Urology Flashcards

Question

Germ cell tumours (**Seminomas**)

Answer 1

Most common type of testicular tumour (\>95%) - peak incidence **40-60** years - Highly responsive to radiotherapy - Metastasize late - Excellent prognosis - Homogeneous macroscopic appearance, clear cytoplasm with central nuclei - **5-10**% secrete **b-HCG** --\> _gynecomastia_

Answer 2

Embryonal carcinoma Yolk sac carcinoma Choriocarcinoma Teratoma Mixed germ cell tumours

Answer 3

1 - Embryonal carcinoma - Immature, primitive cells producing glands - Forms a haemorrhagic mass with necrosis - Aggressive with early haematogenous spread - Chemo may \>\> differentiation into another type of GC tumour (e.g. teratoma) - Increased AFP or B-HCG

Answer 4

2 - Yolk sac (endodermal) - Malignant tumour resembling yolk sac elements - Most common test tumour in children - Schiller-Duval bodies (glomerulus-like) on histology - Elevated AFP

Answer 5

3 - Choriocarcinoma - Malignant tumour of syncytiotrophoblasts & cytotrophoblasts - Early haematogenous spread - Elevated B-HCG --\> hyperthyroidism or gynaecomastia - alpha subunit of hCG similar to FSH, LH & TSH

Answer 6

4 - Teratoma - Tumour composed of mature fetal tissue from 2 or 3 embryonic layers - Malignant in males (benign in females) - AFP or b-HCGmay be increased

Answer 7

5 - Mixed germ cell tumours - Germ cell tumours usually mixed - Prognosis based on the worst component

Answer 8

Usually benign Resemble sex cord-stromal tissues of the testicle Leydig cell tumour - Produces androgen \> precocious puberty in kids, a gynecomastia in adults - Reinke crystals on histology Sertoli cell tumour - Comprised of tubules - Usually clinically silent

Answer 9

Acute inflammation of the prostate, usually bacterial - Chlamydia trachomatis & Neisseria gonorrhoeae (young adults) - E. coli & pseudomonas (older adults) PC - Dysuria with fever & chills - Tender prostate and boggy on DRE - Prostatic secretion - WCC, cultures positive

Answer 10

Chronic inflammation of prostate PC - Dysuria with pelvic or low back pain - Prostatic secretions - WCC, but cultures negative

Answer 11

Hyperplasia of prostatic stroma & glands Age-related change (most men by 60 yoa) - No increased risk for cancer Related to dihydrotestosterone (DHT) - Testosterone converted to DHT by 5α-reductase (stromal cells) - DHT acts on the androgen treceptor of stromal & epithelial cells -\> hyperplastic nodules Occurs in the central periurethral zone of the prostate PC - Problems starting & stopping urine stream - Impaired bladder emptying \> ^risk of infection & hydronephrosis - Dribbling - Hypertrophy of bladder wall smooth muscle -\> ^risk for bladder diverticulae - Microscopic haematuria may be present - PSA slightly elevated (usually less than 10 ng/mL) (increased number of glands)

Answer 12

A proteolytic enzyme produced specifically by prostatic glands * Liquefies the ejaculate * Large amounts secreted into the semen, small amounts into the bloodstream * \>10 ng/mL - a significantly raised PSA Elevated in * Prostate Ca (a small proportion of tumours fail to express PSA) * BPH * UTI * Urethral instrumentation (catheterisation) * Cystoscopy * UTI * Acute urinary retention DRE only affects the PSA by \<1 ng/mL & would not invalidate the result

Answer 13

α1-antagonists (doxazosin) relax smooth muslce - Also relaxes vascular smooth muscle -\> lower BP - Selective α1A-antagonists are used in normotensive pts to avoid α1B effects on blood vessels 5α-reductase inhibitor (finasteride) - Blocks conversion of testosterone to DHT - Takes months to produce results - Useful for male pattern baldness - SEs - gynaecomastia, sexual dysfunction

