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MRCS part A- Principles of surgery in general > Urology for the MRCS part A > Flashcards

Urology for the MRCS part A Flashcards

1
Q

Enumerate types of renal stones with their percentage of occurrence starting with the most common to the less common

A

Mnemonic;CC/US/C

(1) Calcium oxalate(85%)
(2) Calcium phosphate stones(10%)
(3) Uric acid stones(5-10%)
(4) Struvite stones(2-20%)
(5) Cystine stones(1%)

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2
Q

Discuss calcium oxalate stones

A

Percentage =85%

Aetiology
(1)Hypercalciuria
(2)Hyperoxaluria
(3)Hyperuricosuria-may cause uric acid stones to which calcium oxalate binds
(4)Hypocitraturia-increases risk because citrate forms complexes with calcium
making it more soluble

Opacity = Radio-opaque(though less than calcium phosphate stones)

Urine acidity = variable

Urine PH = 6

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3
Q

Enumerate causes of calcium oxalate stones

A

(1)Hypercalciuria
(2)Hyperoxaluria
(3)Hyperuricosuria-may cause uric acid stones to which calcium oxalate binds
(4)Hypocitraturia-increases risk because citrate forms complexes with calcium
making it more soluble

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4
Q

Comment on opacity of calcium oxalate stones

A

Radio-opaque(though less than calcium phosphate stones)

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5
Q

Comment on urine acidity of calcium oxalate stones

A

Variable

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6
Q

What is the urine PH of calcium oxalate stones?

A

6

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7
Q

Why hyperuricosuria causes calcium oxalate stones?

A

May cause uric acid stones to which calcium oxalate binds

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8
Q

Why hypocitraturia causes calcium oxalate stones?

A

Increases risk because citrate forms complexes with calcium making it more soluble

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9
Q

Discuss calcium phosphate stones

A

Incidence = 10%

Aetiology-the following increases supersaturation of urine with calcium and phosphate causing calcium phosphate stones:-
(1)Renal tubular acidosis types 1 and 3(types 2 and 4 do not)
(2)High urinary PH

Opacity = radio-opaque (composition similar to bone)

Urine acidity = Normal/Alkaline

Urine PH > 5.5

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10
Q

What is the incidence of calcium phosphate stones?

A

10%

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11
Q

What is the aetiology of calcium phosphate stones ?

A

the following increases supersaturation of urine with calcium and phosphate causing calcium phosphate stones:-
(1)Renal tubular acidosis types 1 and 3(types 2 and 4 do not)
(2)High urinary PH

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12
Q

What increases supersaturation of urine with calcium and phosphate causing calcium phosphate stones?

A

(1)Renal tubular acidosis types 1 and 3(types 2 and 4 do not)
(2)High urinary PH

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13
Q

Comment on opacity of calcium phosphate stones

A

radio-opaque (composition similar to bone)

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14
Q

Comment on urine acidity of calcium phosphate stones

A

Normal/Alkaline

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15
Q

What is the urine PH of calcium phosphate stones?

A

> 5.5

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16
Q

How does uric acid form?

A

A product of purine metabolism

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17
Q

Discuss uric acid stones

A

Incidence = 5-10%

Aetiology
Mnemonic;TIP
(1)extensive (T)issue breakdown e.g.,malignancy
(2)in children with (I)nborn errors of metabolism
(3)low (P)H-increases uric acid precipitation
(4)Thiazide diuretics
(5)In primary polycythaemia
(6)chemotherapy and cell death can increase uric acid levels.
(7)dehydration

Opacity =radiolucent(unless they have calcium contained within them)
If uric acid stones are unlikely to be coated with calcium therefore will be radiolucent

Urine acidity = acid

Urine PH = 5.5

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18
Q

What is the incidence of uric acid stones?

A

5-10%

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19
Q

What is the aetiology of uric acid stones?

A

Mnemonic;TIP
(1)extensive (T)issue breakdown e.g.,malignancy
(2)thiazide diuretics
(3)in children with (I)nborn errors of metabolism
(4)In 1ry polycythaemia
(5)low (P)H-increases uric acid
precipitation
(6)chemotherapy and cell death can increase uric acid levels
(7)Dehydration

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20
Q

Comment on opacity of uric acid stones

A

Radiolucent (unless they have calcium contained within them)

If uric acid stones are unlikely to be coated with calcium therefore will be radiolucent

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21
Q

Comment on urine acidity in uric acid stones

A

Acid

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22
Q

What is the urine PH in uric acid stones?

A

5.5

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23
Q

Discuss struvite stones

A

Incidence = 2-20%

Aetiology
chronic infections with urease producing bacteria e.g.,proteus mirabilis
Infection with proteus mirabilis accounts for 90% of all proteus infections.
It has a urease producing enzyme.This will tend to favour urinary
Alkalinisation which is a relative prerequisite for the formation of
staghorn calculi.

Composition
(1)Magnesium
(2)Ammonium
(3)Phosphate
(4)Crystals-precipitate under alkaline conditions

Opacity = slightly radio-opaque

Urine acidity = Alkaline

Urine PH = >7.2

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24
Q

What is the incidence of struvite stones?

A

2-20%

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25
Q

What is the aetiology of struvite stones?

A

Chronic infection with protease producing bacteria e.g.,proteus mirabilis
Infection with proteus mirabilis accounts for 90% of all proteus infections.
It has a urease producing enzyme.This will tend to favour urinary
Alkalinisation which is a relative prerequisite for the formation of
staghorn calculi.

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26
Q

What is the composition of struvite stones?

A

(1)Magnesium
(2)Ammonium
(3)Phosphate
(4)Crystals-precipitate under alkaline conditions

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27
Q

Comment on opacity of struvite stones

A

Slightly radio-opaque

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28
Q

Comment on urine acidity in struvite stones

A

Alkaline

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29
Q

What is the urine PH in struvite stones?

