen.
O/E he is SOB and has a cough. His chest is clear and S1+S2 are pure. He has swollen ankles. A Rinne’s and Weber’s test shows sensorineural hearing loss bilaterally.
Urinalysis shows blood++ and protein++.
What condition are you suspicious of?
What investigations would you wish to run?
How would you manage this?
Alport Syndrome
- FBC: elliptocytosis; leykocytosis; anaemia
- Metabolic panel: may suggest renal impairment
- Urinalysis: haematuria/proteinuria
- Fasting lipid panel: ?dyslipidaemia
- Audiometry: High-tone sensorineural hearing loss
- Ophthalmoscopy: corneal/retinal abnormalities/ lenticonus/ maculopathy/ cataracts
- Renal ultrasound: Normal – exclude other renal tract pathology
- Renal biopsy: loss of staining for type IV collagen
- ECG: ? LV hypertrophy
- Genetic testing: COL4A5
- Supportive: Annual monitoring – FBC; U+Es; eGFR; lipids; uric acid; urinalysis
± Nephrotic Syndrome
- ACEi
+
ARB
Aim for < 130/80mmHg
± Chronic Renal Failure
- RRT
± Sensorineural deafness
- Audiologist referral
± Visual disturbance
- Ophthalmology referral
± Symptomatic leiomyomas
- Surgical excision
What is the target blood pressure for a patient with Alport Syndrome?
<130/80mmHg
Which gene is mutated in Alport Syndrome?
COL4A5
In Fabry Disease, which enzyme is deficient?
a-Galactosidase A
Deficiency of what results in accumulation of what substrate in Fabry Disease?
alpha Galactosidase A deficiency results in accumulation of Ceramide trihexoside
What are the clinical manifestations of Fabry Disease?
Foamy urine (Fabry nephropathy)
Anhidrosis/Angiokeratoma
Burning pain (dysaesthesia)
Really dry
CVD/ Corneal disease/ Cataracts
How do you manage a patient with Fabry Disease?
What is the gold standard test for a patient with suspected Cystinuria?
- Urinary cyanide nitroprusside test: positive
(Cyanide converts cystine to cysteine with nitroprusside binding to cause a purple hue which detects levels of cystine)
How do you manage cystinuria?
- Supportive: IV fluids
+ - Alkalising agent: Potassium citrate; Acetazolamide
+ - Chelating agent: Penicillamine-D
Describe Cystinosis.
Inherited inborn error of metabolism of autosomal recessive nature that involves lysosomes improperly transporting cystine hence accumulation (lysosomal storage disease).
What is the diagnostic test for suspected Cystinosis?
- WBC Cystine test: Elevated
How do you manage Cystinosis?
- Supportive: IV Fluids; Electrolytes
+ - Cysteamine
(binds to cystine to form cysteine which is transported)
+ - Renoprotection/RRT
How do you manage Cystinosis?
- Supportive: IV Fluids; Electrolytes
+ - Cysteamine
(binds to cystine to form cysteine which is transported)
+ - Renoprotection/RRT
What drug can be used to bind Cystine in Cystinosis?
Cysteamine
What is the most common form of Renal Cell Carcinoma?
Clear Cell (75%)
What syndrome describes hepatic dysfunction in the absence of metastasis with hepatic derangements seen in Renal Clear Cell Carcinoma?
Stauffer Syndrome
Describe Stauffer Syndrome.
paraneoplastic disorder associated with RCC resulting in hepatic dysfunction in the absence of metastasis with hepatic derangements seen
What is the 1st line imaging for a suspected Renal Cell Carcinoma?
US-Abdomen
Deranged LFTs in the presence of RCC with unremarkable US-Liver suggests…?
Stauffer Syndrome
How do you manage a Renal Cell Carcinoma?
Stage 1 or 2
- Surveillance
or
- Surgery
Stage 3
- Surgery: Radical nephrectomy
+
- Chemotherapy
Stage 4
- Chemotherapy
+
- Radiotherapy
What is the most common bladder cancer?
Urothelial (transitional)
What are the types of bladder cancer?
- Urothelial (transitional = TCC) – derived from epithelium
- Squamous Cell Carcinoma (SCC) – derived from bladder lining
- Adenocarcinoma (derived from urachas; AC) – derived from glandular cells
Stae 3 RFs for bladder cancer.
• Smoking
• Age > 55 years
• Exposure to chemical carcinogens
• Pelvic radiation
• Systemic chemotherapy
What investigation is used to diagnose Bladder Cancer?
• CT-urogram: Bladder tumours
• Cystoscopy: Rough, erythematous patch in bladder (stain with Methylene Blue)
How is Bladder Cancer managed?
Non-invasive
• Surgery: Transurethral resection of Bladder tumour (TURBT)
• Chemotherapy: Intravesical chemotherapy
Locally invasive tumours (T1)
• Surgery: Radical/partial cystectomy with pelvic lymph node dissection
• Chemotherapy: Preoperative + postoperative chemotherapy
Metastatic Disease
• Chemotherapy
• Surgery/Radiotherapy
• Immunotherapy
What are the clinical features of Acute Epididymitis?
Unilateral scrotal pain
Unilateral scrotal swelling
Hot, erythematous hemiscrotum
Dysuria
Enlarged testes
Negative Prehn’s test
What clinical examination can be used to differentiate between Epidydimitis and Testicular Torsion?
Prehn’s Test
Give 5 aetiological factors for Epididymitis?
• C. trachomatis
• N. gonorrhea
• M. genitalium
• E. coli (anal sex + elderly patients)
• Proteus spp. (older men urine stasis + outflow obstruction)
• Mumps (Viral epididymitis)
• Candida spp. (Fungal epididymitis)
• Amiodarone (reversible, sterile epididymitis) Anti-amiodarone Abs attack epididymis at high [amiodarone]
• Vasculitides (Behcet’s; HSP)
• Idiopathic
How do you treat Epidydimitis caused by Gonorrhoea?
Ceftriaxone (250mg IM) + Azithromycin (1mg PO)
How do you treat Epidydimitis caused by Mumps?
Supportive: Paracetamol; Rest; Elevation
How do you treat Epididymitis occurring following commencing Amiodarone?
