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General Surgery > Urology > Flashcards

Urology Flashcards

1
Q

What is the most common bladder cancer (89-90%) & renal cancer (85%)?

A

Transitional cell carcinoma - bladder

Renal cell carcinoma (adenocarcinoma) - kidneys

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2
Q

4 layers of the bladder wall

A

Inner lining - transitional epithelium/ urothelium

2nd - CT lamina propria

3rd - muscularis propria

4th - fatty CT

(Trigone with internal urethral orifice & ureter orifices)

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3
Q

How does bladder cancer present?

A

Painless haematuria
(Visible/ non)

Recurrent UTIs/ LUTS

May ureteric obstruction

Locally advanced - pelvic pain
Metastatic - systemic

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4
Q

How do we stage bladder can ear?

A

TNM

Tis - in situ
T1 - lamina propria
T2 - muscularis propria
T3 - perivesical tissues
T4 - adjacent local structures

N0 - no nodal involvement
N1 - single node <2cm
N2 - single node 2-5cm/ multiple
N3 - 1+ nodes >5cm

M0 - no metastases
M1

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5
Q

Investigations for bladder cancer

A

Urgent flexible cystoscope
Suspicious lesion -> rigid cystoscope (GA)

Tumours identified - biopsy, transurethral resection of bladder tumour (TURBT)

Muscle invasive - CT staging
May initially have US/ CT

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6
Q

Management of bladder cancer

A

T1 - TURBT

Higher risk - intravesical therapy (BCG/ Mitomycin C), radical cystectomy

70% recurrence 3yrs - regular cytology & cystoscopy

Muscle invasive: radical cystectomy, neoadjuvant chemoT (cisplatin) -> urinary diversion (ileal conduit formation, bladder reconstruction segment SB) - regular CT, bloods, B12, folate

Locally advanced/ metastatic - otherwise well ChemoT (cisplatin/ carboplatin)

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7
Q

Investigations BPH

A 
Urinary frequency & volume chart
Urinalysis 
Post void bladder scan 
DRE
PSA
USS renal tract 
Urodynamic studies
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8
Q

Medical & main surgical management BPH

A

Alpha-adrenoreceptor antagonist e.g. tamsulosin (relax SM)
❌postural hypotension, asthenia, rhinitis, retrograde ejaculation

5alpha- Reductase inhibitors e.g. Finasteride
Prevent conversion testosterone-> DHT (decrease prostatic volume)

Surgery:
TURP
❌TURP syndrome - fluid overload & hyponatremia (confusion, N, agitation, visual changes)

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9
Q

What are prostate cancers >95% & which zone do they occur? How can it be categorised?

A

Adenocarcinomas
75% peripheral zone

Acinar adenocarcinoma - most common
Ductal adenocarcinoma - metastases faster

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10
Q

Gleason grading of prostate cancer

A

1 - small, uniform glands
->
5 - only occasional gland formation

Most common growth pattern + 2nd most common
Lowest with cancer = 3+3

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11
Q

Watchful waiting vs active surveillance

A

WW - symptom guided, definitive therapy deferred & hormonal therapy initiated if symptoms
Generally older with lower life expectancy

AS - low risk disease, monitoring 3 monthly PSA, 6 month-annual DRE, re biopsy 1-3 yearly intervals
Intervening when appropriate

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12
Q

Treatment prostate cancer

A

Radical prostatectomy

External beam radioT
BrachyT - radioactive seeds

ChemoT - metastatic
Chemo drugs: docetaxel, cabazitaxel

Androgen deprative therapies: LHRH agonists (goserelin), GnRH R agonists (degarelix)

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13
Q

Types of prostatitis

A

Acute bacterial
Chronic bacterial
Non bacterial
Prostatodynia

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14
Q

Pathophysiology of prostatitis

A

Ascending urethral infection/ lymphatic spread from rectum/ haematogenous bacterial sepsis

E.coli most common
Enterobacter
Serratia

STIs rare causes

Chronic - inadequately treated acute

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15
Q

Investigations prostatitis

A

DRE - tender & boggy
Inguinal lymphadenopathy

Urine culture
STI screen
Routine bloods
PSA

Initial therapy failed (quinolone prolonged) - TRUS
Transrectal prostatic USS / CT

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16
Q

A sign for epididymitis

A

Prehn’s sign - supine, scrotum elevated by examiner

Pain relieved by elevation +ve

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17
Q

What is bell-clapper deformity & what does it put you at risk of?

