Urology Flashcards
Principles of prostate cancer management
Young- radial prostectomy
Old- no symp- watch and wait
Symptoms i.e blockage- no pain- hormonal
Pain from mets- pain ladder then radiotherapy
Management of BPH
Tamsulosin- a blocker for SM relaxation- work at neck of bladder
Finasteride- 5a reductase inhibitor- blocks DHT
If severe symptoms not responding to medical therapy
TURP
If small prostate- bladder neck incision procedures
Torsion of testes vs appendage
Teste- no cremastatic reflex present
Elevation of teste does not ease pain
Twisting of testicular cord
10-30 age
Red scrotum
Appendage- present
May be a blue dot
Pain of tests aided by elevation
Varicocele
Tx of testicular torsion
Surgical exploration
Bilateral fixation
Since Bell Clapper testes are usually bilateral
Types and presentation of urethra rupture
Blood in urethra- most common
Bulbar
Most common
Cyclist
Perineal Haematoma
Urinary retention
Membranous
Pelvic fracture
High riding prostate
Mx of ?membranous urethra rupture
Ascending Urethrogram
Suprapubic catheter
Urethroplasty definitive
Tense, tender non-transuluminating mass in scrotum , dx and mx
Haematocele - require surgical exploration
Hx of trauma
Haematocele vs hydrocele
Haematocele- painful, ischaemic, non transilluminating
Hydrocele- non painful, fluctuating, can get above, transilluminating
Perineal injury and butterfly haematoma
Penile urethral and Bucks fascia injury (Depp fascia of penis)
Varicocele veins and ix
Pampiniform plexus
US to ix for RCC
Teste malignacy surgery
Orchidectomy vie inguinal approach
Allows high ligation of artery and avoid exposure of lymphatics
Dribbling incontinence
Vaginal vesicle fistula
Post labour
Renal and ureteric stone management
Renal-<5mm asymptomatic- watch and wait- most will pass within 4w
<10mm- ESWL
10-20mm- ESWL or ureteroscopy- ( or if pregnant)
Lower pole calyx- PCNL if >1cm
Upper pole ESWL if <2cm
> 20mm or staghorn- PCNL
Ureteric - if upper or middle 1/3- push bang technique
Lower 1/3- JJ stent
<5mm WW
5-10- ESWL
10-20 ureteroscopy
Obstructive features- RF/ Sepsis/ Solitary Kidney/ Continuing obstruction) present then
Nephrostomy. If no Nephrostomy option in answer key ,then give Ureteric stent opt
Organisms with renal tract
E coli
Prophylactic gent
When is lithotripsy CI
Pregnancy
Impending AAA rupture
Significant vascular calcification
Urosepsis
Uncorrected coagulopathy
Which stones are more likely to pass spontaneously
Distally sited
Primary vs secondary hydrocele
Primary- congenial- incomplete fusing of tunica vaginalis
Seconday- develops over longer period- not tense swelling
Features of hydrocele
Difficulty palpating test
Can get above it
Transilluminates
Fluctuant
Features of each type of renal stone
Calcium oxalate- high calcium
Radio-opaque
Hyperuricosuria
Cystine -multiple stone
Inherited disorder- familial
Inherited recessive
Sulphur
Acidic
Uric acid- occur in malignancy
Radiolucent
Most acidic
Calcium phosphate- renal tubular acidosis 1 and 3
Alkaline pH
Most radio-opaque
Struvate- Associated with chronic infections
Only Slightly radio-opaque
Alkaline pH
Mg, Ammonium, P
Which stones with most acidic vs alkaline pH
Acidic- Uric acid - 5.5
Cysteine
Alkalinic- strivate >7.2
calcium phosphate >5.5
Cause of SCC of kidney to arise
From chronic inflammation of kidney
Such as staghorn calculi
Part of nephron that RCC arises from
PCT
Testicular cancer by age and tumour markers
> 30- Seminoma
bHCG- elevated in 10%
Lactate DH- 10-20%
Sheet like fribous, lymphatic and granuloma
<30- Non seminoma
AFP high in 70%
bHCG in 40%
Testicular caner pathology
Seminoma
Sheet like lobular patterns of cells with substantial fibrous component. Fibrous septa contain lymphocytic inclusions and granulomas may be seen.