• Reduction/Discontinuation + Supportive measures
Describe Testicular Torsion
Urological emergency caused by twisting of spermatic cord, constricting vascular supply with resultant ischaemia and/or necrosis of testicular tissue characterised by severe onset pain, N+V and scrotal swelling.
What anatomical variation may increase risk of Testicular Torsion?
• Bell clapper deformity (testes rotate within tunica vaginalis)
A 19 year old male presents with pain in the scrotum, nausea and a high temperature. He said the pain began suddenly when he was watching TV.
O/E there is scrotal oedema and erythema. The stroking the medial thigh does not elicit a response. Elevation of the testes worsens the pain.
What is your differential?
What investigations should you order?
What are the examination special tests called?
What is the management?
Testicular torsion
None, its a clinical diagnosis
Cremasteric Reflex
Prehn’s Test
Supportive: Admission; IV Analgesia; Fluids
Surgery: Exploration and Orchidopexy/Orchiectomy
Describe a Varicocoele.
Enlargement of pampiniform plexus of scrotum causing low sperm production (hypospermia), reduced concentration (oligoospermia) and low sperm quality (tetrazoospermia/asthenozoospermia)
What is hypospermia?
Reduced volume (< 1.5ml)
What is Oligoospermia?
Low count (<15 million/ml)
What is Tetrazoospermia?
Abnormal morphology (< 4% normal)
What is Asthenozoospermia?
• Asthenozoospermia: Reduced motility (< 40% moving)
What is the primary clinical find of Varicocoele?
• Painless scrotal mass (bag of worms)*
• Asymmetrical testes*
What is the management of a Varicocoele?
• Supportive (reassurance and observation)
+
• Surgery
Describe a Hydrocoele.
Collection of serous fluid between tunica vaginalis or spermatic cord characterised by scrotal oedema that can undergo transillumination
What are the two types of Hydrocoele.
• Communicating: patent processus vaginalis connects peritoneal cavity and scrotum
• Non-Communicating (Simple): Processus vaginalis closed, fluid production > output (by tunica vaginalis)
What are the primary clinical features of a Hydrocoele?
• Scrotal mass/oedema
• Transillumination
How do you manage a Hydrocoele?
Child 2-11/Adolescent
• Surgery: Exploration + Repair
Adult: No bothersome Sx
• Observation
Adult: Discomfort
• Intervention: Surgery/Aspiration/Sclerotherapy
What is an Epididymal cyst?
smooth, spherical cyst in head of epididymis
What are the clinical features of an Epididymal Cyst?
• Testicular lump: well-defined, fluctuant, non-transilluminating
• Can get around the lump
How do you manage an Epididymal Cyst?
• Supportive, watch and wait
What are the two main types of testicular cancer?
Seminomas
Non-Seminomas
How does a Testicular cancer present?
Painless lump - may cause testicular pain
Hard
Irregular
Non fluctuant
No transillumination
Gynaecomastia (in Leydig Cell Tumour)
What specific testicular cancer may cause gynaecomastia?
Leydig Cell Tumour
What is the first line investigation used to diagnose a Testicular Cancer?
US
Which Tumour Markers are used in Testicular Cancer?
What are they suggestive of?
Alpha fetoprotein (teratomas)
ß-hCG (both teratoma and seminoma)
LDH (non-specific)
Mnemonic:
FeToprotein = TeraToma
Beta-hCG = Both
What Staging System is used in Testicular Cancer?
Royal Marsden Staging System
Stage 1 = isolated to testicle
Stage 2 = retroperitoneal lymph nodes
Stage 3 = LN above diaphragm
Stage 4 = other organs
Where are the most common sites of metastasis for a Testicular Cancer?
Lymphatics
Lungs
Liver
Brain
How do you manage a Testicular cancer?
MDT decision
Sperm bank (for future)
+
Surgery: Radical orchidectomy
+
Chemotherapy
+
Radiotherapy
Which type of testicular cancer has a better prognosis?
Semimomas
What is a phimosis?
Tight foreskin
What is a Paraphimosis?
Foreskin retraction
What is a Hypospadias?
urethral opening below penis
What is an Epispadias?
urethral opening above penis
What is a buried penis?
penis present in dartos tissue
What are the clinical features of a phimosis?
• Penile pain
• Erythema
• Glans oedema
• Voiding symptoms
• Black tissue on glans
What are the clinical features of a Paraphimosis?
• Penile pain
• Erythema
• Glans oedema
• Cicatrix (sclerotic white ring at tip)
What are the clinical features of a Hypospadias?
• Voiding symptoms: flow/direction
• Opening of urethra inferior to usual
What are the clinical features of an Epispadias?
• Voiding symptoms: flow/direction
• Opening of urethra at superior to usual
What are the clinical features of a buried penis?
• Voiding symptoms
• Prominent pre-pubic fat pad
How do you manage a Phimosis?
• Surgery: Circumcision
How do you manage a Paraphimosis?
• Medical: Paraphimosis reduction
OR
• Surgery: Surgical reduction (dorsal slit)
How do you manage an Epispadias?
• Surgery: Urethroplasty
How do you manage a Hypospadias?
• Surgery: Urethroplasty
How do you manage a Buried Penis?
• Surgery: Phalloplasty
A 35 year old man presents with an itchy glans of the penis. O/E there are erosions and erythematous patches.
What investigations would you order?
What is your differential?
What is the management?
• Swab + NAAT/PCR: May be positive for pathogen
• Skin Biopsy: Histopathological find for cause
Balanoposthitis
• Tx underlying cause
What are the causes of Balanoposthitis?
• Inflammatory
• Infection
• Pre-cancerous
Describe Erectile Dysfunction.
The consistent or recurrent inability to attain/maintain a penile erection sufficient for sexual intercourse
State 10 RFs for Erectile Dysfunction
- Advanced age
- CAD
- PAD
- HTN
- DM
- Smoking
- Hyperlipidemia
- Drugs: Anti-depressants/Anti-hypertensives
- Libido disorder
- Obesity
- SCI
- Pelvic injury
- Neurological disease
- Peyronie’s Disease (fibrous nodules in tunica albuginea)
What is the most common cause of Erectile Dysfunction?
• Vascular/Arteriogenic (40%)
What are the clinical features of Erectile Dysfunction?