Answer 14

Malignant proliferation of prostatic glands RFs * Age * Race (african americans \> caucasians \> asians) * Diet high in saturated fats Usually clinically silent * Arises in the **peripheral, posterior** region of the prostate * Does not produce primary urinary symptoms early on * Normal PSA increases with age due to BPH - PSA \> 10 ng/mL highly worrisome at any age * Decreased % free-PSA suggestive of Ca (Ca makes bound PSA) * Prostatic biopsy to confirm the diagnosis * Small, invasive glands with prominent nuclei Gleason grading system - Histological assessment of prostate Ca - Correlates with prognosis * Accounts for the heterogeneous nature of the disease (grades the two predominant areas of a tumour) * From Gleason grade 1 (well differentiated) to 5 (poorly differentiated) - Leading to a sum score of 2-10 when the scores of the two areas are combined * Metastatic disease * Bone pain * Pathological fracture (^ ALKP) * Spinal cord compression * Median survival * Asymptomatic - 2-3 years * Symptomatic - 12 months * Malignant changes can happen in any prostatic tissue left behind after TURP

Answer 15

Based on the TNM system * Localised & advanced disease * T1 or T2 - localised - potentially curable * T3 - locally advanced, unlikely to be cured * T4 & metastatic - advanced disease TNM classification system combines * Examination * Histological * Imaging findings (MRI) 75% of adenocarcinomas are located in the **peripheral** zone & most (85%) are **multifocal**

Answer 16

1. **Active surveillance** 2. **Radical prostatectomy** 1. Short-term * Bleeding * PE 2. Long-term * 70% erectile dysfunction * 5% incontinence rate 3. Radical **radiotherapy** or brachytherapy 1. 6w of daily treatments - avoids operation for localised prostate Ca 2. Minimal complications, but bladder & bowel toxicity can occur 3. Neoadjuvant hormone therapy improves the results of RT

Answer 17

Locally advanced disease - Radical prostatectomy usually not indicated - Active monitoring in asymptomatic men - Good 5-year survival with palliative RT, often in comb with hormonal therapy Metastatic disease - Systemic palliative treatment - Hormonal Rx may prevent complications (SSC, pathological fractures)

Answer 18

Increased flow within an area of the kidney (hypervascular flush) is indicative of a renal tumour

Answer 19

To assess the overall function of a transplanted kidney - Important in the early identification & Mx of renal transplant complications

Answer 20

Vesicoureteric reflux - Can determine the presence or absence of vesicoureteric reflux Simple renal cysts - Appear as cold spots on the DTPA (no blood supply) Obstructive uropathy - DTPA renogram won't demonstrate drainage of the affected kidney

Answer 21

Pseudomonas - Usually indicative of a foreign body (mesh, suture) E.coli - Responsible for most UTIs in the community Staphylococcus saprophyticus - Esp in sexually active women Staphylococcus aureus - Most likely pathogen with recent surgeries on the urinary tract

Answer 22

Criteria - freely filtered across the glomerulus into Bowman's capsule - Neither reabsorbed, secreted nor metabolised by the cells of the nephron Inulin

Answer 23

Para-amino hippuric acid

Answer 24

Retrograde ejaculation - Semen flows back into the bladder TURP syndrome

Answer 25

TURP syndrome caused by a combination of dilutional hyponatraemia, fluid overload & glycine toxicity - fluid overload (and reflex bradycardia) - acutely unwell (confused with a reduced GCS) - hyponatraemia (Na \<120) - hyperkalaemia (K \> 6.0) - glycine toxicity - DIC

Answer 26

Hydrocoele * Painless * Difficult or impossible to feel the testis, which is surrounded by a fluid collection * Often chronic * Slowly increases in size over time Epidydimal cyst * Often felt distinct from the testis itself and often multiple * Consists of fluid accumulating within the **tunica vaginalis** 2nd to * A patent processus vaginalis in neonates (congenital) * Idiopathic in origin (primary) * Transilluminate \> a red glow with pen-torch Gumma * Rare & due to syphilis of the testis * Round, hard insensitive mass involving the testis Epididymo-orchitis * An inflammatory condition of the testicle & epididymis 2nd to infection * Viral (mumps) * Bacterial (UTI) * STI (*Chlamydia* or *gonorrhoea*) * Swollen & painful Hernia * An indirect hernia may extend into the scrotum \> discomfort * Difficult to palpate above Spermatocoele * Also called epididymal cyst * A fluid-filled cyst found within the epididymis * Clearly palpable with a swelling noted above & behind the affected testicle

