Urology

Question 1

Anatomy of the penis

Answer 1

• The corpora cavernosum are paired, cylinder like sturctures
• The corpora cavernosum are enclosed by the tunic albuginea
• The corpora cavernosum and spongiosum are surrounded by Bucks fascia
• Priapism is defined as persitent erection of more than 4 hours

Question 2

Bladder cancer

Answer 2

PAtients with limited node involvement may be cured by surgery alone

• Patients who are T2 - immediate (within 3 months) cystectomy with extended LN dissection
• Patients with non-muscle invasive bladder cancer (confined to the mucosa or submucosa) managed with trabsurethral resection alone and adjuvant intravesical chemotherapy/immunotherapy

Question 3

Testicular cancer

Answer 3

Most commn malignancy in men between 15 and 35 years

• Chest and abdominal imaging must be performed to evaluate for evidence of metastasis
• Most common site of spreadc- retroperitoneal LN extending from the common iliac vessels to the renal vessels

Question 4

Kidney cancer

Answer 4

• Lesions are useually solid but can be cystic
• May be sporadic or hereditary
• 20-30% presents with metastatic disease
  
  • surgical debulking can improve survival in patients who present with metastatic disease
• up to 10% invaseds the lumen of the renal vein or vena cava
• Degree of venous extension directly impacts the surgical approach
• Patients with thrombus can below the level of the liver can me managed by
  
  • cross clamping above and below the thrombus and extraction from a cavotomy at the insertion of renal vein

Question 5

Prostatic carcinoma

Answer 5

• Annual digital rectal examination and serum PSA determiantions are recommended beginning at age 55
• Lung metastasis is less common than bone metastasis
  
  • MOST COMMON: Pelvic LN and bones
• Once prostate cancer has spread, it is no longer curable but can be contained by lowering serum testosterone and/or administration of adrogen receptor blockers
• Radical prostactomy is associated with early incontinence and erectile dysfunction
  
  • IMPROVES SIGNIFICANTLY WITH TIME

Question 6

Ureteric trauma

Answer 6

Retrograde pyelogram is the msot sensitive test to detect ureteral injury

• Partial injuries can be primarily repaired, although all devitalized tissue must be debrided
• Ureteral stents to faciliatet healing without stricture
• Midurethral level injuries can be treated with ureto-uretostomy if a spatulated, tension free repair can be achieved
• Longer defects - bladder can be mibilized and brought up to the psoas muscle (PSOAS hitch)
• For additional length - BOARI flap (tubualrized flap of the bladder)

Question 7

Treatment of acute urinary retention

Answer 7

• Coude catheterization
• Placement of suprapubic drainage
• Continous bladder irrigation if hematuria is the cause of retention
• Fluid replacement
  
  • 0.5 mL of 0.45 normal saline for every 1 mL or urine output above 200 mL in hour

Question 8

Testicular torsion

Answer 8

• Risk factors
  
  • Undescended testis, testicular tumor
  • Bell clapper deformity - poor gubernaculum fixation of the testicles to the scrotal wall
• Decreased blood flow relative to the contralateral testicle demonstrable by ultrasound
• Surgical exploration should include fixation of the contralateral testicle
• More than 80% can be salvaged if surgery is performed within 6 hours

Question 9

Priapism

Answer 9

• Persistent erection for >4 hours unrelated to sexual stimualtion
• Low flow priapism can be confirmed with a penile blood gas determination
• Treatment may require injection of phenylephrine
  
  • up to 200 mg in 20 mL normal saline
• Risk factors
  
  • sickle cellm nakignancy, medications, cocaine abuse, certain antidepressants, and total parenteral nutrition

Question 10

BPH

Answer 10

Consequences of BPH include gross hematuria, chronic infection, bladder calculi, urinary retention, and paraphimosis

• Medical therapy is the first step
• Transurethral resection is the mainstay of endoscopic surgical BPH

Question 11

Urolithiasis

Answer 11

Most common type is calcium oxalate

• 10% of the population
• CT scans will dmeonstrate all calculi except, INDDINAVIR CYSTALS
  
  • noncontrast CT scan
• Recurrent stones = stone composition and 24 hour urine metabolic workup
• Better hydration is useful for all etiologies
• Most patient will benefir from alkalinization of the urine (potassium citrate)