• Premature ejaculation
• Abnormal prostate exam/DRE
• Psychosocial stressors
• Penile abnormalities: Plaques/Deformities/Angulation
• Teste abnormalities: Cryptorchidism/ Microorchidism
• Lack of male pattern of hair
What investigations may you order in a patient describing Erectile Dysfunction?
• International Index of Erectile Dysfunction (IIED): Abnormal
• FBG: Normal; Raised (DM)
• HbA1c: ≥ 48mmol/L (≥ 6.5%)
• Lipid panel: Normal; Raised (Hyperlipidemia)
• Sex hormones: Variation; Low = hypogonadotrophic hypogonadism; Normal = eugonadotrophic hypogonadism; Elevated = hypergonadotrophic hypogonadism
-> FSH + LH
• Prolactin: Normal; Elevated (hypogonadotrophic hypogonadism)
• Doppler-US: Normal
How do you manage Erectile Dysfunction?
• Tx Underlying Condition
+
• Psychotherapy: CBT
+
PDE5 inhibitors: Sildenafil
± (Peyronie’s Disease/Trauma)
OR
• Surgery: Surgical correction/Prosthesis/Revascularisation
Describe an Inguinal Hernia.
protrusion of abdominopelvic contents into inguinal canal via inguinal floor or internal inguinal ring
What are the types of Inguinal Hernia?
- Direct inguinal hernia: herniates via inguinal floor medial to inferior epigastric artery and deep inguinal hernia
- Indirect inguinal hernia: herniates via deep inguinal ring, lateral to inferior epigastric artery
- Reducible
- Irreducible (incarcerated)
- Strangulated (blood supply compromised thus ischaemia)
What is the difference between an Incarcerated and a Strangulated hernia?
An incarcerated hernia is irreducible whilst a strangulated hernia has compromised blood supply with ischaemia
What are the borders of Hesselbach’s Triangle?
Inguinal ligament (inferiorly)
Inferior epigastric vessels (laterally)
Lateral border of rectus abdominis muscle (medial)
Where is the Inferior Epigastric Artery found?
Between the posterior wall of rectus abdominis and the transversalis fascia
What are the clinical features of an inguinal hernia?
- Groin pain: dull/heaviness/dragging
- Groin bulge/mass: soft; pliable; ∆s when coughing; reducible?
- N/V
- Constipation
What are the management options for an Inguinal Hernia?
Small, asymptomatic
- Watch and wait
Large/ Symptomatic
- Open/ Laparoscopic repair
±
- Prophylactic ABX
Strangulated hernia/incarcerated
- Open repair
±
- Prophylactic ABX
What is the difference between an incarcerated and strangulated hernia?
Incarcerated hernias cannot be reduced into the proper position (irreducible), which may lead to an obstruction and strangulation.
Strangulation is where the hernia is non-reducible with the base of the hernia becoming so tight that the blood supply is reduced causing ischaemia. Bowel will undergo necrosis rapidly
Describe a Richter’s Hernia?
This is where only part of the bowel wall and lumen herniate through the defect with the remainder remaining within the peritoneal cavity.
These can become strangulated and rapidly progress to ischaemia.
Describe Maydl’s hernia?
This is where two different loops of bowel are contained within the hernia.
How may hernias be managed?
Supportive: leave
Surgery:
Tension-free repair (mesh sutured to muscles and tissue either side)
Tension repair (suture muscle and tissue either side of defect back together
What foetal remnant gives the route for a hernia to form?
What type of hernia is this?
Processus vaginalis
Indirect inguinal hernia
What are the boundaries of Hesselbach’s Triangle?
Mnemonic: RIP
Rectus abdominis (medial border)
Inferior epigastric vessels (superolateral border)
Poupart’s Ligament (inferior border)
Outline the boundaries of the femoral canal?
Mnemonic: FLIP
Femoral vein (lateral)
Lacunar ligament (medial)
Inguinal ligament (anteriorly)
Pectineal ligament (posteriorly)
Outline the boundaries of the femoral triangle.
Mnemonic: SAIL
Sartorius (lateral)
Adductor longus (medial)
Inguinal Ligament (superior)
What are the contents of the femoral triangle?
Mnemonic: NAVY-C
Nerve (Femoral)
Artery
Vein
Y fronts
Femoral Canal (lymphatic vessels and nodes)
What is an incisional hernia?
Herniation occurring at the site of previous surgery due to muscle weakness
What is an umbilical hernia?
Herniation due to defect in musculature around the umbilicus
What is an epigastric hernia?
Herniation through the epigastric region of the abdomen
What is a Spigelian Hernia?
What aids the diagnosis?
Hernia occurring at the site of Spigelian fascia, between rectus abdominis and linea semilunaris.
Imaging - US-Abdomen or CT-Abdomen
What is Diastasis Recti?
What accentuates this?
Widening of the linea alba resulting in a larger gap between the rectus muscles.
Laying supine and lifting the head accentuates the bulge
Describe an Obturator Hernia?
Herniation of abdominopelvic contents through the obturator foramen which may irritate the obturator nerve
What is the term for the clinical examination find of pain when internally rotating the hip in an Obturator hernia?
Why is this occurring?
Howship-Romberg Sign
Internal rotation of the hip compresses the obturator nerve
What is a hiatus hernia?
Herniation of the stomach through the diaphragm at the T10
Outline the types of Hiatus Hernia?
Type 1: GO junction into thorax
Type 2: separate portion into thorax
Type 3: mixed
Type 4: large hernia with other IA organs into diaphragm
How are hiatus hernias managed?
Conservative: treat reflux symptoms (PPI)
Surgical: Laparoscopic fundoplication
How may you manage a hydrocoele?
Non-Operative: Aspiration
Operative: Hydrolectomy (incision in scrotum and drained via suction then close communication between canal and abdominal cavity and suture up)
When do you refer a hydrocoele to Urology?
Painful
Cannot palpate testicle in scrotum (US-Testes)
What are the layers you pierce through when doing an aspiration of the scrotum in a hydrocele?
Skin > Dartos Muscle > External spermatic fascia > Cremasteric muscle and fascia > Internal spermatic fascia
Other layers:
- Tunica Vaginalis
- Tunica albuginea
Mnemonic: Some Damn Englishman Called It The Testes
What are the clinical features of bulbar urethra rupture?
