Urology Flashcards Preview

FinalMB Part I - Surgery > Urology > Flashcards

Flashcards in Urology Deck (65)
Loading flashcards...
1

Presentation of an obstructive uropathy (split into upper and lower urinary tract) ?

Upper Urinary Tract Obstruction (i.e. ureters):

-Loin to groin / flank pain on affected side (result of stretching / irritation of ureter and kidney
-Reduced / no urine output
-Non-specific symptoms (e.g. vomiting)
-Reduced renal function on bloods

Lower Urinary Tract Obstruction (i.e. bladder / urethra):

-Acute urinary retention (unable to pass urine and increasingly full bladder)
-Lower urinary tract symptoms (e.g. poor flow, difficulty initiating urination, terminal dribbling)
-Reduced renal function on bloods

2

Common causes of an obstructive uropathy (split into upper and lower urinary tract) ?

Upper Urinary Tract:

-Kidney stones
-Local cancer masses pressing on the ureters
-Ureter strictures (scar tissue narrowing tube)

Lower Urinary Tract:

-Benign prostatic hyperplasia (enlarged prostate)
-Prostate cancer
-Ureter or urethra strictures (from scar tissue)
-Neurogenic bladder (no neurological signal telling bladder to contract)

3

Name 5 complications of an obstructive uropathy

-Acute Kidney Injury (postrenal AKI)
-Eventually chronic kidney disease
-Infection (from pooling of urine and retrograde infection: bacteria tracking back up urinary tract)
-Dilated kidney / ureters / bladder
-Pain

4

Presentation of acute urinary retention ?

Pt is uncomfortable, unable to pass urine, tender + distended bladder.

5

Investigations for acute urinary retention + what could they potentially show ?

-USS bladder - post void residual urine (<50ml is normal, <100ml is acceptable), hydronephrosis, structural abnormalities
-Urinalysis - infection, haematuria, proteinuria, glucosuria
-MSU - infection
-Blood tests: FBC, U+E, Cr, eGFR, PSA (n.b. this is elevated in the context of AUR so not great)
-Hunting for cause/depending on history
-CT abdo pelvis - looking for mass causing bladder neck compression
-MRI spine - disc prolapse, cauda equina, spinal cord compression MS

6

Management of acute urinary retention ?

Immediate and complete bladder decompression with catheter.

Men should be offered an alpha blocker prior to removal

7

What is the most common type of kidney cancer + how is it staged ?

Renal cell carcinoma.

The TNM system.

8

What are “Cannon ball metastases” and how are they relevant to the kidneys ?

Cannonball metastases is a description given to a select type of lung metastases in which multiple large masses are evident.

Renal cell carcinoma is by far the commonest cause - This is a common exam question.

9

Presentation of kidney cancer ?

-Often asymptomatic
-Haematuria
-Vague loin pain
-Non-specific symptoms of cancer (e.g. weight loss, fatigue, anorexia, night sweats)

10

Types of renal cell carcinoma ?

-Clear cell (75-90%)
-Papillary (10%)
-Chromophobe (5%)
-Collecting duct carcinoma (1%)
-Children: Wilms Tumour (in children < 5 years old)

11

RF's for kidney cancer ?

-Smoking
-Obesity
-Hypertension
-Long-term dialysis
-Von Hippel-Lindau Disease

12

Management of kidney cancer ?

-Surgery (partial nephrectomy first line) / - radiotherapy and chemotherapy depending on disease stage.

13

Paraneoplastic features of RCCs ?

-Polycythaemia (RCC secretes unregulated erythropoietin)
-Hypercalcaemia (RCC secretes a hormone that mimics the action of PTH)
-Stauffer Syndrome (abnormal liver function tests demonstrating an obstructive jaundice – without any localised liver or biliary me

14

Types of bladder cancer ?

-90% transitional cell carcinoma
-10 % squamous cell carcinomas
-Rarer causes are adenocarcinoma, sarcoma, small cell.

15

RF's for bladder cancer ?

-Smoking (50%)
-Key workplace carcinogens - Carcinogens include aromatic amines, polycyclic aromatic hydrocarbons, arsenic and tetrachloroethylene. These are found in hair dyes, industrial paint, rubber, motor, leather, and rubber workers, blacksmiths etc.
-Age, 70% > 65
-Pelvic radiation (prostate Ca)
-Men > Women
-HNPCC for upper tract urothelial cancers
-Chronic inflammation, schistosoma infection and indwelling cancers - squamous cell carcinoma

16

Presentation of bladder cancer ?

