Urology Flashcards
Commonest stone type
Calcium oxalate (85%)
hypercalciuria, hypercalcaemia, hyperoxaluria or hypocitraturia
Magnesium ammonium phosphate (struvite) stones
Secondary to UTI that breakdown urea into CO2 and ammonia
–> Alkalising urine
Proteus
Stone <0.5cm
Should pass conservatively
Pelviureteric junction obstruction (idiopathic hydronephrosis)
Moderate hydronephrosis causes ill-defined renal pain or ache that may be exacerbated by drinking large volumes of liquid (Dietls’ Crisis).
May produce a large painless mass in the loin;
Severest form: volume of urine in the hydronephrotic sac may simulate free fluid in the peritoneal cavity
Mx:
Either laparoscopic or open pyeloplasty
Retroperitoneal fibrosis
May cause ureteric obstruction and hydronephrosis
-Ureter often difficultto define on imaging
Causes:
Idiopathic
-Mediastinal fibrosis and Dupuytren’s contracture may coexist
-RAISED ESR
Malignant infiltration
Reactive fibrosis
-Radiotherapy, resolving blood clot, or extravasation of sclerosants
Innervation for detrusor contraction
S2- S4
Reach the sphincter either by the pelvic plexus or via the pudendal nerves
Intra-peritoneal rupture of bladder
Dome rupture –> intra-peritoneal leak
Ileus
Abdominal distension
Trauma with full bladder i.e. alcohol-fuelled fights
Management of bladder rupture
Intra-peritoneal
-laparotomy and repair
Extra-peritoneal
-Catheter to relieve any tension
-Conservative management, catheter in for minimum 6-10 days
Cancer of the bladder
Most common = transitional cell
Then: squamous cell carcinoma due to chronic inflammation e.g. schistomsomiasis
Rarely: Adenocarcinoma in urachal remnant in dome of bladder or form colorectal metastasis
Transitional cell carcinoma
Most common bladder and ureter cancer
Papillary tumours are less aggressive superficial cancers
Ulcerating are much more aggressive.
Management of superficial bladder tumours Ta, T1
Transurethral resection of the bladder tumour down to detrusor muscle is desired
If not endoscopic diathermy possible
Intra-vesical mitomycin C useful for multiple lesions
Regular check cystoscopies requried
Treatment of carcinoma in situ bladder cancer
Intra-vescial bacille Calmette-Guerin
BCG
Management of invasive bladder cancer T2-T3
<70 years –> Radical cystectomy
> 70 years –> Radiotherapy
Cystectomy always necessitates urinary diversion. Where the urethra can be retained, it may be possible to construct a new bladder from colon or small bowel
(orthotopic bladder replacement),
Treatment of T4 bladder cancer with fixed organ invasion
Palliative
Resection not possible
Mitomycin C
Single intra-vesical dose of mitomycin C post transurethral resection of superficial bladder cancer improves outcomes
Management of organised/localised prostate cancer
If patient young / life expectancy >10 years –> treat with curative intent
If Gleeson >/7, indicates high risk of progress so should be treated
If elderly, watchful waiting as most tumours take 10-15 years to be clinically relevant
Management of locally advanced prostate cancer
External beam radiotherapy
AND
Hormonal therapy
Surgery is not curative
Management of metastatic prostate cancer
Androgen suppression through orchiectomy or through gonadal axis suppression using GnRH
Bone pain can be treated with external beam radiotherapy or strontium
Benign prostatic hyperplasia
Hyperplasia of peri-urethral tissues
Forms adenomas in transitional zone
Complications of bladder diverticula
Drain poorly causing stasis
Leading to:
Infection
Stones
Tumour
Small prostate benign hyperplasia obstruction management
Alpha-blockers
Tamulosin
Large prostate benign hyperplasia obstruction management
5alpha-reductase inhibitors
Management of acute retention
Catheter
Alfuzosin
TWOC 12 hours later
if fails –> TURP
Dribbling incontinence in a child
Ectopic ureter
Detrusor-sphincter dyssynergia
UMN lesion
Injury between the sacral segment and the pontine micturition centres
Develops a reflex bladder with impaired or absent
cortical control; that is, the bladder loses the coordination imposed by the pontine micturition centre.
Detrusor becomes overactive and attempted voiding results in detrusor contraction occurring synchronously with that of the external sphincter (detrusor-sphincter dyssynergia)
Result is poor bladder emptying and the development of a thick, trabeculated bladder wall
Atonic myogenic bladder
Caused by prolonged outlet obstruction and
is found in the late stages of bladder decompensation.
Most common cause is silent prostatic obstruction, where progressive loss of the desire to void results in overflow incontinence
Nerve innervation for micturation
Parasympathetic innervation S2 - S4 to the detrusor
Sympathetic innervation T10 - L2 to bladder neck and proximal urethra
Somatic innervation S2 - S4 to the bladder, pelvic floor and urethra
Spinal cord damage and micturation
Below / at the level of T12 -L1
–> Flaccid bladder with overflow
Above T12 -L1 = UMN
–> Overactive bladder with poor coordination, causes poor bladder emptying
Seminomas
Arise from Seminiferous tubules
Often low-grade
Sensitive to radiotherapy