Blood in meatus
Perineal oedema
Urinary retention
What are the clinical features of membranous urethral rupture?
penile/perineal oedema
difficult to palpate on PR as prostate displaced superiorly
How long does Finasteride take to work?
6-9 months
What is the MOA of Bicalutamide?
Anti-androgen, blocking effect of testosterone to reduce tumour growth
How long after a UTI can a PSA be done according to NICE?
4 weeks
How long following a Prostate biopsy can a PSA be done?
6 weeks
How long after vigorous exercise and ejaculation can a PSA be done?
48 hours
How long after a DRE can a PSA be done?
1 week
Which of the following is not a risk factor for Renal Cell Carcinoma?
A. Aniline Dye
B. Smoking
C. Rubber manufacture
D. Schistosomiasis
D - Schistosomiasis is a RF for squamous cell carcinoma of the bladder
What is the MOA of Gorserelin?
GnRH agonist thus stimulates HPG axis to elevate LH which reduces endogenous secretion of testosterone. Testosterone rises for 2-3 weeks then depressed (chemical castration)
What is the MOA of Degarelix?
What effect is different to Gorsorelin?
GnRH agonist however artificially depresses HPG axis without the initial 2-3 week elevation of Testosterone
What is the MOA of Bicalutamide?
Non-steroidal anti-androgen, blocking the androgen receptor to depress testosterone secretion
What is the MOA of abiraterone?
When is it indicated?
Androgen synthesis inhibitor
Metastatic prostate cancer in patients where androgen deprivation therapy has failed and before chemotherapy is indicated
What is the MOA of crypoterone acetate?
Steroidal anti-androgen which prevents DHT binding from IC protein complexes.
Used as an adjunct with Gorsorelin at times to reduce prostate growth.
What is the MOA of crypoterone acetate?
Steroidal anti-androgen which prevents DHT binding from IC protein complexes.
Used as an adjunct with Gorsorelin at times to reduce prostate growth.
Give 5 causes of balanitis.
Outline the brief differences.
Candidiasis (itching; white, non-urethral discharge)
Dermatitis (itchy; painful; may have exudate/discharge and skin elsewhere affected)
Bacterial (painful; itchy; discharge)
Lichen planus (hexagonal, purple papules with Wickham’s striae)
Balanitis xerotica obliterans (itchy, white plaques and scarring)
Plasma cell balanitis of Zoon (no itch; areas of inflammation; plasma cell on biopsy)
What is Priapism?
A penile erection lasting >4 hours which is not sexually stimulated
Give 3 causes of Priapism.
Idiopathic
Haematological: Sickle cells; Thalassaemia; Lymphoma
Iatrogenic: PDE5i; SSRIs; Anti-hypertensives; Anticoagulants
Trauma
What investigations may you conduct in a patient with Priapism?
Cavernosal blood gas analysis
Doppler-US
FBC
Toxicology screen
What is urinary tract obstruction?
Mechanical or functional blockage stopping flow of urine
State 5 causes of urinary tract obstruction.
Renal:
Nephrolithiasis
Carcinoma of renal pelvis
Renal papillary necrosis
UPJ obstruction
Ureteral
Intraluminal:
Nephrolithiasis
Blood clots
Intramural:
Strictures
Ureteric carcinoma
Surgical ligation
Extraluminal:
Pregnancy
Neoplasia
Aortic aneurysm
Iliac artery aneurysm
Tubo-ovarian masses (endometriosis; prolapse; haematoma)
GI masses (CD; diverticulitis)
Retroperitoneal fibrosis
Iatrogenic
Ectopic ureter
Ureterocele
Bladder:
Bladder carcinoma
Neurogenic bladder
Bladder calculi
Bladder neck dysfunction
Post-operative urinary retention
What are the functions of the urinary system?
Excretion
Volume and solute regulation
Detoxification
Elimination
Endocrine (EPO; Vitamin D synthesis)
Acid-base regulation
Mnemonic: A WET BED
Acid-base regulation
Water balance
Electrolytes
Toxin removal
BP control
EPO synthesis
D Vitamin synthesis
Where are the kidneys located?
Retroperitoneal structures located at T12-L3
What 3 connective tissue layers surround the kidney?
Fibrous capsule
Perinephric fat
Renal fascia (Gerota’s fascia)
What is the arterial supply to the kidney?
Renal artery (br. Abdominal aorta)
What vertebral level does the renal artery branch from the aorta?
L1/L2
Which vein drains the kidney?
Renal vein (into IVC)
Which structures are present at the hilum of the kidney?
Mnemonic: VAD (both anterior and superior)
Vein
Artery
Duct
At what vertebral level is the ureter visualised?
L2, the hilum of the kidney projects at this level, bearing the ureter.
What is the potential space between the liver and right kidney called?
Hepatorenal pouch of Morison
Which structure traverses the anterior concavity and the medical convexity of the right kidney?
Descending duodenum (L3)
What is the relation to the lateral part of the inferior pole of the right kidney?
Hepatic flexure
And the SI (jejunum)
What organ(s) contact the superior pole of the left kidney?
Peritoneum of stomach contacted medially and spleen laterally
Pancreas contacts just inferiorly
What organ/structure contacts the inferior pole of the left kidney?
Splenic flexure
and peritoneum of the jejunum
What are the posterior structures related to the kidneys?
Mnemonic: All Boys Need Muscles
Artery - Subcostal artery
Bones - 11th and 12th ribs
Nerves - subcostal, iliohypogastric and ilioinguinal nerves
Muscles - Diaphragm, Psoas major, quadratus lumborum, transversus abdominis
What are the two parenchymal divisions of the kidneys?
Renal cortex and medulla
What is the main unit of the renal medulla?
Renal pyramid
What is the apical projection of the renal medulla called?
Renal papilla
What is a papilla?
Small, rounded protuberance
What does the renal papilla open into?
Minor calyx
What do the minor calyces combine to form?
The major calyx
What do the major calyces form?
The renal pelvis
What is the union of the renal pelvis and ureter named?
PUJ
Pelvoureteric Junction
What separates the renal pyramids?
