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Phase 4 > Urology Surgery > Flashcards

Urology Surgery Flashcards

1
Q

What are the symptoms of prostate cancer?

A

Bladder outflow obstruction

Erectile dysfunction

Haematuria

Pain in lower abdomen/ perineum

Weight loss

Reduced semen

Anaemia

  • damage to kidneys
  • Involvement of bone marrow
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2
Q

What investigations should be done in prostate cancer, what is the grading system used? and outline management:

A 
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
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3
Q

If there is pain in the lower abdomen and inguinal canal, when the canal is pressed, which nerve is being compressed?

A

Ilioinguinal nerve

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4
Q

What are the symptoms of bladder cancer? what is the most common type and what investigations should be done?

A

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
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5
Q

What are some risk factors for developing bladder cancer?

A 
Smoking 
Hydrocarbon exposure - industrial plants/ rubber factory 
Schistosomiasis 
Trauma 
Cyclophosphamide
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6
Q

What are the gradings of bladder cancer?

A

T0: mucosa
T1: subconnective tissue

T2A/B: Muscle invassive

T3: Perivisceral fat invasion

T4: Local infiltration into surrounding organs

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7
Q

What is the treatment for Bladder cancer?

A

T0 and T1 = Transurethral resection of bladder tumour (TURBT) + local chemotherapy

> T2 = radial cystectomy + M-VAC chemotherapy

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8
Q

What are the features of testicular torsion?

A

Sudden intense scrotal pain
Pain radiates into the abdomen
N&V

Hot swollen teste which may slightly retracted up
*cremaster reflex is lost

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9
Q

What is the diagnostic procedures in suspected testicular torsion?

A

Surgical exploration if symptoms fit.
Ultrasound if diagnosis is uncertain

Both testes should be clipped

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10
Q

Which drug can be used to prevent kidney stones?

A

thiazides

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11
Q

What investigation is best for kidney stones?

A

KUB CT

*non contrast CT scan

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12
Q

What is the most common pathogen to cause Epididymo - orchitis? and what must be excluded?

A

Chlamydia - in sexually active

those who are at low risk of STI it is more likely to be E.Coli.

Must rule out torsion.

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13
Q

What is the treatment of epididymo- orchitis?

A

Chlamydia/ N. Gonorrhoeae:
Ceftriaxone mg IM - single dose
+
Doxycycline 100mg PO BID for one week

E.Coli suspected:
- Ciprofloxacin

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14
Q

What blood markers can be done for testicular cancer?

A

Alpha Fetoprotein (AFP) - teratomas

Beta HGC - seminomas and teratomas

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15
Q

What are the treatment options for prostate cancer?

A

T1/T2:
Watchful monitoring
Radical Prostatectomy
Radiotherapy and brachytherapy

T3/T4:
Hormonal therapy
Radical Prosectomy

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16
Q

What type of hormonal therapies are available for prostate cancer?

A

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

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17
Q

Men with ED should be screened for what?

A

Diabetes
Cardiovascular disease
Hypogonadism
- this will include testosterone levels. if they are low then LH and FSH should be measured.

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18
Q

What is the blood supply to the prostate?

A

Mainly inferior vesicle
inferior rectal
pudendal

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19
Q

What is done when assessing the risk of malignancy of the prostate?

A

Digital rectal examination
PSA levels

Transrectal ultrasound + guided biopsy
- if worried about malignancy

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20
Q

What is the treatment algorithm for benign prostate hyperplasia?

A

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
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21
Q

How is prostatic cancer graded?

A

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

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22
Q

What are the risk factors for renal carcinoma?

A

Smoking
Obesity
Long term dialysis

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23
Q

What are the paraneoplastic effects of renal cell cancer?

A

Polycythemia
Hypercalcaemia - secretion of PTH
Stauffer syndrome - abnormal LFTs of obstruction despite being none.

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24
Q

What is a potentially life threatening complication of TURP treatment? how does it present?

A

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

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25
Q

What is the gold standard for investigating potential lower urinary tract tumours?

