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Urology Flashcards

1
Q

Describe obstructive uropathy

A

Back-pressure in the urinary system causing areas proximal to the obstruction to become swollen with urine

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2
Q

Describe the presentation of an upper urinary tract obstruction

A

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

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3
Q

Describe the presentation of a lower urinary tract obstruction

A

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

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4
Q

What investigation is used to diagnose obstructive uropathy

A

Ultrasound KUB

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5
Q

List some causes of upper urinary tract obstruction

A 
Kidney stones
Tumours pressing on ureters
Ureteric stricture
Retroperitoneal fibrosis
Bladder cancer 
Ureterocoele
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6
Q

List some causes of lower urinary tract obstruction

A 
Benign prostatic hyperplasia
Prostate cancer
Bladder cancer
Urethral strictures
Neurogenic bladder
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7
Q

Describe a neurogenic bladder

A

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

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8
Q

List some causes of neurogenic bladder

A 
Multiple sclerosis
Diabetes
Stroke
Parkinson's disease
Brain or spinal cord injury 
Spina bifida
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9
Q

List the complications of neurogenic bladder

A

Urge incontinence
Increased bladder pressure
Obstructive uropathy

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10
Q

Describe the management of obstructive uropathy

A

Nephrostomy - bypass the obstruction in upper urinary tract - drain through skin

Urethral or suprapubic catheter - bypass obstruction in lower urinary tract

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11
Q

List some complications of obstructive uropathy

A 
Pain
AKI - post renal 
CKD
Infection
Hydro nephrosis
Urinary retention and bladder distension
Overflow incontinence of urine
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12
Q

Describe hydronephrosis

A

Swelling of the renal pelvis and calyces in the kidney

Obstruction of the urinary tract causing back pressure into the kidneys

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13
Q

What is idiopathic hydroneprhosis

A

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

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14
Q

List some features of hydronephrosis on presentation

A

Vague renal angle tenderness

Mass in kidney area

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15
Q

How is hydronephrosis diagnosed

A

Ultrasound, CT or IV urogram

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16
Q

How is hydronephrosis treated?

A

Treat underlying cause
Percutaneous nephrostomy - tube through skin and kidney into the ureter
Anterograde ureteric stent

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17
Q

How would you treat acute urinary retention in a man with an enlarged prostate

A

Insert a catheter
Start Tamsulosin
Discharge to have a trial without a catheter (TWOC) in the community

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18
Q

What type of drug is Tamsulosin

A

Alpha blocker

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19
Q

What are some side effects of Tamsulosin

A

Postural hypotension - Dizziness on standing

Falls

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20
Q

Describe a TWOC

A

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

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21
Q

Describe the treatment of catheter-associated urinary tract infections

A

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

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22
Q

Describe benign prostatic hyperplasia

A

Benign hyperplasia of the stromal and epithelial cells in the prostate leading to enlargement
Common in men >50yo

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23
Q

Describe the presentation of BPH

A

Lower urinary tract symptoms

  • Hesitancy
  • Weak flow
  • Urgency
  • Frequency - small amounts frequently
  • Straining
  • Terminal dribbling
  • Incomplete emptying
  • Nocturia
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24
Q

What is a scoring system used to assess the severity of lower urinary tract symptoms

A

International prostate symptom score

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25
Q

How are men with lower urinary tract symptoms asseesd

A

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

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26
Q

List some causes of a raised PSA

A 
Prostate cancer
Benign prostatic hyperplasia 
Prostatitis 
Urinary tract infections
Vigorous exercise 
Recent ejaculation or prostate stimulation (DRE)
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27
Q

Describe the differences between a benign and a cancerous prostate on DRE

A

Benign - smooth, symmetrical and slightly soft with maintained central sulcus

Cancerous - feel firm/hard, asymmetrical, craggy or irregular with loss of the central sulcus

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28
Q

Describe the management of BPH

A

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

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29
Q

Describe the mechanism of action of 5-alpha reductase inhibitors

A

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

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30
Q

List a common side effect of finasteride

A

Sexual dysfunction

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31
Q

Describe transurethral resection of the prostate

A

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

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32
Q

List the major complications of TURP

A 
Bleeding
Infection
Urinary incontinence 
Erectile dysfunction
Retrograde ejaculation
Urethral strictures
Failure to resolve symptoms
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33
Q

