Urology Flashcards
Describe obstructive uropathy
Back-pressure in the urinary system causing areas proximal to the obstruction to become swollen with urine
Describe the presentation of an upper urinary tract obstruction
Loin to groin/flank pain on affected side - irritation and stretching of the ureter and kidney
Reduced or no urine output
Non-specific systemic symptoms - vomiting
Impaired renal function on blood tests
Describe the presentation of a lower urinary tract obstruction
Difficulty or inability to pass urine - poor flow, difficulty initiating urination or terminal dribbling
Urinary retention - increasingly full bladder
Impaired renal function on blood tests - raised Cr
What investigation is used to diagnose obstructive uropathy
Ultrasound KUB
List some causes of upper urinary tract obstruction
Kidney stones Tumours pressing on ureters Ureteric stricture Retroperitoneal fibrosis Bladder cancer Ureterocoele
List some causes of lower urinary tract obstruction
Benign prostatic hyperplasia Prostate cancer Bladder cancer Urethral strictures Neurogenic bladder
Describe a neurogenic bladder
Abnormal function of the nerves innervating the bladder and urethra
Overactivity or underactivity in the detrusor muscle of the bladder and the sphincter muscles of the urethra
List some causes of neurogenic bladder
Multiple sclerosis Diabetes Stroke Parkinson's disease Brain or spinal cord injury Spina bifida
List the complications of neurogenic bladder
Urge incontinence
Increased bladder pressure
Obstructive uropathy
Describe the management of obstructive uropathy
Nephrostomy - bypass the obstruction in upper urinary tract - drain through skin
Urethral or suprapubic catheter - bypass obstruction in lower urinary tract
List some complications of obstructive uropathy
Pain AKI - post renal CKD Infection Hydro nephrosis Urinary retention and bladder distension Overflow incontinence of urine
Describe hydronephrosis
Swelling of the renal pelvis and calyces in the kidney
Obstruction of the urinary tract causing back pressure into the kidneys
What is idiopathic hydroneprhosis
Narrowing at the pelviureteric junction
The site where the renal pelvis becomes the ureter
May be congenital or may develop later
Treated with operation - pyeloplasty
List some features of hydronephrosis on presentation
Vague renal angle tenderness
Mass in kidney area
How is hydronephrosis diagnosed
Ultrasound, CT or IV urogram
How is hydronephrosis treated?
Treat underlying cause
Percutaneous nephrostomy - tube through skin and kidney into the ureter
Anterograde ureteric stent
How would you treat acute urinary retention in a man with an enlarged prostate
Insert a catheter
Start Tamsulosin
Discharge to have a trial without a catheter (TWOC) in the community
What type of drug is Tamsulosin
Alpha blocker
What are some side effects of Tamsulosin
Postural hypotension - Dizziness on standing
Falls
Describe a TWOC
Trial without a catheter - remove the catheter to see if the patient can manage without it
Urine output is monitored and a bladder scan is used to make sure there is minimal residual urine left in the bladder
Describe the treatment of catheter-associated urinary tract infections
Patients with asymptomatic bacteriuria require no antibiotics
Patients with symptoms require treatment with 7 days of antibiotics. Depending on severity of symptoms this may be with oral antibiotics or require admission to hospital and IV antibiotics. The catheter should be changed as soon as possible
Describe benign prostatic hyperplasia
Benign hyperplasia of the stromal and epithelial cells in the prostate leading to enlargement
Common in men >50yo
Describe the presentation of BPH
Lower urinary tract symptoms
- Hesitancy
- Weak flow
- Urgency
- Frequency - small amounts frequently
- Straining
- Terminal dribbling
- Incomplete emptying
