Surgery - Urology Flashcards
(116 cards)
1
Q
What is the best form of imaging for kidney stones?
A
CT KUB
2
Q
Recall the 4 main types of kidney stone in order of highest to lowest radiointensity
A
Calcium phosphate
Calcium oxalate
Triple (struvite) stones
Uric acid (radiolucent)
3
Q
Which type of kidney stone is associated with urease bacteria?
A
Triple (struvate) stones
4
Q
Which type of kidney stone is associated with hypercalciuria?
A
Calcium oxalate
5
Q
How should kidney stone pain be managed?
A
PR/IM diclofenac
6
Q
Recall one contra-indication to diclofenac
A
CVS disease
7
Q
How should kidney stones be managed depending on size?
A
Renal stones
Watchful waiting if < 5mm +/- tamsulosin (up to 1cm)
5-10mm shockwave lithotripsy
10-20 mm shockwave lithotripsy OR ureteroscopy
<2cm and pregnant: uteroscopy
> 20 mm percutaneous nephrolithotomy
Uretic stones
< 10mm shockwave lithotripsy +/- alpha blockers
10-20 mm ureteroscopy
If hydronephrosis/infection: percutaneous nephrostomy and antibiotics
8
Q
Recall 2 options for medically managing BPH and some side effects of each
A
- alpha-1 antagonists (tamsulosin): postural hypotension, dry mouth
- 5 alpha reductase inhibitors (finasteride): ED, reduced libido, gynaecomastia, ejaculation problems
9
Q
What is the main way in which BPH can be surgically managed?
A
TURP (transurethral resection of the prostate)
10
Q
What is the main complication of TURP to be aware of?
A
TURP syndrome
Hyponatraemia, fluid overload and glycine toxicity caused by over-irrigation
11
Q
When can PSA levels not be done?
A
Within:
- 6 weeks of a prostate biopsy
- 1 week of DRE
- 4w following a proven UTI/prostatitis
- 48 hours of vigorous exercise and/or ejaculation
12
Q
When would a multi-parametric MRI be used to investigate possible prostate cancer?
A
If PSA is inappropriate or if high chance of Ca
13
Q
What is the gold-standard investigation for prostate cancer?
A
Multiparametric MRI (this has replaced TRUS-guided biopsy)
14
Q
Recall 3 options for managing localised prostate cancer (T1/T2)
A
- Conservative with active monitoring
- Radical prostatectomy
- Radiotherapy (external beam and brachytherapy)
15
Q
Recall 3 options for managing localised advaced prostate Ca
A
- Hormonal therapy
- Radical prostatectomy
- Radiotherapy
16
Q
How should metastatic prostate cancer disease be managed?
A
Hormonal therapy only
17
Q
What are the options for hormone therapy in prostate cancer?
A
Synthetic GnRH agonist + 3w cover of anti-androgen
18
Q
Recall 2 types of benign epithelial renal tumour
A
Papillary adenoma
Renal oncocytoma
19
Q
What sort of tumour is an angiomyolipoma?
A
Benign mesenchymal renal tumour composed of thick-walled blood vessels, smooth muscle and fat
20
Q
What is the maximum size for a papillary adenoma?
A
15mm
If more than this = malignant papillary renal cell carcinoma
21
Q
What type of renal tumour can be seen in Birt-Hogg-Dube syndrome?
A
Renal oncocytoma
22
Q
What type of renal tumour can be seen in tuberous sclerosis?
A
Angiomyolipoma
23
Q
Which genetic syndrome predisposes to renal cell carcinoma?
A
Von Hippel Lindau
24
Q
What are the 3 main subtypes of renal cell carcinoma, and which is most common
A
Clear cell (70%)
Papillary
Chromophobe
25
Which tumours are people with Von-Hippel-Lindau predisposed to?
Phaeochromocytoma
Neuroendocrine pancreatic
Clear cell renal
26
Which type of renal cell tumour is associated with loss of 3p?
