You are on page 1of 10

Optimal management of <2 cm radio-opaque kidney stone is: ESWL (Extracorporeal shock wave

lithotripsy) if radiolucent stone: dissolution therapy

Optimal management of 1 cm upper ureter stone is ESWL

3 cm stone in the kidney: PCNL not ESWL

Magnesium ammonium phosphate is usually associated with infection by: Proteus

Optimal management of 1.5 or 2 cm radiolucent kidney (pelvic) stone is: Medical treatment

It is NOT diagnosed by: KUB

Contraindications for ESWL, include all of the following (Coagulopathy, distal obstruction, pregnancy)
except (Renal impairment)

The most diagnostic radiological investigation for posterior urethral valve (vesico-ureteric reflux) is:
VCUG (voiding cystourethrogram)

Treatment of PUJO (pelviuretral junction obstruction): Pyeloplasty

Cobra head sign: Uretrocele

Adult polycystic kidney is: Autosomal dominant bilateral

Infantile polycystic kidney is: Autosomal recessive

Horse shoe kidney is lower in position due to: Inferior mesenteric artery

All of the following types (Cystiene, calcium oxalate, struvite) of renal calculi are radio-opaque except:
Uric acid (purely radio-lucent)

All of the following (Low purine diet, alkalinization of urine, allopurinol) are used for treatment of uric
acid stones [Hyperuricosuria] except: Calcium channel blockers

All of the following are predisposing factors of urolithiasis (Supersaturation of urine with poorly soluble
salts, deficiency of inhibitors of crystallization, stenosis of urinary tract) except: Smoking

Risk factors of bladder cancer: Cigarette smoking, industrial carcinogens (aniline dye) and bilharziasis

Anti-TB drugs: Rifampicin, INH, Pyrazinamide

All of the following (Alpha blockers, 5-alpha reductase inhibitor, phytotherapy) are used as medical
treatment except: Calcium channel blockers or anti-depressant

Irritative symptoms of BPH include: All (Urgency, Frequency of urination, Nocturia)

Not a surgical treatment option in BPH: Urethrotomy: (Millins prostatectomy, TURB, LASER ablation)

Initial treatment for a male presenting with chronic retention and uremia due to BPH is (Fixtion of
catheter) not (Medical, dialysis or TURB)

Treatment of superficial bladder cancer (T1) is: Transurethral resection (TURT) + BCG + Follow up
cystoscopy

Used for treatment of cancer bladder (Weekly instillation intravesical) is: BCG

T2 bladder cancer is best treated by: Radical cystectomy

Definitive treatment of T1 RCC is: Radical nephrectomy with lymphadenectomy

Main investigation for urethral trauma is: Ascending urethrogram

Method of choice for diagnosis of renal trauma is: CT with contrast

Best investigation for testicular torsion: Doppler U/S

First pathophysiologic change with infravesical obstruction: Detrusor hypertrophy

Supradiaphragmatic IVC thrombus of RCC is: T3C

All are risk factors in bladder cancer except: DM

Causes of erectile dysfunction are all except: bilateral varicocele

Best treatment of urothelial tumors: Nephroureterectomy with excision of a bladder cuff

Most common type of bladder cancer: Transitional cell carcinoma (TCC) (followed by squamous,
adenocarcinoma) but not choriocarcinoma

Most common microscopic picture in prostate cancer is: adenocarcinoma

Hormone dependent cancer: Prostate cancer

Most common cause of obstructive uropathy (leading to end stage renal failure or unilateral
hydronephrosis) in boys: posterior urethral valve (complications: repeated UTI, renal scarring and
impairment, HTN): treated by valve excision

Signs of prostate cancer: asymmetry, hard nodule, extra-prostatic extension

Types of hypospadias: penile, scrotal, perineal but not suprapubic

The urachus involutes to become: median umbilical ligament

Patient with bleeding per urethra/Rupture urethra, the best diagnostic modality is: Retrograde
urethrogram/Ascending urethrogram: signs: bleeding inability to urinate palpable full bladder high
riding prostate butterfly peritoneal hematoma