- Nocturia
What is a scoring system used to assess the severity of lower urinary tract symptoms
International prostate symptom score
How are men with lower urinary tract symptoms asseesd
Digital rectal examination - size, shape and characteristics of the prostate
Abdominal examination - palpable bladder
Urinary frequency volume chart - 3 days of fluid intake and output
Urine dipstick - blood
PSA
List some causes of a raised PSA
Prostate cancer Benign prostatic hyperplasia Prostatitis Urinary tract infections Vigorous exercise Recent ejaculation or prostate stimulation (DRE)
Describe the differences between a benign and a cancerous prostate on DRE
Benign - smooth, symmetrical and slightly soft with maintained central sulcus
Cancerous - feel firm/hard, asymmetrical, craggy or irregular with loss of the central sulcus
Describe the management of BPH
Alpha blockers - Tamsulosin to relax the smooth muscle
5-alpha reductase inhibitors (finasteride) - gradually reduce the size of the prostate
Surgery - TURP (transurethral resection of the prostate)
Transurethral electro vaporisation of the prostate (TEVAP/TUVP)
Holmium laser enucleation (HoLEP)
Open proctectomy - abdominal or perineal incision
Describe the mechanism of action of 5-alpha reductase inhibitors
5-alpha reductase usually converts testosterone to dihydrotestosterone (DHT) which is a more potent androgen hormone
Inhibitors of 5-alpha reductase reduce DHT in the tissues, leading to a reduction in prostate size
Usually takes 6 months of treatment for the effects to improve the symptoms
List a common side effect of finasteride
Sexual dysfunction
Describe transurethral resection of the prostate
Remove part of the prostate from inside the urethra using a retroscope and diathermy loop used to remove prostate tissue
Aim is to create a more expansive space for urine to flow through, thereby improving the symptoms
List the major complications of TURP
Bleeding Infection Urinary incontinence Erectile dysfunction Retrograde ejaculation Urethral strictures Failure to resolve symptoms
What are the different types of prostatitis
Acute bacterial prostatitis - acute infection in the prostate with more rapid symptoms
Chronic prostatitis (>3months) - chronic prostatitis/chronic pelvic pain syndrome (no infection) or chronic bacterial prostatitis (infection)
Describe the presentation of chronic prostatitis
Pelvic pain - perineum, testicles, scrotum, penis, rectum, groin, lower back or suprapubic area
Lower urinary tract symptoms - dysuria, hesitancy, frequency and retention
Sexual dysfunction - erectile dysfunction, pain on ejaculation and haematospermia
Pain with bowel movements
Tender and enlarged prostate on examination
Describe the presentation of acute bacterial prostatitis
More acute presentation of similar symptoms to chronic prostatitis
May also be systemic symptoms too - malaise, fever, myalgia, nausea, fatigue and sepsis
What investigations should be done for prostatitis
Urine dipstick testing
Urine microscopy, culture and sensitives (MC&S)
Chlamydia and gonorrhoea (NAAT) testing - 1st pass urine if STI considered
Describe the management of acute bacterial prostatitis
Hospital admission if systemically unwell
Oral antibiotics - 2-4weeks
Analgesia
Laxatives
Describe the management of chronic prostatitis
Alpha blockers - Tamsulosin - relax smooth muscle with rapid improvement of symptoms
Analgesia
Psychological treatment - CBT/Antidepressants
Antibiotics
Laxatives
List the complications of acute bacterial peritonitis
Sepsis
Prostate abscess - felt as a fluctuant mass and requires surgical drainage
Acute urinary retention
Chronic prostatitis
Where does advanced prostate cancer spread?
Bones and lymph nodes
What do most prostate cancers rely on for growth?
Androgens
What type of cancer are most prostate cancers?