Clear cell renal
27
Which type of renal tumour is associated with long-term dialysis?
Papillary renal cell carcinoma
28
What is Wilm's tumour?
Nephroblastoma
29
How should high-grade transitional cell carcinomas be managed?
1st: intravesical immunotherapy
2nd: radical cystectomy
30
How should traumatic urethral injuries be investigated and managed?
Ix: ascending urethrogram
Mx: suprapubic catheter
31
How should traumatic bladder injuries be investigated and managed?
Ix: Intravenous urogram or cystogram
Mx: laparotomy if intraperitoneal, conservative if extraperitoneal
32
What proportion of testicular tumours are germ cell tumours?
95%
33
What are the subtypes of germ cell testicular tumours?
Seminomas (50%)
| Non-seminoma (embryonal, yolk sac, teratoma an choriocarcinoma)
34
What is the biggest risk factor for testicular seminoma?
Cryptochidism
35
What are the signs and symptoms of testicular cancer?
Painless lump +/- hydrocele, gynaecomastia
36
How should testicular cancer be investigated?
1st = USS
2nd = AFP, hCG, LDH
3rd = CT TAP
NO biopsy
37
How can testicular cancer be managed?
Orchidectomy +/- chemotherapy +/- radiotherapy
38
Is the cremasteric reflex pos or neg in testicular torsion?
Neg
39
What is the cremasteric reflex?
Stroking of the skin of the inner thigh causes the cremaster muscle to contract and pull up the ipsilateral testicle toward the inguinal canal
40
What is Prehn's test?
Elevating scrotum and assessing for difference of pain - positive if pain is relieved
41
Is Prehn's test pos or neg in testicular torsion?
Neg
42
What condition is Prehn's test positive in?
Epididymitis
43
How should testicular torsion be managed?
Surgical exploration + BL orchidopexy
44
What is an orchidopexy
Surgical procedure that moves undescended testicle into the scrotum, permanently fixing it there
45
What are the main RFs for ED?
EtOH
Drugs (beta-blockers, SSRI)
CVD RFs (metabolic syndrome, hyperlipidaemia etc)
46
How should ED be investigated?
```
QRisk score
Free testosterone (9-11am) --> if low, FSH, LH, prolactin --> if abnormal, refer to endo
```
47
How can ED be managed?
1st: PDE4 inhibitors (sildenafil)
| 2nd line: vacuum devices
48
How should pregnant women with asymptomatic bacteriuria/UTI be managed?
MC&S --> Abx
7 days nitrofurantoin 100mg BD (AVOID AT TERM )
OR
Amoxicillin/cephalexin
49
How should UTIs in men be managed?
7 days trimethoprim/nitrufurantoin
50
When should men be referred to urology for UTI?
If 2 or more uncomplicated UTIs
51
How should catheterised patients with asymptomatic bacteriuria be managed?
No treatment needed
52
How should catheterised patients with symptomatic UTI be managed?
7 days trimethoprim/nitrofurantoin and change catheter
53
What is the causative organism in 95% of cases of prostatitis?
E coli
54
What are the signs and symptoms of prostatitis?
Referred pain to perineum, penis, rectum or back
Obstructive voiding symptoms
Fever and rigors may be present
55
How should prostatitis be investigated?
DRE --> tender, boggy prostate gland
56
How should prostatitis be managed?
Quinolone 14/7
| STI screening
57
How should urinary incontinence be investigated?
1st: speculum - exclude prolapse
2nd: Urine dip and MC&S (rule out DM and UTI)
3rd: Bladder diaries (minimum 3 days) - if inconclusive -->
4th: Urodynamic testing (if mixed incontinence)
58
What is measured by urodynamic testing?
3 pressures measured from inside rectum and urethra:
- bladder
- detrusor
- IAP
59
How should stress incontinence be managed?
