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Surgery Block > Urology > Flashcards

Urology Flashcards

1
Q

RCC

A

Most common renal cancer, also have TCC, SCC.
Adenocarcinoma of the renal cortex, mainly affecting upper pole.
Spread direct (to tissues, IVC, adrenal glands), haematogenous (to bone, liver, brain, lungs), lymphatic.

Differentials- UTI, urological malignancy, renal stones.

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2
Q

RCC-
RF
Features

A

Smoking, obesity, HTN, ADPKD, horseshoe kidney, dialysis (*30), male, increasing age, carcinogen exposure.

Presents with visible/non visible haematuria. Also flank mass, pain or general lethargy/weight loss. Stauffer syndrome; non metastatic hepatic dysfunction.
Paraneoplastic- Renin-HTN, PTH-HyperCa, EPO-PC.

NB MOST CASES PRESENT INCIDENTALLY

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3
Q

RCC- Investigation

A

Abdo/pelvis CT with contrast- Gold standard.
May also biopsy.

Bloods- U+Es, LFTs, Ca, CRP. Urinalysis and cytology.

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4
Q

RCC- Management

A

Partial/radical (including lymphatics and perinephric fat) nephrectomy, if organ confined.

If contraindicated then radiofrequency ablation, monitor.
Metastasis- not responsive to chemo; +/-surgical removal and immunotherapy preferred.

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5
Q

Bladder cancer

A

Originates at bladder wall lining, commonly TCC but also SSC and rarer adenocarcinoma.

Classified into non-muscle invasive-NMI, MI or locally advanced/metastatic- beyond the bladder.

Differentials- prostate/renal cancer, renal stone, UTI.

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6
Q

Bladder cancer-
RF
Features

A

Smoking, exposure too carcinogens are main RF- FHx not really relevant. increasing age more common. Also male.

Present with (non)/visible haematuria. Also can get recurrent UTIs and LUT symptoms i.e. frequency.

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7
Q

Bladder cancer- Investigation

A

Urgent cystoscopy, if can suspicious lesion switch to rigid cystoscopy.
Take biopsy. If superficial lesion then remove during rigid cystoscopy via TURBT, if invasive wait for biopsy.

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8
Q

Bladder cancer- Management

A

NMI- TURBT woth adjuvant Mitomycin C (reduce recurrence but not progression) or BCG (more commonly in superficial- reduce recurrence and progression)with neoadjuvant cisplatin. (Increased recurrence with superficial). If high risk disease/non responsive to treatment then radical cystectomy.

MI- Radical cystectomy- replace bladder with ileal conduit or bladder reconstruction.

Locally advance/metastatic- Chemo

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9
Q

Testicular cancer

A

Most common cancer in male 20-40yrs.
Can be NGC (Leydig/sertoli, usually benign) or germ cell (malignant).
Germ cell can be semionomas or non-seminomatous.

Differentials- hydrocoele, epididymal cyst, epididymitis, haematoma.

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10
Q

Testicular cancer-
RF
Features

A

RF- undescended testes, FHx, previous testicular malignancy.
Features; unilateral painless lump in the testes. Lump will feel firm, fixed and irregular on palpation- cannot transilluminate. If metastatic then may get back pain, dyspnoea, weight loss.

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11
Q

Testicular cancer- Investigations

A

USS and tumour markers (Beta-HCG) initially.
Then with CT contrast of chest, abdomen and pelvis.
Don’t take a biopsy as can lead to seeding of tumour.

Stage I- Contained to testes
Stage II- Infra-diaphragmatic LN involved.
Stage III- Supra and infra-D LN involved.
Stage IV- Extra-lymphatic metastasis.

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12
Q

Testicular cancer- Management

A

Confirmed cases need discussing for best treatment.
Conduct fertility assessment before treating- radio/chemotherapy harmful.

Treat with surgery (orchidectomy), radio/chemo.

NSGCT- Treat with surgery then follow with adjuvant chemo if high risk.
Metastatic- Poor prognosis is one chemo cycle, otherwise a few cycles.

Seminomas- Surgeryand surveillance.
Metastatic- Radio/chemo

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13
Q

Prostate cancer-

A

Common cancer in men. Usually adenocarcinoma (AC) affecting the peripheral zone of the prostate. Can be either acinar AC (more common), affecting the cells lining the prostate or ductal- cells linign the ducts.

Differentials; BPH, bladder cancer, kidney stones, pyelonephritis, prostatitis.

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14
Q

Prostate cancer-
RF
Features

A

Age, FHx, ethnicity (Afro-Car) . Also smoking, obesity, BRAC1/2 gene, DM.