A

Horizontal lie, lack normal attachment to tunica vaginalis

Testicular torsion (twisting of spermatic cord within tunica vaginalis)

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18
Q

Clinical features testicular torsion

A

Sudden onset severe unilateral testicular pain

N&V secondary to pain

Referred abdo pain

Testis high position with horizontal lie

Swollen
Tender

Cremasteric reflex absent
Pain despite elevation of testis (-ve prehn’s sign)

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19
Q

What’s a bilateral orchidopexy & when is it done?

A

Cord & testis untwisted & both testicals fixed to the scrotum

Prevent testicular torsion (within 4-6hrs)

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20
Q

How are primary testicular tumours categorised?

A

Germ cell tumours 95%
- seminoma (localised until late)
- non-seminomatous (yolk sac tumours, choriocarcinoma, embryonal carcinoma, teratoma - metastasise early)
Usually malignant

Non-germ cell tumours 5%
- leydig cell tumours -> androgens
- Sertoli cell tumours -> oestrogen
Usually benign

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21
Q

Investigations testicular cancer

A

Tumour markers:
BetaHcG elevated 60% NSGCTs & 15% seminoma

AFP raised some NSGCTs

LDH tumour volume

Scrotal USS
CT with contrast Chest-abdo-pelvis

No biopsy as could cause seeding of cancer

22
Q

How can urethritis be classified?

A

Gonococcal - caused by N.gonorrhoeae
✅ceftriaxone + azithromycin

Non-gonococcal - most often C.trachomatis, M.genitalium, T.vaginalis
✅doxycycline or azithromycin

23
Q

Urethritis symptoms & investigations

A

Dysuria
Penile irritation
Discharge

Epididymitis
Reactive arthritis

Gram stain - urethral swabs
First void urine - NA
Mid stream urine dipstick

Sti screening

24
Q

What is paraphimosis? What causes it & what can it lead to?

A

Inability to pull forward a retracted foreskin over glans penis -

often due tight constricting band as part of foreskin -> glans oedematous

  • > vascular engorgement
  • > ischaemia/ infection (Fournier’s gangrene)

✅urgent reduction

25
Q

What is priapism? Pathophysiology? What can it lead to?

A

Unwanted painful erection not associated with sexual desire
>4 hrs

Low flow/ Ischaemic priapism - blood stays within corpus cavernosa, prolonged venous stasis, veno-occlusive - associated intracavernosal drug therapy, SCD, haematological disorders, pelvic malignancy - painful & rigid

High flow/ non-ischaemic - unregulated cavernous arterial inflow (more quickly than can be drained) - associated trauma, can triggered stimulation - painless & not fully rigid

Can lead to fibrosis & impotence

26
Q

Management of priapism

A

Corporeal aspiration - alleviates 30%
Also obtains corporeal blood gas sample

If no response - intracavernosal injection of sympathomimetic agent e.g. phenylephrine trialled

Surgical: shunt between corpus cavernosa & glans - 70% (can lead to erectile dysfunction)

27
Q

What is a penile fracture?

A

Traumatic rupture of corpus cavernosa & tunica albuginea in erect penis

Caused blunt trauma (penis violently deviated away from axis)

Popping sensation
Penile swelling & discolouration - aubergine sign - deviation
May firm immobile haematoma shaft - rolling sign

28
Q

Investigations & management penile fracture

A 
Clinical diagnosis 
Bloods
Cavernosography- identify rupture site 
Ultrasonography 
Urethral injury - retrograde urethography

✅surgical exploration & repair - sutures, haematoma evacuated
Abstinence 6-8weeks

29
Q

What is Fournier’s gangrene? Signs & management?

A

Necrotising fasciitis (rapidly spreading necrosis)affects perineum, mortality 20-40%

Monomicrobial/ polymicrobial - Group A streptococcus, C. Perfringes & E.coli

Severe pain out of proportion to signs or pyrexia -> crepitus, skin necrosis, haemorrhagic bullae-> sepsis

✅ Immediate surgical exploration, bloods, CT -> surgical debridement +/- partial/ total orchiectomy, broad ABs, fluid

30
Q

Define pyelonephritis, what causes it?