1st line: lifestyle advice, WL if BMI>30, pelvic floor exercises
2nd line: duloxetine or surgical treatment
60
How should pelvic floor exercises be done for stress incontinence?
8 contractions, TDS, 3 months
61
Recall some options for sugical management of stress incontinence
- Burch colposuspension
- Autologous rectus fascial sling
- Bulking agents
62
Recall some RFs for stress vs urge incontinence
Stress: age*, children, traumatic delivery, pelvic surgery, obesity*
Urge: age*, obesity*, smoking, FHx, DM
63
What is the normal post-void volume for <65 vs >65ys?
```
<65 = <50mLs
>65 = <100mLs
```
64
How should urge incontinence be managed?
1st line: lifestyle advice, bladder training, avoid fizzy drinks, DM control
2nd line: oxybutynin/tolterodine or desmopressin
3rd line: mirabegron (beta-3 agonist)
4th line: surgical
65
Recall an important side effect of oxybutynin and an alternative option if there is concern
Falls
| Can give mirabegron instead
66
How can urge incontinence be managed surgically?
Botox injection, sacral nerve stimulation, urinary diversion
67
How should overflow incontinence be managed?
Refer to specialist urogynaecologist
| 1st line = timed voiding
68
How should hydrocele be managed?
- Watch and wait
- Aspiration for symptomatic relief
- Surgical = Lloyd's repair/ Jaboulay's repair
69
Why does varicocele affect the LHS more than the RHS?
Left testicular vein:
- drains into renal vein at 90 degree angle
- is longer than right
- often lacks a terminal valve to prevent backflow
- can be compressed by renal and bowel pathology
70
What is the best investigation for varicocele?
Doppler USS
71
If varicocele has a sudden onset, what must be considered?
Renal cell carcinoma
72
How should varicocele be managed?
```
Conservative (scrotal support)
or surgical (radiological embolisation or operation to expose and ligate vein)
```
73
In a patient with hypercalciuria and recurrent calcium renal stones, what drug can be used as prevention?
Thiazide like diuretics (they decrease urinary calcium)
74
What should be done before treatment with goserelin for prostate cancer?
Pretreatment with flutamide (anti-androgen) to avoid initial "flare effect" of goserelin
75
If NSAIDs are contraindicated in a patient with renal colic, what is second line?
IV paracetamol
76
When is vasectomy considered a valid form of contraception?
Once 2x semen analyses have been done to confirm azoospermia - patients should use contraception during this time
77
When would you refer under 2ww pathway for non-visible haematuria?
If >60yo and no explanation for non-visible haematuria AND raised WCC/dysuria
78
What is the management of intermittent testicular torsion?
Emergency bilateral ochidopexy (as there is still a high risk of re-torsion so should be done ASAP)
79
Which urological condition is a contraindication to circumcision during infancy?
Hypospadias - as the foreskin can be used in repair surgeries
80
Up to what size tumour is a partial nephrectomy offered?
<7cm
81
What can be prescribed to prevent calcium stones?
Potassium citrate
82
What is the investigation of choice for epididymo-orchitis?
Younger adults: Urethral swab for NAAT
Older adults/low-risk sexual Hx: MSU
83
When would percutaneous nephrolithotomy be used?
Stones > 20mm
84
What is the best imaging modality for hydronephrosis?
USS
85
What is balantis xerotica obliterans?
The equivalent of lichen sclerosis in women, it is a chronic skin condition causing raised, white and sometimes itchy white plaques on the external genitalia
86
What can BXO increase your risk of?
Squamous cell carcinoma + associated with phimosis
87
What are the two types of urethral injury?
* Bulbar
* Membranous
88
What is the most common type of urethral injury and what is the typical MoA?
Bulbar - usually saddle type injury e.g. bicycle
89
What is the triad of symptoms in bulbar urethral damage?
* Perianal haematoma
* Urinary retention
* Blood at the meatus
90
What signs and symptoms would be present in membranous urethral damage?
