Urology Flashcards
Hytadid of morgani is an embryological remnant of which structure?
What is the classic sign seen?
Mullerian Duct
Blue dot sign
Testicular torsion can be either ____ (rotation within tunica vaginalis - usually peripubertal) or _____ (rotation of spermatic cord - usually neonates) .
Intravaginal
Extravaginal
Treatment options in BPH?
Conservative
Avoid caffeine, sugary drinks, evening fluids
Medical
(1) Alpha blocker - Tamsulosin/ Alfuzosin
(2) 5a- reductase inhibitor - Finasteride/dutasteride
Surgical
TURP/ Laser Vaporisation/ Enucleation
What are the LUTS Storage and Voiding Symptoms?
Remember Mnemonic **FUN WISE Harry*.
Storage:
Frequency
Urgency
Nocturia
Voiding:
Weak Stream
Intermittent Flow
Straining
Emptying incompletely
Hesitancy
Renal stone management
Ureteric stones ______
Small stones (< ___ cm) ______
Large stones (> ____ cm) ______
Ureteric stones - Ureteroscopy and laser ablation
Small stones <2cm - Extracorporeal Shock Wave Lithotripsy
Large stones > 2cm - Percutanous nephrolithotomy
Common sites of renal stone obstruction
PUJ VUJ and BRIM
PUJ - pelvic-ureteric junction
Pelvic brim
VUJ - Vesicoureteric Junction
95% of prostate cancers are what type of cancer?
Which lobe of the prostate are they most likely to be found?
95%** adenocarcinoma**
In situ malignancy is sometimes found in areas adjacent to cancer.
** Multiple biopsies** needed to call true in situ disease.
Often multifocal- 70% lie in the peripheral zone.
Most renal tumours are ______ in colour.
TCC’s are one of the few tumours to appear _____.
.
RCC - yellow or brown
TCC - appear pink
The finding of a TCC in the renal pelvis mandates a nephroureterectomy - as TCC can migrate to the ureters and beyond
Squamous cell carcinoma of the kidney usually arises in an area of chronic inflammation such as a _____. They are rare.
staghorn calculus
Renal Tumour Staging
T1 lesions may be managed by partial nephrectomy and this gives equivalent oncological results to total radical nephrectomy.
For T2 lesions and above a radical nephrectomy is standard practice and this may be performed via a laparoscopic or open approach.
Patients with completely resected disease do not benefit from adjuvant therapy with either chemotherapy or biological agents.
Patients with **transitional cell cancer **will require a nephroureterectomy with disconnection of the ureter at the bladder.
____ is superior to ____ in the assessment of renal function in damaged kidneys (as it is subjected to tubular secretion).
MAG 3 > DMSA when assessing renal function (NB - when we know eGFR is already impaired)
DMSA is the gold standard for identifying scarring but if we already know kidney is scarred, MAG 3 is imaging of choice to assess renal function.
MAG3 and DMSA are both nuclear medicine scans that can be used to evaluate the kidneys using radioisotopes.
MAG3 assesses flow (vessels/tubules etc)
DMSA assesses static tissue
Diethylene-triamine-penta-acetic acid (DTPA)
This is primarily a glomerular filtration agent. It is most useful for the assessment of renal function. Because it is filtered at the level of the glomerulus it provides useful information about the GFR. Image quality may be degraded in patients with chronic renal impairment and derangement of GFR.
MAG 3 renogram
Mercaptoacetyle triglycine is an is extensively protein bound and is 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).
A _____ scan provides information relating to bladder reflux and is obtained by filling the bladder with contrast media (via a catheter) and asking the child to void. Images are taken during this phase and the degree of reflux can be calculated
Micturating cystourethrogram (MCUG scan)
_____ tumours are a sub type of renal cell cancer it is associated with specific genetic changes localised to chromosome ____
Clear cell
Chromosome 3
Renal cell carcinoma
Most present with haematuria (50%)
Common renal tumour (85% cases)
Paraneoplastic features include ___ and ___
Most commonly has ____ metastasis
Treatment - Usually ____ or _____
hypertension and polycythaemia
haematogenous
radical or partial nephrectomy
A posterior urethral valve is an obstructive, developmental uropathy that usually affects male infants (incidence 1 in 8000).
Diagnostic features include bladder wall hypertrophy, hydronephrosis and bladder diverticula.
Urethral valves
Posterior urethral valves are the commonest cause of infravesical outflow obstruction in males. They may be diagnosed with ____ . Because the bladder has to develop high emptying pressures in utero, the child may develop renal parenchymal damage. This translates to renal impairment noted in 70% of boys at presentation. Treatment is with ____.