A

Inflammation of the kidney parenchyma & renal pelvis typically due bacterial infection (ascending UTI, blood stream, lymphatics)

Uncomplicated - structurally/ functionally normal urinary tract, non-immunocompromised

80% Escherichia coli
Klebsiella, proteus
Enterococcus faecalis - catheters

31
Q

Symptoms of pyelonephritis

A

Classic triad: fever, unilateral loin pain, N&V
Typically over24-48hrs

UTI Symptoms
Haematuria

Costovertebral angle tenderness

  • renal USS
  • CT non contrast if obstruction suspected
32
Q

What are urinary tract stones made from?

A 
80% calcium 
Calcium oxalate 35%
Ca phosphate 10% 
Mixed 35% 
Struvite
Urate (radiolucent) - ⬆️purine red meats/ haematological disorder
Cystine - hypocystinuria

Over saturation urine

33
Q

Where do ureteric stones typically impact?

A

3 narrowed points

  • pelviureteric junction
  • crossing pelvic brim where iliac vessels travel across ureter
  • vesicoureteric junction
34
Q

Clinical features of renal tract calculi & investigations

A

Ureteric colic
Loin to groin
N&V

Haematuria 90%, typically non visible

Urine dip
Bloods (urate, Ca)
Retrieval stone - analysis

⭐️non contrast CT KUB
USS - hydronephrosis

35
Q

Management renal tract calculi

A

Majority pass spontaneously

Infection - IV ABs

Obstructive nephropathy/ significant infection - stent insertion/ nephrostomy

Stones do not pass:
Extracorporeal shock wave lithotripsy
Percutaneous nephrolithotomy
Flexible uretero-renoscopy

Recurrent: 
Stay hydrated 
Oxalate - avoid high purine foods
Ca - PTH levels 
Urate - avoid high purine 
Cystine - genetic testing
36
Q

Types of renal malignancies

A

Renal cell carcinoma - 85% (adenocarcinoma)

TCC
Nephroblastoma children (Wilm’s tumour)
Squamous CC

37
Q

Risk factors for renal cancer

A 
Smoking doubles
Industrial exposure carinogens 
Dialysis 30X
Hypertension 
Obesity
Anatomical abnormalities (polycystic kidneys, horseshoe kidneys) 
Genetic disorders
38
Q

Clinical features of renal cancer

A

Haematuria - most common presenting complaint

Flank pain

Flank mass

Weight loss
Lethargy

50% incidental on abdo imaging (compression left testicular vein as joins renal vein)

Left masses - left varicocele

Paraneoplastic syndromes - secretions of hormones -> polycthaemia, hypercalcaemia, hypertension, pyrexia

Triad 15% haematuria, flank pain, mass

25% metastases at presentation

39
Q

Simple vs complex renal cysts

A

Simple - well defined outline, homogenous, older pts, from renal tubule epithelium

Complex - thick walls/ septations/ calcification/ heterogenous enhancement on imaging, all risk malignancy

40
Q

Risk factors for renal cysts & clinical features

A 
Older
Smoking
Hypertension 
Male 
Genetic conditions - PKD, tuberous sclerosis
Often found incidentally abdo imagin
Usually asymptomatic 
Flank pain
Haematuria 
Uncontrolled hypertension - PKD
Flank mass - PKD

Ct/ mri IV contrast

41
Q

Storage vs voiding symptoms LUTs

A

Storage - when bladder should otherwise be storing urine
Urgency, frequency, nocturia, urgency incontinence

Voiding - bladder outlet obstruction
Hesitancy, intermittency, straining, terminal dribbling, incomplete emptying

42
Q

Pharmacological management of LUTs

A

Conservative insufficient

Anticholinergics e.g. oxybutynin, tolterodine
OAB

Alpha blockers e.g. alfuzosin. Tamsulosin
5 alpha reductase inhibitors e.g. finasteride
BPH