A

> 7.2

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30
Q

Discuss cystine stones

A

Incidence = 1%

Aetiology
Inherited-recessive disorder of transmembrane cystine transport leading to decreased absorption of cystine from intestines and renal tubules

Feature = multiple stones may form

Opacity = because they contain sulphur,they may have the following appearance
(1)radiosense or
(2)semi-opaque
(3)ground glass

Urine acidity = normal

Urine PH = 6.5

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31
Q

Why the urine PH is measured?

A
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32
Q

What is the incidence of cystine stones?

A

1%

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33
Q

What is the aetiology of cystine stones?

A

Inherited-recessive disorder of transmembrane cystine transport leading to decreased absorption of cystine from intestines and renal tubules

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34
Q

What is the feature of cystine stones?

A

multiple stones may form

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35
Q

Comment on opacity of cystine stones

A

because they contain sulphur,they may have the following appearance
(1)radiosense or
(2)semi-opaque
(3)ground glass

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36
Q

Comment on urine acidity in cystine stones

A

Normal

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37
Q

What is the urine PH in cystine stones?

A

6.5

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38
Q

Summarise types of renal stones for the exam

A
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39
Q

Classify renal stones

A
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40
Q

Discuss therapeutic selections for renal stones

A
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41
Q

How do you manage a ureteric calculi <5mm?

A

Expectantly

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42
Q

How do you manage a stone burden <2cm?

A

(1)Lithotripsy or
(2)Ureteroscopy-if pregnant or impacted

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43
Q

How do you manage complex renal calculi?

A

Percutaneous nephrolithotomy(PCNL)

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44
Q

How do you manage staghorn calculi?

A

Percutaneous nephrolithotomy(PCNL)

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45
Q

How do you manage stone of any size+obstructed and infected system ?

A

Urgent decompression(ureteroscopy or nephrostomy)

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46
Q

How do you manage an obstructed stone or a stone causing obstruction?

A

Urgent decompression(ureteroscopy or nephrostomy)

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47
Q

How do you manage a stone causing infected system?

A

Urgent decompression(ureteroscopy,nephrostomy)

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48
Q

Discuss staghorn renal calculi

A

Definition
(1)Involve the renal pelvis hence the stag horn shape
(2)Extend into at least 2 calyces

Aetiology = Recurrent Urinary Tract Infection(UTI)with urea plasma producing bacteria
(1)Ureaplasma urealyticum
(2)Proteus mirabilis
Infection with proteus mirabilis accounts for 90% of all proteus infections.
It has a urease producing enzyme.This will tend to favour urinary
Alkalinisation which is a relative prerequisite for the formation of
staghorn calculi.
(3)Klebsiella
(4)Pseudomonas
(5)Enterobacter

Composition
1st/struvite which is composed of(Mnemonic;MAP/T)
(1)magnesium
(2)ammonium
(3)Phosphate
(4)triple phosphate
2nd/Calcium carbonate appatite

Type of stone
(1)Struvite(magnesium,ammonium,phosphate,triple phosphate) or
(2)Calcium carbonate appatite

Opacity=radio-opaque

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49
Q

Define staghorn renal calculi

A

(1)Involve the renal pelvis
(2)Extend into at least 2 calyces

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50
Q

What is the aetiology of staghorn renal calculi?

A

Recurrent Urinary Tract Infection with urea producing bacteria
(1)Ureaplasma urealyticum
(2)Proteus mirabilis
Infection with proteus mirabilis accounts for 90% of all proteus infections.
It has a urease producing enzyme.This will tend to favour urinary
Alkalinisation which is a relative prerequisite for the formation of
staghorn calculi.
(3)Klebseila
(4)Pseudomonas
(5)Enterobacter

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51
Q

What is the composition of staghorn renal calculi?

A

1st/struvite which is composed of(Mnemonic;MAP/T)
(1)magnesium
(2)ammonium
(3)Phosphate
(4)triple phosphate
2nd/Calcium carbonate appatite

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52
Q

Discuss renal stones appearance on imaging

A
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53
Q

What is the effect of urinary PH on stone formation?

A
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54
Q

What is the incidence of urolithiasis?

A

15%

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55
Q

What are the clinical features of urolithiasis?

A

Abdominal pain which is
(1)the classic feature in history
(2)loin to groin
(3)sudden onset
(4)almost always associated with haematuria

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56
Q

How to diagnose urolithiasis?

A

Helical non contrast CT(CT KUB)-the most sensitive and specific diagnostic test

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57
Q

Discuss shock wave lithotripsy

A

Also known as = extracorporial shock wave lithotripsy(ESWL)

Definition
(1)a shock wave is generated external to the patient
(2)internally,cavitation bubbles and mechanical stress lead to stone fragmentation

Side effects
(1)fragmentation of larger stones results in the development ureteric obstruction
(2)the passage of shock waves results in solid organ injury
(3)the procedure is uncomfortable and requires analgesia during and after the procedure

Indications and contraindications

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58
Q

What is the other name for shock wave lithotripsy?

A

extracorporial shock wave lithotripsy(ESWL)

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59
Q

Define shock wave lithotripsy

A

(1)a shock wave is generated external to the patient
(2)internally,cavitation bubbles and mechanical stress lead to stone fragmentation

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60
Q

Draw a schematic diagram illustrating cavitation bubbles in ESWL

A
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61
Q

Real picture of cavitation bubbles in ESWL

A
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62
Q

What are the side effects of shock wave lithotripsy(ESWL)

A

(1)fragmentation of larger stones results in the development ureteric obstruction
(2)the passage of shock waves results in solid organ injury
(3)the procedure is uncomfortable and requires analgesia during and after the procedure

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63
Q

What are the indications and contraindications of shock wave lithotripsy (ESWL)?

A
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64
Q

What are the indications of shock wave lithotripsy (ESWL)?