A

Flexible Cystoscopy

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26
Q

What sign on the CT may indicate a stone has passed?

A

Stranding of periureteric fat

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27
Q

Which testicular tumour typically has normal AFP and HCG levels?

A

Seminoma

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28
Q

What is the best investigation for hydronephrosis?

A

Renal Ultrasound

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29
Q

Which testicular tumours have a better prognosis?

A

Seminomas

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30
Q

Which ethnicity group has the highest risk of prostatic cancer/

A

Afro-caribbean

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31
Q

which type of kidney stone is most likely to be associated with family history

A

cystine - inherited metabolic syndrome

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32
Q

When undertaking an investigation into haematuria what must be done?

A

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

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33
Q

What is a complication following high pressured urine obstruction release?

A

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

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34
Q

When should someone be referred following a case of haematuria? what is the gold standard for investigating these people?

A

> 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
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35
Q

What organisms are most likely to cause epididymitis?

A

<35 years: sexually transmitted.

  • Gonorrhea
  • Chlamydia

> 35 years: Enteric infections:
- E.Coli

*in men who practice anal sex it is E.Coli

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36
Q

What investigations should be done into epididymitis?

A

Bloods: FBC, CRP

Urine Dipstick

STI screen: NAAT from urine sample

Ultrasound if diagnosis is uncertain

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37
Q

Where are stones most likely to become impacted?

A

Pelvic-ureteric junction

Pelvic brim

vesicoureteric junction

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38
Q

What symptoms are associated with the stone at the vesicoureteric junction?

A

Lower quadrant pain
urinary urgency
frequency
strangulation

**symptoms mimic cystitis

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39
Q

What symptoms are also associated with struvite stones?

A

recurrent UTIs
Malaise
weakness
loss of appetite

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40
Q

What are some differentials for renal colic?

A

Pyelonephritis

Lobar pneumonia

acute abdomen - (appendicitis, pancreas, AAA)

ectopic pregnancy

radicular pain - herpes

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41
Q

What is an extremely important differential of renal colic to consider in a male >60 years with no history of renal colic?

A

AAA

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42
Q

How do you investigate renal colic in a pregnancy female?

A

USS

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43
Q

Which stones are radiolucent?

A

Uric Acid

Xanthine

44
Q

What are the indications for surgical interventional removal of stones?

A

Pain that fails to respond to analgesia

Associated fever

Impaired renal function

> 4 weeks

Bilateral obstruction

Obstructing calculus in the kidney

45
Q

What are some indications and contraindications to extra- corporeal shock wave lithotripsy?

A

Indications:
<2cm
favourable anatomy

Contraindications:

  • pregnancy
  • distal obstruction
  • uncorrected coagulopathy
  • pacemaker
46
Q

When is percutaneous nephrolithotomy used?

A 
Indications: 
> 2cm stones 
Staghorn 
multiple >1cm stones 
Proximal ureteral stone

Contraindications:

  • Active infection
  • coagulopathy
  • pregnancy
  • unsafe access

hospital time is 3-4 days

47
Q

Given contraindications to lithotripsy in certain populations, such as:

  • pregnancy
  • coagulopathies
  • poorly visualised stones

what alternative approach can be done for large stones?

A 
Ureteroscopy 
stones are removed via a basket. 
used when: 
- pregnancy 
- Coagulopathies 
- Stones that can easily be visualised

Larger stones are:

  • lasered
  • ultrasonic
  • electro hydraulic
48
Q

Name 3 types of surgery that can be done for ureteric stones:

A

Pyelo- nephrolithotomy

Ureterolithotomy

Cystolithotomy

49
Q

What are some complications of acute urinary retention?

A

Infection

AKI

Post obstruction diuresis

50
Q

What does dyssynergia mean?

A

Dyssynergia

= incomplete relaxation of urinary sphincter

51
Q

What are some common causes of glomerular haematuria?

A

IgA nephropathy

Thin glomerular basement membrane disease

Alport’s syndrome

52
Q

What are some causes of upper tract haematuria?