Adenocarcinomas
List some risk factors for prostate cancer
Age FH African or caribbean origin Tall stature Anabolic steroids
Describe the presentation of prostate cancer
Asymptomatic or lower urinary tract symptoms - hesitancy, frequency, weak flow, terminal dribbling and Nocturia
Haematuria
ED
Symptoms of advanced disease - weight loss, bone pain, cauda equina
Where is PSA released from
Prostate epithelial cells into the semen with a small amount entering the blood
What may an inflamed prostate feel like on examination
Warm, tender and enlarged
Describe multiparametric MRI for prostate cancer
1st line investigation for suspected localised Prostate cancer
results reported on a Likert scale 1- very low suspicion 2 - low suspicion 3 - equivocal 4- probable cancer 5 - definitive cancer
Describe a prostate biopsy
If Likert >3 from MRI
Risk of false negative if sample wrong area so MRI is used to focus the biopsies
Transrectal ultrasound guided biopsy or trans perineal biopsy
What are the main risks of prostate biopsy
Pain Bleeding Infection Urinary retention Erectile dysfunction
Describe isotope bone scan in prostate cancer
Radioactive isotope given by IV injection, short wait (2-3hrs) to allow the bones to take up the isotope. A gamma camera is used to take pictures of the entire skeleton
Metastatic lesions take up more isotopes making them stand out on scan
Describe the Gleason grading system
Based on histology
2 numbers added together
1st number - grade of the most prevalent pattern in the biopsy
2nd number is the grade of the second most prevalent pattern in the biopsy
6 - low risk
7 - Intermediate risk - 4+3 then this is a higher risk than 3+4
>8 - high risk
Describe the TNM staging system for prostate cancer
Tumour - Tx - T4
Nodes - Nx-N1
Metastasis M0-M1
Describe the management of prostate cancer
MDT
Surveillance/watchful waiting in early disease
External beam radiotherapy
Brachytherapy
Hormone therapy
Surgery - radical prostatectomy
List a complication of external beam radiotherapy
Proctitis - inflammation of the rectum - pain, altered bowel habit, rectal bleeding and discharge
What can be given to reduce proctitis
Prednisolone suppositories
Describe brachytherapy
Implanting radioactive metal seeds into the prostate
Delivers continuous, targeted radiotherapy to the prostate causing inflammation in nearby organs such as bladder or rectum
What the symptoms of complications of brachytherapy
ED
Incontinence
Bladder or rectal cancer
Describe hormone therapy for prostate cancer
Reduce the level of androgens that stimulate the cancer to grow
Used in combination with radiotherapy or alone in advanced disease for palliation
What are the different types of hormone therapy for prostate cancer
Androgen receptor blockers - bicalutamide
GnRH agonists - goserelin (zoladex) or leuprorelin (prostap)
Bilateral orchidectomy - rarely used
List the side effects of hormone therapy for prostate cancer
Hot flushes Sexual dysfunction Gynaecomastia Fatigue Osteoporosis
What are the complications of radical prostatectomy
Erectile dysfunction
Urinary incontinence
What is a normal post voidal volume in patients aged <65
<50ml
Describe epididymo-orchitis
Inflammation of the epididymis and testicle
Describe the anatomy of the testicle
At the back of each testicle is the epididymis - sperm are released from the testicle into the head of the epididymis and travel through the head, body and tail. The sperm mature and are stored in the epididymis. This drains into the vas deferens
List the causes of epididymo-orchitis
E.coli
Chlamydia trachomatis
Neisseria gonorrhoea
Mumps
Describe the symptoms of mumps
Parotid gland swelling
Orchitis - only affecting testicle
Pancreatitis
Describe the presentation of epididymo-orchitis
Testicular pain Dragging or heavy sensation Swelling of testicle and epididymis Tenderness on palpation Urethral discharge Systemic symptoms - fever and potentially sepsis
What is the key differential diagnosis of epididymo-orchitis
Testicular torsion
Describe how epididymo-orchitis is diagnosed
Urine microscopy, culture and sensitivity
Chlamydia and gonorrhoea NAAT testing on first pass urine
Charcoal swab of purulent discharge for gonorrhoea culture and sensitivities
Saliva swab - PCR - mumps
Serum antibodies
Ultrasound - torsion and tumour
Describe the management of epididymo-orchitis
Acutely unwell or septic patients - IV antibiotics
Patients with high risk of STI - urgent GUM referral
Local guidelines guide choice of antibiotic - low risk of STIS a typical choice is ofloxacin for 14 days or ciprofloxacin, doxycycline or co-amoxiclav