A
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65
Q

What are the contraindications of shock wave lithotripsy (ESWL)?

A
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66
Q

Discuss ureteroscopy

A

Indications
(1)where lithotripsy is contraindicated(e.g.,pregnant)
(2)complex stone disease
(3)stone burden of less than 2cm in pregnants

Technique
(1)passes retrograde
-through the ureter
-into the renal pelvis
(2)left in situ for 4 weeks after the procedure

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67
Q

What are the indications of ureteroscopy?

A

(1)where lithotripsy is contraindicated(e.g.,pregnant)
(2)complex stone disease
(3)stone burden of less than 2cm in pregnants

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68
Q

What is the technique for ureteroscopy?

A

(1)passes retrograde
-through the ureter
-into the renal pelvis
(2)left in situ for 4 weeks after the procedure

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69
Q

What do(left in situ) mean for ureteroscopy?

A

Left in the renal pelvis

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70
Q

For how long the ureteroscopy is left in situ inside the renal pelvis?

A

4 weeks

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71
Q

Discuss percutaneous nephrolithotomy(PCNL)

A

Indications
(1)Staghorn stones
(2)Large stones(mostly > 2 cm)-It should be considered 1st line for stones>20mm
(3)Multiple stones
(4)complicated stones(e.g.,upper UTI,obstruction by a stone of whatever the size)
(5)Lower pole calyx or region stones,two options
->1cm do percutaneous nephrolithotomy (PCNL)
-<1cm do flexible ureteroscopy
(6)PCNL is a safe treatment for stones in a transplant kidney but it should be done in a specialist centre
(7)PCNL is often considered in patients with kidney stones that have undergone urinary diversion.
A retrograde approach can also be considered if access to the ureters can be gained

Contraindications
(1)Uncorrected bleeding disorders or coagulopathy
(2)Uncooperative patient
(3)Severe hyperkalemia (>7 mEq/L); this should be corrected with hemodialysis before the procedure

Technique
(1)Access is gained to the renal collecting system
(2)Intracorporial lithotripsy or stone fragmentation is performed
(3)Stone fragments removed

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72
Q

What are the indications of percutaneous nephrolithotomy(PCNL)?

A

(1)Staghorn stones
(2)Large stones(mostly > 2 cm)-It should be considered 1st line for stones>20mm
(3)Multiple stones
(4)complicated stones(e.g.,upper UTI,obstruction by a stone of whatever the size)
(5)Lower pole calyx or region stones,two options
->1cm do percutaneous nephrolithotomy (PCNL)
-<1cm do flexible ureteroscopy
(6)PCNL is a safe treatment for stones in a transplant kidney but it should be done in a specialist centre
(7)PCNL is often considered in patients with kidney stones that have undergone urinary diversion.
A retrograde approach can also be considered if access to the ureters can be gained

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73
Q

What is the technique used for percutaneous nephrolithotomy(PCNL)?

A

(1)Access is gained to the renal collecting system
(2)Intracorporial lithotripsy or stone fragmentation is performed
(3)Stone fragments removed

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74
Q

What does radiosense for renal stones mean?

A

Radio-opaque

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75
Q

What does radio-opaque for renal stones mean?

A

Radiosense

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76
Q

Discuss nephrostomy

A
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77
Q

What is the difference between stent(down)and nephrostomy(above)?

A
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78
Q

Define nephrostomy

A

Opening in the kidney

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79
Q

What are the indications of nephrostomy?

A

(1)pyelonephritis
(2)signs of obstruction(especially,distal obstruction)
-RF
-sepsis
-solitary kidney
-continuing obstruction
(3)fever

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80
Q

What is the technique used for renal stents?

A

Placed from the urethra down so you are not coming from the kidney above

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81
Q

What is the indication of nephrectomy?

A

If kidney function <15%

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82
Q

Discuss management of renal stones in general

A

1st/According to the urgency of the case
[I]NON EMERGENCY CASES
#Options
(1)Conservative treatment for 2 weeks
For stones<5mm;90% pass through urine within 4 weeks of symptoms onset
(2)Extracorporial shock wave lithotripsy(ESWL)
(3)Percutaneous nephrolithotomy(PCNL)
(4)Flexible ureteroscopy
(5)Open surgery for selected cases-minimally invasive options are the most popular first line treatment
[II]MORE INTENSIVE AND URGENT TREATMENT
#Indications
(1)Ureteric obstruction
Ureteric obstruction due to stones together
with infection is a surgical emergency and
the system must be decompressed
(2)Renal developmental abnormalities such as horseshoe kidney
(3)Renal transplant
#Options
(1)Nephrostomy tube placement
(2)Ureteric cathetre insertion
(3)Ureteric stent placement

2nd/According to the stone size

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83
Q

What is the management of renal stones according to the urgency of the case?

A

1st/According to the urgency of the case
[I]NON EMERGENCY CASES
#Options
(1)Conservative treatment for 2 weeks
For stones<5mm;90% pass through urine within 4 weeks of symptoms onset
(2)Extracorporial shock wave lithotripsy(ESWL)
(3)Percutaneous nephrolithotomy(PCNL)
(4)Flexible ureteroscopy
(5)Open surgery for selected cases-minimally invasive options are the most popular first line treatment
[II]MORE INTENSIVE AND URGENT TREATMENT
#Indications
(1)Ureteric obstruction
Ureteric obstruction due to stones together
with infection is a surgical emergency and
the system must be decompressed
(2)Renal developmental abnormalities such as horseshoe kidney
(3)Renal transplant
#Options
(1)Nephrostomy tube placement
(2)Ureteric cathetre insertion
(3)Ureteric stent placement

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84
Q

What are the options of management of renal stones of non emergency cases?