Treatment of metastatic prostate cancer: Hormonal therapy

Most common presentation of RCC: Asymptomatic

Most common presentation of TCC: haematuria

Differentiate between renal cyst & tumor: U/S

Split renal function: radio-isotope renogram

Bilateral ureteric stones: anuria (less than 100 cc/24 hours) Double J-stent or PCN (percutaneous
nephrostomy tube)

Define:

Erectile

Persistent inability to attain and/or maintain an erection sufficient to permit satisfactory

dysfunction

sexual intercourse

Urgency

Sudden, compelling urge to void which is difficult to defer

Hydronephrosis

Chronic aseptic progressive dilatation of the pelvicalyceal system with 2ry ischemic

atrophy of renal parenchyma due to partial or intermittent complete obstruction

Criteria of horse shoe kidney:


o Lower position due to inferior mesenteric artery (L3)
o Longitudinal axis is directed downward and medially
o Malrotation
o Lower pole is connected by an isthmus
o Ureter is anterior to the isthmus

DD of filling defect in renal pelvis: Stone, Tumor, sloughed papillae, blood clot, fungal ball not calcium
phosphate stone

3 differences between anuria and acute urine retention


Acute urine retention

Anuria

Urine passes by catheterization

Urine doesnt pass

Good general condition

Bad general condition

Full bladder

Empty bladder

Pathological lesions of bilharzial cystitis: Cystitis glandularis, cystitis cystica, sandy patches

Values
o Maximum flow rate in normal adult: > 20 ml/sec (less than 10 ml/sec in case of obstruction)
o Normal: Blood urea: 20-40 mg/dl
o Serum uric acid (<7 mg/dl): male 3-7, female 2-6
o Creatinine: 0.5-1.5 mg/dl
o PSA = 0-4 ng/ml (more than 4 in prostate cancer)

Spots

Jars: kidney, bladder, prostate, testis

Hydronephrosis

Renal parenchymal tumor (RCC): most common pathologic type: clear cell carcinoma adenocarcinoma
hypernephroma Griphth tumor most common malignancy in kidney is metastasis most common
primary malignancy is RCC most common presentation = asymptomatic IVC tumor thrombus (not
hematogenous spread) Paraneoplastic syndrome 2ry Varicocele - Stauffer syndrome (non-neoplastic
hepatic dysfunction due to released cytokines AST, ALT abnormality diagnosis improved by radical
cystectomy: if not improved: either not removed completely or metastatic if improved and raised again =
recurrence) radical nephrectomy

Paraneoplastic syndrome in RCC: definition pathology of RCC: proximal convoluted tubule clear cell
adenocarcinoma ectopic erythropoietin (polycythemia) + hypercalcemia + stauffers syndrome

Urothelial tumor: nephroureterectomy with excision of bladder cuff

Bladder tumor: papillary tumor growth Radical cystectomy + urinary diversion muscle invasive

Prostate: open prostatectomy

Testis: testicular tumor (seminoma is most common) inguinal orchiectomy tumor marker of seminoma:
no specific seminoma HCG = choriocarcinoma yolk sac tumor of the testis: AFP

KUB: Count from downwards (L5 from sacrum) most common site for prostate metastasis is lumbar
vertebra (valvless venous connections) osteoblastic metastasis

Calcified bladder wall: bilharzial

KUB: Radio-opaque shadow in pelvis: bladder stone Lower 1/3 ureter stone

U/S prostate + stone: treat both together (not medical treatment)

Treatment:
o Wait and see: small stone + water + analgesic + antispasmodic
o Specific medical treatment: uric acid: alkalinization of urine dissolution therapy
o Intervention:

Non-invasive: ESWL (no bleeding tendency infection obstruction below stone pregnant
radiolucent) 0.5-2 cm

Minimally invasive: PCNL ureteroscopy cystoscopy impacted ureteral stone = acute urine
retention urethroscopy

Invasive: nephrotomy (nephrolythotomy) pyelolythotomy -

Contrast: nausea vomiting allergic reaction (itching-skin rash) renal failure (RFT must be done
before) cardiac decompensation DM (metformin stopped to prevent lactic acidosis)

