UROLOGY

BPH
Assessment and management of benign prostatic hyperthrophy (Nov 2005:S)
a. Definition – is a histologic diagnosis characterized by proliferation of the cellular elements
of the prostate. Cellular accumulation and gland enlargement may result from epithelial
and stromal proliferation, impaired preprogrammed cell death (apoptosis) or both
b. Assessment
i. Urinalysis
ii. Urine culture
iii. Prostate-Specific Antigen
iv. Electrolytes, BUN and Creatinine
v. Ultrasonography – abdominal, renal, transrectal
vi. Flexible cystoscopy
vii. Biopsy
c. Management
i. Watchful waiting – Mild (IPSS score <7)
ii. Medical treatment – Alpha-blocker, 5-alpha-reductase inhibitors
iii. Surgery
 TURP (Transurethral Resection of the Prostate)
 TUIP (Transurethral Inicision of the Prostate)
 LASER
 TUMT (Transurethral Microwave Therapy)
 TUNA (Transurethral Needle Ablation of the Prostate)
 Prostatic Stent

Medical management of Benign Prostatic Hyperplasia. (2007, NOTES)

α-1 blocker only

o selective: tamsulosisn, alfazocin

o non-selective: doxazocin,, terazocin

o advantages: fast relieve of symptoms

o works in bladder and prostate smooth muscle

o may cause postural hypotension esp. with non-selective type

 5-α reductase inhibitor only

o Example fenesteride, dutasteride

o Inhibits conversion of testosterone to DHT

o Used in large prostate volume

o May take 3-6 months to show improvement

o Will reduce PSA level

TURP syndrome (May 2008:S)

a. TURP syndrome is an uncommon but serious complication of a specific type prostate
surgery.
 b. During transurethral resection of the prostate surgery, a sterile irrigation solution is used
to keep the surgical area clean and to prevent distribution of cancer cells if they are
present. This solution is low in sodium. When this solution enters the bloodstream, it can
lower the sodium level in the body.
c. Hyponatremia, or low blood sodium, can cause disorientation, nausea, vomiting, fatigue,
and in severe cases, brain edema and seizures.
d. Treatment varies based upon the severity of the low sodium, which can be determined by
a simple blood test. Treatment may be as simple as restricting fluid intake, or may involve
IV medication, or the administration of salt.

URINARY RETENTION AND INCONTINENCE

Question 2 (2010, ESSAY)

A 70 year old man presents with acute renal failure secondary to obstructive uropathy

a. List the possible causes – lower urinary tract obstruction (Nov 2010:E)
i. Benign prostatic enlargement
ii. Urethral stricture
iii. Meatal steonsis
iv. Phimosis
v. Prostate cancer
vi. Stone or foreign body in the urethra
vii. Spinal cord compression
b. Discuss the acute management
viii. Examination – DRE
ix. Investigation
1. BUSE/Creat, UFEME, Urine C&S (TRO UTI)
2. Ultrasound – hydronephrosis
3. Urine flow rate, Urodynamics
x. Management
1. Resuscitation and correction of electrolyte
2. Find out the possible underlying cause or precipitating factors
3. Bladder decompression – suprapubic/urethral catheterization
4. Treat renal failure
5. Flexible cystoscopy

Assessment and management of obstructive uropathy (Nov 2008:S)

a. Obstructive uropathy
i. Upper urinary tract obstruction
ii. Lower urinary tract obstruction
b. Upper urinary tract obstruction
i. Cause – most common acute ureteric obstructing stone
ii. Investigation
 BUSE/Creat, FBC, UFEME/C&S,
 KUB X-ray, US KUB, CTU
 DMSA(split renal function), DTPA (obstruction)
iii. Management
 Resuscitation, correct electrolyte, pain relief
 Acute decompression – DJ stent, nephrostomy
 Treat the underlying cause
c. Lower urinary tract obstruction
i. See question No. 15

A 60-year-old man presents with acute retention of urine. (2012, NOTES)

a. List the causes.

 b. How would you assess this patient?

