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MBBS Surgery > Urology > Flashcards

Urology Flashcards

1
Q

Medical Tx of BPH - names, MOA, SE

A
  1. Alpha blockers: tamsulosin, alfuzosin
    reduce outflow resistance at bladder neck, prostate, urethra
    reduce bladder instability
    SE: postural hypotension - fall risk, lethargy, giddiness
    (3 days to be effective)
  2. 5-alpha reductase inhibitors: finasteride, dutasteride
    reduce prostate size by inhibiting conversion from testosterone to dihydrotestosterone
    SE: impotence, dec libido, erectile dysfunction, ejaculation dysfunction, gynaecomastia
    (need 6m to work)
  3. combodart - tamsulosin + dutasteride
    consider: Ach inhibitors, phosphodiesterase inhibitors
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2
Q

Complications of TURP

A

Transurethral resection of prostate

EARLY CX

  • GA cx: CVM, MI, allergic reaction
  • bleeding, infection, urosepsis
  • risk of perforation, fistula formation
  • retrograde ejaculation (less ejaculate but penile erectile and sexual function preserved)
  • local injury - sphincter (incontinence), nerves, arteries/veins
  • TURP syndrome - hypoNa due to constant irrigation during TURP (RF: high pressure, prolonged procedure - but now rare as current practice uses isotonic irrigation) (presents as N&V, confusion, HTN, giddiness, seizure)

LATE CX

  • urethra stricture, bladder neck stenosis
  • prostate regrowth/ recurrence of symptoms
  • incontinence
  • retrograde ejaculation
  • impotence
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3
Q

Indications for TURP

A
  1. significant symptoms, failed med tx
  2. complications
    - lower tract: UTI, ARU, recurrent gross hematuria, bladder calculi
    - upper tract: hydronephrosis, obstructive uropathy, renal impairment
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4
Q

Cancer marker for prostate

  • what is normal
  • screening guidelines
  • when is it falsely elevated
  • when is it falsely low
A

Prostate specific antigen (PSA)
normal: <4

SCREENING

  • > 10: yes, 60% risk
  • 4-10: yes, 20% risk
  • <4: look at PSA density (serum psa/ prostate volume), PSA velocity (rate>0.75), free/total PSA ratio (<10%)

ELEVATED in: recent UTI, ARU, IDC, ureteric instrumentations, prostatitis

LOW: medications - NSAIDS, statins, 5alpha reductase

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5
Q

Diagnostic/ prognostic tool in prostate cancer

A

Transrectal ultrasound + biopsy (TRUS)
- hypoechoic lesions are suggestive

Gleason Classification - architecture of gland under low magnification

  • addition of primary and sec score
  • higher = more aggressive
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6
Q

anti-androgen treatment of prostate CA

A
  1. Castration (surgical - orchidectomy/ medical)
    - med: GnRH agonists (Goserelin, Leuprorelin)
    - -> give together with 5alpha reductase inhibitors: finasteride (to reduce interim spike in testosterone)
  2. Anti-androgen
    - non-steroidal: flutamide, bicalutamide, enzalutamide
    - steroidal: cyproterone acetate
  3. Combination
  4. Estrogen therapy
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7
Q

Castration resistant prostate CA

- what and mgx

A

2 consecutive rise in PSA (2w apart) despite castrate levels of testosterone

  1. Med:
    - androgen synthesis inhibitors
    - glucocorticoids
    - estrogen therapy
    - adrenal suppressives: ketoconazole
  2. Chemo
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8
Q

Mets from prostate to bone commonly via

A

Batson venous plexus

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9
Q

How to differentiate bladder outlet obstruction from detrusor dysfunction

A

NOT via uroflowmetry
via VUDS - video, urodynamic study
(compulsory to do before TURP for BPH)

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10
Q

Significant positive uroflowmetry

A

minimum >150ml void
Qmax<15ml/sec
Residual urine >0 (young), >100 (elderly)
duration ~30s male, ~20s female

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11
Q

Complications of BPH

A 
Hematuria - anemia
Lower tract: stones, UTI
Upper tract: renal insufficiency, hydronephrosis, pyonephrosis, hydroureter
Renal impairment - fluid overload, AVF
overflow incontinence
Chronic straining - hernias
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12
Q

