Genito urinary Surgery

1. A 60 year old man has an enlarged right testis.

1) Describe the clinical features on which a testicular tumor is diagnosed in this (30
History Sudden enlargement, unilateral involvement, loss of testicular sensation, loss of
appetite wasting and dyspnoea (metastasis)
Examination-enlarged testes or a nodule. Surface is irregular, non tender, no temperature
change, heavy , firm to hard in consistency
Not flutuant. Enlarged abdominal lymph nodes. Gynaecomastia
2) Describe the pathological basis for the investigations necessary for diagnosis of
testicular tumour in this patient.(40)
96% are Germ cell tumors. Seminoma Choriocarcinoma are the commonest.
Seminoma- age 30 to 40 years. Common in un descended testes. Hard fleshy
homogenous tumor. Spread to para aortic LN, liver and lungs. Causes Feminization due to
hormones. Some tumors secret bHCG
Teratoma- age 20 to 30 years,Cystic, areas of haemorrhage and infarction. May contain
cartilage bone and muscle. Early spread via blood. aFP, bHCG, HPL and LDH is increased.
Investigations Scrotal USS, Tumor markers(aFP,bHCG). Abdominal USS( LN and Liver
mets), CXR, CT abdomen. NO FNAC as it causes seeding to skin
3) Outline the treatment of one type of testicular tumor in this man. (30)
Mx- Stage the disease
Surgery- Orchidectomy through inguinal incision to avoid exposure to scrotal
lymphatics.
Radio therapy- For seminona after surgery
Chemotherapy- For Teratoma
2. A 65 year old man has been admitted to a surgical ward with a history of passing
blood in the urine and haematuria has been confirmed on urine microscopy.
1) List three (3) likely causes for the haematuria in this patient, giving the
characteristic clinical features of each. (30 marks)

Urinary calculi Colicky pain, Stranguri and intermittent stream(Bladder)

UTI Dysuria, frequency, fever
Malignancies Bladder( painless intermittent terminal haematuria), Renal ( Ballotable mass
on examination associated with left sided varicoceles and supraclavicular
lymphadenopathy) , Urothelial ( can present as a colic)
Glomerulonephritis Painless whole stream haematuria, Reduced urine out put, Frothy urine,
hypertension
2) List the investigations and the characteristic features in each investigation that will help to
differentiate the. conditions listed in 2.1 (40 marks)

UFR + WBC (UTI), RBC casts (GN), RBC>>WBC ( stones) , protein (GN)
Xray KUB Stones
USS KUB Malignancies, Calculi +_ Hydronephrosis
FBC High WBC(UTI)
ESR high (GN)
IVU Calculi, Malignancies
CT- Calculi (non contrast CT), Tumors( Renal cell ca- variegated appearance, Oncocytma
cart wheel appearance)

3) Outline the treatment of one cause given in 2.1.(30 marks)

Bladder Ca
Diagnose and Stage the disease This is mainly by transurtral resection, No FNAC or open
biopsy.Resect the tumor first, then resect the tumor bed separately for staging purposes.
Palpate the bladder bimanually before and after resection.If still palpable its suggestive of
deep muscle involvement.
For further staging Chest xray, USS abdomen, CT abdomen

Definitive Treatment Superficial tumors- Transuretral resection it self is Curative. Follow up

with frequent USS
Tumors involving lamina popria Intravesical chemo, If CA insitu give
intravesical BCG
Muscle invasive Total cystectomy with Bladder reconstruction
1) Enumerate the ways of clinical presentation of renal cell carcinoma (30)
2) Explain the above clinical features on a pathological basis (30)
3) List the investigations necessary in a patient with suspected renal cell carcinoma indicating
the changes expected to be seen (40)