2. 60yo man with AUR

a. List the causes (5m)

Differential:

1.BPH

2.Prostatic abscess/Carcinoma

3.Bladder stone

4.Urethral stone

5.Bladder Ca

a. How would you assess this pt? (15m)

Investigation:

History:

Previous urinary retention

LUTS

prostatic disease

Any previous intervention

Bladder irradiation

Pelvic trauma

Back pain/neurological pain

Malignancy constitutional symptoms

Examination:
General condition: malignancy features

Palpable bladder

Enlarged prostate

Neurologic examination

Lab Test:

FBC & inflammatory markers

PSA

RP

Bladder ultrasound

Flexible cystoscopy

Urodynamic study

TRUS Biopsy

Discuss the management of a 64-year-old male with recurrent acute urinary retention with
failed attempt at urethral catheterisation at the Emergency Department. (2013, NOTES)

60 years old comes with AUR. Cant catheterise.Has reducible hernia. Bloods urea 24 creat
1200 Hb 8 (2020, NOTES)
AXR with bladder stone
a) Differential diagnosis (6)
b) Immediate and definitive management (14)

7. SHORT – URO, HERNIA

(AUR, Irreducible hernia, Prostate, stricture, CKD, bladder Stone)

A 70 years-old male presented with a one-day history of acute urinary retention (AUR). On
examination the urinary bladder was distended, there was also a right irreducible inguinal hernia.
The prostate was enlarged and clinically benign on digital rectal examination.
He was warded to ICU a year ago due to dengue fever where a urinary catheter was inserted. Since
that episode he experienced some difficulty in passing urine.

At the Emergency Department, Foley’s catheter insertion was attempted, but failed.

His renal function was as follows

Creatinine: 500 mmol/dl

Blood urea: 25 mmol/dl
Prostate specific antigen (PSA): 2.0 mmol/dl

Ultrasound of the abdomen showed bilateral hydronephrosis, hydroureter with a urinary bladder
stone of 5 cm diameter. Prostate size was 5.4 x 4.5 x 4.5 cm.

Q1. List 4 possible causes of acute urinary retention in this patient. (4 marks )
Urethral stricture
Bladder stone
Benign prostatic hyperplasia
Prostate cancer.

Q2. What is your initial treatment strategy (10 marks )

i. Reattempt CBD insertion.
ii. If failed, insert suprapubic catheter (SPC).
iii. Close monitoring of urinary output and vital signs
iv. May include CVL
v. Look for post obstructive diuresis.
vi. Rehydrate patient judiciously – avoid overload
vii. Repeat blood investigation,
viii. if persistently high blood urea level, refer nephrology for haemodialysis.
ix. Start intravenous antibiotic, to prevent infection in obstructed system.
x. Monitor sign of intestinal obstruction , patient may develop obstructed hernia

Q3. Outline the definitive surgical management for this patient. (6 Marks)
Confirm the cause of bladder outlet obstruction
a. urethral stricture (internal ureterostomy)
b. BPH (TURP)
c. Urinary bladder stone (Open vesicolithotripsy)
d. Hernioplasty

Management of hematuria (May 2011:S)

a. Definition
i. Presence of blood in the urine
b. Classification
i. Microscopic hematuria
ii. Macrosocpic hematuria
c. Cause of hematuria
i. Malignancy
ii. Infection
iii. Renal stone
iv. BPH
v. Trauma
vi. Hematological – coagulopathy
d. History
 e. Examination – abdominal mass, DRE in male, VE in female
f. Investigation
i. Urine FEME, C&S, cytology
ii. FBC (anaemia), BUSE/Creat (renal function)
iii. Flexible cystoscopy
iv. US abdomen, KUB, IVU, CTU
g. Mangement
i. Identify and treat the underlying cause
ii. Malignancy: bladder – TURBT, renal - nephrectomy
iii. Infection – treat with antibiotic
iv. Renal stone – PCNL/ESWL, Ureteric stone – URSL/ESWL
v. BPH – treat with drug
vi. Hematological – treat coagulopathy, refer hemato