Horse shoe kidney

Ectopic pelvic kidney

Hydronephrosis: search for the reason (not a diagnosis)

Crossed fused ectopia

Duplex system

Cobra head sign: uretrocele treated by incision

IVU: basal smooth regular filling defect: BPH BPH + Balloon of folley

3 signs: basal smooth (sun rise appearance) cellule (diverticulum) Fish hook sign

IVU cystogram: irregular filling defect in bladder wall: cancer bladder (if hydronephrosis = muscle
invasive)

IVU pelvi calyceal system - * Radiolucent upper 1/3 ureter IUD/Zipper

Mass effect/spider leg appearance: RCC

Descending studies via nephrostomy tube (lower 1/3 ureteric stricture)

Ascending studies

Ascending urethrogram: urethral stricture (bulbar) urethroplasty EVU (endovisual-urethrotomy)

Rupture bladder (extraperitoneal)

VCUG: best in posterior urethral valve (hydronephrosis if neglected + dilated posterior urethra key hole
sign) incontinence

U/S image of posterior urethral valve includes any of the following except: polyhydramnios

Which is not true about obstructive anuria: bladder is always full

Oliguria less than 400 CC/24 hours

Management of obstructive anuria:


o Definition: Urine output less than 100 CC/24 hours due to resistance of urine flow through the
urinary tract leading to obstructive uropathy (renal failure)
o DD: Bilateral stone or stone on solitary kidney or only functional kidney longstanding neglected PPH
Most common congenital cause: Posterior urethral valve
o Diagnosis
o Treatment: Stone: PCN & Double-J stent PPH: catheter then TURT PUV: catheter then vasicotomy
then fulguration

Most common organism in 1ry UTI: E. coli

Sudden severe pain in left testis: next step is: Exploration

Female patient: total painless hematuria: bladder mass: cystoscopy and biopsy (TURB)

35 year old, RTA, painless hematuria, suprapubic ecchymosis: ascending cystogram: extravasation of
contrast into the surrounding cavity: most proper management: surgical exploration

Male 22 years, falling from the 2nd floor, normal vital signs, on examination bleeding per urethra: rupture
urethra: next step: ascending urethrogram

65 year old male patient PSA = 150, multiple bone metastasis, definitive treatment: hormonal treatment

Most common cause of bilateral hydrouretronephrosis in a small boy: posterior urethral valve

Site of prostate cancer: peripheral zone - BPH: transition zone

DD of hard nodule in the prostate: cancer prostate infarction TB prostate

Prognostic factors of superficial bladder cancer except: site

Markers of testicular tumors include all except: PSA

Cancer prostate is definitively diagnosed by: TRUS biopsy

Critically ill patient with infected hydronephrosis over an impacted ureteric stone: PCN to drain

Treatment of symptomatic stone in pregnancy includes all except: ESWL

Most common complication of ESWL: ureteric obstruction with fragmented stones

Ureteric tumor of upper ureter is treated by: nephroureterectomy with excision of bladder cuff

All are manifestations of paraneoplastic syndrome of RCC except: hypercalcemia

Acid-base imbalance in uretrosigmoidostomy: hyperchloremic metabolic acidosis

Short essay questions:

Discuss the management of superficial bladder tumor: TURT Follow up BCG

Illustrate the management of prostate cancer:


o Very early
o Very late
o In between

Enumerate causes of hydronephrosis (write the definition first): impacted stone reflux BPH Tumor
occluding the ureteric orifice ureteral stricture posterior urethral valve

Stones

Etiology of urinary stones:


o Super-saturation: increased salts or decreased hydration
o Deficiency of inhibitors of crystallization: most important: Citrate
o Stasis along the urinary tract: PBH + chronic retention Ureteric stricture
o Infection: E. coli Struvite stone Magnesium ammonium sulphate stone (Proteus secretes urease
ammonia alkalinization of urine)