Renal columns
What are the functional regions of the nephron?
Renal corpuscle and renal tubule
What are the features of the renal corpuscle?
Bowman’s (glomerular) capsule
Glomerulus
What is the structure of the glomerular membrane?
Fenestrated endothelial cells
Glomerular basement membrane
Podocytes
Integrins link the cells to the BM via laminin
What substances are not filtered into the urinary space at the glomerular membrane?
RBCs
Plasma protein
What are the divisions of the renal artery?
Split into anterior and posterior branch of renal arteries
Anterior branch arborists into 5 segmental arteries which branch into interlobar arteries and then into arcuate arteries. Arcuate arteries branch into interlobular arteries which then go into afferent arterioles.
What is nutcracker phenomenon?
Compression of L renal vein which passes between the aorta and SMA resulting in testicular infarction
What is the lymphatic drainage of the kidney?
Lateral aortic lymph nodes
What is the innervation of the kidney?
Renal plexus
Plexus gives input from: SNS (lower thoracic splanchnic nerves)
PSNS from Vagus nerve (CN X)
Sensory nerves from T10-T11
Give 3 anatomical variations in renal structure
Third kidney
Renal agenesis
Horseshoe kidney
What is the function of the ureters?
Urine transport from the kidneys to the urinary bladder
What is the blood supply to the kidney?
Ureteric branches of renal artery
Ureteric branches of abdominal aorta and common iliac arteries
Ureteric branches of superior and inferior vesical and uterine arteries
What is the innervation of the ureters?
Renal plexus and ganglia
Ureteric branches of intermesenteric plexus
Pelvic splanchnic nerves
Superior and inferior hypogastric plexuses
What are the pelvic splanchnic nerves?
Preganglionic, parasympathetic nerve fibres from anterior rami of S2-S4
What are the regions of the bladder?
Apex
Body
Fundus
Neck
What are the surfaces of the bladder?
x1 superior surface
x2 inferolateral surfaces
Upon cystoscopy, what landmark may be suggestive of the prostatic urethra?
Seminal colliculus - ejaculatory ducts distal to it; prostatic ducts proximal to it.
What is the longest portion of the urethra?
Spongy; ≈15cm
Which part of the urinary tract has the internal urethral sphincter?
Junction of bladder and urethra
What is the term for the posterior elevation of the prostatic urethra?
Urethral crest, merging to form prostatic utricle
Which ducts drain into the prostatic urethra?
Prostatic ducts superior to seminal colliculus
Ejaculatory ducts
What exits via the ejaculatory ducts?
Seminal fluid and sperm
What portion of the male urethra houses the external urethral sphincter?
Membranous urethra
What are the two regions of the spongy urethra?
Bulbar urethra and pendulous urethra
What are the two widened areas of the spongy urethra?
Ampulla of urethra
Navicular fossa of urethra
Which glands drain into the spongy urethra in a male?
Bulbourethral glands (pre-ejaculate)
Urethral glans of Littre (mucous)
What are the shapes of the pelvis determined by pelvic inlet shape?
Android (heart shaped; narrow apex; narrow pelvic outlet
Anthropoid (oval shaped; long and narrow sacrum; narrow pelvic outlet)
Gynecoid (oval in TR axis; broad sacrum; wide pelvic outlet 90-100)
Platypelloid (oval in TR axis; wide pelvic outlet; narrow sacrum and slightly curved)
What cartilaginous feature deepens the acetabulum?
Acetabular labrum
Which bones fuse to form the hip bone?
Ilium + Ischium + Pubic bone
What are the two portions of the ilium?
Ala (wing)
Body
What are the key bony landmarks of the ilium?
ASIS
AIIS
PSIS
PIIS
Which feature of the ilium spans between the ASIS and the PSIS?
Iliac crest (with inner lip, outer lip and intermediate zone)
Houses the iliac tubercle
Which ligaments help form the greater sciatic foramen?
Sacrotuberous and sacrospinous ligaments
What are the contents of the greater sciatic foramen?
Sciatic nerve (L4-S3)
Sacral plexus branches: superior and inferior gluteal; pudendal; posterior femoral cutaneous; nerve to quadratus femoris; nerve to obturator internus
Superior gluteal art. ; Inferior gluteal art.; internal pudendal art.;
Piriformis muscle
What 3 lines are present on the gluteal surface of the ilium?
Anterior gluteal line (oblique line from tubercle of iliac crest towards posterior gluteal line)
Posterior gluteal line (anterosuperior to greater sciatic notch)
Inferior gluteal line (superior to acetabular margin)
What are the surfaces of the ilium?
Gluteal
Iliac (iliac crest to arcuate line)
Sacropelvic
What are the causes for bladder cancer?
Mnemonic: ACTS
Aniline dye
Cyclophosphamide
Tobacco
Schistosomiasis
HPV
Chronic cystitis
Prolonged catheters
Pelvic radiation
What is the most common renal malignancy in childhood?
Nephroblastoma
Which genes may be responsible for Nephroblastoma development?
WT1 gene 11p13
WT2 gene 11p15
Give 3 examples of conditions associated with Wilms’ tumours?
Beckwith-Wiedemann syndrome
Sotos syndrome
WAGR syndrome
What is WAGR syndrome?
Syndrome featuring
Wilms tumour
Aniridia
Genitourinary abnormalities
Retardation
Discuss the pre-malignant stage thought to be associated with Wilms’ tumour.
Nephrogenic rests of primitive blasternal renal elements (derived from renal stem cells) are found in the kidney
What are the main clinical features of a nephroblastoma?
Abdominal pain
Haematuria
SOB
Anorexia
Fever
Abdominal mass
Pallor
Varicocele
Bone pain
What is the initial imaging test ordered when suspecting a Wilm’s tumour?
US-Abdo
shows an evenly echogenic solid mass
Why may LFTs be done when suspecting a Wilms’ tumour?
Cholestasis secondary to hepatic metastasis
Baseline value prior to hepatotoxic chemotherapy
Why is it important to do coagulation studies in a patient with Wilms’ tumour?
can be a cause of acquired vWB disease;
Reduced endothelial adhesion, reduced factor 8 stabilisation and increased tendency to bleed
Should check APTT
Outline the criteria for staging Nephroblastoma.
