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
An 18 month old boy presents with recurrent urinary tract infections. An ultrasound scan is performed and shows bilateral hydronephrosis and hydroureter.
Posterior urethral valves
Diagnostic features include bladder wall hypertrophy, hydronephrosis and bladder diverticula.
Mx of posterior urethral valves
Treatment is with bladder catheterisation. Endoscopic valvotomy is the definitive treatment of choice with cystoscopic and renal follow up.
Renal imaging
DMSA- useful for cortical defects, ectopic or aberrant kidneys, no info of ureters
MAG3- secreted by tubulars- useful if GFR is impaired - often used in investigating failing transplant
PREFERRED in neonates, impaired function, obstruction
DTPA- filtered at the level of the glomerulus -GFR and renal fucntion
What cells on mets suggest renal cell carcinoma
Clear cell tumours
By what age should 95% of foreskins be retractable
16
Pelvic frature and peritonism
Bladder rupture
Firm mass felt in distal spermatic cord of 3m old boy
Rhabdomyosarcoma
TCC of kidney features
Exposure to chemicals in textile, plastic and rubber
Angiomyolipoma features
Tuberous sclerosis
Tumour is composed of blood vessels, smooth muscle and fat
Massive bleeding may occur in 10% of cases
Mx of angiomyolipoma
50% of patients with lesions >4cm will have symptoms and will require surgical resection
Child with flank mass, hypertensive dx ix and mx
Nephroblastoma
US and CT
Surgical resection combined with chemotherapy
Child with calcified tumour of adrenal gland, dx, ix and mx
Neuroblastoma
Neural crest origin
MIBG scan, CT to stage
Resection, radio and chemo
Child has urine that is difficult to control
Hypospadias
No hesitancy
Male with testicular mass and gynaecomastia
Leydig cell tumour-produce testosterone and oestrogen
Which drug causes haemorrhage cystitis
Cyclophosphamide
Epopnymou name for Renal AC
Grawitz tumour
A 58 year old man has an episode of painless frank haematuria whilst undergoing a 24 urine collection for investigation of hypertension.
Renal adenocarcinoma
A 20 year old male notices a mild painful swelling of his right scrotum. He also complains of abdominal pain. Clinically, the patient is found to have a swollen right testicle. Supraclavicular node lymphandenopathy
Teratoma
Thats mets
Will need orchidectomy via inguinal approach
Classification of priapism
Low flow
Due to veno-occlusion (high intracavernosal pressures).
Most common type
Often painful
Often low cavernosal flow
If present for >4 hours requires emergency treatment
High flow
Due to unregulated arterial blood flow.
Usually presents as semi rigid painless erection
Recurrent
Typically seen in sickle cell disease, most commonly of high flow type.
Aspiration of priapism
Bright red- high flow
Dark red- low flow
Mx of low flow priapism
Aspiration from corpus cavernosa ini attempt to decompress
Pink renal tumour
TCC
Most others are yellow or brown
Preg with brisk frank Haematuria, prev c section
Placenta percreta
Which meds are associated with less risk of urinary retention
FInasteride
Ix of prostate cancer
PSA
MRI for staging
Biopsy
Incidental adrenal lesions ix
Morning and midnight plasma cortisol measurements
Dexamethasone suppression test
24 hour urinary cortisol excretion
24 hour urinary excretion of catecholamines
Serum potassium, aldosterone and renin levels
When should you be suspicious of malignancy in adrenal mass
25% of all adrenal lesions >4cm in diameter are malignant
Tx of TCC blocking ureteric orifice
Antegrade ureteric stent
Ureteric filling defects and irregular renal pelvis
TCC- as can do down ureter
Differentiating between neuro vs nephrology in child on examination
Nephroblastoma – if midline not crossed Neuroblastoma – if midline crossed
Which artery if ligated would affect supply to seminal vesicles the most
middle rectal artery,also supplied by inferior vesicle
What can happen as a consequence of TURP
HypoNa
Hypertension
Bradycardia reflex
Most common area for renal stones
Uterovesical junction
Which urinary stones are acidic
Uric and cystein
What is the patient at risk of if had testicular torsion
Cancer in ispilateral and contralateral teste
Risks with TURP
Retrograde ejactulation
