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Urology Flashcards

1
Q

causes of haematuria

A 
tumours
infection
trauma
stones
nephrological causes (e.g. IgA nephropathy)
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2
Q

what type of cancer is a renal cell carcinoma?

A

adenocarcinoma of the renal parenchyma
derived from the PCT epithelium
~70% are clear cell which are associated with Von-Hippel Lindau disease

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3
Q

what is the classic triad of pt presentation of RCC?

A

seen in 10% –> loin pain, haematuria and a palpable mass

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4
Q

what paraneoplastic syndromes can RCC cause?

A 
Stauffer's syndrome (abnormal LFTs)
hypercalcaemia 
hypertension 
polycythaemia/anaemia 
pyrexia
amenorrhoea, baldness, Cushings
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5
Q

what Ix are needed for visible haematuria?

A

FBC, U&Es, clotting
USS, CT Urogram with contrast
flexible cystoscopy with LA
cystoscopy and washout under GA if actively bleeding

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6
Q

risk factors for RCC

A

smoking
obesity
FH
genetic syndromes

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7
Q

how is RCC diagnosed?

A

USS initially and then CT with contrast to confirm and stage

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8
Q

staging of RCC

A

T1a = <4cm (needs partial nephrectomy and surveillance)
T2a = 7-10cm (laparoscopic radical nephrectomy)
T2b + >10cm (open radical nephrectomy)
T3a = perinephric fat and renal vein invasion (open radical nephrectomy)
T3b/c = involvement of the IVC (open nephrectomy and IVC thrombectomy/ resection)
T4 = into adjacent structures (open nephrectomy and resection of other structures and LNs)
N1 = regional lymph node spread (open nephrectomy and resection of other structures and LNs)
M1 = metastasis (nephrectomy and resection of mets, also give tyrosine kinase inhibitors)

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9
Q

what is Upper Tract Transitional Cell Carcinoma

A

an uncommon cancer of the renal pelvis
small and low grade tumours can be treated with laser ablation
non-metastatic tumours can be treated with nephroureterectomy laproscopically

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10
Q

penile cancer

A

squamous cell carcinoma that is very rare
needs to be excised –> circumcision, glansectomy and partial/total penectomy plus inguinal/pelvis and sentinel node biopsy
if superficial can give topical 5 F-U as an adjuvant

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11
Q

what are the different types of bladder cancer?

A

~80% are TCC
20% are SCC
1% are adenocarcinomas

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12
Q

how is a bladder cancer assessed?

A

usually detected by flexible cystoscopy and then initial management is by a transurethral resection of bladder tumour (TURBT)
TURBT allows the histological assessment of type, grading and staging

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13
Q

what is the treatment of bladder cancer?

A

if a SCC or adenocarcinoma then they are invasive so must have radical treatment and scan for any metastasis
if a superficial TCC:
low risk - cytoscopic surveillance
intermediate risk - 6x weekly mitomycin instillations
high risk - BCG regimen (reduces progression), mitomycin (reduces recurrence) +/- cystectomy
if muscle invasive - organ confined then neoadjuvant chemo, cystectomy and chemoradiotherapy, if metastatic then palliative chemotherapy to slow progression of the disease

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14
Q

how does the BCG regimen used to treat high risk bladder TCCs work?

A

BCG (same as TB vaccines) regimen is given intravesically to stimulate type IV hypersensitivity reaction in order to active immune cells to the tumour antigen

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15
Q

what are the side effects of the BCG regimen?

A 
dysuria
frequency 
urgency 
UTIs
haematuria 
rarely - systemic BCGosis, bladder contracture and ureteric stenosis can occur
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16
Q

what is a cystoprostatectomy?

A

a radical cystectomy in a male

involves removal of the bladder +/- urethra

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17
Q

what is an anterior exenteration?

A

a radical cystectomy in a female

involves removal of the bladder, uterus, fallopian tubes, ovaries and anterior vaginal wall

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18
Q

types of urinary diversion

A

ileal conduit
neobladder
continent cutaneous diversion

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19
Q

what is an ileal conduit?

A

ureters are connected to a section of the small bowel which is brought out as a stoma and drains into a bag

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20
Q

what is a neobladder?

A

“new bladder” made of small bowel so the pt “voids” urine
CI if the tumour extends to the urethra
neobladder needs to be stretched so pt has to set alarms to void every 3 hours initially, it can kink so pts need to manipulate it to release the urine

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21
Q

what is a continent cutaneous diversion aka Indianna Pouch?