Stage 1 = kidney
Stage 2 = penetrates renal capsule
Stage 3 = microscopic abdominopelvic spread
Stage 4 = haematogenous mets
Stage 5 = bilateral renal involvement
What are the management options for a nephroblastoma?
Surgery: radical nephrectomy
+
Chemotherapy
Stage 3 / 4
+ Radiotherapy
Stage 5 and ESRF
Consider Renal transplant
What are the causes of RCC?
Smoking
High BMI
Hypertension
VHL syndrome
Birt-Hogg-Dubé syndrome
Tuberous sclerosis (mainly angiomyolipomas, but increases RCC risk)
What is the size of a small renal mass?
<4cm
What are the various types malignant renal neoplasms?
Clear cell
Papillary
Chromophobe
Medullary
Collecting duct
Neuroendocrine
Lymphoma
Nephroblastic
Give an example of a benign renal cancer.
Renal adenoma
Oncocytoma
Angiomyolipoma
Neuroendocrine tumours
What classification system may be used for cystic renal masses?
Bosniak classification
Outline the Bosniak classification.
Mnemonic: F is for follow; Enhance means excise
3cm is the sweet spot
1 = thin wall, no septa, no calcifications; water density (-10 to 20 HU)
2 = fine calcifications; no enhancement
2F = multiple hair-line septa; calcification; >3cm
3 = irregularly thickened walls or septa; enhance
4 = enhancing tissue components
How may a renal cell carcinoma present?
Asymptomatic (>50%)
Haematuria
Flank pain
Palpable abdominal mass
Cachexia/fever/weight loss/pallor/ sweats
Varicocele
Stauffer syndrome (nephrogenic hepatomegaly)
Endocrine: Polycythaemia / ACTH
Dermatological signs e.g. papules (Birt-Hogg-Dube)
Vision loss - VHL
Why may a renal cell carcinoma present via a varicocele?
Tumour blocks renal vein, reducing drainage from the testicular vein thus varicocele
How may RCC be categorised by tumour?
Use T categories
T1 = <7cm in kidney
T2 = >7cm in kidney
T3 = in major veins/tissues but not beyond Gerota’s fascia
T4 = Extends beyond Gerota’s fascia
How may RCC be managed?
Surgery: RFA/ Cryoablation/Partial/Total nephrectomy
+
TKI immunotherapy: Sorafenib
When might you consider RFA for a RCC?
Small Renal mass/RCC stage 1/2
What is the most common histological subtype of ureteral cancer?
TCC (90%)
SCC (8%)
How may Ureteral cancer present?
Haematuria
Storage symptoms
Dyspareunia
What is the gold-standard investigation for ureteral cancer?
Ureteroscopy ± CT-Urogram
How may Ureteral cancer be staged?
Stage 0is = CIS (flat on tissue lining)
/
Stage 0a = NI papillary carcinoma (thin protuberances from epithelia)
Stage 1 = invades lamina propria
Stage 2 = ureteric (smooth muscle)
Stage 3 = spread beyond muscle
Stage 4 = spread to surrounding organ
How may bladder cancer present?
Haematuria
Dysuria
Storage symptoms
What are the gold-standard methods for diagnosing bladder cancer?
Cystoscopy
CT-urogram
A bladder cancer is found to be present only at the surface, flat and not extending beyond the epithelia. How would you classify it?
Urothelial cancer Tis
Cancer in situ
A bladder cancer is found to be invading into the outer half of muscularis propria. Correctly stage this cancer.
T2b
A bladder cancer is found to be invading into the inner half of muscularis propria. Correctly stage this cancer.
T2a
How may you manage bladder cancer?
NMIBC
Surgery: TURBT
+
Intravesical chemotherapy
+
BCG Immunotherapy
Invasive
Surgery: Partial/Radical cystectomy
+
Chemotherapy
Metastatic
Chemotherapy
±
Radiotherapy
How may a urethral cancer present?
Haematuria
Palpable mass
Voiding symptoms
How can you manage a urethral cancer?
NI:
Transurethral resection
+
Intraurethral BCG
I:
Urethrectomy
+
Chemotherapy
What are the risk factors for prostate cancer?
> 50 years old
Black ethnicity
FHx
What are some potential risk factors for prostate cancer, currently under investigation?
Saturated fat
Red meat
Elevated androgens
Elevated IGF-1
How may prostate cancer present?
Storage symptoms (FUN)
Voiding symptoms (WISE)
Haematuria
Weight loss
Bone pain
What may cause an elevation in PSA?
BPH
DRE
Cycling
Sex/ejaculation
Prostatitis
Urinary retention
Instrumentation of urinary tract
What is the gold-standard test for prostate cancer diagnosis?
Multi-parametric MRI
What grading score can be used in prostate cancer?
Gleason score
2 samples of highest dysplasia and /10
Why may the PSA test be described as poor?
Poor sensitivity with 60% of men with a PSA of 10-20ng/mL found to have prostate cancer
Around 20% of men with prostate cancer have a normal PSA
Under what circumstances would you refer a patient for suspected prostate cancer?
PSA > 3ng/mL
OR
abnormal DRE
A tumour with a Gleason score of 5 is classified as?
Low-grade
A tumour with a Gleason score of 8 is classified as?
High-grade
A tumour with a Gleason score of 7 is classified as?
Intermediate grade tumour
What are the management options for a prostate cancer?
Very low risk (T1 disease/ PSA <10/<50% Ca in each core/ negative DRE)
Supportive: Observation (v low risk); active surveillance (yearly)
Radical prostatectomy
±
Brachytherapy
±
External beam radiotherapy
OR
Surgery/Androgen deprivation therapy/External beam radiotherapy
What age does testicular cancer tend to occur?
20-30 years old
What are the risk factors for testicular cancer?
Infertility
Cryptorchidism
FH
Klinefelter’s syndrome
Mumps
Why may gynaecomastia occur in testicular cancer?
Either germ cell or non-germ cell tumours can contribute.
Germ-cell tumours can secrete hCG which alter Leydig cell function thus increasing oestradiol and T but oestradiol»_space; T
Leydig cell tumour secretes more oestradiol thus high circulating oestrogens
In which type of testicular tumour is LDH mostly raised in?
