Medbear Urology Flashcards
1
Q
What are the functions of the urinary system?
A
- Storage and excretion of urine
- Hormone production (e.g RENIN, ERYTHROPOIETIN, 1-25-DIHYDROXYCHOLECALCIFEROL)
- Electrolyte maintenance
- Acid-base maintenance
- Fluid maintenance
2
Q
What are the benign causes of hematuria?
A
- Menstruation
- Exercise-induced myoglobinuria
- Sexual intercourse
- Trauma
3
Q
Classify hematuria based on when during urination does the blood appear?
A
Initial - Disease in the urethra, distal to UG diaphragm
Terminal - Disease near bladder neck or prostatic urethra
Throughout - Disease in the bladder or upper urinary tract
4
Q
State the lower urinary tract symptoms (FUN DISH)
A
Storage problem - irritative symptoms
- Frequency
- Urgency
- Nocturia
Possibly -> UTI, stones, bladder tumor
Voiding problem - obstructive symptoms
- Terminal dribbling
- Intermittency
- Poor stream/straining to pass urine
- Hesitancy
Possibly -> BPH, prostate CA, urethral strictures
Others:
- Polyuria
- Oliguria
- Urethral discharge
5
Q
State (5) red flags for malignancy
A
- Male gender
- Age (>35Y)
- Past or current smoker
- Occupational exposure - chemicals or dyes
- History of exposure to carcinogenic agents
6
Q
Describe on urinalysis.
A
- Direct visual observation or inspection of urine
- Urine dipstick
- GOLD STANDARD -> For detection of microscopic hematuria
- If patient presents with red/brown urine, but negative on dipstick, consider other cause:
a. Food dye
b. Drugs
c. Others - porphyria, alkaptonuria, bilirubinuria - Urine Full Examination Microscopic Element (UFEME)
- Confirms presence of RBC and cast
- Absence of RBC/cast despite positive urine dipstick suggest HEMOGLOBINURIA, MYOGLOBINURIA
7
Q
State (5) risk factor of renal cell CA
A
- Smoking
- Industrial exposure
- Prior kidney irradiation
- Family history
- Von Hippel Lindau syndrome due to mutation of VHL gene
- Hereditary papillary RCC due to mutation of the MET proto-oncogene on chromosome 7q31 -> MULTIFOCAL PAPILLARY RENAL CELL CA - Acquired polycystic kidney disease
8
Q
Classify the types of renal cell carcinoma based on the following parameters:
1. Accounts for
2. Arise from
3. Pathogenesis
4. Prognosis
A
- Appears well-encapsulated with areas of hemorrhage/necrosis
- Malignant tumor arising from RENAL TUBULAR EPITHELIUM
9
Q
Classify renal cyst based on Bosniak Classification
1. Type
2. Description
3. Features
4. Workup
5. Malignancy
A
10
Q
What are the local symptoms of renal cell carcinoma?
A
- Painless gross hematuria (Only when tumor invades the collecting system) -> Severe bleeding can cause clots leading to colicky pain
- Historical triad (FLANK PAIN, PAINLESS HEMATURIA, PALPABLE FLANK MASS)
- Pathological fracture
- Aching loin pain
- Episodes of acute pain
11
Q
What are the regional symptoms of renal cell carcinoma?
A
- Left varicocele -> due to invasion of the left renal vein with tumor -> Obstruction of the left testicular vein -> Can’t enter the renal vein -> Fail to empty when patient is in supine position
- Extension into IVC causes:
1. Lower limb edema
2. Ascites
3. Liver dysfunction
3. Pulmonary embolism
12
Q
State (6) paraneoplastic syndrome of renal cell carcinoma
A
- Hypertension -> due to RENIN OVERPRODUCTION
- Non-metastatic liver dysfunction -> Stauffer syndrome (Resolved after tumor removal) -> elevation of ALP
- Hypercalcemia
- Polycythemia -> due to production of erythropoietin by the tumor
- Cushing syndrome -> due to corticosteroid synthesis
- Feminization or Masculinization (gonadotropin release)
13
Q
Describe how you would investigate on a case of renal cell carcinoma?
