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
Teratoma
(non-seminomas)
Arise from primitive germinal cells
Not sensitive to radiotherapy
Treatment of hydronephrosis
acute: nephrostomoy tube
chronic: ureteric stent or pyeloplasty
Signs of bulbar urethral injury
most common
- straddle type injury e.g. bicycles
- triad signs: urinary retention, perineal haematoma, blood at the meatus
Signs of membranous urethral injury
prostate displaced upwards (beware co-existing retroperitoneal haematomas as they may make examination difficult
Investigation for damaged urethra
Ascending urethrogram
Management for ruptured urethra
Suprapubic catheter
Mx of renal stone
Less than 5mm and asymptomatic: Watchful waiting
Less than 10mm:
ESWL
10 20mm:
ESWL or ureteroscopy
Greater than 20mm (including staghorn calculi):
PCNL
Mx of ureteric stones
Less than 5mm Watchful waiting
5-10mm ESWL (if upper ureter)
10-20mm Ureteroscopy
Autonomic nerves of erection
Sympathetic nerves originate from T11-L2 and parasympathetic nerves from S2-4 join to form pelvic plexus.
Most common location of prostate cancer
Peripheral zone
Best and worst Gleason score
2 and 10
First nodes that prostate cancer spreads to
Obtruator
Most common renal cancer
Adenocarcinoma
Paraneoplastic syndrome commonly seen in renal cancer
Polycythaemia and HTN
How does renal adenocarcinoma spread?
Haematogenous
Tx for renal adenocarcinoma
radical or partial nephrectomy
Treatment of nephroblastoma
Vincrystine
Actinomycin D
Doxorubicin
Ix for Nephroblastoma
USS and CT
Most common lower urinary tract carcinoma
Transitional cells
RFs for TCC of LUT
Dyes
Rubber
Common PC of TCC in lower urinary tract
painless haematuria
Treatment for TCC
Nephroureterectomy
What type of cancer does schistosomiasis cause?
Squamous
Why does cysteine produced a radio-opaque stone?
Contains sulphur
Describe staghorn calculus
involve the renal pelvis and extend into at least 2 calyces. They develop in alkaline urine and are composed of struvite (ammonium magnesium phosphate, triple phosphate)
What bacteria result in staghorn calculus?
Ureaplasma urealyticum and Proteus infections predispose to their formation
How are testicular tumours treated?
Testicular malignancy is always treated with orchidectomy via an inguinal approach
What is the difference in management of a hydrocele between adults and children?
in children where the underlying pathology is a patent processus vaginalis and therefore an inguinal approach is used in children so that the processus can be ligated. In adults a scrotal approach is preferred and the hydrocele sac excised or plicated
What is the most common type of testicular tumour?
Seminoma
How to differentiate between seminoma and non seminoma tumour?
AFP is normal in seminoma, raised in non-seminoma
What drug can cause non-infective epididymo orchitis?
Amiodarone - stop the drug
What is DMSA scan used for?
DMSA localises to the renal cortex with little accumulation in the renal papilla and medulla. It is useful for the identification of cortical defects and ectopic or aberrant kidneys. It does not provide useful information on the ureter of collecting system.
What is MAG 3 scan used for?
primarily secreted by tubular cells rather than filtered at the glomerulus. This makes it the agent of choice for imaging the kidneys of patients with existing renal impairment (where GFR is impaired).
to assess for failing transplants
Causes of unilateral hydronephrosis
PACT
Pelvic-ureteric obstruction (congenital or acquired)
Aberrant renal vessels
Calculi
Tumours of renal pelvis
Causes of bilateral hydronephrosis
SUPER
Stenosis of the urethra
Urethral valve
Prostatic enlargement
Extensive bladder tumour
Retro-peritoneal fibrosis
Which fascia separates prostate from rectum?
Deonvilliers
What fascia does bucks surround?
spongiose part of urethra
How do alpha blockers work on the prostate?
These block the action of noradrenaline on prostatic smooth muscle causing relaxation and improved bladder emptying.
Added benefit of finasteride
reduction in urinary retention
Which specific infection can cause haematuria
TB
Management of hydronephrosis
Acute upper urinary tract obstruction: Nephrostomy tube
Chronic upper urinary tract obstruction: Ureteric stent or a pyeloplasty
Most common type of priapism and causes
low flow
venous occlusion
Often painful
Often low cavernosal flow
If present for >4 hours requires emergency treatment
Post renal tumour resection tx
Patients with completely resected disease do not benefit from adjuvant therapy with either chemotherapy or biological agents
How are epididymal cysts removed?
Excision using scrotal approach