Germ cell tumours
Which type of testicular tumour has AFP raised?
Non-seminomas
Which type of testicular tumour has hCG raised?
Seminomas
What is the first line investigation for a suspected testicular cancer?
US-Testes
A prostate cancer which is not palpated on DRE but seen on imaging is classified as?
T1
A prostate cancer which is palpated on DRE but seen on imaging in more than half of one lobe is classified as?
T2b
A prostate cancer that is present in both lobes of the prostate is classified as?
T2c
A prostate cancer that has spread to a seminal vesicle is classified as?
T3b
Explain why BPH has both a dynamic and static aspect.
Static element is the increase in prostatic size reducing the urethral lumen
The dynamic element is the tone of the prostate mediated by alpha-1 adrenoceptors
Treatment modalities can address either
How may BPH present?
Storage symptoms (FUN)
Voiding symptoms (WISE)
Urinary retention
What is the greatest RF for BPH?
Age
50% of men by 50 years old
What investigations should be done if suspecting BPH?
Urinalysis
U+Es
PSA
IPSS
Urodynamics
What is the first line management for a patient with bothersome symptoms of BPH?
Alpha blocker: Tamsulosin
How may BPH be managed?
Medical: Tamsulosin ± Finasteride
Surgery: 30g or 80g
>30g
TUIP/TURP/ PUL
> 80g
Prostatectomy
How does PUL work in BPH treatment?
Prostatic urethral lift may be used when prostate volume 30-80g and wish to preserve ejaculatory and erectile function
T-shaped, spring-loaded device delivered via cystoscope and placed between prostatic capsule and in the urethral lumen.
What is the normal weight of the prostate?
20-25g
State 3 types of urinary incontinence.
Urge incontinence
Stress incontinence
Mixed incontinence
Overflow incontinence
Functional incontinence
What investigations would you order in a patient with urinary incontinence?
Bladder diary
Urinalysis
Urine MC+S
Bloods
Urodynamic studies
What urodynamic studies may you utilise?
Uroflowmetry - volume and rate
Postvoid residual measurement (<150mL normal)
Cystometric testing (catheter and manometer placement with retrograde filling until urgency noted, then recorded)
What are the management options for stress urinary incontinence?
Supportive: Pelvic floor training
Medical: Duloxetine
Surgery: Retropubic mid-urethral tape; peri-urethral bulking
What are the management options for urgency urinary incontinence?
Supportive: Bladder retraining
Medical: Oxybutynin; Tolterodine; Mirabegron
Surgical: Sacral nerve stimulation; botulinum toxin A
What class of drug is tolterodine?
Anticholinergic, acting as an antagonist at the muscarinic receptors
What class of drug is tolterodine?
Anticholinergic, acting as an antagonist at the muscarinic receptors
What class of drug is mirabegron?
ß3 adrenoceptor agonist to relax the detrusor muscle in the bladder
Outline the pathophysiology of renal colic.
Stones form on the basement membrane in the Loop of Henlé/Collecting duct which erode and anchor to nucleate and grow; these pass into the urinary system. The stone occludes the passage of urine which leads to a rise in intraluminal pressure proximal to the stone. The distension results in stretch and afferent feedback through T11-L2 dorsal nerve roots, yielding pain in those dermatomes.
List 3 types of renal stone.
Calcium oxalate
Calcium phosphate
Uric acid
Cystine
Struvite
Which pathogens may result in struvite stone development?
Proteus
Pseudomonas
Klebsiella
Under what conditions do uric acid stones form?
pH <5.5
What is the gold-standard investigation when suspecting renal stones in a non-pregnant individual?
Non-contrast CT-KUB within 14 hours of admission
Which types of stones are radiolucent to XR-KUB?
Uric acid
Indinavir
Cystine (partially)
How might you manage an acute presentation of renal stones?
Medical: IV fluids; diclofenac
Surgery: urgent decompression (nephrostomy/ureteric stent)
<5mm
Anyone: manage expectantly
<2cm
Non-pregnant: ESWL
Pregnant: Ureteroscopy
> 2cm
Non-pregnant: PCNL
How would you advise a patient to prevent the risk of renal stones?
Increase fluid intake
Reduce salt
Reduce meat intake
TZD diuretics
Oxalate stones:
Pyridoxine / Cholestyramine (reduced urinary oxalate secretion)
Uric acid stones:
Allopurinol
Oral bicarbonate (urinary alkalinisation)
Define a paraphimosis.
Foreskin is retracted, resulting in vascular engorgement and oedema of the distal glans
How may a paraphimosis present?
Penile pain
Constricting band proximal to
gland engorgement
Swollen penis glans
What are the risk factors for paraphimosis?
Not being circumcised
Urinary catheterisation
Poor hygiene
Tight foreskin
Previous phimosis
Bacterial infection
Lichen sclerosis
Diabetes
Haemangiomas
Penile piercing
How does phimosis lead to paraphimosis?
A phimosis results in scarring which creates a white fibrous ring around the preputial orifice; this can result in physical obstruction and vascular engorgement contributing to a paraphimosis
How is paraphimosis diagnosed?
Clinical diagnosis
How can you manage a paraphimosis?
Depends on urgency - based on tissue compromise.
Without ischaemia and necrosis:
Manual manipulation (reduction with ice/compression/osmotic agent)
2nd: Puncture technique
Ischaemia and necrosis:
Debridement; dorsal slit
What two types of hydrocele are there?
Communicating: patency of processus vaginalis
Non-communicating: excessive fluid production in tunica vaginalis
What clinical features of a hydrocele are there?
Soft, fluctuant mass
Can get above the mass
Transilluminates pen torch
How may you manage a hydrocele?
Infantile: repaired if not resolved by 1-2 years
Adult: watch-and-wait; aspiration;
surgical repair
Why are varicoceles more common on the left side?
The left testicular vein drains into the left renal at a sharper angle than the right does, draining into the larger IVC
What are the clinical features of a varicocele?
‘Bag of worms’
Infertility
What is the management of a varicocele?
Supportive: watch-and-wait
Infertility/Pain
Surgery: Percutaneous occlusion; Surgical ligation
What are the indications for an intervention of a varicocele?
