Urology Surgery Flashcards
What are the symptoms of prostate cancer?
Bladder outflow obstruction
Erectile dysfunction
Haematuria
Pain in lower abdomen/ perineum
Weight loss
Reduced semen
Anaemia
- damage to kidneys
- Involvement of bone marrow
What investigations should be done in prostate cancer, what is the grading system used? and outline management:
PR Exam TRUS with biopsy PSA levels U&Es Alkaline phosphates Bone scan MRI
Grading:
Gleason’s grading
Management:
- watchful waiting
- Endocrine inhibits - anti androgen, LHRH analogues, radical orchiectomy
- Radiotherapy - Brachytherapy
- Prostatectomy
If there is pain in the lower abdomen and inguinal canal, when the canal is pressed, which nerve is being compressed?
Ilioinguinal nerve
What are the symptoms of bladder cancer? what is the most common type and what investigations should be done?
Frank haematuria
- painless
UTIs
Mucus in the urine
Ureteric obstruction
Lower abdominal pain
- this is a late finding
Types:
- transitional cell carcinoma
- squamous cell carcinoma - schistosomiasis, UTIs
- adenocarcinomas
Investigations:
- urine dipstick - blood
- Flexible Cystoscopy
- this is then followed by:
- Rigid cystoscopy + biopsy *needs GA
- urine microscopy
What are some risk factors for developing bladder cancer?
Smoking Hydrocarbon exposure - industrial plants/ rubber factory Schistosomiasis Trauma Cyclophosphamide
What are the gradings of bladder cancer?
T0: mucosa
T1: subconnective tissue
T2A/B: Muscle invassive
T3: Perivisceral fat invasion
T4: Local infiltration into surrounding organs
What is the treatment for Bladder cancer?
T0 and T1 = Transurethral resection of bladder tumour (TURBT) + local chemotherapy
> T2 = radial cystectomy + M-VAC chemotherapy
What are the features of testicular torsion?
Sudden intense scrotal pain
Pain radiates into the abdomen
N&V
Hot swollen teste which may slightly retracted up
*cremaster reflex is lost
What is the diagnostic procedures in suspected testicular torsion?
Surgical exploration if symptoms fit.
Ultrasound if diagnosis is uncertain
Both testes should be clipped
Which drug can be used to prevent kidney stones?
thiazides
What investigation is best for kidney stones?
KUB CT
*non contrast CT scan
What is the most common pathogen to cause Epididymo - orchitis? and what must be excluded?
Chlamydia - in sexually active
those who are at low risk of STI it is more likely to be E.Coli.
Must rule out torsion.
What is the treatment of epididymo- orchitis?
Chlamydia/ N. Gonorrhoeae:
Ceftriaxone mg IM - single dose
+
Doxycycline 100mg PO BID for one week
E.Coli suspected:
- Ciprofloxacin
What blood markers can be done for testicular cancer?
Alpha Fetoprotein (AFP) - teratomas
Beta HGC - seminomas and teratomas
What are the treatment options for prostate cancer?
T1/T2:
Watchful monitoring
Radical Prostatectomy
Radiotherapy and brachytherapy
T3/T4:
Hormonal therapy
Radical Prosectomy
What type of hormonal therapies are available for prostate cancer?
GnRH Agonists
- Goserelin
- *it is important to cover with an initial anti- androgen as there is a surge of LH initially
Anti- androgens
- cyproterone acetate
Orchiectomy
Men with ED should be screened for what?
Diabetes
Cardiovascular disease
Hypogonadism
- this will include testosterone levels. if they are low then LH and FSH should be measured.
What is the blood supply to the prostate?
Mainly inferior vesicle
inferior rectal
pudendal
What is done when assessing the risk of malignancy of the prostate?
Digital rectal examination
PSA levels
Transrectal ultrasound + guided biopsy
- if worried about malignancy
What is the treatment algorithm for benign prostate hyperplasia?
Watchful waiting
Alpha adrenergic antagonist
- tamsulosin
5 alpha reductase
- finestraite
*combination of these therapies.
Surgical - reserved for symptoms that don’t resolve.
- TURP
- Open retropubic prostatectomy
- Bladder neck incision
How is prostatic cancer graded?
Gleason score
It will receive two numbers. first is the predominance of the grading, the second is less dominance
**important the number of the sum of the most typical appearance which is marked out of 3.
so the lowest score one can get is:
- 3+3
here in the above example the person would have a gleason score of 7.