A

a pouch formed from the right hemicolon
the stoma is catheterisable
CI in those unable to self-catheterise, renal and hepatic impairment, and if their is inadequate small bowel e.g. in Crohn’s

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22
Q

risks of continent urinary diversions

A 
hyperchloraemic metabolic acidosis 
perforation 
stones
mucus
incontinence (leaking)
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23
Q

what type of cancer is prostate cancer?

A

an adenocarcinoma

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24
Q

why aren’t men routinely screened for CaP?

A

as 80% of men >80 have prostate cancer but only 3% will die from it
screening would result in over diagnosis, overtreatment and reduced quality of life for those who would have died with their cancer and not from it

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25
risk factors for CaP
age FH genetics (HPC1 and BRCA) ethnic origin
26
what is PSA?
prostate specific antigen - a serine protease (seminal anticoagulant)
27
what can cause a raised PSA?
CaP (if >100 then likely to be metastatic) UTI BPH urinary retention
28
ix for CaP
PSA DRE MRI TRUS biopsy
29
what is the Gleason Grading (GG) used for?
to grade CaP a grade of 3-5 is given based on differentiation, overall grade is the sum of the two highest found low grade = GG 3+3=6 intermediate grade = GG 3+4=7 high grade = GG 4+3=7 or above
30
what are the treatment options for CaP?
if low grade then active surveillance/watchful waiting radical prostatectomy (risk of incontinence and impotence) external beam radiotherapy and hormones brachytherapy (implantation of radioactive seeds/wires) HIFU and cryotherapy (fringe/experimental) if metastatic androgen deprivation therapy
31
what does androgen deprivation therapy for metastatic CaP consist of?
bicalutamine for 28 days LHRH analogue injection after 14 days and then every 3/6 months early docetaxel chemotherapy
32
how do you treat castrate resistant CaP? | ie PSA continues to be raised despite hormone therapy
``` add bicalutamide dexamethasone docetaxel chemotherapy abiracterone/ enzalutamide palliative care ```
33
testicular cancer types
are uncommon | are mainly Germ cell (non-seminomatous and seminoma) but can be lymphoma and Leydig Cell
34
non-seminomatous vs seminoma Germ Cell testicular cancer
NSGCT - raised AFP (specific), raised LDH and raised beta-HCG seminoma (more common) - raised beta-HCG in 10% and raised LDH
35
O/E what is seen in testicular cancer?
a solid mass that is inseparable from the testis need to do an USS and CT chest/abdo/pelvis to stage
36
what is the survival rate for testicular cancer with treatment?
98%
37
how is testis cancer treated?
inguinal orchidectomy retroperitoneal LN dissection for NSGCT prophylactic/ if metastatic disease give chemo
38
why are the testis removed via the inguinal canal in testicular cancer?
scrotal lymphatics = inguinal LN testis lymphatic = paraaortic LN testis are removed via the inguinal canal in order to maintain the integrity of the scrotal lymphatics and prevent spread during incision
39
what are the risk factors for a UTI?
``` being female - shorter urethra length pregnancy UT malformation/obstruction bladder outlet obstruction calculi bladder diverticulum catheters spinal injury trauma malignancy DM immunosuppression ```
40
what is the definition of a recurrent UTI
>2 infections in 6 months or >3 infections in 1 year
41
how would you manage recurrent UTIs
``` oestrogen replacement therapy low dose Ax prophylaxis post-intercourse Ax self start Ax therapy treat the underlying cause ```
42
what is cystitis?
infection and/or inflammation of the bladder often caused by E.coli S&S - frequency, urgency, dysuria, small voids, suprapubic pain, haematuria, incontinence
43
what is pyelonephritis?
inflammation of the kidney presents with fever, flank pain, raised WCC, N&V, UTI symptoms ~80% caused by E.coli complications --> renal papillary necrosis, pyonephrosis and perinephric abscess
44
what is pyonephrosis?
pus in the renal pelvis due to infection - causes kidney distension can cause irreversible AKI, renal failure, sepsis and death
45
what is Fournier's Gangrene?
NF of the external genitalia and the perineum is an urological emergency - mortality is up to 30% can be caused by aerobes (E.coli, enterococci) and anaerobes (clostridium) risk factors include DM, local trauma, paraplegic and surgery to external genitalia