A

Urolithiasis

pyelonephritis

Renal cell carcinoma

Transitional cell carcinoma

Urinary obstruction

53
Q

Name somec causes of pseudo- haematuria?

A

Myoglobinuria

Food colouring

Menses

Metronidazole

54
Q

What are the imaging techniques done into haematuria?

A

Imaging studies of the upper urinary tracts:

  • Ultrasound
  • CT Urography

Lower urinary tracts:
- cystoscopy (direct visualisation)

55
Q

What are the different types of torsion that can occur to the testi?

A

Extra- vaginal torsion

Intra- vaginal torsion

Appendage torsion

56
Q

If there is any doubt regarding testicular torsion what should be done and what is a diagnostic feature?

A

Ultrasonography of testes

  • testicular perfusion
57
Q

What is the management of testicular torsion?

A

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

58
Q

Why is a biopsy of a testicular lump not done?

A

If it is cancer, then there is a very high risk of seeding it with a biopsy

Histology is only performed after an orchiectomy

59
Q

What are the blood markers done for testicular carcinoma?

A

LDH

AFP

Beta HGC

60
Q

Which bacterial infection are struvite stones most associated with?

A

Proteus

these are urease agents which create alkaline conditions promoting Mg2+ PO4- formation

61
Q

If a young person with no previous history of hydrocele presents with one, what investigation should be done?

A

Ultrasound

- to rule out malignancy as testicular can present with it

62
Q

What are the symptoms of acute urinary retention?

and what physical examinations do you want to do?

A

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
63
Q

What are the complications of urinary retention?

A
  • Post obstructive diuresis
    • Hydronephrosis with kidney failure
    • UTI/ Pyelonephritis
    - Stagnant urine• Renal calculi
    - Due to the stagnant urine• Urethral trauma
    As the catheter is being placed in
64
Q

Which part of the prostate is most typically affected in BPH and how does this differ to prostate cancer?

A

Transitional zone which is closer to urethra and thus causes symptoms quicker typically

Peripheral zone in prostate cancer

65
Q

Name some symptoms of voiding and some of storage problems:

A

Voiding:

  • hesitancy
  • post void dripping
  • incomplete emptying
  • weak stream

Storage:

  • nocturia
  • Frequency
  • incontinence
66
Q

What things can raise the PSA?

A 
• Age 
	• PSA 
	• Ejaculation 
	• Exercise 
	• Medical procedures 
           UTIs
67
Q

What are the risk factors for prostate cancer?

A

Age

Ethnicity

Continually STI infection

Family History

BRCA1/ BRCA 2

DM

Smoking

68
Q

What other way can the PSA be used to measure likely hood of cancer?

A

PSA density

  • serum PSA/ Size of the prostate
69
Q

What is a risk factors for testicular torsion?

A

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

70
Q

What are the differentials to testicular torsion?

A

Epididymitis

Torsion around the epididymal appendage

Acute hydrocele

Trauma

Incarceration of an inguinal hernia

71
Q

What is the test called where lifting the scrotum up, reduces pain in epididymitis but in testicular torsion it remains?

A

Phren’s test

72
Q

Which types of testicular tumours are more common in age groups?

A

Teratoma - 20-30 years

Seminoma - 30- 40 years

Lymphoma> 60 years

73
Q

What are the risk factors for testicular cancer?

A

Cryptorchidism

Klinefelter’s

Previous malignancy

Family history

74
Q

Which lymph nodes should be taken with teratomas?

A

Retroperitoneal

75
Q

Why is a renal ultrasound done in the setting of suspected renal carcinoma?

A

To asses between a solid and cyst

76
Q

What are the major types of testicular tumours?

A

Germ cell Tumours
- Seminomas

Non - Seminomas Germ cell tumours
- Teratomas

Non Germ cell tumours:

  • leydig
  • sertoli
  • Lymphoma
77
Q

Which lymph nodes do the testes drain to?

A

Paraaortic

78
Q

What classification system is used for testicular cancer?