**There is a new grading system of grades:
1 to 5
which just correlates to the degree of differentiations
What are the risk factors for renal carcinoma?
Smoking
Obesity
Long term dialysis
What are the paraneoplastic effects of renal cell cancer?
Polycythemia
Hypercalcaemia - secretion of PTH
Stauffer syndrome - abnormal LFTs of obstruction despite being none.
What is a potentially life threatening complication of TURP treatment? how does it present?
TURP Syndrome
where there is damage to the venous system and absorption of the irragation fluid.
- leads to severe hyponatremia
Presents with:
- confusion
- agitation
- Breathlessness
*operation >1 hours are most at risk
What is the gold standard for investigating potential lower urinary tract tumours?
Flexible Cystoscopy
What sign on the CT may indicate a stone has passed?
Stranding of periureteric fat
Which testicular tumour typically has normal AFP and HCG levels?
Seminoma
What is the best investigation for hydronephrosis?
Renal Ultrasound
Which testicular tumours have a better prognosis?
Seminomas
Which ethnicity group has the highest risk of prostatic cancer/
Afro-caribbean
which type of kidney stone is most likely to be associated with family history
cystine - inherited metabolic syndrome
When undertaking an investigation into haematuria what must be done?
The entire urinary tract system must be evaluated.
Upper:
- Imaging: US kidneys and CT urography (this is with contrast) for high risk
Lower:
- flexible cystoscopy
What is a complication following high pressured urine obstruction release?
Post obstructive diuresis
The medully loses its ability to concentrate the urine
- resulting in excessive diuresis
> 200ml/hour urine should result in 50% replacement IV
When should someone be referred following a case of haematuria? what is the gold standard for investigating these people?
> 45 with asymptomatic visible haematuria with no explanation
> 45 with visible haematuria following successful eradication of UTI
> 60 with non-visible haematuria but symptoms of dysuria and raised WCC
- *flexible cystoscopy
- lower urinary tract
- *CT urogram
- upper genitourinary tract
What organisms are most likely to cause epididymitis?
<35 years: sexually transmitted.
- Gonorrhea
- Chlamydia
> 35 years: Enteric infections:
- E.Coli
*in men who practice anal sex it is E.Coli
What investigations should be done into epididymitis?
Bloods: FBC, CRP
Urine Dipstick
STI screen: NAAT from urine sample
Ultrasound if diagnosis is uncertain
Where are stones most likely to become impacted?
Pelvic-ureteric junction
Pelvic brim
vesicoureteric junction
What symptoms are associated with the stone at the vesicoureteric junction?
Lower quadrant pain
urinary urgency
frequency
strangulation
**symptoms mimic cystitis
What symptoms are also associated with struvite stones?
recurrent UTIs
Malaise
weakness
loss of appetite
What are some differentials for renal colic?
Pyelonephritis
Lobar pneumonia
acute abdomen - (appendicitis, pancreas, AAA)
ectopic pregnancy
radicular pain - herpes
What is an extremely important differential of renal colic to consider in a male >60 years with no history of renal colic?
AAA
How do you investigate renal colic in a pregnancy female?
USS
Which stones are radiolucent?
Uric Acid
Xanthine
What are the indications for surgical interventional removal of stones?
Pain that fails to respond to analgesia
Associated fever
Impaired renal function
> 4 weeks
Bilateral obstruction
Obstructing calculus in the kidney
What are some indications and contraindications to extra- corporeal shock wave lithotripsy?
Indications:
<2cm
favourable anatomy
Contraindications:
- pregnancy
- distal obstruction
- uncorrected coagulopathy
- pacemaker
When is percutaneous nephrolithotomy used?
Indications: > 2cm stones Staghorn multiple >1cm stones Proximal ureteral stone
Contraindications:
- Active infection
- coagulopathy
- pregnancy
- unsafe access
hospital time is 3-4 days
Given contraindications to lithotripsy in certain populations, such as:
- pregnancy
- coagulopathies
- poorly visualised stones
what alternative approach can be done for large stones?
Ureteroscopy stones are removed via a basket. used when: - pregnancy - Coagulopathies - Stones that can easily be visualised
Larger stones are:
- lasered
- ultrasonic
- electro hydraulic
Name 3 types of surgery that can be done for ureteric stones:
Pyelo- nephrolithotomy
Ureterolithotomy
Cystolithotomy
What are some complications of acute urinary retention?