Answer 27

Ascending urinary tract infection that has ascended to affect the kidney Severe cases can lead to - Pyonephritis - Urosepsis - Kidney failure

Answer 28

AFP & B-HCG elevated in ~ 50% & 40% of NSGCTs If elevated at first presentation - repeat 7 days post-orchidectomy - used to monitor response to treatment & recurrence

Answer 29

Testes not palpable in the scrotum are undescended * 2-3% incidence * At birth - 4% * 1 year - 1.3-1.8% * 8x fold risk of testicular cancer * Reduced fertility long-term * 5 categories * **Retractile** - *intermittently active cremasteric reflex results in a testis that retracts up & out of the scrotum* * **Ectopic** - abnormal migration of the testis below the external ring * I.e. Perineum, base of penis, femoral triangle * **Incompletely descended** * Intra-abdominal * Intra-inguinal * Pre-scrotal * **Atrophic** (absent) * **Acquired UDT**: testes that have previously descended RF * Family history * Twins * Pre-term infants * **Low** birthweight Location of ectopic testes (left their normal path) * Superficial inguinal pouch (most common) * Base of penis * Perineum * Femoral region Treatment - **orchidopexy** (fixing of the testes within the scrotum)

Answer 30

Hypercalcaemia * Most common PNS in RCC (~ 20%) * Secretion of PTH by the tumour \> increased bone resorption \> decreased renal clearance of calcium

Answer 31

A minimally-invasive procedure to remove stones from the kidney by a small puncture wound through the skin Treatment of choice for large-volume stones in the kidney * Should be considered for stones \> 20 mm * Safe procedure for stones in a transplanted kidney (but in specialised centers) * Safe in AAA Clotting abnormalities must be corrected

Answer 32

Indications * Intractable fluid overload (ITU) * Hyperkalaemia * Acidosis (\<7.1) * Ureamia (when medical therapy failed) Can be administered * To cover an acute crisis * In chronic setting Often an arteriovenous fistula is formed surgically to allow easy vascular access for haemodialysis

Answer 33

Haemofiltration * Patient's own BP drives the formation of an ultrafiltrate * Machinery less complex than in dialysis * Can continue for many hours * Good in acute setting (e.g. ITU) Haemodialysis * Better in the chronic setting in which the maintenance of a reasonable lifestyle of the patient is requisite & the process must be rapid/intermittent * Often an **arteriovenous fistula** is formed surgically to allow easy _vascular access_ for haemodialysis

Answer 34

Epididymitis * Most commonly caused by bacterial infection * \<35 - Chlamydia or N. gonorrhoea * Older - E. coli * Amiodarone (non-infectious) * Accumulates in high concentrations within the epididymis \> inflammation) * Can be unilateral or bilateral * Resolves on discontinuation of the drug * Rx with 2 weeks of ABx * Complications * Abscess formation * Infarction of the testis * Chronic pain & infection * Infertility

Answer 35

Histology * TCC - 90% * SCC - 5% * Rest - adenocarcinomas TCC of the bladder * A urothelial tumour * Urothelium lines the entire urinary tract * 95% affect the bladder * 5% affect the upper tract * 3:1 M:F PC - usually painless, but can present with cystitis or ureteric colic (if tumour obstructs ureteric flow) Treatment * Superficial tumours * TURBT with intra-vesical therapy (e.g. BCG vaccine, mitomycin) * Require frequent surveillance with cystoscopy * Muscle invasive tumours * Radical cystectomy

Answer 36

* Initial blood test markers * AFP * HCG * LDH * Ultrasound of the testes *to characterise the lump* * Staging CT *to assess the extent of cancer spread* (prior or after the surgery) * MDT discussion - *gold standard*