A

(1)Conservative treatment for 2 weeks
For stones<5mm;90% pass through urine within 4 weeks of symptoms onset
(2)Extracorporial shock wave lithotripsy(ESWL)
(3)Percutaneous nephrolithotomy(PCNL)
(4)Flexible ureteroscopy
(5)Open surgery for selected cases-minimally invasive options are the most popular first line treatment

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85
Q

What are the indications of more intensive and urgent treatment for renal stones?

A

(1)Ureteric obstruction
Ureteric obstruction due to stones together
with infection is a surgical emergency and
the system must be decompressed
(2)Renal developmental abnormalities such as horseshoe kidney
(3)Renal transplant

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86
Q

What are the options of more intensive and urgent treatment for renal stones?

A

(1)Nephrostomy tube placement
(2)Ureteric cathetre insertion
(3)Ureteric stent placement

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87
Q

What is the treatment of renal stones according to the stone size?

A
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88
Q

What is the treatment of renal stones according to the symptoms ?

A
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89
Q

What is the complication of instrumentation of renal tract and what is the treatment?

A
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90
Q

What is the complication of instrumentation of renal tract?

A
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91
Q

What are the organisms causing sepsis during instrumentation of renal tract as part of management of renal stones?

A

Gm(-)ve sepsis caused by organisms such as
(1)E.coli
(2)Bacteroides

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92
Q

What is the treatment of the organisms causing sepsis during instrumentation of renal tract as part of management of renal stones?

A
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93
Q

What is the indication of conservative management of renal stones?

A

(1)Conservative treatment for 2 weeks for stones<5mm
(Salah stated < 0.5cm in MRCS but in reality<1 cm)
without obstruction features ;
90% pass through urine within 4 weeks
of symptoms onset
(2)Conservative treatment is not for patients with solitary kidney and a chance of obstructing this kidney

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94
Q

What is the treatment of renal stones <5mm size?

A

Conservative treatment for 2 weeks for stones<5mm;90% pass through urine within 4 weeks of symptoms onset

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95
Q

For how long the conservative treatment of renal stones lasts?

A

2 weeks

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96
Q

How long do renal stones need to pass out if treated conservatively?

A

4 weeks

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97
Q

What is the percentage of renal stones passing through the urine if treated conservatively?

A

90%

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98
Q

What is the way through which renal stone pass out if treated conservatively?

A

Urine

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99
Q

What is the treatment of renal stones > 5mm?

A
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100
Q

What are the features of obstruction of renal tract by stones?

A

(1)RF
(2)Sepsis
(3)Solitary kidney
(4)Continuing obstruction

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101
Q

What is the treatment of renal stones > 5mm with obstruction features?

A

Nephrostomy
If no nephrostomy option in answer key,then ureteric stent option

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102
Q

What is the treatment of renal stones > 5mm with obstruction features and no nephrostomy in answer key?

A

ureteric stent option

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103
Q

What is the treatment of renal stones > 5mm with no obstruction features?

A
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104
Q

What is the treatment of renal stones > 5mm in the renal pelvis with no obstruction features?

A

(1)Extracorporial shock wave lithotripsy(ESWL)1st line treatment
(2)Percutaneous nephrolithotomyPCNL) if staghorn or large stone > 2cm

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105
Q

What is the treatment of simple renal stones > 5mm with no obstruction features?

A

Extracorporial shock wave lithotripsy(ESWL) 1st line treatment

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106
Q

What is the treatment of staghorn renal stones with no obstruction features?

A

Percutaneous nephrolithotomy (PCNL)

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107
Q

What is the treatment of large renal stones > 2cm with no obstruction features?

A

Percutaneous nephrolithotomy (PCNL)

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108
Q

What is the treatment of renal stones > 5 mm and ≤ 2cm in the upper pole calyx with no obstruction features?

A

Extracorporial shock wave lithotripsy (ESWL)

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109
Q

What is the treatment of renal stones > 1cm in the lower pole calyx with no obstruction features?

A

Percutaneous nephrolithotomy (PCNL) if > 1cm otherwise ESWL

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110
Q

What is the treatment of renal stones > 5 mm in the upper 1/3rd ureter with no obstruction features?

A

Push-Bang or ESWL in situ

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111
Q

What is the treatment of renal stones > 5 mm in the middle 1/3rd ureter with no obstruction features?

A

Mnemonic;PULLL
(1)Push-Bang 1st line treatment or
(2)USG or
(3)Laser or
(4)Lithoclast or
(5)Lithotripsy(if not considering surgery)

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112
Q

What is the treatment of renal stones > 5 mm in the lower 1/3rd ureter with no obstruction features?

A

Mnemonic;DJU
(1)Dormia Basket &
(2)JJ stent(Ureteroscopic removal if mild obstruction)

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113
Q

What is the treatment of renal stone <2cm with no obstruction features?

A
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114
Q

What is the treatment of small stone at the collecting system?

A

Flexible ureter-Renoscopy+Laser+Lithotripsy but never ESWL

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115
Q

What is the treatment bladder stone ?

A

Lithoclast fragmentation but required surgery if >5cm

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116
Q

What is the treatment of cystine calculi?

A

Dissolves by alkaline diuresis

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117
Q

What is the management of stones according to the symptoms?

A
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118
Q

What are the symptoms of bladder instability?

A

H/o
(1)urgency
(2)frequency
(3)nocturia
(4)uroflowmetry flow rate>15ml

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119
Q

What is the treatment of bladder instability?

A

Antimuscarinic drug like Tolterodine

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120
Q

What is the 1st line analgesia for renal colic?

A

NSAID

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121
Q

What is the 2nd line treatment for renal colic?

A

Strong opiates

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122
Q

Discuss diabetic nephropathy very briefly?

A
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123
Q

How is the diabetic nephropathy detected early?

A

By Micro-albuminaemia

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124
Q

What are the histological features of diabetic nephropathy?

A

Diffuse and nodular glomeruloscelerosis

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125
Q

What do we mean by antegrade and retrograde?