A
CT kidney (alternative US kidney)
- Renal parenchymal mass with thickened irregular walls and enhancement after contrast injection suggests MALIGNANCY
- CT kidney is triphasic
1. Staging
2. LN involvement, perinephric extension
3. Renal veins or IVU extension
- US -> to differentiate cystic from solid renal masses
MRI Kidneys
- Useful if CT is inconclusive or if contraindication to contrast
- Most effective in demonstrating presence and extent of renal vein or IVU tumor thrombus
Intravenous Urogram (IVU)
- Determine position, size and outline of kidneys
- CA -> MOTTLED CENTRAL CALCIFICATION (90% specificity), PERIPHERAL CALCIFICATION (associated with RCC)
Pathological diagnosis
- In resectable lesion, a partial or total nephrectomy is done and provides tissue diagnosis post-operatively
- In metastatic lesions, biopsy of metastatic site is performed
14
Q
State 3 major criteria for diagnosing a classical cyst.
A
- Round and sharply demarcated with smooth walls
- Anechoic
- Strong posterior acoustic enhancement (indicating good transmission through a cyst)
15
Q
Elaborate on the staging of renal cell carcinoma
A
16
Q
What are the complications of nephrectomy?
A
- GA -> Atelectasis, AMI, pulmonary embolism, CVA, pneumonia, thrombophlebitis
- Operative mortality rate - 2%
1. Bleeding/Infection
2. Pleural injuries can result in pneumothorax
3. Injury neighboring organs
4. Temporary or permanent renal failure
17
Q
State (4) modifiable risk factors for urolithiasis
A
- Diet
- Dehydration -> Low urine volume
- Massive ingestion of vitamin D or vitamin C (calcium oxalate)
- Milk Alkali Syndrome
Triad of milk alkali syndrome
- Hypercalcemia
- Metabolic alkalosis
- AKI
18
Q
List 3 points of constriction for the ureter.
A
- Pelvic-ureteric junction (PUJ)
- Pelvic brim (near bifurcation of the common iliac arteries)
- vesicoureteric junction (VUJ) - entry into the bladder
19
Q
State 2 types of stones that can cause STAGHORN CALCULI
A
- Struvite stones
- Cystine stones
20
Q
Mention the clinical manifestations of renal stones.
A
- Mostly asymptomatic unless stone gets lodged in the pelvic-ureteric junction -> hydronephrosis -> infection -> pyonephrosis
- Vague flank pain
- Small stones (commonest) / large branched staghorn calculi
-> If bilateral kidneys are affected -> lead to chronic renal failure
21
Q
What are the causes of stone formation?
A
- Super-saturation (Most common)
- Infection -> STRUVITE STONES
Proteus vulgaris infection (urea-splitting organism) -> Splits urea into ammonium -> Generating alkaline urine
More common in women (More prone to UTI)
Common organisms -> PROTEUS, PSEUDOMONAS, KLEBSIELLA - Drugs
22
Q
State the clinical manifestation of ureteric stones
A
- Even small stones can cause severe symptoms (Ureter is narrow)
- Classic ureteric colic pain (SEVERE, INTERMITTENT LOIN-TO-GROIN PAIN)
- Hematuria - gross or microscopic
- Can cause upper UTI (e.g FEVER, PAIN)
- Stone at VUJ - frequency, urgency, dysuria
23
Q
State the clinical features of bladder stone
A
- May be asymptomatic
- Irritative urinary symptoms - FREQUENCY, URGENCY
- Hematuria
- If infection is present -> Dysuria, fever
24
Q
State the principles of management of urolithiasis
A
- Provision of effective pain control
- Treatment of any suspected UTI - antibiotics
- Allow for spontaneous passage of stones or decide on active stone removal
- Treat underlying etiology of stone formation
25
What are the conservative treatment indicated for urolithiasis?