46
how do you spot and treat Fournier's Gangrene?
must have a low threshold for suspicion S&S - systemically unwell, erythema, tenderness, oedema, UTI symptoms, later get fever, sepsis, cellulitis and palpable crepitus management is surgical debridement and Ax
47
what is epididymo-orchitis and what causes it?
inflammation of the epididymis/testis <35y/o then STI (Gonorrhoea or Chlamydia) >35y/o then the usual uropathogens rare causes include mumps orchitis, secondary to amiodarone and TB
48
what is the clinical picture of epididymo-orchitis?
acute scrotal pain, swelling, erythema, reactive hydrocele, UTI symptoms and suprapubic pain DDx - torsion - low threshold for scrotal exploration
49
what is acute bacterial prostatitis?
infection and/or inflammation of the prostate affects half of men at some point S&S - systemic malaise, perineal and suprapubic pain, irritative and obstructive LUTS, DRE shows a tender prostate
50
what antimicrobials are used in urology?
trimethoprim (is an antifolate so avoid in 1st trimester of pregnancy as increased risk of spina bifida, has a 30% resistance rate) nitrofurantoin (doesn't affect bowel flora, do not use if eGFR is <45, doesn't work for pyelonephritis) co-amoxiclav (used IV in pyelonephritis) gentamycin (used form gram -ves, in pyelonephritis, need to monitor drug level as is nephrotoxic and oophrotoxic to pt and foetus) ciprofloxacin (is broad spectrum, can be used in renal impairment and has a high oral bioavailability) doxycycline
51
types of renal stones
calcium oxalate (75%) calcium phosphate (in hyperPTH) struvite (magnesium ammonium phosphate - alkaline urine) urate (risk factors include obesity, T2DM, acid urine - not seen on a plain X-Ray) cysteine xanthine pyruvate (congenital metabolic disorders) indinavir (old HIV treatment, invisible on CT) 90% are radio-opaque ie contain calcium
52
incidence of renal stones
10% of white males will develop one peak incidence 20-50 years old M:F 3:1
53
risk factors for developing a renal stone
``` diet dehydration stasis infection hyperparathyroidism gout chemotherapy ```
54
treatment of renal stones
fluids, analgesia (NSAIDs) watchful waiting (if <4cm will probably pass) symptomatic control (analgesia - PR Naproxen) ESWL (extracorporeal shock wave lithotripsy) urethroscopy PCNL (percutaneous nephrolithotomy) open stone surgery
55
what can a scrotal lump be?
``` hydrocele epididymal cyst varicocele testicular tumour orchitis indirect inguinal hernia ```
56
what is a hydrocele?
an abnormal quantity of fluid between the visceral and parietal layers of the tunica vaginalis will transilluminate
57
what is a varicocele?
a dilation of the pampiniform plexis - has the appearance of a bag of worms
58
what is an epididymal cyst?
a cyst that is derived from the collecting tubules of the epididymis
59
what is a phimosis?
when the foreskin cannot be retracted behind the glans of the penis can be physiological or pathological
60
what is a paraphimosis?
the foreskin is retracted behind the glans of the penis and cannot be reduced
61
what is a hypospadias?
a congenital or acquired deformity where the urethral meatus is sited on the ventral (underside) of the penis
62
causes of erectile dysfunction
vascular (IHD, early warning sign of CVD) neurological (DM, CVA, spinal injury) venogenic/ cavernosal (young and primary ED - venous leak or cavernosal eg from an untreated penile fracture) hormonal (low testosterone) medication (antidepressants, beta-blockers) psychological (is it episodic, are early morning erections present, is the onset acute)
63
Ix for erectile dysfunction
BP, lipids, BM, smoking Hx early morning testosterone Prolactin, LH, FSH test PSA before commencing testosterone treatment
64
treatment of erectile dysfunction
``` PDE5 inhibitors eg siddenafil (is CI if on nitrates for IHD) treat low testosterone intracavernosal prostaglandin injection vacuum tumescence device inflatable penile prosthesis ```
65
what is priaprism?
a prolonged erection in the absence of sexual stimulation often becomes ischaemic due to ED drugs, cocaine, HbS can be high flow (rare) - AV malformation, pelvic trauma) or low flow - give phenylephrine after aspiration
66
presentation of penile fracture