A
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126
Q

Discuss ureteric colic

A
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127
Q

Discuss rate of stones passage

A
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128
Q

Discuss over active bladder

A
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129
Q

Define the following terms
Urinary urgency,urge incontinence,urinary frequency and nocturia

A
130
Q

Define urinary urgency

A

Inability to defer voiding

131
Q

Define urge incontinence

A

Urgency causing non-voluntary urinary incontinence

132
Q

Define urinary frequency

A

8 or more voids per 24hrs

133
Q

Define nocturia

A

Awakening to void >1 instance per night

134
Q

Discuss indinavir stones

A
135
Q

What type of renal stones produced by indinavir could be seen on imaging?

A

Radiolucent stones

136
Q

Discuss risk factors for stone disease

A
137
Q

What is the effect of corticosteroids on stones formation?

A
138
Q

Are urine cultures necessary in stone disease?

A
139
Q

How to briefly manage urosepsis according to Pastest?

A
140
Q

What are the sites of narrowing in the renal tract and what is its importance?

A

The following are the sites where the renal stones dislodge:
(1)Ureteropelvic junction(UPJ) or pelviureteric junction(PUJ)
(2)Ureteral crossing of the iliac vessels
(3)Ureterovesical junction(UVJ) or vesicoureteric junction(VUJ)

141
Q

What is the duration required for complete renal obstruction to cause permanent renal dysfunction?

A

28 days

142
Q

Enumerate causes of hydronephrosis

A
143
Q

Enumerate causes of bilateral hydronephrosis

A
144
Q

Enumerate causes of unilateral hydronephrosis

A
145
Q

What is the sequele of pelvic ureteric junction obstruction?

A

Dietl’s crisis

146
Q

Discuss Dietl’s crisis

A

Definition
Intermittent hydronephrosis

Aetiology
Pelvis Ureteral junction (PUJ) obstruction

Clinical features
Swelling in the loin
(1)appears after an attack of acute renal colic
(2)disappears after passage of urine

147
Q

Define Dietl’s crisis

A

Intermittent hydronephrosis

148
Q

What is the clinical feature of Dietl’s crisis?

A

Swelling in the loin
(1)appears after an attack of acute renal colic
(2)disappears after passage of urine

149
Q

What is the aetiology of Dietl’s crisis?

A

Pelvic ureter junction(PUJ) obstruction

150
Q

What are the investigations of hydronephrosis?

A
151
Q

What is the role of USS in hydronephrosis?

A

(1)Identifies hydronephrosis
(2)Assess kidneys

152
Q

What is the role of IVU in hydronephrosis?

A

Assess the position of the obstruction

153
Q

What is the role of Antegrade and retrograde pyelography in hydronephrosis?

A

Allows treatment

154
Q

What is the role of CT scan in hydronephrosis?

A

CT scan is done if suspect renal colic as the majority of stones are detected this way

155
Q

What is the management or treatment of hydronephrosis?

A

Mnemonic;CAR

156
Q

What is the treatment of acute urinary tract obstruction as part of management of hydronephrosis?

A

Nephrostomy tube placement

157
Q

What is the treatment of chronic urinary tract obstruction as part of management of hydronephrosis?

A

(1)Ureteric stent placement or
(2)Pyeloplasty

158
Q

What is the importance of proteus mirabilis infection in the renal stones formation?

A

Infection with proteus mirabilis accounts for 90% of all proteus infections.
It has a urease producing enzyme.This will tend to favour urinary alkalinisation which is a relative prerequisite for the formation of staghorn calculi.

159
Q

What is the clinical picture of pelvic ureteric junction(PUJ)obstruction?

A
160
Q

What is the cardinal feature of pelvic ureteric junction(PUJ)obstruction?

A

Back and flank pain correlates with periods of increased fluids intake and food ingestion with diuretics properties

161
Q

What is the other name for ureteropelvic junction(UPJ)?

A

Pelviureteric junction

162
Q

What is the other name for ureterovesical junction?

A

Vesicoureteric junction(VUJ)

163
Q

What is the other name for renal cell carcinoma?

A

(1)Renal cell carcinoma of the renal cortex
(2)Renal adenocarcinoma
(3)Adenocarcinoma of the kidney
(4)Hypernephroma
(5)Grawtis tumour
(6)Clear cell carcinoma

164
Q

What are the other names for renal cell carcinoma?

A

(1)Renal cell carcinoma of the renal cortex
(2)Renal adenocarcinoma
(3)Adenocarcinoma of the kidney
(4)Hypernephroma
(5)Grawit’s tumour
(6)Clear cell carcinoma

165
Q

Discuss the incidence of the renal cell carcinoma

A
166
Q

What is the general incidence of renal cell carcinoma?

A

Renal cell carcinoma are the most common renal tumour comprising 75-85% of all renal malignancies

167
Q

What is the sex incidence of renal cell carcinoma?

A

M>F

168
Q

What is the age incidence of renal cell carcinoma?

A

Sporadic tumours affect patients in their 6th decade.

169
Q

Discuss manifestations of renal cell carcinoma

A
170
Q

Discuss the asymptomatic presentation of the renal cell carcinoma

A

-Incidence:50%
-most commonly present as asymptomatic unilateral tumour in adults not in children

171
Q

What is the percentage of asymptomatic presentation of renal cell carcinoma?