- Stones <5mm can be treated conservatively as 70% will be passed out of urine
- Spontaneous stone passage aided with prescription of NARCOTIC PAIN MEDICATIONS and DAILY ALPHA-BLOCKER THERAPY (TAMSULOSIN)
- HIGH FLUID INTAKE (Drink about 2-3L of water/day)
- Diet modifications
26
State the medical therapy for the following stones
1. Calcium stones
2. Struvite stones
3. Uric acid stones
Medical therapy is limited, and indicated to slow down the process
- Calcium stones - THIAZIDE (increase urinary calcium excretion)
- Struvite stones - eradications of underlying INFECTION
- Uric acid stones - Alkalinizing urine with BAKING SODA or POTASSIUM CITRATE, ALLOPURINOL
Urine should be strained with each void and
Radio-opaque stone tracked with KUB X-ray
27
State the indications for surgical intervention for urolithiasis
Hint: 7s
- 7s - Size, Site, Symptoms, Stasis, Stuck, Sepsis, Social
- Stone complications
- Unlikely to resolve with conservative treatment
Example: Does not pass after 1 month, too large to pass spontaneously
28
State the complications of urolithiasis if left untreated
- Hematoma/Significant bleeding
- UTI
- Ureteric injury - perforation/ureteric avulsion
- Failure of procedure -> Unable to assess stone with URS
29
State the MOST COMMON bladder CA
Transitional cell carcinoma
30
State 2 occupational risk factors for bladder CA
- Exposure to aromatic amines (printing, textile) - due to 2-NAPHTHYLAMINE
- Industrial chemicals
31
State (5) non-occupational risk factors for bladder CA
- Cigarette smoking
- Chronic analgesic abuse (PHENACETIN)
- Chronic parasitic infection (SCHISTOSOMA HAEMATOBIUM -> Squamous metaplasia -> squamous cell CA)
- Chemotherapy
- Chronic cystitis (e.g pelvic radiation)
32
What are the clinical presentations of bladder CA?
- Persistent painless hematuria
- Lower urinary tract symptoms (LUTS)
- Pain (in locally advanced or metastatic tumour)
- Loco-regional complications - extensions to other organs: FISTULA FORMATION
- Metastatic complications
- Constitutional symptoms - LOW, LOA, fatigue
LUTS
1. Irritative symptoms (frequency, dysuria, urgency) -> CARCINOMA IN SITU
2. Obstructive symptoms (decreased stream, intermittent voiding, feeling of incomplete voiding, strangury) -> tumor at bladder neck or prostatic urethra
3. Dysuria -> persistent pyuria
33
What investigations should be done to diagnose a case of bladder CA?
- Baseline blood investigations
- Urine cytology -> for malignant cells
- Imaging (IVU/CT urogram or US KUB)
- Flexible cystoscopy or rigid cystoscopy KIV transurethral resection of bladder tumor
34
List the staging of the bladder tumor.
Ta =
Tis =
T1 =
T2a =
T2b =
T3a =
T3b =
T4a =
T4b =
Ta = Superficial, DOES NOT involve lamina propria
Tis = CARCINOMA IN SITU
T1 = Superficial, INVOLVES lamina propria (up to muscularis propria)
T2a = Superficial involvement of muscularis propria - up to inner half of muscle
T2b = Deep involvement of muscularis propria
T3a = Microscopic extension outside bladder
T3b = Macroscopic extension outside bladder
T4a = Invasion of prostate, vagina, uterus
T4b = Invasion of lateral pelvic wall, abdominal wall
35
How would you manage a case of superficial tumour of bladder CA?
- TURBT
- Intravesical therapy
1. BCG -> 1 instillation per week for 6 weeks
2. Mitomycin C -> Single instillation within 24 hours of TURBT
36
How to manage a case of muscle-invasive bladder CA?