Important measurements in teratoma management
Tumour markers
To monitor if orchidectomy is effective
Increased vascularity of DTPA scan
Tumour -SOL
First line Ix for LUTS
DRE, PSA, creatinine, post void volume, Flow rate, renal US
Most common cancer to be multi centric
TCC
More than 1 at once
Young patient has proteinuria - next ix and mx
ACR- more sensitive
Fasting blood glucose
urine protein electrophoresis
Nephrology referral
Myeloma or renal disease
Other tx patients with prostate cancer undergoing radio with sig LUTS
TURP - otherwise risk of retention
Colour of hydrocele when pen torch used
Red
Types of undescended teste
Retractile
Ectopic
Incomplete descent
Atrophic
Acquired UDT - ascended
Risk fo cryptochordism
Cancer 8x and infertility
Other processus vaginalis likely patent
White blood cell casts on urine
Glomerulonephritis and TI nephritis
Pyelonephritis
What is used to estimate GFR
Serum creatinine
Anomalies assorted With hyposadius
Undescended testes, inguinal hernia, disorder of sexual development and hydrocele
When is hhyospadius repair done
Indicated if deformity severe, intervenes with voiding or predicted sexual function
6-18m age
Appendage commonly affected by torsion
Hydatid of Morgagni
Tx of Wilms tumour
Resection and chemo
Where Wilms tumour spread to
Lung
Kidney transplant anastomosis
To external iliac artery and vein
When are anticholinergics CI
MG
Bowel disorders
Glaucoma
Bladder Outflow obstruction
CI of PCNL
Clotting abnormalities
What does urine specific gravity measure
Renal concentrating ability
Examples of benign renal tumours
Oncocytoma and angiomyolipoma
Tumour to develop in maldescended teste
Seminoma
TNM of renal tumour
T1 <7cm a <4cm b4-7
2- >7cm limited to kidney
3a- into renal veins but not Gerotas
b- in IVC below diaphragm
c- above diaphragm
T4- gerotas even adrenals
N1- single
N2- mutliple
Tx of muscle invasive bladder cancer
Cystectomy
Tx of non muscle invasive bladder cancer
Low risk - TURBT and Intravesicle mitomycin C
Intermediate-TURBT anf 6x Intravesicle mitomycin C
High- TURBT and again within 6w then BCG or radical cystectomy
Renal replacement therapy indication and options
Indicated in fluid overload, hyperkalaremia, acidosis and uraemia
Haemofilatration or peritoneal
Urinary sodium in ATN vs pre renal
Low <20 in pre rnal
High in ATN
As tubules non functioning and unable to absorb
C diff diagnosis
Toxin in faeces
Examples of urease producing bacteraemia
Proteus
Klebsiella
Pseudomonas
Appearance of squamous cell carcinoma
Solid
Trigone or lateral walls
Invasive
Most common organic cause of impotence
Diabetes
HIV patient with loin pain but no stone on imaging
Indinavir stone - radiolucent
Gout renal stones
Uric acid
TNM of teste cancer
T1- teste
2- tunica albuginea or vaginalis with vascular/lymph
3- spermatic cord
4- scortum
N1- node <2cm, less than 5
2- 2-5 all <5 or
3- lymph node >5cm
M1 distant mets
UTI pathogen with recent surgery
Staph aureus
Mx of priapism
Low flow- urgent decompression with aspiration of blood from corpora
High flow- conservative
Condition causing priapism
Sickle cell
Define priapism
Prolonged unwanted erection in absence of sexual desire for >4hrs
RF of SCC of bladder
Long term indwelling
Schisto
Best scan for obstruction
MAG3
Abx for preg UTI at term allergic to amox
Cephalexin
Drug causing epipid-orchitis
Amiodarone
Epididymo-orchitis abx course
2w doxy or cipro
Microscopic haematura ix
Flexible cystocopy
When should urethral repair surgery happen after injury
6-12w
Pt mass in abdo, unsure if started period
Imperforate hymen
Haematocolpos
?renal stones and preg ix
USS first line
Gleason score meaning
8-10 poorly differentiated
7 mod
<7 well
Pre orhcidetomy work up
AFP, bhcg, LDH
CT chest abdo pelvis
Fertility counselling
Fixing method of testes in torsion
Both testes invaginated in the tunica vaginalis and sutured to the midline septum with non absorbable sutures
Ureters on X ray location
Medial to transverse processes of lumbar
Start at L1
What is posterior to ureters at pelvic brim
Bifurication of common lilac artery
Mx of undescended teste
After 6m should be corrected by 12m
If >2cm from deep- Fowler Stephen method
<2cm- 1 stage orchidoplexy
Sudden flank pain, anuria, elevation in creatinine
Renal vein thrombosis