Additional measures - analgesia, supportive underwear, reduce physical activity, abstain from intercourse
Describe the use of quinolone antibiotics
Ofloxacin and ciprofloxacin - powerful broad spectrum antibiotics used for UTIs, pyelonephritis, epidymo-orchitis and prostatitis
Give excellent gram negative cover
List two side effects of quinolone antibiotics
Tendon damage/rupture (Achilles)
Lower the seizure threshold
What are the complications of epididymo-orchitis
Chronic pain Chronic epididymitis Testicular atrophy Sub-fertility or infertility Scrotal abscess
List some features which make an STI cause of epididymo-orchitis more likely than E.coli
<35yo
Increased number of sexual partners
Discharge from urethra
Describe testicular torsion
Twisting of the spermatic cord with rotation of the testicle
Urological emergency
Can lead to ischaemia and necrosis of the testicle - sub/infertility
May be history of recurrent symptoms where there is intermittent testicular torsion
Usually triggered by activity
Describe the examination findings of testicular torsion
Firm swollen testicle Elevated (retracted) testicle Absent cremasteric reflex Abnormal testicular lie Rotation so the epididymis is not in normal posterior position
Describe the presentation of testicular torsion
Unilateral testicular pain
Acute rapid onset
Abdominal pain and vomiting
What is a Bell-clapper deformity
A cause of testicular torsion
Fixation between the tunica vaginalis and testicle is absent so the testicle hangs in a horizontal position instead of vertical and more likely to rotate within the tunica vaginalis twisting on the spermatic cord and cutting off the blood supply
Describe the management of testicular torsion
Urological emergency NBM Analgesia Urgent senior urology assessment Surgical exploration of scrotum Orchidopexy - fixing them in place Orchidectomy - removal of the testicle if necrotic
What can be used to diagnose testicular torsion
Scrotal ultrasound - whirlpool sign - spiral appearance to the spermatic cord and blood vessels
What is a hydrocele?
Collection of fluid in the tunica vaginalisis that surrounds the testes
How do hydroceles present
Painless swelling of the scrotum Palpable testicle within Soft, fluctuant and may be large Irreducible and no bowel sounds Trans illuminated
What causes hydroceles
Idiopathic
Can be secondary to testicular cancer, testicular torsion, epididymo-orchitis and trauma
Describe the management of hydroceles
Exlcude serious causes
Idiopathic managed conservatively
Surgery, aspiration or sclerotherapy if large or symptomatic
Describe a varicocele
When the veins in the pampiniform plexus (venous plexus found in the spermatic cord and drains the testes into the testicular vein, has a role in temperature control of blood entering the testes ) become swollen as a result of increased resistance in the testicular vein and incompetent valves in the testicular vein allowing blood to flow back into pampiniform plexus.
Common in 15% of men
Can cause impaired fertility - due to disrupting the temperature in the affected testicle
May result in testicular atrophy, reducing the size and function of the testicle
Where does the right testicular vein drain
IVC
Where does the left testicular vein drain
Left renal vein
Which side are most varicoles
Left sided due to increased resistance in the left testicular vein
What might a left sided varicole indicate
Renal cell carcinoma
Describe the presentation of varicoceles
Throbbing/dull pain or discomfort worse on standing
Dragging sensation
Subfertility or infertitlity
Describe examination findings of a varicocele
Bag of worms - scrotal mass
More prominent when standing and disappears when lying down
Asymmetry in testicular size if affected the growth of the testicle
What do varicoceles which do not disappear when sitting down raise suspicion of
Retroperitoneal tumour
Describe the investigations of varicoceles
US with doppler imaging
Semen analysis if fertility concern
hormone function - FSH and testosterone if concern about functioning
Describe the management of varicoceles
Uncomplicated - conservative
Pain, testicular atrophy or infertility - surgery or endovascular embolisation
Describe epididymal cysts
Cysts occuring at the head of the epididymis
Contains sperm - spermatocele
Common in adults
Most asymptomatic
Round, soft lump at top of testicle associated with the epididymis and separate from the testicle. May be able to trans illuminate large cysts appearing separate from the testicle.