What are the different types of prostatitis

A

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)

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34
Q

Describe the presentation of chronic prostatitis

A

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

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35
Q

Describe the presentation of acute bacterial prostatitis

A

More acute presentation of similar symptoms to chronic prostatitis

May also be systemic symptoms too - malaise, fever, myalgia, nausea, fatigue and sepsis

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36
Q

What investigations should be done for prostatitis

A

Urine dipstick testing
Urine microscopy, culture and sensitives (MC&S)
Chlamydia and gonorrhoea (NAAT) testing - 1st pass urine if STI considered

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37
Q

Describe the management of acute bacterial prostatitis

A

Hospital admission if systemically unwell
Oral antibiotics - 2-4weeks
Analgesia
Laxatives

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38
Q

Describe the management of chronic prostatitis

A

Alpha blockers - Tamsulosin - relax smooth muscle with rapid improvement of symptoms
Analgesia
Psychological treatment - CBT/Antidepressants
Antibiotics
Laxatives

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39
Q

List the complications of acute bacterial peritonitis

A

Sepsis
Prostate abscess - felt as a fluctuant mass and requires surgical drainage
Acute urinary retention
Chronic prostatitis

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40
Q

Where does advanced prostate cancer spread?

A

Bones and lymph nodes

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41
Q

What do most prostate cancers rely on for growth?

A

Androgens

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42
Q

What type of cancer are most prostate cancers?

A

Adenocarcinomas

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43
Q

List some risk factors for prostate cancer

A 
Age
FH
African or caribbean origin
Tall stature
Anabolic steroids
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44
Q

Describe the presentation of prostate cancer

A

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

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45
Q

Where is PSA released from

A

Prostate epithelial cells into the semen with a small amount entering the blood

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46
Q

What may an inflamed prostate feel like on examination

A

Warm, tender and enlarged

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47
Q

Describe multiparametric MRI for prostate cancer

A

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
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48
Q

Describe a prostate biopsy

A

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

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49
Q

What are the main risks of prostate biopsy

A 
Pain 
Bleeding
Infection
Urinary retention 
Erectile dysfunction
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50
Q

Describe isotope bone scan in prostate cancer

A

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

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51
Q

Describe the Gleason grading system

A

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

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52
Q

Describe the TNM staging system for prostate cancer

A

Tumour - Tx - T4
Nodes - Nx-N1
Metastasis M0-M1

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53
Q

Describe the management of prostate cancer

A

MDT

Surveillance/watchful waiting in early disease

External beam radiotherapy

Brachytherapy

Hormone therapy

Surgery - radical prostatectomy

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54
Q

List a complication of external beam radiotherapy

A

Proctitis - inflammation of the rectum - pain, altered bowel habit, rectal bleeding and discharge

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55
Q

What can be given to reduce proctitis

A

Prednisolone suppositories

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56
Q

Describe brachytherapy

A

Implanting radioactive metal seeds into the prostate

Delivers continuous, targeted radiotherapy to the prostate causing inflammation in nearby organs such as bladder or rectum

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57
Q

What the symptoms of complications of brachytherapy

A

ED
Incontinence
Bladder or rectal cancer

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58
Q

Describe hormone therapy for prostate cancer

A

Reduce the level of androgens that stimulate the cancer to grow

Used in combination with radiotherapy or alone in advanced disease for palliation

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59
Q

What are the different types of hormone therapy for prostate cancer

A

Androgen receptor blockers - bicalutamide

GnRH agonists - goserelin (zoladex) or leuprorelin (prostap)

Bilateral orchidectomy - rarely used

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60
Q

List the side effects of hormone therapy for prostate cancer

A 
Hot flushes 
Sexual dysfunction
Gynaecomastia
Fatigue 
Osteoporosis
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61
Q