Radical cystectomy with urinary diversion
- MALE -> Radical cystoprostatectomy with pelvic lymphadenectomy
- FEMALE -> Anterior exenteration with pelvic lymphadenectomy
Ways of diverting urine output:
1. Cutaneous ureterostomy
2. Ileal conduit
3. Neobladder construction using ileum
4. Stoma with pouch construction
37
State (2) choice of chemotherapy in metastatic bladder CA
- GC - Gemcitabine + Cisplatin
- MVAC - MTX + Vinblastine + Doxorubicin + Cisplatin
38
State (4) risk factors of prostate CA
- Advanced age
- Hormonal -> growth of tumor can be inhibited by ORCHIDECTOMY or administration of ESTROGENS
- Genetic
- Environmental - Industrial chemical exposure, diet containing high animal fat consumption, Vitamin E, Soy
*Low-fat diet lowers testosterone levels
39
State the pathophysiology of prostate CA
1. Prostatic Intraepithelial Neoplasia (Architecturally benign prostatic acini and ducts lined by atypical cells)
- Low grade PIN (PIN 1): Mild dysplasia - No increase risk of prostate CA
- High-grade PIN (PIN 2/3): Moderate and severe dysplasia - 30-40% chance of concurrent/subsequent invasive cancer
2. Adenocarcinoma (95%)
- Arise from outer parts of prostate
- Thus palpable on DRE and not resectable by TURP
40
What are the clinical (symptomatic) presentations of prostate CA?
- Incidentally picked up during DRE or due to elevated PSA level (>100 highly suggestive)
- Urinary symptoms
1. Dysuria
2. Hematuria
3. Hesitancy
4. Dribbling
5. Retension
6. Incontinence
Upon examination,
Asymmetrical, hard, irregular, craggy enlargement of prostate
Metastasis -> BONE (Pain, pathological fractures, anemia)
41
What are the (3) routes of metastasis for prostatic cancer?
1. Direct -> Stromal invasion through the prostatic capsule, urethra, bladder base, seminal vesicle
2. Lymphatics -> SACRAL, ILIAC, PARA-AORTIC
3. Hematogenous -> LUNGS, LIVER, BONES
42
State the complications from metastatic disease for prostatic cancer
- Pathological fractures, spinal cord compression
- Ureteral obstruction, urethral obstruction
- Extra-skeletal metastasis
43
What clinical investigations can be done to diagnose a case of prostatic CA?
Serum PSA levels
- >10ng/mL = Biopsy recommended as 67% of patients will have prostate CA
- 4-10ng/mL = Biopsy advised, though only 20% will have prostate CA
- <4ng/mL = Majority will have negative biopsies
Transurethral US with biopsy
- Histology of prostate CA is graded by GLEASON SCORE -> Looking at glandular architecture at low magnification
- Classically: HYPOECHOIC
- Procedure-related complications:
1. Risk of sedation
2. Bleeding
3. Infection
4. Urosepsis (GENTAMICIN - prophylactic antibiotics)
44
How would you stage prostatic cancer?
- Clinical examination (palpable tumor -> T2)
- TRUS biopsy for staging purposes (GLEASON SCORE)
- CT scan of abdomen and pelvis -> To assess the extent of tumor invasion and nodal status - PELVIC LYMPHADENOPATHY
- Bone scan for metastasis
*Metastasis usually spread via BATSON VENOUS PLEXUS to VERTEBRAL COLUMN
45
What is the difference between active surveillance and watchful waiting in prostatic cancer?
46
What is the surgical intervention of prostate cancer?
Radical Prostatectomy KIV bilateral pelvic lymph node dissection
- Surgical procedure to remove the prostate, surrounding tissue and seminal vesicle
- For patient with life expectancy >10Y
- Lymph nodes are removed between external iliac vein and obturator vessels bilaterally
- Complications:
1. Urinary incontinence
2. Erectile dysfunction
3. Lymphocele
4. Rectal/urethral injury
47
How would you treat a locally advanced disease (T3/T4) of prostate cancer?
Radiotherapy
- External beam radiotherapy
- Interstitial bradytherapy
- Alpha-emitter radiation - Radium-223
48
If a prostate cancer patient presented with metastatic disease, how would you treat him?
Plan:
Androgen deprivation therapy -> Lower serum testosterone
1. Surgical Orchidectomy (Remove testicle)
- Rapid decrease serum testosterone -> Improvement in bone pain and disease related symptoms
2. Medical orchidectomy
- LHRH/GnRH agonist -> GOSERELIN, LEUPROLIDE
- LHRH/GnRH antagonists -> DEGARELIX
3. Anti-androgen -> BICALUTAMIDE
- Combined androgen blockade: prevents disease flare during initiation of GnRH agonist
- Steroidal anti-androgen - rarely used
49
List 4 pathology for BPH.