Usually harmless and not associated with cancer or infertility
occasionally pain or discomfort and removal considered or torsion
Describe testicular cancer
Arises from germ cells that produce gametes
Common in younger men 15-35yo
Two types - seminomas and non seminomas (teratomas)
List some risk factors for testicular cancer
Undescended testes
Male infertility
FH
Increased height
Describe the presentation of testicular cancer
Painless lump Non tender Arising from testicle Hard Irregular Not fluctuant No transillumination Gynaecomastia - leydig cell tumour (rare)
What investigations should you do for testicular cancer
Scrotal ultrasound
Tumour markers - AFP, beta hCG, lactate dehydrogenase
Staging CT
Describe the staging system for testicular cancer
Royal marsden staging system 1 - isolated to testicle 2 - spread to the retroperitoneal lymph nodes 3 - spread to nodes above the diaphrgm 4 - metastasis
Where does testicular cancer metastasise to
Lymphatics
Lungs
Liver
Brain
Describe the management of testicular cancer
MDT Surgery - radical orchidectomy Chemotherapy Radiotherapy Sperm banking
Which type of testicular cancer has the better prognosis
Seminomas > teratomas
Describe lower urinary tract infections
Infection of the bladder
Describe the presentation of lower urinary tract infections
Dysuria Suprapubic pain or discomfort Frequency Urgency Incontinence Haematuria Cloudy or foul smelling urine Confusion
What might urine dipstick show in lower urinary tract infection
Nitrites - gram negative bacteria break down nitrates to form nitrites - suggest bacteria in urine
Leukocytes - white blood cells, leukocyte esterase is tested on urine dipstick which is a product of leukocytes
Red blood cells - indicates blood - microscopic haematuria is where blood is visible in the urine - seen in bladder cancer or nephritis
When should a midstream urine sample (MSU) be sent for microscopy, culture and sensitivities
Pregnant patients
Patients with recurrent UTIs
Atypical symptoms
When symptoms do not improve with antibiotics
List the causes of lower urinary tract infections
E.coli - gram negative anaerobic rod shaped bacteria Klebsiella pneumoniae Enterococcus Pseudomonas aeruginosa Staphylococcus saprophyticus Candida albicans
Describe the antibiotic therapy for lower urinary tract infection
Trimethoprim (avoid in 1st trimester pregnancy)
Nitrofurantoin (avoid in 3rd trimester pregnancy and if eGFR is <45)
Amoxicillin
Cefalexin
Pivmecillinam
3 days of antibiotics - lower UTI in women
5-10days of antibiotics for immunosuppressed women, abnormal anatomy or impaired kidney function
7 days antibiotics for men, pregnant women or catheter related UTIs
Describe pyelonephritis
Inflammation of the kidney resulting from bacterial infection
Inflammation affects the renal pelvis and parenchyma
List some risk factors for pyelonephritis
Female sex
Structural urological abnormalities
Vesico-ureteric reflux
Diaabetes
Which bacteria cause pyelonephritis
E.coli Klebsiella pneumoniae Enterococcus Pseudomonas aeruginosa Staphylococcus saprophyticus Candida albicans
Describe the presentation of pyelonephritis
Fever Loin or back pain Nausea or vomiting Systemic illness Loss of appetite Haematuria Renal angle tenderness on examination
Describe the investigations for pyelonephritis
Urine dipstick - nitrites, leukocytes and blood
Midstream urine for microscopy, culture and sensitivity
Bloods - raised WCC and raised inflammatory markers
Imaging - ultrasound and CT scan
Describe the management of pyelonephritis
Refer to hospital if features of sepsis
7-10days of antibiotics - co-amoxiclav, trimethoprim, ciprofloxacin, cefalexin - refer to guidelines
Sepsis 6 if sepsis
Describe chronic pyelonephritis
Recurrent episodes of infection in the kidneys
Lead to scarring of the renal parenchyma - CKD - can progress to end stage renal failure
Describe the scan done in chronic/recurrent pyelonephritis
DMSA scan - inject radiolabelled DMSA which builds up in healthy kidney tissue
When imaged using gamma cameras it indicates scarring or damage in areas that do not take up the DMSA
Used in recurrent pyelonephritis to assess for renal damage
Describe interstitial cystitis
Chronic condition causing inflammation of the bladder, resulting in lower urinary tract symptoms and suprapubic pain