LUTS initially. Once advanced localised; haematuria, haematospermia, suprapubic pain, loin pain, bone pain, weight loss etc.

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15
Q

Prostate cancer-

Investigations

A

DRE- palpable, firm irregular mass.
PSA- Although not specific.
Biopsy- transperineal/trasnsrectal. Repeat biopsy if persistent abnormal PSA/DRE.

Grade with Gleason score.

Image with mp-MRI. Stage with CT abdo-pelvis.

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16
Q

Prostate cancer-

Management

A

Look at risk:
Low- Monitor, consider radical if progression.
Intermediate/high- Monitor (If intermediate)/radical.
Metastatic- Chemo/ anti-hormonal agents.

Surveillance- Repeat PSA 3/12, DRE 6/12-1yr, biopsy 1-3yrs.

Surgery- Prostatectomy, and remove seminal vesicles, LN.

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17
Q

Penile cancer

A

Very rare urological cancer.
Often SSC, usually affecting the inner glans.
Differentials; Infections Herpes simplex, syphilis, genital warts etc.

18
Q

Penile cancer-
RF
Features

A

RF; HPV. Also phimosis, smoking, untreated HIV. circumcision is protective.

Features; painless ulcerating lesion which may bleed/discharge. Mainly found on the glans, but also can be at the foreskin, shaft or scrotum. Inguinal lymphadenopathy may be present.

19
Q

Penile cancer-

Investigations

A

Biopsy.

PET-CT for inguinal lymph node involvement (for staging). If positive then CT chest-abdo-pelvis.

20
Q

Penile cancer-

Management

A

Superficial, non invasive- Topical chemo and monitor.

Surgery for most cases; @glans- local excision, partial/complete glansectomy (+ reconstruction).
Invasive- partial amputation / total penectomy with reconstruction. May require neoadjuvant chemo/radiotherapy.

21
Q

LUTS-
Causes
Types
Investigations

A

Main causes; women-UTI, men- BPH
Storage- Frequency, nocturia, urgency incontinence, urgency.
Voiding- Post-micturition dribble, feeling of incomplete emptying, hesitancy, reduced flow.
Bloods (inc PSA), urine dip, culture, cystoscopy.

22
Q

LUTS management-
Conservative
Medical

A

Time fluid intake, reduce alcohol, pelvic floor exercises, bladder training.
Anticholinergics- reduce bladder muscle tone i.e. oxybutynin in overactive bladder.
Muscle relaxants- tamsulosin (a blocker), finasteride- relax prostate muscle therefore reduce size.
Loo[ diuretics- may use to reduce nocturia, take during day.

23
Q

LUTS complications

A

Infection, stone formation, renal failure, bilateral hydronephrosis, acute urinary retention.

24
Q

Haematuria-
Urological causes
Referral pathway

A

Infection, malignancy, stones, trauma.
Refer to one stop haematuria clinic for flexi-cystoscopy (can also do US-KUB or CT-urogram) if 45+yrs with visible haematuria either without or following successful treatment of a UTI. Or 60+yrs with unexplained NVH + dysuria/raised WBC
Treat underlying cause.

25
Q

Acute Urinary Retention

A

Sudden onset, suprapubic pain and tenderness.
Causes include BPH (common), infection, severe pain, medications, strictures, constipation (press on urethra) neurological.
Investigate with bloods (inc PSA), USS for hydronephrosis in high pressure retention.
Insert catheter immediately- can take sample to see if Abx indicated.

26
Q

Chronic Urinary Retention

A

Painless retention of urine, palpable distended bladder, voiding symptoms- since obstructed bladder.
Common cause BPH. Also strictures, neurological, prolapse (women), malignancy.
Investigate with blood, dip, USS- ensure not HP.
May need long term catheter or ISC. Treat underlying condition.
Complications include UTI, bladder canaliculi.

27
Q

Scrotal Lumps differentials

A

Hydrocele- transilluminates
Varicocele- bag of worms, distended pampiniform plexus.
Testicular cancer
Epidydimal cyst- smooth, transilluminate
Epididymitis
Inguinoscrotal hernia- cannot get above it.
Testicular torsion

28
Q

Incontinence-

Types

A 
Stress (common due to weak pelvic floor)
Urge (common due to neurogenic, infection, malignancy)
Mix (S+U)
Overflow (common BPH)
Continuous.
29
Q

Incontinence-
Investigations
Management

A

Urine dipstick, keep bladder diary, urodynamic tests and cystoscopy.