_____ is the definitive treatment of choice with cystoscopic and renal follow up.
ante natal ultrasonography
bladder catheterisation
Endoscopic valvotomy
Adrenal lesions- Incidental
Incidentaloma of the adrenal glands have become increasingly common as CT scanning of the abdomen is widely undertaken. Prevalences range from 1.5-9% in autopsy studies. Overall, 75% will be non functioning adenomas. Investigation to exclude a functioning lesion is as below:
Investigation ____
Management _____
Arrange a hormonal assay!
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
The risk of malignancy is related to the size of the lesion and 25% of all masses greater than 4cm will be malignant.
Such lesions should usually be excised. Where a lesion is a suspected metastatic deposit a biopsy may be considered.
Causes of Haematuria
Causes of haematuria
Trauma
Injury to renal tract
Renal trauma commonly due to blunt injury (others penetrating injuries)
Ureter trauma rare: iatrogenic
Bladder trauma: due to RTA or pelvic fractures
Infection
Remember TB
**Malignancy **
Renal cell carcinoma (remember paraneoplastic syndromes): painful or painless
Urothelial malignancies: 90% are transitional cell carcinoma, can occur anywhere along the urinary tract. Painless haematuria.
Squamous cell carcinoma and adenocarcinoma: rare bladder tumours
Prostate cancer
Penile cancers: SCC
Renal disease
Glomerulonephritis
Stones
Microscopic haematuria common
**Structural abnormalities **
Benign prostatic hyperplasia (BPH) causes haematuria due to hypervascularity of the prostate gland
Cystic renal lesions e.g. polycystic kidney disease
Vascular malformations
Renal vein thrombosis due to renal cell carcinoma
**Coagulopathy **
Causes bleeding of underlying lesions
**Drugs **
Cause tubular necrosis or interstitial nephritis: aminoglycosides, chemotherapy
Interstitial nephritis: penicillin, sulphonamides, and NSAIDs
Anticoagulants
**Benign **
Exercise
**Gynaecological **
Endometriosis: flank pain, dysuria, and haematuria that is cyclical
Iatrogenic
Catheterisation
Radiotherapy; cystitis, severe haemorrhage, bladder necrosis
Pseudohaematuria For example following consumption of beetroot/rhubarb/blackberries
Priapism
Causes ___
Investigations ___
Management ____
Priapism
Prolonged unwanted erection, in the absence of sexual desire, lasting more than 4 hours.
Classification of priapism
Low flow priapism 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 priapism Due to unregulated arterial blood flow.
Usually presents as semi rigid painless erection
Recurrent priapism Typically seen in sickle cell disease, most commonly of high flow type.
Causes
Intracavernosal drug therapies (e.g. for erectile dysfunction>
Blood disorders such as leukaemia and sickle cell disease
Neurogenic disorders such as spinal cord transection
Trauma to penis resulting in arterio-venous malformations
Tests
Exclude sickle cell/ leukaemia
Consider blood sampling from cavernosa to determine whether high or low flow (low flow is often hypoxic)
Management
Ice packs/ cold showers
If due to low flow then blood may be aspirated from copora or try intracavernosal alpha adrenergic agonists.
Delayed therapy of low flow priapism may result in erectile dysfunction.
Treatment for prostate cancer
Treatment
Watch and wait- Elderly, multiple co-morbidities, low Gleason score
Radiotherapy (External)- Both potentially curative and palliative therapy possible. However, radiation proctitis and rectal malignancy are late problems. Brachytherapy is a modification allowing internal radiotherapy. (local insertion of radioactive material adjacent to tumour site)
Surgery- Radical prostatectomy. Surgical removal of the prostate is the standard treatment for localised disease. The robot is being used increasingly for this procedure. As well as the prostate the obturator nodes are also removed to complement the staging process. Erectile dysfunction is a common side effect. Survival may be better than with radiotherapy. Functional outcomes are better when a robotic approach is used.
Hormonal therapy- Testosterone stimulates prostate tissue and prostatic cancers usually show some degree of testosterone dependence. 95% of testosterone is derived from the testis and bilateral orchidectomy may be used for this reason.
Pharmacological alternatives include LHRH analogues and anti androgens (which may be given in combination) -
e.g *flumatide / bicalumatide / cyproterone *
In the UK the National Institute for Clinical Excellence (NICE) suggests that active surveillance is the preferred option for low risk men. It is particularly suitable for men with clinical stage T1c, Gleason score 3+3 and PSA density < 0.15 ng/ml/ml who have cancer in less than 50% of their biopsy cores, with < 10 mm of any core involved.
Causes of Hydronephrosis
Causes of hydronephrosis
Unilateral: PACT
Pelvic-ureteric obstruction (congenital or acquired)
Aberrant renal vessels
Calculi
Tumours of renal pelvis
Bilateral: SUPER
Stenosis of the urethra
Urethral valve
Prostatic enlargement
Extensive bladder tumour
Retro-peritoneal fibrosis
Which form of bacteria are commonly responsible for producing struvite crystals and thereby sometimes staghorn calculi?
Proteus!
Infection urinary stones resulting from urease-producing bacteria are composed by struvite and/or carbonate apatite.