Microcytic anemia causes

A

Iron deficiency anemia
Sideroblastic anemia
Thalassemia

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13
Q

Normocytic anemia causes

A 
Anemia of chronic dz
acute blood loss
renal failure
isolated red cell aplasia
aplastic anemia
sec bone marrow failure - chemoRT, Myelodysplastic syndrome
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14
Q

Macrocytic anemia causes

A 
Folate, B12 deficiency
Liver dz, hypothyroidism
alcohol
MDS
reticulocytosis
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15
Q

Gross hematuria causes

A

TITS
Trauma: procedures, instrumentations, IDC, TURP
Cancer: TCC (bladder, ureter), prostate cancer
BPH
Stones: renal, ureter, bladder
Infection: UTI, cystitis, prostatitis

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16
Q

Timing of hematuria & causes

  • initial
  • terminal
  • throughout
A

initial: urethral
terminal: bladder neck, prostatic urethra
throughout: bladder, renal causes, ureter
spotting: urethral meatus

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17
Q

Things to exclude when u see hematuria

A

food dye - beet root
drugs - levodopa, rifampicin, Senna
mimics - bilirubinuria, porphyria, hemoglobinuria, myoglobinuria

benign causes - sexual intercourse, menses, trauma, exercise induced myoglobinuria

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18
Q

Glom vs non glom causes of hematuria

A

glomerular vs non glom:
(Urine phase contrast)
>Glom: coke coloured, no clots, RBC cast, dysmorphic rbcs, w proteinuria (>500mg/day)
>Non glom: red, clots, no casts, isomorphic rbcs, no proteinuria <500

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19
Q

hematuria red flags

A

male, >35, family hx, occupational exposure to dyes, carcinogens, smoker, analgesia abuse
Previous uro dz/ hematuria, pelvic irradiation, chronic UTI, indwelling FB, chemotherapy (hemorrhagic cystitis)

20
Q

Renal causes of hematuria

- antibodies

A

anti-GBM: Goodpasture (a/w hemoptysis, lung haemorrhage)

ANCA related: wegener (cANCA), microscopic polyangitis (pANCA), eosinophilic granulomatosis with polyangitis (CS)

Immune complex (renal): post strep (2w after infection - low C2, high ASO), IgA Nephropathy (synpharyngitic, young male), MPGN

Immune cx (sys): SLE T3,4 , HSP, IE (duke critieria)

Others: alport (bl SNHL + occular abnormalities), APKD, thin basement mb

21
Q

why is a L varicocele significant?

A

RCC of left kidney with extension of tumour into renal vein, blocking testicular vein which drains into L renal vein

22
Q

CI of IV Urogram

A

contrast allergy
renal impairment (Cr >200)
Pt on metformin (cause lactic acidosis, stop 2 days before and after)
Pt w asthma (give steroid 3 d before study)
Pregnancy: ask LMP

23
Q

What suggests renal hematuria

A

proteinuria
rise in creatinine
hypertension
other RF

24
Q

Differentials for renal mass

A 
Benign
- angiomyolipoma
- renal adenoma/cyst/abscess
- renal oncocytoma
Malignant
- RCC
- wilms tumour (nephrolblastoma)
- mets
- sarcoma
25
Q

Dz a/w RCC

A

von hippel Lindau syndrome (AD) - clear cell
Hereditary papillary RCC (HPRCC) - multifocal b.l pap carcinomas
acquired polycystic kidney dz (chronic dialysis) - needs yearly ultrasound

26
Q

histo types for RCC

A

clear cell (prox tubules), papillary (distal tubules), chromophobe (collecting tubules)

27
Q

RCC triad and presentations

- Paraneoplastic symptoms

A

flank pain, painless gross hematuria, palpable flank mass

  • asym
  • local: triad, acute pain (hemorrhage into tumor)
  • regional: L varicocele, IVC extension (LL edema, ascites, liver dysfunction, pul embolism)
  • mets: lung, liver, bone, brain, LN
  • constitutional: LOW,LOA
  • paraneoplastic: HTN (renin), non mets liver dysfunction (Stauffer syn - hepatosplenomeg), hyperCa, polycythemia (erythropoietin), cushings, feminisation or musculinisation (due to gonadotropin release)
28
Q