* Penile or perineal oedema or haematoma
* Prostate gland displaced upwards (so often not palpable on DRE)
91
What is the typical cause of membranous urethral damage?
Pelvic fracture
92
What would periureteric fat 'stranding' suggest?
Recently passed ureteric calculus (in the absence of visible calculus)
93
What is decompression haematuria?
Haematuria can commonly occur after catheterisation for chronic urinary retention due to the rapid decrease in pressure in the bladder - it does not require any management apart from monitoring
94
What are some causes of unilateral hydronephrosis?
Pelvic-ureteric obstruction (congenital or acquired)
Aberrant renal vessels
Calculi
Tumours of renal pelvis
95
What are some causes of bilateral hydronephrosis?
Aberrant renal vessels
Calculi
Tumours of renal pelvis
Stenosis of the urethra
Urethral valve
Prostatic enlargement
Extensive bladder tumour
Retro-peritoneal fibrosis
96
What is the management of hydronephrosis?
* Remove the obstruction and drainage of urine
* Acute upper urinary tract obstruction: nephrostomy tube
* Chronic upper urinary tract obstruction: ureteric stent or a pyeloplasty
97
What is first line for BPH?
Alpha-1 antagonists (e.g. tamsulosin) for mdoerate-severe symptoms (IPSS > 8)
98
When are 5-a-reductase inhibitors indicated?
When the patient has a significantly enlarged prostate or considered to be at high risk of progression
99
What is the IPSS and the different scores?
A tool for classifying the severity of lower urinary tract symptoms (LUTS) and assessing the impact of LUTS on quality of life
* Score 20–35: severely symptomatic
* Score 8–19: moderately symptomatic
* Score 0–7: mildly symptomatic
100
How do 5-a-reductase inhibitors work?
Prevent the conversion of testosterone to dihydrotestosterone, which is known to induce BPH. Therefore, they can actually reduce the size of the prostate and slow progression.
101
How long can it take 5-a-reductase inhibitors to have an effect on prostate size?
6 months
102
What tumour marker is associated with seminomas?
hCG (20% cases)
103
What tumour marker is associated with non-seminomas?
AFP and/or hCG are raised in 80-85% cases
104
How should post-obstructive diuresis be avoided?
Patients producing >200ml/hr urine output should have around 50% of their urine output replaced with intravenous fluids to avoid any worsening AKI.
105
What is the first line investigation for priaprism?
Cavernosal blood gas sample (differentiates between ischaemic and non-ischaemic, which guides Mx)
106
What symptoms can result of the goserelin 'flare' after initiating treatment?
* Bone pain
* Bladder obstruction
107
What is the top differential for a scrotal lump that is separate to the testicle but cannot be palpated above it?
Inguinalscrotal hernia
108
Which urothelial cancer does schistosomiasis increase the risk of?
Squamous cell cancer of the bladder
109
What test should always be offered for men presenting with ED?
AM testosterone
110
What stage tumour do patients typically present with symptomatic renal cell carcinoma?
Stage 4
111
What is the first line investigation for suspected bladder cancer?
Flexible cystoscopy
112
What are some side effects of prostate radiotherapy?
* Proctitis - can cause bloody diarrhoea
* Increased risk of bladder, colon, and rectal cancer
113
What are some long term complications of a radical prostatectomy?
* Erectile dysfunction
* Urethral stenosis
* Urinary incontinence
114
What can cause retrograde ejaculation?
* Alpha blockers
* TURP surgery
115
What is the Mx of bladder carcinoma in situ (CIS)?
Due to the early, but high-grade nature of such cancer, patients are managed by trans-urethral removal of bladder tumour (TURBT) with adjunctive intravesiclar chemotherapy to reduce the risk of recurrence
116
What is the next step in management if an irregular, craggy and hard prostate is felt on DRE?
Immediate referral via 2ww pathway (irrespective of a normal PSA)