Composition of urinary stone:


o Calcium stones: esp. calcium oxalate: most common (80-85%)
o Uric acid: most common radiolucent stone (20-25%)
o Triple phosphate (Struvite stone)
o Cysteine stone: faintly radio-opaque

Metabolic abnormalities leading to stone formation:


o Absorbtive hypercalcuria renal/Excretory hypercalcuria resorption
o Renal tubular acidosis
o Hyperoxaluria
o Hyperuricosuria: hyperuricemia: gout chronic dehydration high urinary acidity
o Hypocitraturia: Decreased citrate level in urine

Complications of urinary stones


o Renal colic
o Predisposition for infection
o Stasis due to obstruction
o Infection + obstruction = sepsis

o Deterioration of renal function: bilateral solitary solitary functioning


o Calculus anuria: obstructive uropathy

Management of staghorn stone 2 cm upper ureteric stone


o Clinical picture: emergency non emergency: e.g. upper ureteric stone: could be seen with renal colic
only obstructive uropathy + obstructive anuria - hematuria
o Investigations

Lab: Urine analysis: hematuria pyuria crystalluria blood urea and creatinine

Radiology: KUB U/S CT

o Treatment:

Emergency: renal colic (reassurance + analgesia) obstructive anuria (PCN Double J-stent)

Preventive: instruct the patient to drink much water

Definitive:
Watchful waiting: 2-3 ml stone
Specific medical treatment: dissolution therapy in uric acid stone less than 1.5 cm
Intervention
Non-invasive (ESWL): contraindications: Bleeding tendency infection larger than 2.5 cm
pregnancy distal obstruction radiolecent stone
Minimally invasive (Endoscope): kidney (nephroscope PCNL [could be used in staghorn on
multiple sessions]) (ureteroscopy) (Cystoscopy)
Invasive: open surgery [staghorn]: nephrolythotomy pyelolithotomy ureterolithotomy
cystolithotomy

Tumors

Cancer bladder: total painless hematuria/Urgency/Dysuria irregular filling defect in IVU U/S mass
CT cystoscopy & biopsy TURT TCC most commonly: staging treatment: TURT, follow up (every 3
months for 2 years, 6 months for 2 years, 1/year for life) BCG (decreased risk of recurrence in 40-60%)
immunomodulatory intravesical injection once per week for 6 weeks most common side effect =
dysuria

Management of T2, T3a (muscle invasive tumor) Radical cystectomy [bladder + perivesical fat + end of
ureter + bladder + pelvic lymphadenectomy + prostate, seminal vesicle + end of vas or all internal female
genitalia] with urinary diversion [ureterocolic anastomosis 3 complications: ascending infection, cancer
colon, hyperchloremic metabolic acidosis Rectal bladder Iliac conduit]

Prostate:

Pathophysiology of BPH obstruction:


o Static component: presence of the mass itself causing obstruction

o Dynamic component: the smooth muscles found in the stroma and capsule of prostate sympathetic
tone alpha 1a receptors (target of alpha blockers line of treatment)

Discuss lower urinary tract symptoms (LUTS)


o Irritative symptoms: dysuria (pain during micturition) frequency (decreased interval between voiding)
nocturia (frequency at night) urgency: sudden compelling desire to void which is difficult to defer
o Obstructive symptoms: BPH acute urine retention Hesitancy (delayed in the start of the act of
micturition) changes in the character of the stream (bifurcation, trifurcation, weak stream Qmax <10
mL/sec) prolonged post-void dribbling

Management of BPH:
o Complaint: lower urinary tract symptoms
o Lab: increased PSA > 4 ng/mL
o Ascending cystogram: basal regular smooth filling defect
o U/S: size of prostate
o Treatment:

1st line = medical treatment: alpha blockers (non-specific: alfuzosin: postural hypotension retrograde
ejaculation) 5 alpha reductase inhibitors (finasteride inhibit change of testosterone into
dihydrotestosterone) phytotherapy

Intervention: TURB open prostatectomy (Millins prostatectomy)

o Complications of BPH: acute retention stasis = infection stone hematuria chronic retention
backpressure hydroureteronephrosis obstructive uropathy Treatment: catheter then treat BPH