Infection
AKI
Post obstruction diuresis
What does dyssynergia mean?
Dyssynergia
= incomplete relaxation of urinary sphincter
What are some common causes of glomerular haematuria?
IgA nephropathy
Thin glomerular basement membrane disease
Alport’s syndrome
What are some causes of upper tract haematuria?
Urolithiasis
pyelonephritis
Renal cell carcinoma
Transitional cell carcinoma
Urinary obstruction
Name somec causes of pseudo- haematuria?
Myoglobinuria
Food colouring
Menses
Metronidazole
What are the imaging techniques done into haematuria?
Imaging studies of the upper urinary tracts:
- Ultrasound
- CT Urography
Lower urinary tracts:
- cystoscopy (direct visualisation)
What are the different types of torsion that can occur to the testi?
Extra- vaginal torsion
Intra- vaginal torsion
Appendage torsion
If there is any doubt regarding testicular torsion what should be done and what is a diagnostic feature?
Ultrasonography of testes
- testicular perfusion
What is the management of testicular torsion?
Tunica vaginalis is opened.
unwrapped in a warm gauze.
contralateral side under goes orchidopexy.
affected side is examined for perfusion.
if none then: removal.
if re-vascularisation:
- orchidopexy
Why is a biopsy of a testicular lump not done?
If it is cancer, then there is a very high risk of seeding it with a biopsy
Histology is only performed after an orchiectomy
What are the blood markers done for testicular carcinoma?
LDH
AFP
Beta HGC
Which bacterial infection are struvite stones most associated with?
Proteus
these are urease agents which create alkaline conditions promoting Mg2+ PO4- formation
If a young person with no previous history of hydrocele presents with one, what investigation should be done?
Ultrasound
- to rule out malignancy as testicular can present with it
What are the symptoms of acute urinary retention?
and what physical examinations do you want to do?
Suprapubic pain
Urge to void
- Palpation of bladder
- Percussion of bladder
- PR exam
- *feel for enlargement
- impaction
- Tone (cauda equina)
- reflexes lower limb (cauda equina)
- external penile examination
- *looking for phimosis
What are the complications of urinary retention?
- Post obstructive diuresis
- Hydronephrosis with kidney failure
- Stagnant urine• Renal calculi
- Due to the stagnant urine• Urethral trauma
As the catheter is being placed in
Which part of the prostate is most typically affected in BPH and how does this differ to prostate cancer?
Transitional zone which is closer to urethra and thus causes symptoms quicker typically
Peripheral zone in prostate cancer
Name some symptoms of voiding and some of storage problems:
Voiding:
- hesitancy
- post void dripping
- incomplete emptying
- weak stream
Storage:
- nocturia
- Frequency
- incontinence
What things can raise the PSA?
• Age
• PSA
• Ejaculation
• Exercise
• Medical procedures
UTIsWhat are the risk factors for prostate cancer?
Age
Ethnicity
Continually STI infection
Family History
BRCA1/ BRCA 2
DM
Smoking
What other way can the PSA be used to measure likely hood of cancer?
PSA density
- serum PSA/ Size of the prostate
What is a risk factors for testicular torsion?
Family history
- Bell Clapper Deformity
- horizontal lie of the testicle due to poor attachment to the tunica vaginalis making it more mobile
Age
Previous torsion
- a pain that self resolved could of previously been a torsion
Undescended testes
What are the differentials to testicular torsion?
Epididymitis
Torsion around the epididymal appendage
Acute hydrocele
Trauma
Incarceration of an inguinal hernia
What is the test called where lifting the scrotum up, reduces pain in epididymitis but in testicular torsion it remains?
Phren’s test
Which types of testicular tumours are more common in age groups?
Teratoma - 20-30 years
Seminoma - 30- 40 years
Lymphoma> 60 years
What are the risk factors for testicular cancer?
Cryptorchidism
Klinefelter’s
Previous malignancy
Family history
Which lymph nodes should be taken with teratomas?
Retroperitoneal
Why is a renal ultrasound done in the setting of suspected renal carcinoma?
To asses between a solid and cyst
What are the major types of testicular tumours?
Germ cell Tumours
- Seminomas
Non - Seminomas Germ cell tumours
- Teratomas
Non Germ cell tumours:
- leydig
- sertoli
- Lymphoma
Which lymph nodes do the testes drain to?