No explanation fort cause - dysfunction of blood vessels, nerves, immune system and epithelium
More common in women than men - impact on QOL and mental health
Describe the presentation of interstitial cystitis
> 6 weeks
Suprapubic pain - worse with full bladder and better when emptying bladder
Frequency
Urgency
Symptoms worse during menstruation
What investigations are done for interstitial cystitis
Urinalysis
Swabs
Cystoscopy - Hunner lesions (red, inflamed patches of bladder mucosa associated with small blood vessels), granulations (haemorrhages on the bladder wall)
Prostate examination
Describe the management of interstitial cystitis
Supportive - diet change, stop smoking, pelvic floor exercises, bladder retraining, CBT, transcutaneous electrical nerve stimulation
Oral medications - analgesia, antihistamines, anticholinergic medications, mirabegron, cimetidine, pentosan polysulfate sodium, ciclosporin
Intravesical medication - lidocaine, hyaluronic acid, chondroitin sulphate
Hydrodistension - fill bladder with water to a high pressure, during cystoscopy - requires GA and gives a temporary improvement of symptoms
Surgical procedures - cauterisation of Hunner lesions, Botulinum toxin, neuromodulation, augmentation, cystectomy
List some risk factors for bladder cancer
Smoking - TCC
Age
Aromatic amines - carcinogens - dyes and rubber
Schistosomiasis - SCC
Name the two main types of bladder cancer
Transitional cell carcinoma (90)
Squamous cell carcinoma (5%)
Others - adenocarcinoma, sarcoma and small cell carcinoma
How does bladder cancer present
Painless haematuria
Who should be referred under 2ww pathway for bladder cancer
> 45yo with unexplained visible haematuria either without a UTI or persisting after UTI treatment
> 60 with microscopic haematuria plus dysuria or raised WBCs on FBC
How is bladder cancer diagnosed
Cystoscopy - rigid or flexible under LA/GA
Describe the staging of bladder cancer
TNM staging system
Non-muscle invasive bladder cancer (Tis/carcinoma in situ - cells affect urothelium and are flat, Ta - cancer affects the urothelium and projects into the bladder, T1 - cancer invading the connective tissue layer beyond the urothelium but not muscle layer)
Muscle invasive bladder cancer - T2-4 and any lymph node or metastatic spread
Describe the treatment options for bladder cancer
Transurethral resection of the bladder tumour - non-muscle-invasive bladder cancer
Intravesical chemotherapy
Intravesical bacillus calmette-guerin (BCG) - form of immunotherapy - BCG vaccine given into the bladder to stimulate immune system to attack the tumour
Radical cystectomy - urostomy with ileal conduit (most common), continent urinary diversion, neobladder reconstruction, ureterosigmoidostomy, chemo and radiotherapy
Chemo and radiotherapy
Describe an ileal conduit
A section of ileum is removed and end-to-end anastomosis is created so the bowel is continuous. The ends of the ureters are anastomosed to the separate section of the ileum and the other end of this section of ileum forms a stoma out to the skin draining the urine into a urostomy bag
Urostomy bags need to fit tightly around the urostomy to avoid skin contact with urine as this is irritating and may cause skin damage
What are two complications of kidney stones
Obstruction
Infection
List the different types of kidney stone
Calcium based stones (80%) - calcium oxalate and calcium phosphate - Having raised serum calcium and low urine output
Uric acid - not visible on X-ray
Struvite - associated with infection as produced by bacteria
Cystine - associated with cystinuria - autosomal recessive
Describe a staghorn calculus
Stone forms the shape of a renal pelvis
Body sits in the renal pelvis with horns extending into the renal calyces
Plain Xray
Struvite - occur in recurrent upper UTIs
Bacteria hydrolyse the urea in urine to ammonia creating solid struvite
Describe the presentation of kidney stones
Renal colic - unilateral loin to groin pain
Colicky as the stone moves and settles
Patients often restless due to pain
Haematuria
Nausea and vomiting
Reduced urine output
Symptoms of sepsis if infection is present
Describe the investigations for kidney stones
Urine dipstick - haematuria
Bloods- infection and kidney function and raised serum calcium
Abdominal X-ray - show calcium stones and struvite stones, do not show uric acid stones