``` audible pop immediate loss of erection aubergine deformity need to stitch untreated may lead to erectile dysfunction due to cavernosal tear ```
67
presentation of renal colic due to ureteric stones
ipsilateral testicular/ labia pain pt will move around a lot in an attempt to get comfortable pyrexia, may get frequency, urgency and dysuria DDx --> ruptured AAA so must CT within 10 minutes
68
what is high pressure chronic retention?
is characterised by late onset enuresis, recurrent UTIs, a tense, palpable bladder, hypertension, and progressive renal impairment associated with bilateral hydronephrosis and hydroureter commonly leading to uraemia and death can occur due to chronic obstruction eg due to BPH leading to detrusor muscle thickening and leading to a diverticular
69
what is the best analgesia for renal colic?
diclofenac
70
CKD indications for dialysis
stage 5 CKD (eGFR <15ml/ml) symptomatic uraemia (despite conservative treatment) renal bone disease --> osteomalacia (vit. D def.), hyperparathyroidism (increased serum phosphate), osteosclerosis (due to prolonged hyperparathyroidism) and osteoporosis pericarditis volume overload (despite fluid restriction and diuretics) hyperkalaemia (despite treatment)
71
indications for haemodialysis
hypotension hypovolaemia hypokalaemia disequilibration syndrome (cerebral oedema) dialysis related amyloidosis (beta2-microglobulin accumulation causing peripherally neuropathy)
72
voiding/ obstructive LUTS
hesitancy, poor and/or intermittent stream, straining, prolonged micturition, feeling of incomplete bladder emptying, dribbling
73
storage/ irritative LUTS
frequency, urgency, urge incontinence, and nocturia
74
causes of urethral strictures
``` STI trauma radiotherapy recurrent UTIs vaginal atrophic changes ```
75
Tamsulosin uses (alpha-blockers)
rapid action relaxes the muscles in the prostate and bladder neck, making it easier to urinate used in BPH
76
Dutasteride uses (5-alpha-reductase inhibitors)
delayed onset inhibits the conversion of testosterone to dihydrotestosterone hence shrinking the prostate used in BPH
77
Mirabegron uses (beta-3 agonist)
relaxes the detrusor smooth muscle to allow for a larger bladder capacity
78
how would you treat nocturnal polyuria?
diuretics in the evening to empty bladder and oral desmopressin
79
what does urodynamics do?
measure detrusor pressure ie the compliance of the bladder (the ability of it to fill without the pressure increasing)
80
why does peripheral oedema cause nocturnal polyuria?
``` no effect of gravity fluid pools centrally increased CO kidneys produce ADH more urine produced ```
81
kidney stone presentation and treatment
fever, vomiting and acute flank pain, if <1cm then may pass spontaneously ``` treatment: analgesia and antiemetic IV fluids percutaneous nephrostomy ureteric stent insertion shock wave lithotripsy if radio-opaque ```
82
nephrotic syndrome
>3g/24hrs of protein - leads to hypoalbuminaemia and oedema (and hyperlipidaemia, they are hypercoagulable) - due to podocyte or supepithelial injury - minimal change glomerulonephritis - focal segmental glomerulosclerosis - membranous glomerulonephritis - diabetes mellitus - amyloidosis
83
nephritic syndrome
blood in urine - due to endothelial injury - IgA nephropathy - vasculitis - good pastures syndrome - Alport syndrome - thin GBM disease
84
chronic kidney disease
features: "AEIOU" - acidosis, electrolyte problems (hyperkalaemia), insult, overload (fluid retention), ureamina complications - bone disease, hyperparathyroidism, anaemia, metabolic acidosis treatment: NaHCO3, EPO, ACEi, furosemide (for HTN), RRT (usually id eGFR is <10 or <15 if diabetic)
85
renal replacement therapy
- haemodialysis - peritoneal dialysis - kidney transplant
86
stages of AKI
stage 1 = >1.5-1.9 times baseline creatinine stage 2 = 2-2.9 times baseline creatinine stage 3 = >3 times baseline creatinine
87
symptoms of AKI
reduced renal output pulmonary and peripheral oedema arrhythmias features of uraemia - pericarditis, encephalopathy
88
causes of AKI
pre-renal: ischaemia due to hypovolaemia - dehydration/ renal artery stenosis/ shock and reduced renal perfusion renal/intrinsic: toxins, immune mediated, rhabdomyolysis, tumour lysis syndrome post-renal: urinary retention - kidney stone, BPH

EOY3 (20 decks)

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