Initially consider lifestyle changes i.e. weight loss, smoking cessation.
Stress- 3 months supervised PF exercises; unresponsive then duloxetine. Surgery- IM bulking agents, tension free vaginal tape.
Urge- 6 wks bladder training; unresponsive then oxybutynin/tolterodine. Surgery- botox, sacral nerve stimulation.

30
Q

Renal stones-
Compositions
Presentation
Differentials

A

Commonly calcium oxalate, also urate, cysteine and MAP (due to infection) stones.

Asymptomatic, until enters the ureter- loin to groin pain, NV haematuria.
Present when stuck at PUJ, pelvic brim or VUJ.

Differentials include ruptured AAA, pyelonephritis etc.

31
Q

Renal stones-
Investigations
Management
Complications

A

Gold standard non contrast CT-KUB.
Can use USS alongside to look for hydronephrosis.
Manage with fluid resus (dehydrated), <5mm or distal ureter allowed to pass with diclofenac. Tamsulosin can help dilate ureter.

Admit if developed post-obstructive AKI, >5mm, infected stone or uncontrolled pain.
Intervene with shock wave therapy or lasering the stone.

Complications include sepsis or post renal AKI. Treat with stent/nephrostomy, to reduce hydronephrosis.

32
Q 
Bladder stones-
Cause
Presentation
Investigation
Management
Complications
A

Due to stagnation of urine in bladder (chronic retention).
Present with LUTs.
Investigate with non contrast CT KUB.
Manage with cystoscopy +/- laser to drain the stone.
Repetitive trauma to bladder wall predisposes to SCC.

33
Q

Pyelonephritis-
Features
RF
Differentials

A

Inflammation of the renal pelvis and parenchyma causing unilateral loin pain, fever, N+V within 24-48hrs. May also have haematuria, UTI symptoms.

RF: Decreased antegrade flow (obstruction), increased retrograde flow (female gender/catheter), infection/immunocompromised, promotion of bacterial colonisation (stones, sex).

DDx- Ruptured AAA, renal stones.

34
Q

Pyelonephritis-
Investigations
Management

A

Urine dip, pregnancy test, bloods, cultures, US- ?obstruction, if obstruction confirmed then non contrast CT.

A-E, IV fluids resus, Abx, catheter (if high dependency), admit if unstable.

35
Q

Pyelonephritis- Complications

A

Sepsis
Chronic pyelonephritis- repeated infection leading to scarring/fibrosis.
Emphysematous pyelonephritis- Rare, but common in diabetes. Gas forming aerobes- poor response to Abx. Use broad spectrum, if unresponsive then nephrostomy/percutaneous drainage.

36
Q

Renal cysts-
Types and management
RF
Investigation

A

Simple- Usually asymptomatic so no follow up/treatment. If symptomatic then analgesia, aspiration/deroofing.
Complex- May need surgical intervention.

RF- HTN, male, increasing age, genetics, smoking.
Present flank pain, haematuria (if ruptured/twisted), also uncontrollable HTN in ADPKD.

Investigate with CT/MRI IV contrast.

37
Q

BPH medication

A

Tamsulosin- Adrenoceptor antagonist- Reduce SM action.
Finasteride- If still symptomatic. 5a reductase inhibitor, therefore less testosterone-DHT conversion, therefore reduce work and size of prostate.

38
Q

Fournier’s gangrene

A

Necrotising fasciitis of the perineum.
RF- DM, XS alcohol, poor nutrition.
Non-specific features early on followed by rapid deterioration
Need urgent surgical debridement with broad-spectrum antibiotic cover.

39
Q

Prostatitis-

A

Inflammation of prostate gland, usually due to ascending urethral infection (E.coli common).
Acute/chronic where chronic due to poor treatment of acute.
Acute; LUTs, suprapubic pain, discharge.
Chronic; 3 months pelvis pain/discomfort + LUTs.
Urine culture then Abx.

40
Q

Epididymitis-

A

Common in 15-30yrs and again >60yrs
Unilateral scrotal pain and associated swelling; bilateral epididymitis is rare.
Clinical diagnosis, but can be aided by US Doppler imaging
Manage with Abx and analgesia

41
Q

Urethritis-

A

Often due to infection.
Either gonococcal or non-gonococcal urethritis
Presents with dysuria, penile irritation, and discharge.
Manage with Abx, also advice and trace contacts.

42
Q

Paraphimosis

A

Can’t put back the retracted foreskin over the glans penis
The glans becomes progressive oedematous and can lead to necrosis
Need to be reduced immediately and analgesia.

NB. phimosis is inability to retract foreskin.

Surgery Block (7 decks)

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