Infertility
Hypogonadism
Scrotal pain
Testicular hypotrophy
Aesthetics
What are the causes of orchitis?
Bacterial: C trachomatis; N gonorrhoea; M genitalium; E.coli; TB; Candida
Viral: Mumps
Drug: Amiodarone
Vasculitic: Behcet’s; HSP
Idiopathic
What are the clinical features of orchitis?
Unilateral scrotal pain
Tender
Hot ,erythematous hemiscrotum
Frequency/Dysuria/ Discharge
Systemic symptoms
What is the key difference between urinary retention and obstructive uropathy?
Obstructive uropathy occurs when kidney function is compromised
What are some of the clinical features of obstructive uropathy?
Features dependent on cause…
Flank pain/ costovertebral angle tenderness
LUTS
Anuria/oliguria
Haematuria
UTIs
Pelvic mass
Weight loss/lymphadenopathy
Which classes of medication may cause urinary retention?
Anti-cholinergics
Opioid analgesics
Alpha receptor agonists
Which anatomical variation may predispose to a testicular torsion?
Bell Clapper deformity - tunica vaginalis attached superiorly, leaving inferior portion of testicle to rotate freely
What types of testicular torsion are there?
Intra-vaginal (rotation within tunica vaginalis)
Extra-vaginal (occurs per-natally prior to attachment to posterior scrotal wall - spermatic cord twists)
Long mesorchium (CT tissue attaching efferent ductules of epididymis to posterolateral wall of testes. If longer, allows testicles to twist)
What are the clinical features of a testicular torsion?
Sudden-onset testicular pain
Nausea/vomiting
Abdominal pain
Absence cremasteric reflex
Negative Prehn’s sign
Scrotal oedema
What tissue is damaged in a ‘penile fracture’?
Tunica albuginea
What are the clinical features of a penile fracture?
Popping/cracking sound
Significant pain
Swelling
Flaccidity
Skin haematoma
How are penile fractures managed?
Surgical repair
What are the potential complications of a penile fracture?
Erectile dysfunction
Peyronie’s disease
Urethral damage
Dyspareunia
What may preoperative nephrectomy evaluation involve?
US-scan and CT-Kidney (contrast) to identify tumour
Renal function tests - assess contralateral renal function and fitness
CT-Chest (evaluate for pulmonary mets)
Bone scan and bone markers (if symptomatic)
What is the relevance of the white line of Toldt?
Avascular plane for incision
This is the confluence of the colonic visceral peritoneum and parietal peritoneum of lateral abdominal wall
What is meant by kocher manoeuvre in surgery?
Incision of peritoneum at R edge of duodenum with the organ being reflected to the left
Which renal structure is divided first in a nephrectomy?
Renal artery divided first to prevent renal congestion
Why is the separation of kidney from lateral abdominal wall done last?
Prevent specimen falling into operative field
Which structure is a reliable landmark when identifying the ureter?
Psoas muscle
Why use an Endobag in a nephrectomy?
Prevention of port site metastasis
Give 2 examples of absorbable suture.
Monocryl
Vicryl
PDS
Collagen
Outline the differences between Monocryl and Vicryl
Monocryl: monofilament
+ T1/2 of 7-14 days
+ 20-30% breaking strength at 2 weeks
Vicryl: polyfilament
+ Stronger
- Site reaction
- Infection
Which types of uroenteric diversion are you aware of? Give examples.
Ileal conduit: 15-20cm segment of distal ileum connected to ureter with urostomy in RLQ
Continent cutaneous diversion: portion of bowel with reservoir and urostomy
E.g. Indiana pouch with caecum and ascending colon detubularised and urostomy
Orthotropic bladder: bladder in same position as before
E.g. Struder pouch with detubularised ileum connected to native urethra
How is urine voided by a patient with a continent uroenteric diversion?
Credé manoeuvre - void by increasing abdominal pressure
Which structures may be damaged by nephrostomy placement?
Pleura
Diaphragm
Colon
Spleen
Liver
When placing a nephrostomy, what region of the kidney should be aimed for and why?
Posterolateral aspect of kidney, where anterior and posterior vascular territories meet; 20-30 degrees from sagittal plane.
The posterior calyx is usually aligned with the avascular zone thus enter along this 20-30 degree axis from the sagittal plane to reduce risk of vascular damage
Outline the one-stick technique
One stick technique: US-kidney to visualise posterior calyces using long axis of US probe; 18 gauge Trocar needle inserted below 12th rib at 20-30 degrees axis to the sagittal plane. 0.035-inch guidewire can be added with nephrostomy tube placed directly over
Urine aspirated and equivalent volume of contrast used to opacify collecting system and confirm presence in posterior calyx; advance guide wire into proximal ureter
Why should you be cautious regarding overdistension of the collecting system when injecting contrast during a nephrostomy?
May force infected urine into venous system, increasing the risk of sepsis
What are the anterior and posterior renal fascia named?
Gerota’s fascia
Zuckerkandl’s fascia
Give 3 indications for a TURP
Failed medical management
Obstructive nephropathy
Bladder outlet obstruction
Difficulty with clean intermittent catheterisation
Large prostate volume (>80g)
Outline how a TURP procedure is undertaken.
Resectoscope inserted into urethra and visualise bladder with visual obturator
Channel made at 5 and 7 o’clock position down to the verumontanum - allows better visualisation via continuous irrigation during resection
Resection continues and laterally up to 3 and 9 o’clock positions
Use haemostasis, with minimal irrigation towards the end, allowing for assessment of venous bleeding
Bladder irrigation until light pink
What are the potential complications of a TURP?
LUTS
Bladder perforation
Prostate perforation
Bleeding
Poor visualisation
Retrograde ejaculation
Infection
Urethral strictures
TURP syndrome
What are the features of TURP syndrome?
Hypertension
Bradycardia
Mental status change
There will be CNS, respiratory and systemic symptoms
Outline the pathophysiology of TURP syndrome.
Irrigation with large volumes of glycine results in absorption via prostatic venous sinuses. This causes hyponatraemia and glycine broken down into ammonia with hyperammonemia
State 3 risk factors for TURP syndrome.
Surgical time >1 hour
Resected >60g
Large blood loss; Large fluid used
Perforation
Poorly controlled CHF/Renal failure
