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Optimal management of 1.5 or 2 cm radiolucent kidney (pelvic) stone is: Medical treatment
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)
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
All of the following (Alpha blockers, 5-alpha reductase inhibitor, phytotherapy) are used as medical
treatment except: Calcium channel blockers or anti-depressant
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
Most common type of bladder cancer: Transitional cell carcinoma (TCC) (followed by squamous,
adenocarcinoma) but not choriocarcinoma
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
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
Bilateral ureteric stones: anuria (less than 100 cc/24 hours) Double J-stent or PCN (percutaneous
nephrostomy tube)
Define:
Erectile
dysfunction
sexual intercourse
Urgency
Hydronephrosis
Chronic aseptic progressive dilatation of the pelvicalyceal system with 2ry ischemic
DD of filling defect in renal pelvis: Stone, Tumor, sloughed papillae, blood clot, fungal ball not calcium
phosphate stone
Anuria
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
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
Bladder tumor: papillary tumor growth Radical cystectomy + urinary diversion muscle invasive
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
KUB: Radio-opaque shadow in pelvis: bladder stone Lower 1/3 ureter stone
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
Contrast: nausea vomiting allergic reaction (itching-skin rash) renal failure (RFT must be done
before) cardiac decompensation DM (metformin stopped to prevent lactic acidosis)
Duplex system
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)
Ascending studies
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
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
Critically ill patient with infected hydronephrosis over an impacted ureteric stone: PCN to drain
Ureteric tumor of upper ureter is treated by: nephroureterectomy with excision of bladder cuff
Enumerate causes of hydronephrosis (write the definition first): impacted stone reflux BPH Tumor
occluding the ureteric orifice ureteral stricture posterior urethral valve
Stones
Lab: Urine analysis: hematuria pyuria crystalluria blood urea and creatinine
o Treatment:
Emergency: renal colic (reassurance + analgesia) obstructive anuria (PCN Double J-stent)
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:
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)
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
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)
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
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)
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)
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
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
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