A

50%

172
Q

Fill the blanks:
Renal cell carcinoma most commonly present as———,———-,in ———- not in ———

A

Renal cell carcinoma most commonly present as ASYMPTOMATIC,BILATERAL TUMOUR,in ADULTS not in CHILDREN

173
Q

Discuss the unilateral presentation of renal cell carcinoma

A

-most commonly present as asymptomatic,unilateral tumour in adult not in children
-sometimes bilateral multicentric but not often

174
Q

Discuss the triad of renal cell carcinoma

A

Incidence
10%

Presentation
(1)Haematuria(50%)
1)Microscopic-most commonly discovered during diagnostic work up
2)Macroscopic-the patient may develop frank haematuria and have episodes
of clot colic
(2)Renal colic(40%)
sometimes;it would be painless
(3)Renal mass(30%)
-RCCs typically affect the renal parenchyma
-Benign renal tumours are rare,so renal masses should be investigated with
multisliced CT scanning.
Some units will add an arterial or venous phase to the scan to demonstrate
1.vascularity
2.evidence of caval growth

175
Q

What is the incidence of renal cell carcinoma triad?

A

10%

176
Q

Discuss Haematuria in renal cell carcinoma

A

Incidence
50%

Presentation
1)Microscopic-most commonly discovered during diagnostic work up
2)Macroscopic(frank)-the patient may develop frank haematuria and have episodes of
clot colic

177
Q

Discuss presentation of renal cell carcinoma triad

A

(1)Haematuria(50%)
1)Microscopic-most commonly discovered during diagnostic work up
2)Macroscopic-the patient may develop frank haematuria and have episodes
of clot colic
(2)Renal colic(40%)
sometimes;it would be painless
(3)Renal mass(30%)
-RCCs typically affect the renal parenchyma
-Benign renal tumours are rare,so renal masses should be investigated with
multisliced CT scanning.
Some units will add an arterial or venous phase to the scan to demonstrate
1.vascularity
2.evidence of caval growth

178
Q

Discuss renal colic as a presentation of renal cell carcinoma triad

A

Incidence
40%

Presentation
sometimes;it would be painless

179
Q

What is the incidence of renal colic as a presentation of renal cell carcinoma?

A

40%

180
Q

What is the presentation of renal colic as part of the renal cell carcinoma triad?

A

Sometimes,it would be painless

181
Q

Discuss renal mass as part of the renal cell carcinoma triad

A

Incidence
30%

Presentation
-RCCs typically affect the renal parenchyma
-Benign renal tumours are rare,so renal masses should be investigated with
multisliced CT scanning.
Some units will add an arterial or venous phase to the scan to demonstrate
1.vascularity
2.evidence of caval growth

182
Q

What is the incidence of renal mass as part of renal cell carcinoma triad?

A

30%

183
Q

What is the presentation of renal mass as part of renal cell carcinoma triad?

A

-RCCs typically affect the renal parenchyma
-Benign renal tumours are rare,so renal masses should be investigated with
multisliced CT scanning.
Some units will add an arterial or venous phase to the scan to demonstrate
1.vascularity
2.evidence of caval growth

184
Q

Discuss left varicocle as part of the presentation of renal cell carcinoma

A

Due to compression of the left testicular vein as it joins the renal vein

185
Q

What is the cause of left varicocele in renal cell carcinoma?

A

Due to compression of the left testicular vein as it joins the renal vein

186
Q

What is the site of left testicular vein drainage?

A

Left renal vein

187
Q

Why should we do an U/S to left vericocle in renal cell carcinoma

A
188
Q

Discuss paraneoplastic syndrome as part of presentation of renal cell carcinoma

A

Aetiology in renal cell carcinoma
Paraneoplastic syndromes are due to ectopic secretion of hormones by the RCCs

Presentation

189
Q

What is the aetiology of paraneoplastic syndromes as part of presentation of renal cell carcinoma?

A

Paraneoplastic syndromes are due to ectopic secretion of hormones by the RCCs

190
Q

What are the paraneoplastic syndromes as part of presentation of renal cell carcinoma?

A
191
Q

What is the most common paraneoplastic syndromes in general?

A

Endocrinopathies

192
Q

What is the most common endocrinopathies in paraneoplastic syndromes?

A

Cushing syndrome(50%)

193
Q

What is the most common paraneoplastic syndromes in general?

A

Cushing syndrome

194
Q

What is the most common paraneoplastic syndromes in renal cell carcinoma?

A

Hypercalcaemia(20%)

195
Q

What is the cause of hypercalcaemia in renal cell carcinoma?

A

(1)Parathyroid hormone
It leads to increased bone resorption and decreased
renal clearance of calcium
(2)TGF-alpha
(3)TNF
(4)IL-1

196
Q

What is the incidence of hypercalcaemia in renal cell carcinoma?

A

20%

197
Q

What is the presentation of hypercalcaemia in renal cell carcinoma?

A

(1)Depression
(2)Lethargy
(3)Constipation
(4)Abdominal pain
(5)Vomiting

198
Q

What is the effect of parathyroid hormone in hypercalcaemia as a presentation of renal cell carcinoma?

A

(1)Increased bone resorption
(2)Decreased renal clearance of calcium

199
Q

What is the importance of hyponatraemia in renal cell carcinoma?

A

Although not caused by renal cell carcinoma,it may be considered as poor prognostic indicator

200
Q

What is the importance of hypocalcaemia in renal cell carcinoma?

A

Not seen in renal cell carcinoma

201
Q

What is the most common malignancy associated with hypercalcaemia?

A

Squamous cell carcinoma of the lung

202
Q

What is the importance of lymphopaenia in renal cell carcinoma?

A
203
Q

What is the importance of polycythaemia in renal cell carcinoma?

A
204
Q

What is the incidence of symptoms of metastasis in renal cell carcinoma?

A

25%

205
Q

What are the symptoms of metastasis in renal cell carcinoma?

A
206
Q

What are the routes of spread of renal cell carcinoma?

A
207
Q

Discuss the direct route of spread to the metastasis of renal cell carcinoma

A
208
Q

What is the most common route of spread to the metastasis of renal cell carcinoma?

A

Heamatogenous spread

209
Q

Discuss the haematogenous route of spread to the metastasis of renal cell carcinoma

A
210
Q

What are the organs to which the renal cell carcinoma directly metastasise?