1. Stromal epithelial interaction theory
- Proliferation of both epithelial and stromal components of the prostate with resultant enlargement of the gland
2. Hormones
- Major stimulus: DIHYDROTESTOSTERONE -> Stimulates prostate growth and maintenance of size
- Age-related increases in estrogen levels may also contribute to BPH -> By increasing expression of dihydrotestosterone receptors on prostatic parenchymal cells
3. Stem cell theory
- Abnormal maturation and regulation of cell renewal process
- Increase in size of prostate due to decrease in cell death
4. Static and dynamic components of prostatic obstruction??
50
State the clinical presentation of benign prostatic hyperplasia (BPH)
- Lower urinary tract symptoms (obstructive predominate) -> Irritative symptoms
- Irritative symptoms -> complications of urinary retention: UTI, stones
51
What are the complications of obstructive uropathy?
- Hydroureter with reflux of urine
- Hydronephrosis
- Pyonephrosis
- Pyelonephrosis and impaired renal function
52
State (5) other differentials for BPH
- Stricture/bladder neck contracture
- Drug causes: Codeine (Cough mixture), anti-cholinergic, TCAs, BB
- Chronic constipation
- CA bladder neck/CA prostate
- Neurogenic bladder
53
State (4) complications of BPH
- Acute/chronic urinary retention, complicated by bladder stone and recurrent UTI
- Gross hematuria
- Renal impairment secondary to outflow obstruction
- Co-existence of prostate cancer
54
How would investigate a case of BPH?
Blood
- FBC -> anemia? Raised WBC?
- Urea/Electrolyte/Creatinine
- UFEME + Urine C&S
- +/- Urine cytology
- PSA
Imaging
- US Kidney -> Hydronephrosis, stones
- US bladder / prostate
- KUB for bladder stone
- Cystoscopy -> TRO stones, strictures/bladder neck obstruction or cancer
- Uroflowmetry
55
How does a normal uroflowmetry look like?
- Normal bell-shaped curve
- Saw-tooth appearance
- Normal peak flow rate (Qmax) >15mL/sec
- Total duration: 30sec(male), 20sec(female)
- Residual urine: 0mL (young adults), 100-200mL (elderly)
56
What are the medical treatments available for BPH patient?
1. Alpha-blockers (Prazosin, Terazosin, Tamsulosin)
- 1st LINE
- MOA: Block alpha-1 adrenergic receptors in bladder neck, prostate and urethra -> Decreased outflow resistance and decreased bladder instability
- Increase successful trial off catheter (TOC) and continued use reduced need for BPH surgery (during 6 month treatment period)
- Side effect: Postural hypotension, dizziness, lethargy, light-headedness
2. 5-alpha reductase inhibitors (Finaseride, Dutasteride)
- Reduce prostate size (20%), decreased need for surgery (10-15%)
- Side effect (Finasteride) - Decreased libido (erectile dysfunction), Ejaculatory dysfunction, impotence, gynecomastia
57
What surgery is done to treat BPH?
Transurethral resection of prostate (TURP) -> GOLD STANDARD -> Aim to widen bladder neck
Transurethral incision of the prostate (TIUP)
- Decision made during TURP when prostate does not appear to be enlarged
- Make small cuts around the bladder neck area to open it up
58
What are the indications for surgery in BPH patients?
- Failed medical treatment
- Significant complications:
1. Upper tract injury (e.g renal insufficiency, obstructive uropathy, hydronephrosis)
2. Lower tract injury (e.g refractory urinary retention, recurrent UTI, bladder decompensation)
- Recurrent/persistent gross hematuria
- Bladder calculi - secondary to BPH
Caution: Prior to TURP -> do a urodynamic studies to rule out neurogenic bladder / detrusor hypotonia
59
State the complications seen in BPH patients if it is left untreated.