Bacterial urease splits urea and promotes the formation of ammonia and carbon dioxide leading to urine alkalinization and formation of phosphate salts.
Proteus species are urease-producers, whereas a limited number of strains of other Gram negative and positive species may produce urease.
Name 3 Complications of vasectomy
Chronic scrotal pain
Haematomas
Sperm granulomas
A 3 month old boy is brought to the clinic by his mother who has noticed a swelling in the right hemiscrotum. On examination, there is a firm mass affecting the right spermatic cord distally, the testis is felt separately from it. What is the most likely diagnosis?
Rhabdomyosarcoma are paratesticular tumours with a bimodal distribution.
Because the mass is felt separate to the testis, this is the more likely diagnosis.
5% of testicular tumors
Most often arises in distal portion of spermatic cord and may invade testis of surrounding tissues
60% occur in the first 2 decades of life
Bimodal age distribution - 3-4 months - 16 years
Arises from mesenchymal tissue - 90% embryonal variant (better prognosis) - 30% - 50% have metastasis (usually lymph node) at diagnosis
Which chemotherapeutic agent causes haemorrhagic cystitis?
Cyclophosphamide is metabolised into a toxic metabolite acrolein.
The effects may be attenuated by administration of large volumes of intravenous fluids and mesna (which neutralises the metabolite).
The condition may be managed initially by bladder catheterisation and irrigation.
In men with metastatic bone lesions from prostate cancer, the best outcomes are achieved with _____
___ and ___ can also be used as adjuvant therapies to improve symptom control
Androgen supression (ex. **LHRH analogues aka GnRH agonists
(e.g goserelin / leuprorelin / triptorelin)
and anti androgens** (which may be given in combination) -
(**e.g *flumatide / bicalumatide / cyproterone * )
Radiotherapy and Bisphosphonates
Which class of renal stone is the most radiodense on plain xray
Calcium phosphate stones (nearing the composition of bone)
(calcium oxalate stones slightly less so)
Uric acid stones are radiolucent (unless they have calcium contained within them).
Pregnancy and frank haematuria, especially if there is a history of placenta previa or prior caesarean section, should indicate ____ .
Placenta percreta
There is invasive placental implantation into the myometrium, which can rarely extend into the bladder causing severe bleeding.
Hydrocele management in:
Children ____
Adults ____
Hydroceles are managed differently 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 - Lords and Jaboulay procedures
Which classes of renal stones are not fully radio-opaque on XRAY?
urate + xanthine stones: radio-lucent
cystine stones: semi-opaque
Seminoma is the commonest type of testicular tumour and is more common in males aged between ____ years. Classical seminoma is the commonest subtype and histology shows _____ .
30-40
lymphocytic stromal infiltrate
Both nephroblastoma and neuroblastoma may occupy the adrenal and apex of the kidney.
In the case of neuroblastoma the lesion will have arisen from the adrenal (Comes from brain down), in the case of nephroblastoma the lesion will have arisen from the kidney.
Hypertension is more commonly associated with ____ .
In terms of composition Neuroblastomas are usually ____ whereas nephroblastomas are not and this may be of diagnostic usefulness pre operatively.
Wilm’s aka nephroblastoma
nephroblastoma
calcified
Leydig cell tumours are rare testicular sex cord stromal tumours (which also include sertoli cell tumours) which are associated with hormonal activity.
Patients with Leydig cell tumours may present with _____ before they notice testicular enlargement.
Majority are ____
Histology: _____ in columns
gynaecomastia
benign
eosinophilic cells
Name 5 drugs that can cause pseudohaematuria?
Rifampicin
phenytoin
levodopa
methyldopa
quinine
all cause pseudohaematuria.
Renal stones management:
< 5mm and asymptomatic _____
<10mm
10- 20mm
> 20mm (including staghorn calculi)
Ureteric stones management:
< 5mm
5-10mm ____ (if upper ureter)
10-20mm
< 5mm - Watchful waiting
<10mm - ESWL
10-20mm - ESWL or ureteroscopy
> 20mm PCNL
Watchful waiting
ESWL
Ureteroscopy
ESWL is contra-indicated in pregnant females and patients with significant vascular calcification.
Which class of renal stones are associated with an inherited metabolic disorder?
Cystine stones
A 35 year old male presents with haematuria. He is found to have bilateral masses in the flanks. He has a history of epilepsy and learning disability. Which renal lesion is he most likely to have?
angiomyolipoma
This patient has tuberous sclerosis. This is associated with angiomyolipoma, which is present in 60-80% patients. It is a benign lesion.
80% of these hamartoma type lesions occur sporadically, the remainder are seen in those with tuberous sclerosis
Tumour is composed of blood vessels, smooth muscle and fat
Massive bleeding may occur in 10% of cases
50% of patients with lesions >4cm will have symptoms and will require surgical resection