A
211
Q

What are the organs to which the renal cell carcinoma haematogenously metastasise?

A
212
Q

Discuss the histological features of renal cell carcinoma

A
213
Q

What is the origin of renal cell carcinoma?

A

Proximal convoluted tubules(PCT)

214
Q

Discuss role of 20% in renal cell carcinoma

A
215
Q

What is the appearance of renal cell carcinoma

A
216
Q

What are the investigations of renal cell carcinoma?

A
217
Q

What is the reason for which multisliced CT scan is done for renal cell carcinoma?

A

Benign tumours are rare,so renal masses should be investigated with multisliced CT scanning.
Some units will add an arterial or venous phase to demonstrate
(1)Vascularity
(2)Evidence of caval growth

218
Q

What is the reason for which CT scan of the chest and abdomen is done for renal cell carcinoma?

A

To detect distant disease

219
Q

What is the reason for which routine bone scan is done for renal cell carcinoma?

A

Not indicated in the absence of symptoms

220
Q

What is the reason for which biopsy is done for renal cell carcinoma?

A
221
Q

What is the indication of renal biopsy in renal cell carcinoma?

A

Before any ablative therapies

222
Q

What are the contraindications of renal biopsy in renal carcinoma?

A

Post nephrectomy

223
Q

What is the reason for which renal biopsy is contraindicated post nephrectomy?

A

Most cases of malignancy can be accurately classified on imaging

224
Q

What multisliced CT scan show in renal cell carcinoma?

A

A mass with small cystic centre

225
Q

What is the differential diagnosis of renal cell carcinoma?

A
226
Q

What is the importance of oncocytoma as a differential diagnosis of renal cell carcinoma?

A
227
Q

Discuss TNM staging and grading of renal cell carcinoma

A
228
Q

What is the importance of renal cell carcinoma staging and grading?

A

Prognosis

229
Q

Describe primary tumour (T) category of renal cell carcinoma staging?

A
230
Q

Describe regional lymph nodes (N) category of renal cell carcinoma staging?

A
231
Q

Describe distant metastasis (M) category of renal cell carcinoma staging?

A
232
Q

Describe prognostic stage groups of renal cell carcinoma staging?

A
233
Q

What is Tx stage of renal cell carcinoma mean?

A

Primary tumour can not be assessed

234
Q

What is T0 stage of renal cell carcinoma mean?

A

No evidence of primary tumour

235
Q

What is T1 stage of renal cell carcinoma mean?

A
236
Q

What is T1a stage of renal cell carcinoma mean?

A

Tumour ≤4 cm in greatest dimension,limited to the kidney

237
Q

What is T1b stage of renal cell carcinoma mean?

A

Tumor >4 cm but ≤7 cm in greatest dimension, limited to the kidney

238
Q

What is T2 stage of renal cell carcinoma mean?

A
239
Q

What T2a means in staging of renal cell carcinoma?

A

Tumor >7 cm but <10 cm in greatest dimension, limited to the kidney

240
Q

What T2b means in staging of renal cell carcinoma?

A

Tumor >10 cm, limited to the kidney

241
Q

What T3 means in staging of renal cell carcinoma?

A

Tumor extends into major veins or perinephric tissues, but not into the ipsilateral adrenal gland and not beyond Gerota’s fascia

242
Q

What T3a means in staging of renal cell carcinoma?

A
243
Q

What T3b means in staging of renal cell carcinoma?

A

Tumor extends into the vena cava below the diaphragm

244
Q

What T3c means in staging of renal cell carcinoma?

A

Tumor extends into the vena cava above the diaphragm or invades the wall of the vena cava

245
Q

What T4 means in staging of renal cell carcinoma?

A

Tumor invades beyond Gerota’s fascia (including contiguous extension into the ipsilateral adrenal gland)

246
Q

What Nx means in staging of renal cell carcinoma?

A

Regional lymph nodes cannot be assessed

247
Q

What N0 means in staging of renal cell carcinoma?

A

No regional lymph node metastasis

248
Q

What N1 means in staging of renal cell carcinoma?

A

Metastasis in regional lymph node(s)=1 node

249
Q

What N2 means in staging of renal cell carcinoma?

A

Metastasis in regional lymph node(s)=2 nodes

250
Q

What M0 means in staging of renal cell carcinoma?

A

No distant metastasis

251
Q

What M1 means in staging of renal cell carcinoma?

A

Distant metastasis

252
Q

What stage I means in the grading of renal cell carcinoma?

A

T1N0M0

253
Q

What stage II means in the grading of renal cell carcinoma?

A

T2N0M0

254
Q

What stage III means in the grading of renal cell carcinoma?

A

(1)T1N1M0
(2)T2N1M0
(3)T3NxM0
(4)T3N0M0
(5)T3N1M0

255
Q

What stage IV means in the grading of renal cell carcinoma?

A

(1)T4,any N,M0
(2)Any T,any N,M1

256
Q

Discuss management of renal cell carcinoma

A
257
Q

Discuss management of T1 stage of renal cell carcinoma

A
258
Q

What is the main procedure to treat T1 stage in renal cell carcinoma?

A

Partial nephrectomy

259
Q

What is the indication of partial nephrectomy in the treatment of T1 stage in renal cell carcinoma?

A

Inadequate reserve in the remaining kidney

260
Q

What is the advantage of partial nephrectomy in the treatment of T1 stage in renal cell carcinoma?

A

Gives equivalent oncological results to total radical nephrectomy

261
Q

Discuss treatment of T2 stage or above of renal cell carcinoma

A
262
Q

Discuss total radical nephrectomy as an option for treatment of T1 stage or above of renal cell carcinoma

A
263
Q

What is the standard practice for treatment of T1 stage or above of renal cell carcinoma

A

Total radical nephrectomy

264
Q

What is the technique for total radical nephrectomy as an option for treatment of T1 stage or above of renal cell carcinoma

A
265
Q

What is the technique for total radical nephrectomy as an option for treatment of T1 stage or above of renal cell carcinoma if performed via the open approach?