- Risk of GA/spinal analgesia
- Bleeding, infection/urosepsis
- Local injury causing incontinence (1%) / bladder neck stenosis
- Perforation of the urethra or bladder dome -> can form FISTULA
- RETROGRADE EJACULATION (40 - 60%) -> ejaculate volume decrease
- TUR syndrome (<1%) -> HYPONATREMIA (pseudo-hyponatremia/isotonic hyponatremia)
*Hyponatremia due to constant irrigation during TURP (glycine 0.9% is used)
60
Define testicular torsion
- It is a surgical emergency
- True urologic emergency where the testis is rotated on its vascular pedicle resulting in ischemia
- Irreversible damage after 12 hours of ischemia
61
State the clinical presentations and possible findings on physical examination for testicular torsion
Clinical presentations
- Acute abdomen (T10 innervations)
- Acute onset of testicular pain and swelling
- Associated with nausea and vomiting
*No history of voiding complains
Physical examination
- Swollen and tender scrotum
- High riding in scrotum with transverse lie
- ABSENT cremasteric reflex
- NEGATIVE prehn sign
62
Give (3) differentials for testicular torsion
- Epididymitis
- Torsion of testicular appendage (pea colored lump through scrotum)
- Strangulated inguinoscrotal hernia
63
What (1) investigation you would do to confirm a diagnosis of testicular torsion?
COLOUR DOPPLER ULTRASOUND
- Help confirm or exclude diagnosis with 95% accuracy
64
How you manage a case of testicular torsion?
Emergency exploration if DOPPLER US is negative for flow or high index of clinical suspicion
- Untwisting of affected testis and bilateral orchidopexy (Surgical procedure that moves undescended testis into the scrotum)
- Warm up with warm pad to see reperfusion or check with doppler after untwisting
- If dead, excise and replace with prosthesis
65
How would you manage a case of scrotal abscess?
- Analgesia + IV antibiotics (AUGMENTIN)
- Incision and drainage with cavity left open and packed
66
State the complications of scrotal abscess if not treated properly.
- Incomplete drainage leading to persistence of abscess or repeat I&D
- FOURNIER GANGRENE (necrotizing fasciitis due to synergistic poly-microbial infection)
67
What are the (3) risk factors of Fournier gangrene?
1. Diabetes
2. Alcoholics
3. Immunocompromised
68
Name the source of infection to Fournier gangrene.
- Genitourinary (19%) - urethral stone/stricture/fistulae
- Colorectal (21%) - ruptured appendicitis, colonic CA, diverticulitis, perirectal abscess
- Dermatological (24%)
- Idiopathic (36%)
69
What are the clinical presentations of Fournier gangrene?
- Abrupt onset with pruritus, rapidly progressing to edema, erythema, and necrosis within hours
- FEVER, perineal and scrotal pain associated with INDURATED TISSUE
- May progress to FRANK NECROSIS of skin and subcutaneous tissue
- Crepitus in tissue suggest the presence of GAS-FORMING ORGANISMS
70
Describe the management of Fournier gangrene.
- Broad-spectrum antibiotics cover (against aerobic and anaerobic organisms)
e.g IV penicillin G, IV Clindamycin 900mg, IV ceftazidime 2g
- Wide debridement with aggressive post-operative support (testes are often spared due to discrete blood supply)
- If there is damage to external anal sphincter -> COLOSTOMY may be required
- Tight glucose control and adequate nutrition
71
What surgical complication could lead to EPIDIDYMAL CYST?
VASECTOMY (Spermatoceles)
72
Define Varicocele
It is the dilatation of veins of the PAMPINIFORM PLEXUS of the spermatic cord
73
Epidemiology and risk factors of varicocele
- Present in 15-20% of post-pubertal males
- Predominantly occurs in the LEFT HEMI-SCROTUM
Risk factors:
- Idiopathic in young males around puberty
- In older men, with retroperitoneal disease (Need to exclude RCC)
74
State the clinical presentation of varicocele.
- Dull aching, left scrotal pain
- Testicular atrophy
- Decreased fertility
75
What is the possible findings on palpation in a case of varicocele?
