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Yr 3 Surgery > Urology > Flashcards

Urology Flashcards

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1
Q

What are the types of haematuria?

A

Non-visible
Visible

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2
Q

What results are given on a urine dip?

A

Protein
.pH
Glucose
Blood
Nitrites
Leukocytes
Bilirubin
Ketones
Specific gravity
Urobilinogen

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3
Q

What are some causes of haematuria?

A

Nephrological
Trauma
Infection
Cancer
Stones

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4
Q

What’s some imaging that can be done to investigate haematuria?

A

USS KUB
CT urogram - 2 CTs, 1 non-contrast, 1 delayed post contrast
Cystoscopy

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5
Q

What is RCC?

A

Renal cell carcinoma
Tumour of renal parenchyma
Adenocarcinoma

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6
Q

What’s the typical presentation of RCC?

A

Haematuria
Loin pain
Palpable mass
‘classic triad’ seen in <10%

Majority are incidental finding

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7
Q

What are some risk factors for RCC?

A

Heavy smoking
Obesity
Family history/genetic syndromes

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8
Q

What are some paraneoplastic syndromes associated with RCC?

A

Stauffer’s syndrome
Hypercalcaemia
Hypertension
Polycythaemia/anaemia
Pyrexia
Amenorrhoea/baldness/cushings

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9
Q

How is RCC diagnosed?

A

USS KUB
CT with contrast to stage

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10
Q

What staging is used for tumours?

A

TNM

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11
Q

What are the treatments for T1a RCC?

A

T1a = <4cm

Surveillance
Ablation
Laparoscopic radial nephrectomy
Partial nephrectomy (robotic)

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12
Q

What treatments are available for T1b RCC?

A

T1b = 4-7cm

Partial nephrectomy (robotic or open)
Laparoscopic radical nephrectomy

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13
Q

What treatments for T2a and above RCC?

A

Robotic or open radical nephrectomy +/- lymph node dissection

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14
Q

What treatments are available for metastatic RCC?

A

Radical nephrectomy and resection of mets if possible
Tyrosine kinase inhibitors for systemic treatment

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15
Q

How is upper tract TCC diagnosed and treated?

A

Uncommon

Majority presents with visible haematuria

CT Urogram is the test of choice

Ureteroscopy ± biopsy may be needed to confirm diagnosis

Small, low grade tumours can be treated with laser ablation

Majority of non-metastatic cases are treated with laparoscopic nephro-
ureterectomy

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16
Q

What are some types of bladder cancer?

A

TCC (transitional cell) 80%

SCC (squamous cell) 20%

Adenocarcinoma (1%) rare

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17
Q

What are some risk factors for TCC?

A

Smoking
Occupational exposure - aromatic amine exposure, aniline dyes

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18
Q

What are some risk factors for SCC?

A

Assoc w/ long-term catheters, recurrent UTI, bladder stones

Schistosomiasis in endemic areas

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19
Q

What are some treatments available for superficial bladder cancer?

A

TURBT
If T1a - single dose of intravesical mitomycin

Further treatment:
Low risk-Cystoscopic surveillance

Intermediate risk- 6x weekly mitomycin instillations

High risk- BCG
Cystectomy for v.high risk cases

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20
Q

What are some side effects of giving BCG for bladder cancer?

A

Dysuria, frequency, urgency

UTI

Haematuria

Systemic BCGosis (rare)

Bladder contracture/ureteric stenosis (rare)

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21
Q

What are some ways urine is diverted after cystectomy?

A

Ileal conduit - ureter connected to small bowel and stoma created

Neobladder - Ureters connected to new “bladder” made of small bowel and connected to
urethra. Patient passes urine “normally”

Continent cutaneous diversion - Pouch fashioned from e.g. right hemicolon
 Catheterisable stoma – patient passes catheter to empty pouch intermittently

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22
Q

What are some issues with continent diversions?

A

Hypercholoraemic metabolic acidosis
Incontinence
Stones
Mucus
Perforation
Must get up every 3 hours at night to empty at the start

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23
Q

What are some risk factors of prostate cancer?

A

Age (peak 70s)
Family history
Genetics - BRCA, HPC1
Ethnicity - Afro-Caribbean>white>asian

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24
Q

What’s the typical presentation of prostate cancer?