What are the complications of radical prostatectomy

A

Erectile dysfunction

Urinary incontinence

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62
Q

What is a normal post voidal volume in patients aged <65

A

<50ml

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63
Q

Describe epididymo-orchitis

A

Inflammation of the epididymis and testicle

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64
Q

Describe the anatomy of the testicle

A

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

65
Q

List the causes of epididymo-orchitis

A

E.coli
Chlamydia trachomatis
Neisseria gonorrhoea
Mumps

66
Q

Describe the symptoms of mumps

A

Parotid gland swelling
Orchitis - only affecting testicle
Pancreatitis

67
Q

Describe the presentation of epididymo-orchitis

A 
Testicular pain
Dragging or heavy sensation
Swelling of testicle and epididymis 
Tenderness on palpation 
Urethral discharge 
Systemic symptoms - fever and potentially sepsis
68
Q

What is the key differential diagnosis of epididymo-orchitis

A

Testicular torsion

69
Q

Describe how epididymo-orchitis is diagnosed

A

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

70
Q

Describe the management of epididymo-orchitis

A

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

71
Q

Describe the use of quinolone antibiotics

A

Ofloxacin and ciprofloxacin - powerful broad spectrum antibiotics used for UTIs, pyelonephritis, epidymo-orchitis and prostatitis
Give excellent gram negative cover

72
Q

List two side effects of quinolone antibiotics

A

Tendon damage/rupture (Achilles)

Lower the seizure threshold

73
Q

What are the complications of epididymo-orchitis

A 
Chronic pain 
Chronic epididymitis
Testicular atrophy 
Sub-fertility or infertility 
Scrotal abscess
74
Q

List some features which make an STI cause of epididymo-orchitis more likely than E.coli

A

<35yo
Increased number of sexual partners
Discharge from urethra

75
Q

Describe testicular torsion

A

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

76
Q

Describe the examination findings of testicular torsion

A 
Firm swollen testicle 
Elevated (retracted) testicle
Absent cremasteric reflex
Abnormal testicular lie 
Rotation so the epididymis is not in normal posterior position
77
Q

Describe the presentation of testicular torsion

A

Unilateral testicular pain
Acute rapid onset
Abdominal pain and vomiting

78
Q

What is a Bell-clapper deformity

A

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

79
Q

Describe the management of testicular torsion

A 
Urological emergency 
NBM
Analgesia
Urgent senior urology assessment 
Surgical exploration of scrotum
Orchidopexy - fixing them in place
Orchidectomy - removal of the testicle if necrotic
80
Q

What can be used to diagnose testicular torsion

A

Scrotal ultrasound - whirlpool sign - spiral appearance to the spermatic cord and blood vessels

81
Q

What is a hydrocele?

A

Collection of fluid in the tunica vaginalisis that surrounds the testes

82
Q

How do hydroceles present

A 
Painless swelling of the scrotum 
Palpable testicle within 
Soft, fluctuant and may be large
Irreducible and no bowel sounds
Trans illuminated
83
Q

What causes hydroceles

A

Idiopathic

Can be secondary to testicular cancer, testicular torsion, epididymo-orchitis and trauma

84
Q

Describe the management of hydroceles

A

Exlcude serious causes
Idiopathic managed conservatively
Surgery, aspiration or sclerotherapy if large or symptomatic

85
Q

Describe a varicocele

A

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

86
Q

Where does the right testicular vein drain

A

IVC

87
Q

Where does the left testicular vein drain

A

Left renal vein

88
Q

Which side are most varicoles

A

Left sided due to increased resistance in the left testicular vein

89
Q

What might a left sided varicole indicate

A

Renal cell carcinoma

90
Q

Describe the presentation of varicoceles

A

Throbbing/dull pain or discomfort worse on standing
Dragging sensation
Subfertility or infertitlity

91
Q

Describe examination findings of a varicocele

A

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

92
Q

What do varicoceles which do not disappear when sitting down raise suspicion of

A

Retroperitoneal tumour

93
Q

Describe the investigations of varicoceles

A

US with doppler imaging
Semen analysis if fertility concern
hormone function - FSH and testosterone if concern about functioning

94
Q

Describe the management of varicoceles

A

Uncomplicated - conservative

Pain, testicular atrophy or infertility - surgery or endovascular embolisation

95
Q

Describe epididymal cysts

A

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

96
Q

Describe testicular cancer

A

Arises from germ cells that produce gametes
Common in younger men 15-35yo
Two types - seminomas and non seminomas (teratomas)