Bosniak classification

A

1 simple 0%
2 minimally complex 0%
2F: thin sep, thick cal (5%) - follow up CT
3 indeterminate (multiple thick septation, mural nodule) - partial nephrec (50%)
4 solid mass with cystic spaces
- total nephrectomy (100%)

29
Q

Cx of nephrectomy

A

GA: AMI, CVA
Sx: plural injuries - pneumothorax, injury to surrounding orgs - GI/ major blood vessels

Post op: temp/ permanent renal failure, ileus, superficial/ deep wound infections

30
Q

Tx for RCC

A

sx:
- small tumors: partial nephrectomy (spares adrenals)
- T2 and above: radical nephrectomy with clearance of gerota fascia, surrounding LN and affected structures
- if elderly: consider cryoablation and RFA

Chemo/RT: little evidence

Advanced cancers: immunotherapy or VEGFR targeted therapy

31
Q

Angiomyolipoma

  • a/w dz
  • cx
  • tx
A

a/w tuberous sclerosis complex, pulmonary lymphangioleiomyomatosis (LAM)

CX: retroperitoneal hemorrhage, hematuria, renal impairment

Tx:

  • not growing: leave
  • AML<3 + grow: RFA, cryoablation
  • AML>4 + high vascularity: partial nephrec, selective renal art embolisation
32
Q

Management of bladder CA

A

muscle sparing (T1)
- TURBT (transurethral resection of bladder tumour)
(chemo for high risk pts: high grade, multifocality, multiple recurrences, tumor size >3cm, pri or co-existing CA in situ, prostatic urethral development)
- intravescial chemo (mitomycin) within 24h
- intravesical BCG therapy (1/7 x6)
- close surveillance

muscle invasive (T2and above)
- radical cystectomy + urine diversion
a. males: radical cystoprostatectomy with pelvic lymphadenectomy
b. females: anterior exenteration with pelvic lymphadenectomy
urine diversion:
- not continent: cutaneous ureterostomy, ileal conduit, stoma with pouch construction under ab wall
- continent: neobladder construction with ileum

bladder salvage regime (combined modality): TUR + plt chemo + ext beam RT

METS
- chemo (for mets or locally advanced): GC, MVAC

33
Q

RF for urolithiasis

- associated diseases

A

modifiable

  • diet: high protein, Na intake
  • dehydration
  • hyperparathyroidism
  • hypervitD
  • milk-alkali sydnrome
  • drugs: antacids, salicylic acid, anti virals

non modifiable

  • age, male
  • cystinuria (AR)
  • inborn error of purine metabolic
  • chemotherapy
  • idiopathic hyperCa
  • family hx

assoc diseases to ask in history!
crohns. (hyperoxaluria) hyperparathyroidism. MEN1, hyperthyroidism. gout. RTA T1 distal (alkaline urine), mets ca. paraneoplastic.

34
Q

Types of urolithiasis

- special characteristics

A
  1. Calcium oxalate (75%): small and sharp - alkaline urine
  2. Calcium phosphate
  3. struvite stones - alkaline urine, staghorn a.w proteus, pseudomonas, klebsiella (urea splitting organisms)
  4. urate stones - acid urine (radiolucent)
  5. cystine stone
  6. rare - xanthine, pyruvate
35
Q

Ix to measure kidney function

A

MAG-3 renogram
N: 50% per kidney
if <15%: not worth salvaging

36
Q

Tx of urolithiasis

A

Conservative (<5mm)
kidney stones: <5mm observe, tx if >7mm
ureteric stones: Trial of passage if <7mm
(tx if do not pass out after 4-6w or causing symptoms)
- analgesia:IM pethidine, tramadol
- hydration
- alpha blocker: tamsulosin (SE: postural hypotension)
- change diet: low protein, sugar, Na. high fibre. normal calcium diet.
- tx underlying UTI, predisposing facotrs/ dz
- chemical dissolution: alkalinise/ acidify urine