A

Asymptomatic screening
LUTS
Bone pain - advanced disease

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25
What is PSA and when can it be increased?
Prostate specific antigen Increased in: Prostate cancer Urinary retention UTI Instrumentation BPH
26
What are the age specific thresholds for PSA?
40s > 2.5ng/ml 50s > 3.5ng/ml 60s > 4.5ng/ml 70+ > 6.5ng/ml
27
What are some investigations done in suspected prostate cancer?
Multiparametric MRI TRUS biopsy Bone scan for staging
28
How is prostate cancer graded?
Gleason grading 3-5 based on differentiation, sum of two highest scores found or most prevalent scores
29
What surveillance is done for low-risk prostate cancer?
Active surveillance - monitor PSA/DRE 6 monthly Watchful waiting - older patients
30
What are radical treatments available for prostate cancer?
Radical prostatectomy - robotic External beam radiotherapy + hormones - 35 fractions Brachytherapy - implantation of radioactive seeds/wires
31
What are some side effects of radical prostate cancer treatment?
Incontinence Impotence GI upset
32
What treatments are available for metastatic prostate cancer?
Androgen deprivation therapy Early Docetaxel chemotherapy
33
What are some features of testicular cancer?
Majority germ cell tumours Lymphoma Leydig cell tumours Age 15-45
34
What are some germ cell tumours?
Non-seminomatous germ cell tumours (NSGCT) Seminoma
35
What’s the typical presentation of testicular cancer?
Notice a lump Solid mass, inseparable from testis May have systemic symptoms
36
How is testicular cancer diagnosed?
USS CT CAP for staging
37
What are some testis tumour markers?
Alpha-Fetoprotein (AFP) - specific to NSGCT Beta-HCG LDH
38
What treatments are available for testicular cancer?
Inguinal orchidectomy Chemo if metastatic Radiotherapy to lymph nodes can be used in seminoma Retroperitoneal lymph node dissection used for residual NSGCT masses after chemotherapy
39
What is the treatment for penile cancer?
Treatment is excision (occasionally topical 5 F-U for superficial disease – chemotherapy) Circumcision, glansectomy, partial or total penectomy May need inguinal (+ occasionally pelvic) node dissection
40
How does renal colic present?
Sudden, severe flank pain, loin to groin Constant or colicky Rolling around Hx of prev stones
41
What are some differentials to consider in patient presenting with suspected renal colic pain?
Ruptured AAA Pancreatitis Biliary colic Appendicitis Gynae pathology in women
42
What investigations should be done in pt presenting with renal colic?
Urine dip - haematuria Pregnancy test FBC, U+E, calcium CT KUB, non contrast
43
What’s the acute management for renal stones?
NSAIDS - diclofenac PR Opiates as req Monitor for signs of sepsis
44
What are some types of renal stones?
Calcium oxalate - most common Calcium phosphate - hyperthyroidism Urate - obesity, T2DM, radiolucent but seen on CT Triple phosphate Cystine Indinavir - HIV treatment
45
What are the signs and consequence of infected obstructed kidney?
Fever and signs of sepsis Irreversible loss of renal function, worsening sepsis, multi-organ failure, death
46
What’s the treatment for infected obstructed kidney?
Emergency decompression Cystoscopy and retrograde JJ stent Percutaneous nephrostomy
47
What are some management options of renal stones?
Generally present via outpatients (symptoms less acute than ureteric stones for obvious reasons) No intervention if <5mm Observation if minimally symptomatic or >5mm External shockwave lithotripsy (ESWL) Flexible ureteroscopy and laser lithotripsy Percutaneous Nephrolithotomy (PCNL) – larger stones, including staghorn calculi Open/laparoscopic stone surgery almost never done
48
What advice is given to patients post renal stone?
Advise 2-3 litres of water/day (keep urine pale) Avoid excessive salt/red meat Citrate is beneficial (lemon juice in water, apple juice) They should maintain normal calcium intake
49
What categories can LUTS be split into?
Storage Voiding Post-micturition
50
What are some examples of storage LUTS?
Frequency Nocturia Urgency Urge incontinence Stress incontinence
51
What are some voiding LUTS?
Hesitancy Poor flow Incomplete emptying Terminal dribble Dysuria
52
What are some post-micturition LUTS?
Post-micturition dribble
53
What are some causes of LUTS?
Bladder outflow obstruction Overactive bladder UTI Bladder stones
54
What investigations should be done in pt presenting with LUTS?
Abdo exam Genital exam - ?phimosis DRE Urine dip Freq-vol chart PSA Flow rate and post micturition residual volume Urodynamics - bladder pressure
55
What’s the difference between urge and stress incontinence?
Stress: -Provoked by coughing, sneezing, laughing, standing up -Leak a small amount -No sensation of urge Urge: -Preceded by sensation of urgency -Can also be provoked by coughing -Other stimuli such as running water, cold, “latch-key” -Leak large amounts