Cancer prostate:
o DRE: hard nodule rough irregular surface extra prostatic extension
o Screening: > 50 years or >40 if +ve family history: yearly digital rectal examination + PSA (increased in
cancer prostate, Huge BPH, prostatitis, trauma affecting prostate Screening) TRUS biopsy if doubtful
PSA level follow up of patient
o Treatment of cancer prostate:

Very early: radical prostatectomy (Prostate, seminal vesicles, end of vas, pelvic lymphadenectomy
complicated by impotance & incontinence) active surveillance (DRE-PSA elevated surgery)

Very late: watchful waiting symptomatic treatment (pain killers,

In between: hormonal treatment [castration: medical: anti-androgen: clomiphene citrate or surgical:


bilateral orchiectomy] + radiotherapy & chemotherapy

Give short account on angio-myolipoma: it is a renal tumor (hamurtoma) angioma myoma lipoma: can
rupture spontaneously diagnosis (CT) treatment (angio-embolization - follow up exploration up to
nephrectomy)

RCC: clear cell adenocarcinoma: most common presentation: asymptomatic (radiologic tumor) triad
(late): most common site of metastasis = canon ball metastasis of the lung surgical tumor (chemoresistant
and radioresistant): total/partial nephrectomy interferon/IL immunotherapy

TCC: hematuria: nephruretrectomy with excision of bladder cuff

Wilms tumor: most common solid abdominal mass pediatric tumor age 3-5 nephrogenic crest
(triphasic) radio/chemo-affected chemo + radio cytoreduction then remove

Diagnosis of testicular tumor: clinically (hard painless testicular swelling) Tumor markers (AFP, B-HCG)

Congenital anomalies: 3 year female with recurrent attacks of febrile UTI: Pelviureteric junction
obstruction vesicouretral reflux leading to pyelonephritis (order VCUG)

Renal pelvis stone: PCNL ESWL pyelolithotomy

PUJO: endopyelotomy urethroplasty (no relation with laparoscopy)

No catheterization for a patient bleeding per urethra (ascending ureterogram 1st)

59 year old male: CT abdomen and pelvis with IV contrast: showing left renal mass: 1st check the presence
of the mass then assess site, size, extension, effect of contrast staging [inside kidney T1 (<7 cm), T2
(>7cm) radical nephrectomy Outside T3-T4)

Cystoscopy and biopsy is the best diagnostic modality of bladder cancer


o T1: doesnt invade muscle Complete transurethral resection of the tumor intravescical instillation of
chemo- immunotherapy follow up cystoscopy
o T2 invade muscle layer

60 year old male: acute urine retention, PSA = 2 ng/mL, U/S = enlarged prostate catheterization then?
BPH medical treatment (alpha blockers, 5-alpha reductase inhibitors phytotherapy) if failed = TURP
then millins open prostatectomy

If malignant tumor: radical prostatectomy: removal of prostate + capsule

DRE: PSA TRUB are needed to diagnose

37 female patient presenting with involuntary urine leakage per urethra post hysterectomy: vesicovaginal,
urethrovaginal fistulae

3 lines of treatment of ED
o Medical: PDE-5 inhibitors
o Intracorporial vasoactive agent injection
o Penile implants or penile prosthesis

Child, left testicular pain: examination, swelling, transverse lie of the testis Doppler: no vascularity of
left side exploration detorsion orchiectomy with prophylactic orchiopexy

Lower 1/3 ureteric stone 1 cm radio-opaque: ureteroscopy

Upper 1/3: ESWL

1.5 radio-opaque: pelvis: ESWL

2.5 cm radio-opaque bladder stone: cystoscopy and lithotripsy

50 year male, RTA, left loin pain, ecchymosis of left iliac fossa, mild hematuria, vitally stable: CT with IV
contrast: normal kidneys conservative treatment 5 days: low grade fever, persistent mild hematuria
Ureteric injury retrograde urethrogram (ascending study) contrast between bowel loops + empty
bladder extraperitoneal bladder tear surgical exploration

You might also like