Paraaortic
What classification system is used for testicular cancer?
Royal Marsden Classification
Stage 1 - confined to testi
Stage 2 - infra diaphragmatic nodes
Stage 3 - Supra- diaphragmatic nodes
Stage 4 - Extra- nodal involvement
What are the typical clinic findings of renal cell carcinoma?
Loin mass Haematuria Loin pain Left varicocele Paraneoplastic effects
How long does one need to abstain from vigorous exercise or ejaculation before getting PSA measured?
48 hours
What is the grading system used for renal carcinoma?
Robson’s grading
What is renal cell carcinoma?
adenocarcinoma of the renal cortex, usually from PCT
How can renal cell carcinoma present?
usually asymptomatic.
- Loin Pain
- Loin Mass
- Haematuria
- Weight loss
- Left variceal
- Shortness of breath - due to metastasis
What is the management for renal cell carcinoma?
Small tumour: Partial nephrectomy
Large tumour: Total Nephrectomy
Percutaneous radiofrequency ablation
Metastatic disease:
- Biological agents
- Immunotherapy
What are the broad subtypes of renal cancer?
Renal cell carcinoma:
- cell cell
Transitional cell
- Usually effects the pelvis
Squamous cell
- Schistosomiasis
Wilm’s tumour
What is the gold standard investigations for renal cell carcinoma?
CT pre and post IV contrast
What is the second most common type of renal cancer and how is it investigated and treated?
Transitional cell carcinoma
- typically arising in the pelvis of the kidney
Investigations:
- urine cytology
- CT pre/ post IV
Treatment:
- Nephrectomy
- regular follow up cause of bladder cancer
How often should high risk bladder cancers be followed up?
Every 3 months for 2 years. Then 6 monthly afters.
What are the surgeries performed following a radical cystectomy?
Ileo- conduit formation
- ureters put into the ileum
Bladder reconstruction
- using the ileum to create a new bladder
What is the treatment of T4 bladder cell carcinoma?
Palliative chemotherapy + radiotherapy
Urinary diversion
What is the treatment for testicular cancer?
Seminomas:
Stage 1/2: Inguinal Orchiectomy
Stage >2: Inguinal orchiectomy + Radiotherapy
Teratomas:
Stage 1: Inguinal Orchiectomy
Stage 2: Inguinal orchiectomy + para-aortic clearance
Stage >3: Plus chemotherapy
Whats the most common malignant mass in the testicles?
<5: ALL
5-60: Seminoma
> 60: NHL
What are the different types of undescended testes?
and what is the management?
Ectopic testis
- anywhere on the testicular tract
Undescended - cryptorchidism. Usually unilaterally
Retractile testes
- can be felt usually in the inguinal canal and pulled down but retract back up
Medical:
- B- hCG
Surgical:
- Orchiopexy dartos muscle procedure
What investigations should be done into urinary retention and which investigation is of no use?
Bloods:
- FBC
- CRP
- U&Es
- Blood glucose
Orifices:
- Urinalysis
- mention in catheter specimen
do NOT do PSA. it will be falsely elevated
How does a testicular carcinoma present?
Painless lump Non-transluminal Hydrocele Dragging sensation Back pain
What question do you want to ask into haematuria?
Duration?
Colour
- dark red
- Clots?
Timing:
- initial - urethral
- total - bladder or kidney
- Terminal - prostate
Pain
- kidney stone
Associated symptoms
Use of anti-coagulation/ platelets
What is BENCH surgery?
Removal of kidney and stone taken out.
Kidney is cooled
Kidney is then put back in
What is the surgery for a stag horn stone?
Nephropyleolithotomy
Where is the most common place for a stone formation?
Pelvic ureteric junction
Following ureteroscopy lithotripsy what should be done?
Placement of stent to avoid fragments of stones building up
What are the options for stones in the bladder?
Cystoscopy lithotripsy
Suprapubic Percutaneous Cystolithotomy
What is the treatment for stone in urethral?
diagnosed via Urethroscopy
- pushed back into bladder and treated as bladder stone
- ultrasonic lithotripter
What is the typical mode of spread of prostate cancer?
Haematological spread
What are the complications of radical prostatectomy?
Urethral injury
Erectile dysfunction
Urinary incontinence
Urethral stricture
What is the prognostic marker of testicular cancer?
LDH