A
266
Q

What is the reason that early venous control is mandatory during surgery of total radical nephrectomy for treatment of T1 stage or above of renal cell carcinoma?

A

To avoid shedding of tumour cells into the circulation

267
Q

What is not indicated in total radical nephrectomy for treatment of T1 stage or above of renal cell carcinoma?

A
268
Q

What is the treatment of stages 1-4 of renal cell carcinoma?

A
269
Q

Discuss adjuvant therapy as an option for treatment of T2 stage or above of renal cell carcinoma

A
270
Q

What is the treatment of stage 1 renal cell carcinoma?

A

Partial nephrectomy

271
Q

What is the treatment of stage 2,3 and 4 of renal cell carcinoma?

A

Total radical nephrectomy

272
Q

What is the other name for Wilm’s tumour?

A

(1)Wilm’s nephroblastoma
(2)Nephroblastoma

273
Q

Discuss incidence of Wilm’s tumour

A

(1)Rare childhood tumour
(2)It accounts for 80% of all genitourinary malignancies in
pre-school children <15 years
(3)They are the commonest intra-abdominal tumours in
children under 10 years of age
(4)Occurs in children <5 years of life
(5)Usually presents in the first 4 years of life

274
Q

What are the manifestations of Wilm’s tumour?

A
275
Q

What is the chance of a patient with Wilm’s tumour to have a renal mass?

A

90%

276
Q

Discuss renal mass in a patient with Wilm’s tumour?

A
277
Q

What is the chance of a patient with Wilm’s tumour to have bilateral or multi-centric renal mass?

A

10%

278
Q

What is the chance of a patient with Wilm’s tumour to have haematuria ?

A

Renal mass in Wilm’s tumour is rarely associated with haematuria(1/3rd of the patients)

279
Q

What is the number of patients with Wilm’s tumour to have haematuria?

A

1/3rd of the patients

280
Q

What is the chance of a patient with Wilm’s tumour to have fever?

A

50%

281
Q

What is the chance of a patient with Wilm’s tumour to have hypertension?

A

50%

282
Q

At which side the varicocele usually presents in patients with Wilm’s tumour?

A

Left side

283
Q

Discuss WAGR syndrome in patients with Wilm’s tumour?

A

(1)Wilm’s tumour
(2)Aniridia
(3)Genitourinary
(4)Mental Retardation

284
Q

What are the symptoms of metastasis in patients with Wilm’s tumour?

A
285
Q

What is the characteristic feature of children with Wilm’s tumour?

A

Failure to thrive

286
Q

What are the investigations of Wilm’s tumour?

A
287
Q

What does XRs show in Wilm’s tumour?

A

Non calcified lesion

288
Q

What does CT show in Wilm’s tumour?

A

Non calcified lesion

289
Q

Discuss differential diagnosis of Wilm’s tumour

A
290
Q

What is the difference between Wilm’s tumour and neuroblastoma?

A
291
Q

What is the histological feature of Wilm’s tumour?

A

Undifferentiated embryonic tumour

292
Q

What is the management of Wilm’s tumour?

A
293
Q

What is the VAD regime for the management of Wilm’s tumour?

A

It is a chemotherapy regime combined with nephrectomy and includes

294
Q

What is the prognosis of Wilm’s tumour?

A
295
Q

Define neuroblastoma

A
296
Q

What is the origin of neuroblastoma?

A
297
Q

What is the incidence of neuroblastoma?

A
298
Q

What are the manifestations of neuroblastoma?

A
299
Q

What is the name of the syndrome associated with neuroblastoma?

A

Opsoclonus-myoclonus syndrome

300
Q

What are the investigations of neuroblastoma?

A
301
Q

What are the catecholamines secreted by neuroblastoma?

A

(1)Vanillylmandelic acid
(2)Homovanillic acid

302
Q

What does the urine test for in neuroblastoma?

A

Catecholamines

303
Q

What is the diagnostic test of neuroblastoma and what does it show?

A

Meta-Iodophor-Benzyl-Guanidine(MIBG) is diagnostic and shows calcified tumour

304
Q

What does Meta-Iodo-Benzyl-Guanidine(MIBG) show in neuroblastoma?

A

Calcified tumour

305
Q

What is the reason for doing a CT scan in neuroblastoma?

A

For staging

306
Q

What is the management of neuroblastoma?

A
307
Q

Discuss pathology of Wilm’s tumour

A
308
Q

Discuss complications and ways of spread of Wilm’s tumour

A
309
Q

What is the difference between Wilm’s tumour and Hypernephroma(renal cell carcinoma)?

A
310
Q

What is the other name for renal transitional cell carcinoma?

A

Transitional cell carcinoma of the kidney

311
Q

What is the incidence of renal transitional cell carcinoma?

A
312
Q

What is the incidence of renal transitional cell carcinoma for or compared to the upper urinary tract tumours?

A

90%

313
Q

What is the incidence of renal transitional cell carcinoma for or compared to all renal tumours?

A

Rare,approximately 7-10% of all renal tumours

314
Q

What is the sex incidence of renal transitional cell carcinoma?

A

M 3x > F

315
Q

What is the incidence of renal transitional cell carcinoma in males?

A

M 3x > F

316
Q

What is the incidence of renal transitional cell carcinoma in females?

A

M 3x > F

317
Q

What are the risk factors for renal transitional cell carcinoma?

A
318
Q

What is the significance of smoking in renal transitional cell carcinoma?

A
319
Q

What is the significance of smoking in urology ?

A

Renal transitional cell carcinoma

320
Q

What is the significance of the occupation in renal?

A

MRCS part A- Principles of surgery in general (6 decks)

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