Non-contrast computer tomography (CTKUB) - <24hrs of presentation - initial investigation to diagnose stones
Ultrasound KUB is less preferred alternative - negative result does not exclude the stones - helpful in children and pregnant women
Stones should be analysed to determine type and reduce the risk of recurrence
Describe the initial management of kidney stones
NSAIDs - IM diclofenac, IV paracetamol if NSAIDs CI
Antiemetics - metoclopramide, Cyclizine, prochlorperazine
Antibiotics - required if infection present
Watchful waiting - if <5mm may pass themselves within several weeks. Stones >10mm may require Tamsulosin (alpha blocker) or surgical interventions (extracorporeal shockwave lithotripsy, ureteroscopy and laser lithotripsy, percutaneous nephrolithotomy and open surgery)
How are recurrent kidney stones reduced
Drink plenty of fluid (3L)
Add fresh lemon juice to water (reduce formation of calcium stones)
Avoid carbonated drinks
Reduce dietary salt and protein
Maintain low calcium diet
Calcium stones- reduce intake of oxalate rich foods and for uric stones - reduce purine rich food
List two medications used to reduce recurrence of kidney stones
Potassium citrate - reduce calcium oxalate stones
Thiazide diuretics reduce calcium oxalate stones and raised urinary calcium
What type of cancer is a renal cell carcinoma
Adenocarcinoma arising from the renal tubules
How does renal cell carcinoma present
Asymptomatic Haematuria Loin pain Non-specific symptoms of cancer -weight loss, fatigue, anorexia, night sweats Palpable renal mass on examination
List the different types of renal cell carcinoma
Clear cell (80%)
Papillary (5%)
Chromophobe (5%)
List some risk factors for renal cell carcinoma
Smoking Obesity HTN End stage renal failure Von Hippel Lindau disease Tuberous sclerosis
Describe the spread of renal cell carcinoma
Around tissues of kiney within gerotas fascia
Spreads to renal vein then to IVC
Cannonball metastases in the lungs is a classic feature of metastatic renal cell carcinoma
List some paraneoplastic features of RCC
Polycythaemia - increased EPO
Hypercalcaemia
HTN
Stauffers syndrome - abnormal liver function tests without liver mets
Describe the staging of renal cell carcinoma
CT TAP TNM staging Number staging for renal cell carcinoma 1- <7cm 2- > 7cm 3 - local spread but not beyond gerotas fascia Stage 4 - spread beyond fascia
Describe the management of renal cell carcinoma
MDT Surgery - partial/radical nephrectomy Arterial embolisation Percutaneous cryotherapy Radiofrequency ablation Chemotherapy and radiotherapy
Describe renal transplant
Where a kidney transplanted into a patient with end stage failure
How are renal transplant patients donor matched?
HLA matching - HLA A,B,C on chromosome 6 - don’t have to match fully but the closer the better
Describe the process of transplanting a kidney
Patients own kidney left in place
Donor kidney blood vessels anastomosed with pelvic vessels - external iliac vessels
Ureter of donor kidney anastomosed directly with bladder
Donor kidney placed anteriorly in abdomen - palpated in iliac fossa
What is the name of the incision used in renal transplant
Hockey stick
What is required following kidney transplant
Life long immunosuppression
- Tacrolimus
- Mycophenolate
- Prednisolone
Other possible immunosuppressants - cyclosporine, sirolimus, azathioprine
What is the main side effect of tacrolimus
Tremor
What may immunosuppressants cause
Seborrheic warts
Skin cancer
What is the main side effect of cyclosporine
Gum hypertrophy
What are the complications of the transplant
Rejection - hyper acute, acute and chronic
Transplant failure
Electrolyte imbalance
List some complications relating to immunosuppressants
IHD T2DM Non-Hodgkin's lymphoma Skin cancer Infections - CMV, TB and pneumocystis jivoreci pneumonia
What is the most useful investigation to help diagnose overactive bladder
Bladder diary/frequency volume
What is the most appropriate medication for treating urinary urgency
Anticholinergics (inhibition of muscarinic receptors elsewhere)- oxybutynin
Beta 3 agonists - mirabegron
List some side effects of anticholinergics
Dry mouth
Reduced lacrimation
Constipation
Memory problems in older people
What is the best surgical approach for radical orchidectomy and why
Inguinal as a scrotal approach may cause seeding and increase the risk of lymph node involvement