97
Q

List some risk factors for testicular cancer

A

Undescended testes
Male infertility
FH
Increased height

98
Q

Describe the presentation of testicular cancer

A 
Painless lump 
Non tender 
Arising from testicle
Hard
Irregular
Not fluctuant
No transillumination 
Gynaecomastia - leydig cell tumour (rare)
99
Q

What investigations should you do for testicular cancer

A

Scrotal ultrasound
Tumour markers - AFP, beta hCG, lactate dehydrogenase
Staging CT

100
Q

Describe the staging system for testicular cancer

A 
Royal marsden staging system 
1 - isolated to testicle
2 - spread to the retroperitoneal lymph nodes
3 - spread to nodes above the diaphrgm 
4 - metastasis
101
Q

Where does testicular cancer metastasise to

A

Lymphatics
Lungs
Liver
Brain

102
Q

Describe the management of testicular cancer

A 
MDT
Surgery - radical orchidectomy 
Chemotherapy 
Radiotherapy 
Sperm banking
103
Q

Which type of testicular cancer has the better prognosis

A

Seminomas > teratomas

104
Q

Describe lower urinary tract infections

A

Infection of the bladder

105
Q

Describe the presentation of lower urinary tract infections

A 
Dysuria
Suprapubic pain or discomfort 
Frequency
Urgency
Incontinence
Haematuria
Cloudy or foul smelling urine 
Confusion
106
Q

What might urine dipstick show in lower urinary tract infection

A

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

107
Q

When should a midstream urine sample (MSU) be sent for microscopy, culture and sensitivities

A

Pregnant patients
Patients with recurrent UTIs
Atypical symptoms
When symptoms do not improve with antibiotics

108
Q

List the causes of lower urinary tract infections

A 
E.coli - gram negative anaerobic rod shaped bacteria 
Klebsiella pneumoniae 
Enterococcus 
Pseudomonas  aeruginosa
Staphylococcus saprophyticus
Candida albicans
109
Q

Describe the antibiotic therapy for lower urinary tract infection

A

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

110
Q

Describe pyelonephritis

A

Inflammation of the kidney resulting from bacterial infection
Inflammation affects the renal pelvis and parenchyma

111
Q

List some risk factors for pyelonephritis

A

Female sex
Structural urological abnormalities
Vesico-ureteric reflux
Diaabetes

112
Q

Which bacteria cause pyelonephritis

A 
E.coli 
Klebsiella pneumoniae 
Enterococcus 
Pseudomonas aeruginosa 
Staphylococcus saprophyticus
Candida albicans
113
Q

Describe the presentation of pyelonephritis

A 
Fever
Loin or back pain 
Nausea or vomiting 
Systemic illness
Loss of appetite
Haematuria 
Renal angle tenderness on examination
114
Q

Describe the investigations for pyelonephritis

A

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

115
Q

Describe the management of pyelonephritis

A

Refer to hospital if features of sepsis
7-10days of antibiotics - co-amoxiclav, trimethoprim, ciprofloxacin, cefalexin - refer to guidelines
Sepsis 6 if sepsis

116
Q

Describe chronic pyelonephritis

A

Recurrent episodes of infection in the kidneys

Lead to scarring of the renal parenchyma - CKD - can progress to end stage renal failure

117
Q

Describe the scan done in chronic/recurrent pyelonephritis

A

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

118
Q

Describe interstitial cystitis

A

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

119
Q

Describe the presentation of interstitial cystitis

A

> 6 weeks

Suprapubic pain - worse with full bladder and better when emptying bladder
Frequency
Urgency
Symptoms worse during menstruation

120
Q

What investigations are done for interstitial cystitis

A

Urinalysis
Swabs
Cystoscopy - Hunner lesions (red, inflamed patches of bladder mucosa associated with small blood vessels), granulations (haemorrhages on the bladder wall)
Prostate examination

121
Q

Describe the management of interstitial cystitis

A

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

122
Q

List some risk factors for bladder cancer

A

Smoking - TCC
Age
Aromatic amines - carcinogens - dyes and rubber
Schistosomiasis - SCC