Non seminoma
Heterogenous texture with occasional ectopic tissue such as hair
Non infective cause of epipidymo orchitis
Amiodarone
Scan for renal scarring
DMSA
Tx of non muscle invasive/ CIS/T1 TCC
Low risk (G1/2 <3cm)- TURBT and 1 shot of mycomycin
Intermediate risk (G1/2 >3cm)- TURBT and 6x shtos of IC mycomycin
High risk (G3)- TURBT, then another TURBT within 6w and then IC BCG or radical cystectomy
Tx of T2-3 bladder cancer
Radical Cystectomy + chemo
Staging of bladder cancer
T1- subepithelial connective tissue (thru’ lamina propria)
T2- muscle layer
T3- through wall into pre vesicle/fatty layer around it
T4- nearby organs
a- prostate, uterus, vagina
T4b- pelvic wall or abdominal wall
Treatment of T4b bladder cancer
Inoperable pallitaiton
Treatment of N1 bladder cancer
Palliation
Management of incontinence
Stress- pelvic floor exercises 3m
Consider surgery - colposuspension or rectus fascial sling
Urge- training 6w
then oxybutinin
Then botulism to detrusor overreactive
Then sacral nerve stimulation
RCC paraneoplastic
Hypercalcaemia
Hypertension
Polycythaemia
Cushing
Non mets liver dysfunction - Stauffer’s syndrome
Galactorrhoea
CHARGE
Cannon ball mets in lung
Mets from RCC
Non endocrine paraneoplastic RCC
Anaemia
Amyloidosis
Neuropathy
Coagulopathy
Pathophysiology of paraneoplastic syndrome
Triggered by an altered immune system response to a neoplasm. They are defined as clinical syndromes involving nonmetastatic systemic effects that accompany malignant disease
Or it secretes a hormone
Pseudo haematuria
Myoglobinuria
Haemaglobinuria
Rifampicin, methyldopa, phenytoin, quinine
Porphyria
Bilirubinuria
What should you give initially when treating prostate cancer medically
LHRH agonist- goserelin
Anti-androgen- to counter flare in first 3w - flutamide
Which cancers do you not biopsy
Hepatic
Renal
Testicular
Mx of hydrocele in paeds
Non communicating usually disappear by 1st bday
If still present
Likely Communicating hydrocele
Require trans inguinal ligation of the PPV
Gleason scoring
The Gleason score is calculated by adding together the two grades of cancer cells that make up the largest areas of the biopsied tissue sample
On a scale of 1-5 each
The two added together give the Gleason score. Where 2 is best prognosis and 10 the worst.
Where does lymphatic spread of prostate cancer spread to first
Obturator
What gives a higher cancer of distant spread in prostate cancer
Local spread to seminal vesicles
Mx of RCC
T1- partial nephrectomy
For T2 lesions and above a radical nephrectomy
Patients with completely resected disease do not benefit from adjuvant therapy
Transitional cell cancer of kidney/ureter tx
Nephroureterectomy with disconnection of the ureter at the bladder.
Tx for bone mets from prostatic cancer
Androgen
Bisphosphonate
Radiotherapy
Man with malignancy on chemo, colicky pain, with nothing showing on x ray
Uric acid stone
Will not show on X ray
Will show on USS
Penile fracture features and mx
Intercourse
Snap
Proximal shaft
Tense haematoma and blood may be seen at the meatus if the urethra is injured.
Surgical and a circumferential incision made immediately inferior to the glans. The skin and superficial tissues are stripped back and the penile shaft inspected. Injuries are usually sutured and the urethra repaired over a catheter.
Features of tuberous sclerosis
depigmented ‘ash-leaf’ spots which fluoresce under UV light
roughened patches of skin over lumbar spine (Shagreen patches)
adenoma sebaceum: butterfly distribution over nose
fibromata beneath nails (subungual fibromata)
café-au-lait spots* may be seen
Epilepsy
Learning difficulties
polycystic kidneys, renal angiomyolipomata
Effects of a blockers vs 5a reductase
5a - better SE profile
a- faster onset
Innervation of male gentialia
Scortum- anterior- ilioinguinal and gentiofemoral
Posterior- posterior scrotal nerves from perineal
Penis- dorsal nerve of penis
Parasympathetic innervation is carried by cavernous nerves from the peri-prostatic nerve plexus,
Innervation of female genetalia
Anterior – ilioinguinal nerve, genital branch of the genitofemoral nerve
Posterior – pudendal nerve, posterior cutaneous nerve of the thigh.
Clitoris- dorsal nerve of clitoris
The clitoris and the vestibule also receive parasympathetic innervation from the cavernous nerves – derived from the uterovaginal plexus
Man kicked in testes, very swollen and tender what mx?
Scrotal exploration for Acute haematocele
Repair damage
Mx of adult hydrocele
Jaboulay procedure via scrotal approach
subtotal excision of the tunica vaginalis and everting the sac behind the testes followed by placing the testes in a newly created pocket between the fascial layers of the scrotum
Likely organism cause of staghorn calculus
Proteus
Symp vs para innervation of penis
Symp- ejaculation -T11-L1- from pelvis plexus to cavernous nerve
Para- erection- S1-4- splanchnic nerve (nervi erigentes) to cavernous nerve
Which lobe is most likely enlarged in prostate in BPH and which is most likely affected by carcinoma
Median- BPH
Post- carcinoma
What has been damaged when someone post colon surgery has impotence
nervi erigentes
Splachnic nerves- in abdo contain symp- pelvic para
Which stone is most radio dense
Calcium Phosphate