-PAINLESS HAEMATUIRA(frank or microscopic)
-Dysuria
-Abdominal mass
-RFs
-Systemic weight loss + bone pain

17

How is bladder cancer staged ?

TNM system

18

Bladder cancer note:

The majority are superficial (not invading the muscle) at presentation

19

Bladder cancer note

STAGE:

Tis - in situ ‘flat tumour’ worst prognosis

Ta - non-invasive papillary carcinoma

T1 - tumour invades subepithelial connective tissue (lamina propria):
-Not felt

T2 - tumour invades superficial muscle (detrusor or muscularis propria):
-Rubbery thickening

T3 - tumour invades perivesical tissue:
-Mobile mass

T4 - tumour beyond bladder: prostate, uterus, vagina, pelvic/abdo wall:
-Fixed mass

SPREAD:

Lymphatic: Pelvic

Haematogenous: Liver and lungs

20

Bladder cancer gold standard investigation + other investigations ?

Flexible cystoscopy with biopsy TURBT.

Other investigations:

-Urine dip - Haematuria (80% of patients) ± pyuria
-Urine MC + S - cancers may cause sterile pyuria
-KUB USS
-Bimanual EUA for staging
-CT urogram with contrast - in excretory phase shows bladder tumour, upper urinary tract tumour
or obstruction
-Urinary cytology - abnormal cells
-FBC - mild anaemia
-CXR, isotope bone scan, alkaline phosphatase etc…..

21

Treatment of bladder cancer ?

Not invading the muscle:
-Transurethral Resection of a Bladder Tumour (TURBT)
-Chemo into bladder after surgery (use barrier contraception afterwards)
-Weekly treatments for 6 weeks with BCG vaccine squirted into the bladder via catheter, then every six months for 3 years.

Muscle-invasive bladder cancer:
-Radical cystectomy with ileal conduit
-Radiotherapy (as neoadjuvant, primary treatment or palliative)
-IV chemotherapy as neoadjuvant or palliative

22

Presentation of BPH ?

Storage symptoms:
-FUN - frequency, urgency, nocturia

Voiding symptoms:
-HIIPP - hesitancy, intermittent/incomplete emptying, poor flow/post-void dribbling

23

Investigations for BPH ?

TRIAD:
-DRE
-TRUSS ± biopsy
-PSA - increased may indicate prostate cancer or prostatitis

Other investigations:

Urinalysis - MSU/urine dip to rule out pyuria and complicated UTI

Scoring system -IPSS - International Prostate Symptom Score (0-35) also includes quality of life
Mild = 0-7, Mod = 8-19, Severe = 20+

-Volume chart

-USS KUB - To rule out hydronephrosis, urolithiasis, mass

24

Management of BPH ?

Treatment depends on severity and impact on life:

For all = behavioural management:
-Avoid caffeine, alcohol (decrease storage problems), void twice in row, bladder training, limit fluids

Mild (no bother):
-Watch and wait

Mild (bother):
-FIRST LINE: Alpha blocker (tamsulosin or doxazosin) or 5-alpha reductase (finasteride) or NSAID (preferably a COX-2 inhibitor e.g. celecoxib)

Mod/severe - as above, first line drug + behavioural management

Abnormal DRE or elevated PSA:
-Surgical referral
-Prostate < 80g - TURP, TUVP (transurethral resection/vaporisation) or HoLEP (Holmium laser enucleation of the prostate )
-Prostate > 80g - Open prostatectomy

25

Complications of TURP ?

Bleeding
Infection
Incontinence
Retrograde ejaculation (semen goes backwards and is not produced from the urethra during ejaculation)
Urethral strictures
Failure to resolve symptoms
Erectile dysfunction

26

How do alpha blockers work in relation to BPH ?

Smooth muscle relaxation in prostate and bladder neck.

27

How do 5-alpha reductase inhibitors work ?

They reduce the conversion of testosterone into dihydrotestosterone

28

Presentation of prostate cancer ?

->50M
-LUTS
-Haematuria
-Weight loss/anorexia/lethargy (advanced metastatic)
-Bone pain (advanced metastatic)
-Palpable LNs (advanced metastatic)

29

How does a benign vs a cancerous prostate feel during a DRE ?

-A benign prostate feels smooth, symmetrical and slightly soft with a maintained central sulcus

-A cancerous prostate may feel firm/hard, asymmetrical, craggy or irregular with loss of the central sulcus

30

PSA note in relation to prostate cancer:

-Traditionally done prior to DRE to avoid stimulating release of PSA

-Not very sensitive or specific (positive and negative results are unreliable)

-Most useful in monitoring the progression of the disease and success of treatment