4. A 12 year old boy is admitted to casualty with pain and swelling of the left side of
his scrotum of 4 hours duration. He was playing football at the time of onset of
symptoms.
1) List 3 most likely diagnosis (15)
Torsion of testis
Epididymo orchitis
Scrotal haematoma
2) Describe the clinical features and investigation findings that would help
differentiate between those diagnosis listed in 2.1. (45
Torsion- Severe very sudden(over seconds) onset lower abdominal pain, Vomiting, past
history of similar less severe episodes, No significant LUTS, affected testis lie higher than
the affected side, very tender difficult to touch
Epididymo orchitis Less severe pain of sub acute onset (hours to days), Fever , associated
LUTS suggestive of UTI, Hx of urinary tract abnormality or Catheterization.
Scrotal pain is reduced by keeping the affected testis elevated.
Scrotal haematoma Over seconds to minutes, History of trauma to the testis. Swelling,
Bruising and haematoma formation
3) Outline the treatment of each condition listed above (40)
Torsion all the acute testis are due to torsion unless proven otherwise, Surgical
exploration as soon as possible. Untwist the cord, if the testis is viable fix the both testis
and close.If the testis is dead do orchidectomy and fix (orchidoplexy)the opposite testis.Get
consent for orchidectomy before surgery.
Postop- analgesics, Scrotal support, Antibiotics
Epididymo orchitis Give analgesics. Scrotal support to reduce pain( keep the scrotum
elevated).Do UFR and culture. Broad sprectum antibiotics. Investigate for underlying
anatomical defects
Scrotal Haematoma Conservative- If haematoma is small, No penetrative injury and no
testicular disruption.Do USS and Doppler to confirm. Bedrest, Scrotal support, NSAIDS,
Intermittent cold press to reduce swelling, Antibiotics if required.
Surgical Exploration- Remove dead tissue and repair. Drain haematoma
5. A 70 year old man presents to your general practice clinic with lower urinary tract
symptoms.
1) Describe clinical features on which you diagnose benign enlargement of the
prostate in this man (40)
History- Voiding symptoms-Hesitancy, Poor stream,Intermittent stream, Terminal
dribbling, Feeling of incomplete emptying.
Storage symptoms Frequency(>6/d), nocturia(1<), urgency and urge
incontinence
Slowly progressive symptoms, No recent onset sever backache or fractures on trival
trauma.
Examination Symmetrically enlarged prostate, median grove palpable, prostate firm
in consistency, surface is smooth, rectal mucosa is mobile over the prostate, no blood
on finger withdrawal , No neurological deficits on examination

2) List 3

other possible causes for his symptoms (10)

Prostatic Ca
UTI
Urethral strictures
Bladder neck hypertrophy
Diabetic neuropathy

3) Enumerate the complications of BPH and explain the pathophysiological basis of

these. (30)
Acute retention- Usually after a precipitating event( Stress, alcohol, anticholinergic drugs,
diuretics, post op)
Chronic retention-Painless retention of more than 300cc of urine after micturition. Initially
due to obstruction bladder muscle is hypertrophied to compensate for the increased
resistance. Later bladder muscle fails and residual urine occurs.
UTI Stasis due to incomplete emptying
Calculi Stasis and infection (work as a nidus)
Obstructive uropathy due to obstruction intravesicsl pressure is increased and transmitted
to the kidneys due to vesicoureteric reflux leading to hydronephrosis. Due to bacteuria
patient is predisposed to pyelonephritis.
4) State the indications for referral of this man to a specialist unit (20
Clinical findings suggestive of other pathologies (Ca, Stricture, Neurological
Severe symptoms not responding to drugs
Any of above complications
6. Write notes on
1) Prostate carcinoma-include Clinical features investigations and management
Clinical features
History
Symptoms identical to those benign enlargement(obstructive symptoms,irritative
symptoms and symptoms due to complications)
Symptoms from secondary deposits-pain in the back from involvement of vertebra.
Systemic features of malignancy like LOW,LOA,anaemia
Examination
Bimanual examination of the prostate reveals hard mass in the prostate,loss of normal
sulcus between 2 lateral lobes, ,features of infiltration of surrounding tissues including
rectal mucosa being attached to the mass
And systemic effects and features of metastatic disease

Ix-For diagnosis and staging

PSA- if >4nmol/l do transrectal biopsy.if >10 do bone scan
Renal Functions
X ray Chest, abdomen and Pelvis for osteosclerotic mets.
LFT- mets
CT abdomen- staging
Bone scan- staging
Ix For Medical fitness

Management
Stages- T1 & T2- Early, asymotomatic , Curable
T3 & T4- late, symptomatic, Not Curable
Tx- depends on stage and age
Early- 1. Watchful waiting- T1 disease with elderly(>70) and / or Unfit.Do reguller PSA
and PR. OR

Late

2. Radical prostatectomy- Improves survival. Cause erectile disfunction and

incontnance
OR
3.External beam radiotherapy and Brachytherapy- Similar outcome as
prostatectomy
Non metastatic
1. Hormonal therapy- Only slow the progress. Dont cure. Can combine with
radiotherapy,
GnRH analogs- Given as a Depot 3 monthly. Cause impotence,
loss of libido
Anti androgens- eg; Cryptoterone acetate
SI- breast enlargement
Metastatic
70% die within 5 years
1. Bilateral orchedectomy + or 2. Hormonal therapy
Follow up
PSA come to zero after radical prostatectomy. Should be followed up with regular
PSA and PR.If PSA is risen do bone scan.