A

Royal Marsden Classification

Stage 1 - confined to testi
Stage 2 - infra diaphragmatic nodes
Stage 3 - Supra- diaphragmatic nodes
Stage 4 - Extra- nodal involvement

79
Q

What are the typical clinic findings of renal cell carcinoma?

A 
Loin mass
Haematuria 
Loin pain
Left varicocele
Paraneoplastic effects
80
Q

How long does one need to abstain from vigorous exercise or ejaculation before getting PSA measured?

A

48 hours

81
Q

What is the grading system used for renal carcinoma?

A

Robson’s grading

82
Q

What is renal cell carcinoma?

A

adenocarcinoma of the renal cortex, usually from PCT

83
Q

How can renal cell carcinoma present?

A

usually asymptomatic.

  • Loin Pain
  • Loin Mass
  • Haematuria
  • Weight loss
  • Left variceal
  • Shortness of breath - due to metastasis
84
Q

What is the management for renal cell carcinoma?

A

Small tumour: Partial nephrectomy

Large tumour: Total Nephrectomy

Percutaneous radiofrequency ablation

Metastatic disease:

  • Biological agents
  • Immunotherapy
85
Q

What are the broad subtypes of renal cancer?

A

Renal cell carcinoma:
- cell cell

Transitional cell
- Usually effects the pelvis

Squamous cell
- Schistosomiasis

Wilm’s tumour

86
Q

What is the gold standard investigations for renal cell carcinoma?

A

CT pre and post IV contrast

87
Q

What is the second most common type of renal cancer and how is it investigated and treated?

A

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
88
Q

How often should high risk bladder cancers be followed up?

A

Every 3 months for 2 years. Then 6 monthly afters.

89
Q

What are the surgeries performed following a radical cystectomy?

A

Ileo- conduit formation
- ureters put into the ileum

Bladder reconstruction
- using the ileum to create a new bladder

90
Q

What is the treatment of T4 bladder cell carcinoma?

A

Palliative chemotherapy + radiotherapy

Urinary diversion

91
Q

What is the treatment for testicular cancer?

A

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

92
Q

Whats the most common malignant mass in the testicles?

A

<5: ALL

5-60: Seminoma

> 60: NHL

93
Q

What are the different types of undescended testes?

and what is the management?

A

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

94
Q

What investigations should be done into urinary retention and which investigation is of no use?

A

Bloods:

  • FBC
  • CRP
  • U&Es
  • Blood glucose

Orifices:

  • Urinalysis
  • mention in catheter specimen

do NOT do PSA. it will be falsely elevated

95
Q

How does a testicular carcinoma present?

A 
Painless lump
Non-transluminal 
Hydrocele 
Dragging sensation 
Back pain
96
Q

What question do you want to ask into haematuria?

A

Duration?
Colour
- dark red
- Clots?

Timing:

  • initial - urethral
  • total - bladder or kidney
  • Terminal - prostate

Pain
- kidney stone

Associated symptoms

Use of anti-coagulation/ platelets

97
Q

What is BENCH surgery?

A

Removal of kidney and stone taken out.
Kidney is cooled

Kidney is then put back in

98
Q

What is the surgery for a stag horn stone?

A

Nephropyleolithotomy

99
Q

Where is the most common place for a stone formation?

A

Pelvic ureteric junction

100
Q

Following ureteroscopy lithotripsy what should be done?

A

Placement of stent to avoid fragments of stones building up

101
Q

What are the options for stones in the bladder?

A

Cystoscopy lithotripsy

Suprapubic Percutaneous Cystolithotomy

102
Q

What is the treatment for stone in urethral?

A

diagnosed via Urethroscopy

  • pushed back into bladder and treated as bladder stone
  • ultrasonic lithotripter
103
Q

What is the typical mode of spread of prostate cancer?

A

Haematological spread

104
Q

What are the complications of radical prostatectomy?

A

Urethral injury
Erectile dysfunction
Urinary incontinence
Urethral stricture

105
Q

What is the prognostic marker of testicular cancer?

A

LDH

Phase 4 (49 decks)

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