Surgical: depends on site

  • extracorporeal shockwave lithotripsy (ESWL)
  • Percutaneous nephrolithotomy (PCNL)
  • ureterorenoscopy (URS) lithotripsy
  • cystolithopaxy
  • open cystolithotomy

Adjuncts: Double J stent

37
Q

Mechanical Causes of ARU

A

MECHANICAL

  • intramural: stones, blood clot (bladder tumour), FB
  • mural: bladder neck tumour, urethritis, stricture
  • extramural: BPH, prostate CA, fecal impaction, pelvic/ GI/ retroperitoneal masses, UV prolapse - cystocele/ rectocele
38
Q

Functional causes of ARU

A

FUNCTIONAL
- infx: prostatitis
- neuro
> brain: CVA, PD, MS, NPH
> spinal cord: cord trauma, spinal stenosis, transverse myelitis, hematoma/abscess
> peripheral n: DM neuropathy. GBS
- drugs: opioid, anticholinergics, sympathomimetics
- others: prolonged immobility, post anesthesia, post op cx, pain/trauma

39
Q

Complications post IDC insertion for RU

A
  1. post obstructive diuresis
    >200ml/h for 2 hours
    tubular damage from CRU
    leads to hypotension, and electrolyte ab: hypoNa, hypoK, hypovol
  2. transient hematuria
  3. hypotension: vasovagal, relief of pelvic venous congestion
40
Q

options for failed TOC

A

long term catherisation
SE: infx, strictures, stones, devt of scc

clean intermittent self catheterisation (for neurogenic bladder)
- avoid cx of obstructive nephropathy

if BPH: alpha blocker, 5a reductase inhibitors (take time to work)
- elective TURP

41
Q

Paraneoplastic syndromes of RCC

A

(a) hypertension secondary to renin overproduction by RCC cells
(b) polycythaemia secondary to ectopic erythropoietin production
(c) Stauffer Syndrome (hepatic injury associated with non-metastatic RCC)
(d) Cushing’s syndrome,
(e) amyloidosis
(f) hypercalcemia mediated by PTH-related peptide
(g) trousseau sign (thrombophlebitis migricans)

42
Q

Diagnosis and typical features for RCC

A

DIAGNOSIS
- IVU: mottled central calcification (90%), peripheral cal (20%), renal enlargement, displacement of renal pelvis/ calyces, irregular borders, change in cortical density

  • CT urogram (triphasic): renal parenchymal mass with thickened irregular walls and enhancement after contrast injection
  • ultrasound: differentiate from cyst (smooth, definite border, no int echogenicity, with post acous enhancement)
  • biopsy (done during op itself or over metastatic site)
  • MRI kidneys
43
Q

T staging for RCC

A 
T1a: <4cm, limited to kidney
T1b: <7cm
T2a: <10cm
T2b: >10cm, limited to kidney
T3a: extend into renal vein and perinephric tissues
T3b: extend into IVC below diaphragm
T3c: ICV above diaphragm
T4: beyond gerota fascia
44
Q

RF for bladder CA

A
  • Occupational: industrial chemicals
  • Non occupational: smoking, chronic analgesia abuse (phenacetin), chronic parasite infection (schistosomiasis), chemotherapy (cyclophosphomide - hemorrhagic cystitis), pelvic irradiation, males
45
Q

how to describe

  • benign BPH on DRE
  • prostatic cancer on DRE
A 
BENIGN
- smooth, symmetrically enlarged (>3FB), no nodule
- median sulcus is intact
- firm consistency
- rectal mucosal is smooth, not attached to prostate
CANCER
- asymmetrical are of induration
- hard, irregular, craggy enlargement
- nodule fixed to pelvic wall
46
Q

what is the precursor of prostate cancer

A

prostatic intraepithelial neoplasm: architecturally benign prostatic acini and ducts lined by atypical cells

  • low grade PIN1: mild dysplasia, no increased risk of CA
  • high grade PIN2/3: mod and severe dysplasia, 30-40% chance of invasive cancer
47
Q

2 main tx approaches for prostate cancer

A

active surveillance vs watchful waiting (life expectancy <10y, poor premorbids/ surgical candidate)

MBBS Surgery (18 decks)

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