Answer 37

* Hydrocele * Epididymal cyst * Testicular malignancy * Indirect inguinal hernia * Hydrocele secondary to testicular tumour, injury, HF or obstruction of retroperitoneal lymphatics

Answer 38

By the **Jaboulay procedure** * Involves the excision & eversion of the hydrocoele sac **Lord's** procedure * Plication of the sac

Answer 39

* Rare * _Oncocytoma_ * _Angiomyolipomas_ * 20% of AMLs associated with * AD syndrome **tuberous sclerosis** * Mental retardation * Epilepsy * Adenoma sebaceum * Hamartoma

Answer 40

Specific gravity reflects _renal concentrating ability_ In humans * Normal specific gravity - 1.002 h/mL to 1.028 g/mL * Increased SG (^ concentration of solutes in urine) * Dehydration * Glucosuria * SIADH * Decreased SG (decreased concentration of solutes in urine) * Renal failure * Pyelonephritis * Diabetes insipidus * Acute tubular necrosis * Interstitial nephritis * Excessive fluid intake Paired osmolality is more commonly used to assess renal concentrating ability

Answer 41

Urinary sodium concentration less than 20 mmol/l * This suggests that renal tubular function is intact * If oliguria was due to acute tubular necrosis, we would expect the urine [Na] to be over 80 mmol/l * Due to leaching of Na from the tubules with a urine:plasma osmolality of 1:1

Answer 42

Definition * A prolonged, unwanted erection in the absence of sexual desire or stimulus lasting for \>4h * Commonly iatrogenic, occurring after the administration of intracavernosal agents used to treat erectile dysfunction * **Low flow (ischaemic)** * Most common form due to veno-occlusion * Ischaemic pripaism \> 4h - emergency intervention * **High flow (non-ischaemic)** * Due to unregulated arterial blood flow * PC: semi-rigid painless erection * Usually due to trauma * Recurrent * Most commonly seen in **sickle-cell** disease patients Associated conditions * Sickle-cell Management of priapism * **Low flow** (failure of detumescence mechanism) * Urgent decompression with aspiration of blood from the corpora * If no change after 10 min * Intracavernosal injection of alpha-1-adrenergic agonist every 5-10 min until detumescence occurs * Monitor BP and pulse during the administration * If this fails \> surgical intervention (caverno-spongiosal shunt) * **High flow** (uncontrolled arterial inflow) * Conservative treatment recommended in most cases * Traumatic or delayed presentation need * Arteriography * Embolisation * Ligation of fistula

Answer 43

The presence of myoglobin in the urine * Associated with * Rhabdomyolysis * Muscle destruction * Trauma * Electrical injuries & burns * Vascular problems * Excessive exercise * Venoms & certain drugs can damage the muscle \> releasing myoglobin into the circulation & the kidneys * Normally, myoglobin will be filtered by the kidneys, but if excessive amount is released, it can overwhelm the kidneys * Can cause **casts** to form (solid massess of myoglobin) * Can occlude the renal filtration system * \> **Acute tubular necrosis** and **AKI** * Patients with severe rhabdomyolysis (e.g. crush injury victims) should receive **high volumes of IV fluids** to _prevent cast formation_

Answer 44

The Royal Marsden hospital staging system Stage I * Tumour confined to testis Stage II * Abdominal node mets Stage III * Supradiaphragmatic nodal mets Stage IV * Extralymphatic mets

Answer 45

* T1 * **≤7cm**, limited to the kidney * T2 * **\>7cm,** limited to the kidney * T3a * Involve the **Renal Vein** * T3b * Involve the **IVC** **below** the diaphragm * T3c * Involve the **IVC above** the diaphragm

Answer 46

Kidney placed **extraperitoneally** in the right or left iliac fossa (usually **right** side – easier for access for biopsies & surgeries in the case of post op problems Renal vessels anastomosed (end to side) to the recipient’s **external iliac vessels** Ureter taken down into the pelvis – anastomosed to the bladder ureter * Extravesical approach (directly) * Intravesical approach (thread it through a submucosal tunnel & suture from inside the bladder through a separate incision in the bladder wall

Urology Flashcards

(71 cards)