123
Q

Name the two main types of bladder cancer

A

Transitional cell carcinoma (90)
Squamous cell carcinoma (5%)

Others - adenocarcinoma, sarcoma and small cell carcinoma

124
Q

How does bladder cancer present

A

Painless haematuria

125
Q

Who should be referred under 2ww pathway for bladder cancer

A

> 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

126
Q

How is bladder cancer diagnosed

A

Cystoscopy - rigid or flexible under LA/GA

127
Q

Describe the staging of bladder cancer

A

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

128
Q

Describe the treatment options for bladder cancer

A

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

129
Q

Describe an ileal conduit

A

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

130
Q

What are two complications of kidney stones

A

Obstruction

Infection

131
Q

List the different types of kidney stone

A

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

132
Q

Describe a staghorn calculus

A

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

133
Q

Describe the presentation of kidney stones

A

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

134
Q

Describe the investigations for kidney stones

A

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

135
Q

Describe the initial management of kidney stones

A

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)

136
Q

How are recurrent kidney stones reduced

A

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

137
Q

List two medications used to reduce recurrence of kidney stones

A

Potassium citrate - reduce calcium oxalate stones

Thiazide diuretics reduce calcium oxalate stones and raised urinary calcium

138
Q

What type of cancer is a renal cell carcinoma

A

Adenocarcinoma arising from the renal tubules

139
Q

How does renal cell carcinoma present

A 
Asymptomatic 
Haematuria
Loin pain 
Non-specific symptoms of cancer -weight loss, fatigue, anorexia, night sweats 
Palpable renal mass on examination
140
Q

List the different types of renal cell carcinoma

A

Clear cell (80%)
Papillary (5%)
Chromophobe (5%)

141
Q

List some risk factors for renal cell carcinoma

A 
Smoking
Obesity
HTN
End stage renal failure
Von Hippel Lindau disease
Tuberous sclerosis
142
Q

Describe the spread of renal cell carcinoma

A

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

143
Q

List some paraneoplastic features of RCC

A

Polycythaemia - increased EPO
Hypercalcaemia
HTN
Stauffers syndrome - abnormal liver function tests without liver mets

144
Q

Describe the staging of renal cell carcinoma

A 
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
145
Q

Describe the management of renal cell carcinoma

A 
MDT
Surgery - partial/radical nephrectomy
Arterial embolisation 
Percutaneous cryotherapy 
Radiofrequency ablation 
Chemotherapy and radiotherapy
146
Q

Describe renal transplant

A

Where a kidney transplanted into a patient with end stage failure

147
Q

How are renal transplant patients donor matched?

A

HLA matching - HLA A,B,C on chromosome 6 - don’t have to match fully but the closer the better

148
Q

Describe the process of transplanting a kidney

A

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

149
Q

What is the name of the incision used in renal transplant

A

Hockey stick

150
Q

What is required following kidney transplant

A

Life long immunosuppression

  • Tacrolimus
  • Mycophenolate
  • Prednisolone

Other possible immunosuppressants - cyclosporine, sirolimus, azathioprine

151
Q

What is the main side effect of tacrolimus

A

Tremor

152
Q

What may immunosuppressants cause

A

Seborrheic warts

Skin cancer

153
Q

What is the main side effect of cyclosporine

A

Gum hypertrophy

154
Q

What are the complications of the transplant

A

Rejection - hyper acute, acute and chronic
Transplant failure
Electrolyte imbalance

155
Q

List some complications relating to immunosuppressants

A 
IHD
T2DM
Non-Hodgkin's lymphoma
Skin cancer 
Infections - CMV, TB and pneumocystis jivoreci pneumonia
156
Q

What is the most useful investigation to help diagnose overactive bladder

A

Bladder diary/frequency volume

157
Q

What is the most appropriate medication for treating urinary urgency

A

Anticholinergics (inhibition of muscarinic receptors elsewhere)- oxybutynin

Beta 3 agonists - mirabegron

158
Q

List some side effects of anticholinergics

A

Dry mouth
Reduced lacrimation
Constipation
Memory problems in older people

159
Q

What is the best surgical approach for radical orchidectomy and why

A

Inguinal as a scrotal approach may cause seeding and increase the risk of lymph node involvement

Finals (18 decks)

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