Loop diuretics, desmopressin
Prevent nocturia

43
Q

6 Ss for describing a scrotal lump & acronym for palpating

A 
Site
Size
Shape
Symmetry 
Skin changes
Scars 
CAMPFIRE
Consistency
Attachments
Mobility
Pulsation 
Fluctuation
Irreducibility
Regional LNs
Edge 
(Temp, transillumination, tenderness)
44
Q

Differentials for scrotal lumps

A

Extra-testicular:
Hydrocoele - collection peritoneal fluid between parietal & visceral layers of tunica vaginalis
Painless, transilluminate, fluctuant

Varicocele - abnormal dilation pampiniform plexus
May disappear lie flat, 90% left (renal vein)

Epididymal cysts - smooth, fluctuant nodule, transilluminate

Epididymitis- pain, swelling, erythematous, fever

Inguinal hernia

Testicular:
Tumours - cancer firm, irregular, painless
Orchitis - inflammation testis, mumps
Torsion - severe pain, N&V
Benign lesions - leydig cell tumours, Sertoli cell tumours, lipomas, fibromas, lysts

45
Q

Causes of acute & chronic urinary retention

A 
BPH
Urethral strictures
Prostate cancer
UTIs -> urethral sphincter close
Constipation 
Severe pain 
Meds (anti-muscarinics, spinal/ epidural anaesthesia) 
Neurological (peripheral neuropathy, iatrogenic nerve damage pelvic surgery, UMNd, bladder sphincter dysinergy)
Chronic: 
BPH
Urethra strictures
Prostate cancer
Pelvic prolapse (cystocele, rectocele, uterine prolapse)
Pelvic masses (large fibroids) 
Neurological
46
Q

What is high pressure urinary retention? As well as a post void bedside bladder scan, routine bloods & CSU (catheterised specimen of urine) what other investigation is required for high pressure cases? Treatment?

A

Urinary retention causing high intra-vesicular pressures that anti reflux mechanism of bladder & ureters is overcome & backs up into upper renal tract

-> hydroureter & hydronephrosis
(Impairing kidneys clearance levels)

Confirmed USS - assess hydronephrosis
Follow up subsequent weeks

✅keep catheters in situ until definitive management can be arranged due risk further episodes leading AKI -> renal scaring & CKD
- no evidence renal impairment TWOC

47
Q

What do patients with large retention volume (>1000mls - only seen acute on chronic) need to be monitored post catheterisation for?

A

Post obstructive diuresis
Kidneys can often over diurese due to loss of medullary conc grad -> worsening AKI

Monitor Urine output over following 24hrs

> 200mls/ hr - should have 50% of urine output replaced IV fluids

48
Q

Which major vessel provides the arterial supply to the bladder?

A

Internal iliac artery

49
Q

Causes of haematuria

A 
Urological
UTI 
Urothelial carcinoma 
Stone disease 
Adenocarcinoma prostate 
BPH 
Trauma/ recent surgery 
Radiation cystitis
Parasitic - schistosomiasis

Non-urological:
Medical (cyclophosphamide, naproxen, nitrofurantoin)
Pseudohaematuria

50
Q

Urological referral criteria for haematuria

A

For specialist haematuria investigation:
Aged >45yrs with any
- unexplained visible H without UTI
- visible H persists or recurs after successful treatment UTI

Aged >60yrs with any
- unexplained non visible H & dysuria or raised WCC

Asymptomatic Non visible H 2/3 tests

51
Q

Causes of urinary incontinence & treatment options

A

Stress ✅PFMT -> duloxetine (serotonin- NA reuptake inhibitor), tension free vaginal tape, open colposuspension, intramural bulking agents, artificial urinary sphincter

Urge (OAB/ detrusor hyperactivity - neurogenic/ infection/ malignancy/ idiopathic/ cholinesterase inhibitors)
✅anti muscarinics e.g. oxybutynin/ tolterodine, bladder training, botulinum toxin A injections, percutaneous sacral N stimulation, augmentation cystoplasty, urinary diversion via ileal conduit

Mixed (stress & urge)

Overflow (complication chronic urinary retention)

Continuous (constant leaking - anatomical abnormality e.g. ectopic ureter/ bladder fistulae severe overflow IC)

General Surgery (7 decks)

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