- Mass is separate from testis (Can get above it)
- Feels like a BAG OF WORMS
- Compressible mass above or surrounding the testis
- NOT TRANSILLUMINABLE
76
Describe the classification of varicocele.
77
What surgical management can be done to treat a case of varicocele?
- Trans-femoral angiographic embolization with coil or sclerosant
- Surgical ligation (excise the surrounding dilated veins)
78
Define hydrocele
Asymptomatic fluid collection around the testicles (processus vaginalis) that transilluminates
79
State the clinical presentation of hydrocele.
- Very swollen scrotum, uniformly enlarged
- Cannot define testis well
- Maybe firm, tense or lax
- Maybe TRANSILLUMINABLE if acute (Less in chronic hydrocele)
- Can get above the mass*****
80
Classify hydrocele based on its anatomy.
- Vaginal hydrocele
- Hydrocele of the cord
- Congenital hydrocele
- Infantile hydrocele
81
State (4) causes of secondary hydrocele.
- From testicular tumour
- From torsion/trauma
- From orchitis (any inflammation)
- Following inguinal hernia repair
82
What are the (2) surgical procedures done to treat a case of hydrocele?
1. Lord's plication of the sac - for small sac with thin wall
2. Jaboulay's operation to evert the sac - for large sac with thick wall
83
Describe the procedure steps for Lord's plication of the sac in hydrocele.
- Vertical paramedian incision is made
- Layers of scrotum are divided along the incision to identify the tunica vaginalis sac - from superficial to deep: (Skin, Dartos, External spermatic fascia, Cremasteric fascia, Internal spermatic fascia)
- TV sac is opened, draining the hydrocele fluid out
- TV is bunched up by placing multiple plicating sutures, such that the TV becomes crumpled up around the testis
- Secretions can then be absorbed by the lymphatics and venous system, avoiding reaccumulation of the hydrocele
- Scrotal support to reduce edema
84
Describe Jaboulay's operation
- It is similar to Lord's plication
- Except that there is SUBTOTAL EXCISION of TV sac
- With the cut edge of the sac everted and sutured behind the testis, instead of plication
85
State 3 complication of surgical management for hydrocele
- Hematoma (higher risk for Jaboulay)
- Wound infection -> pyelocele (purulent collections)
- Injury to the spermatic cord
86
State (3) risk factor for testicular tumour
- Cryptorchidism
- HIV infection
- Gonadal dysgenesis (e.g KLINEFELTER SYNDROME)
87
What are the positive findings on clinical examination of a case of testicular tumor?
- Inseparable from the testis, distinct from superficial inguinal ring
- Hard, nodular, irregular, non-tender
- Not-transilluminable
88
State 2 differential diagnosis for testicular tumor.
1. Chronic infection with scarring (e.g Orchitis/TB)
2. Long standing hydrocele with calcification
89
What investigations can be done to diagnose a case of testicular tumor?
*No role for percutaneous biopsy -> risk of seeding, risk of changing lymphatic drainage
- US scrotum
Seminoma -> HYPOECHOIC INTRATESTICULAR MASS
Non-seminoma -> INHOMOGENOUS LESIONS
- Tumor markers
LDH (Assess tumor burden)
AFP
B-HCG
Staging -> CT TAP (assess para-aortic lymph node involvement and distant metastasis)
90
Stage testicular tumor based on CT TAP
Stage 1 = Testis lesion, no nodes involved
Stage 2 = Nodes below diaphragm
Stage 3 = Nodes above diaphragm
Stage 4 = Pulmonary and hepatic metastasis
91
Classify testicular tumour.
- Germ cell tumour (90-95%) -> most commonly seminomatous tumours
- Sex cord stroma tumours (5-10%)
Secondary testicular tumor -> lymphoma, leukemia
92
How would you manage a case of testicular tumor?
- Fertility and sperm banking
- Staging, radical orchidectomy via inguinal approach +/- retroperitoneal lymph node dissection with combination chemotherapy
*Not to violate scrotal skin -> risk of altering lymphatic drainage of testis
*Intra-op, perform early clamping of testicular artery and vein within the spermatic cord before testis is mobilized -> Prevent intra-operative seeding of tumor up the testicular vein