56
What are some conservative treatments for stress incontinence?
Supervised pelvic floor exercises Weight loss
57
What are some surgical treatments for stress incontinence?
Colposuspension - risk of prolapse Artificial urinary sphincter Urinary diversion (stoma) Autologous fascial sling TVT (tension-free vaginal tape) and TOT (transobturator) tape
58
What are some conservative treatments for bladder outflow obstruction caused by BPH?
Lifestyle advice – fluid intake, caffeine, etc Drink to thirst
59
What are some medical treatments for BOO caused by BPH?
Alpha blockers - tamsulosin, alfuzosin 5-alpha reductase inhibitors - finasteride, dutasteride Anticholinergics (if have OAB)
60
61
How do alpha blockers work in BPH treatment and what are some side effects?
Relax prostatic/bladder neck smooth muscle Tamsulosin/Alfuzosin - uro-selective Only improves symptoms Side effects: -retrograde ejaculation -postural hypotension
62
How do 5-alpha reductase inhibitors work and what are some side effects?
Reduce conversion of Testosterone to DHT Reduce prostatic volume Takes 6 months to see effect Only works with enlarged prostates (>30g, PSA>1.4) Can reduce progression of the disease/decrease need for surgery Side effects: -erectile dysfunction -decreased libido -rash
63
What are some indications for surgery for BOO caused by BPH?
Failure of medical therapy: -LUTS not controlled by medication -Acute retention – failed TWOC on alpha-blockers Development of complications: -Chronic retention (especially high-pressure) -Bladder stones -Benign prostatic haematuria (if persistent)
64
What surgical treatment is available for treatment of BOO caused by BPH?
TURP
65
What is overactive bladder syndrome?
urgency, with or without incontinence, often accompanied by frequency and nocturia in men and women In men often accompanies obstruction, not in women
66
What are some conservative treatments for OAB?
Weight loss, stop smoking, avoid caffeine Drink when thirsty! Pelvic floor exercises Bladder training
67
What are some medical treatments for OAB?
Anti-cholinergics - oxybutynin, tolterodine, solifenacin (trial for 4wks, switch to another if not working) Topical vaginal oestrogens in peri- and post-menopausal women Beta 3 agonist - Mirabegron
68
What are some side effects for Mirabegron?
Can cause HTN Can cause arrhythmia
69
What are some side effects of anti-cholinergics?
Dry mouth Dry eyes - blurred vision Urinary retention Constipation
70
What are some surgical treatments for OAB?
Botulinum toxin injections -Need retreatment every 6-12 months -Risk of retention – must be able/willing to self-catheterise Sacral nerve stimulation Ileocystoplasty
71
What are the types of urinary retention?
Acute: Painful inability to void Residual volume 300-1500ml Chronic: Painless May still be voiding Residual volume 300-4000ml Acute on chronic
72
What are some causes of urinary retention in men?
BPH Prostate cancer UTI Constipation Neurological dysfunction Recent surgery Drugs Urethral stricture - common cause is STI
73
What are some causes of urinary retention in women?
UTI Constipation Neurological dysfunction Recent surgery Drugs Urethral stricture/stenosis Pelvic mass High-tone non-relaxing sphincter (Fowler’s syndrome)
74
What investigations and management should be done in pt with acute urinary retention?
Catheterise and record residual vol History Abdo, external genitalia exam + DRE Urine dip U&Es Treat obvious cause Alpha blockers in men TWOC in 1-2 weeks on alpha-blocker If fails - TURP
75
How can you differentiate high vs low pressure chronic urinary retention?
High-pressure: -Abnormal U+Es (Beware hyperkalaemia) -Hydronephrosis Low-pressure: -Normal renal function -No hydronephrosis
76
How should chronic urinary retention be managed?
Catheterise and always record residual volume History Exam Urine dip, U+Es Monitor for post-obstructive diuresis (usually admit overnight) High-pressure: -Do not TWOC -Discuss with Urology as may need TURP Low-pressure -TURP, but only 50% will void again (rest = detrusor failure) -Intermittent self-catheterisation (instead of TURP or if TURP fails) -If unable/unwilling to do ISC – long-term urethral or suprapubic catheter
77
78
What is a complication to be aware of after treating urinary retention?
Post-obstructive diuresis Initially physiological off-loading of accumulated salt and water during chronic retention a few cases, can become excessive/severe and lead to dehydration/electrolyte imbalance Careful monitoring and oral fluid replacement usually sufficient – a few need saline IVI

Yr 3 Surgery (6 decks)

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