UROLOGICAL INFECTIONS
Fourniers Gangrene (Nov 2003:S)
e. Definition - a polymicrobial necrotizing fasciitis of the perineal, perianal, or genital areas
f. Etiology
i. Localized infection
ii. Obliterative endarteritis, cutaneous and subcutaneous vascular necrosis
iii. Localized ischemia and bacterial proliferation
iv. Infection to superficial perineal fascia – spread to penis, scortum, scarpa fascia
v. Necrosis of the superficial and deep fascial planes
vi. Fibrinoid coagulation of the nutrient arterioles
vii. Polymorphonuclear cell infiltration
viii. Microorganism identified within the involved tissues
g. Presentation
i. History – fever, lethargy, genital pain, dusky skin, crepitation, purulent drainage
ii. Examination – fever, tachycardia, hypotension, genitalia redness, edematous,
blistered, gangrenous, feculent odor, crepitus
h. Workup
i. Blood – FBC, ABG, Blood, urine and abscess culture
ii. CT scan – identifies the underlying cause of infection, assist in surgical planning
iii. Ultrasound – detect fluid or gas
i. Treatment
i. Antibiotic and antifungal therapy
ii. Surgical debridement
iii. Reconstruction

Fourniers gangrene. (2010, NOTES)

Write short notes on the pathophysiology and the management of Fournier’s gangrene.
(2014, NOTES)
UROLITHIASIS
The treatment for renal stone diseases. (Nov 2011:S)
a. Investigation
i. FBC, BUSE, Creat
ii. Calcium, phosphate, uric acid, UFEME
iii. X-ray KUB, US, CTU, IVU
iv. DTPA (function/obstruction), DMSA (relative renal function)
b. Management
i. Acute
 Pain relief – NSAIDs, pethidine
 Resuscitation – rehydration, antibiotic in urosepsis
 Relief of obstruction - retrograde DJ stenting, antegrade nephrostomy
ii. Definitive management
 Depend on site and size of the stone
c. Type of treatment
i. PCNL – large staghorn calculi, stone > 2cm, lower pole stone, failed ESWL
ii. ESWL – renal stone < 2cm
iii. Nephrectomy – poorly functioning kidney containing stone

60 year old man is referred to this hospital by a general practitioner with 2 day history of hematuria.
He voided every 3-4 hours during the day, associated with occasional slow stream of urine the last 2
months (Nov 2009)
a. How do you approach this man complaint?
b. What is / are possible diagnosis
c. How do you approach that / those diagnoses?
This is his second episode of hematuria. The first one happened a month ago while he was in
Kuala Lumpur whereby he gave history of normal ultrasound of the abdomen. An endoscopic
examination performed by a general surgeon in a private hospital in the city also was
unremarkable
d. What is your action now?
The investigation of the upper tract performed showed a filling defect in the renal pelvis
e. How would you confirm this?
f. What is your possible diagnosis now?
g. How would you manage this

Management of impacted stone in lower 3rd of the ureter (May 2008:S)

a. History
b. Examination
c. Investigation
i. KUB X-ray, US TRO hydronephrosis
ii. BUSE/Creat, calcium, phosphate, uric acid
iii. Urine FEME/C&S
d. Diagnosis
i. Acute
 Pain relief
 Relief o obstruction – retrograde DJ stenting or antegrade nephrostomy
 Antibiotic – Urosepsis
 Rehydration
ii. Definitive management
 Ureteroscopy with lithotripsy (ballistic or LASER)

ESWL; mechanism, indication and contraindications (May 2008:S)

a. ESWL = Extracorporeal shockwave lithotripsy (ESWL)
b. Mechanism
i. Shockwaves are generated and then focused onto a point within the body
 ii. The shockwaves propagate through the body with negligible dissipation of energy
(and therefore damage) owing to the minimal difference in density of the soft tissues.
iii. At the stone-fluid interface, the relatively large difference in density, coupled with the
concentration of multiple shockwaves in a small area, produces a large dissipation of
energy.
iv. Via various mechanisms, this energy is then able to overcome the tensile strength of
the calculi, leading to fragmentation.
v. Repetition of this process eventually leads to pulverization of the calculi into small
fragments (ideally < 1 mm) that the body can pass spontaneously and painlessly.
c. Indication
i. Treatment for ureteral and renal stones smaller than 2cm
ii. Individuals who work in professions in which unexpected symptoms of stone passage
may prompt dangerous situations (eg, pilots, military personnel, physicians) (In such
individuals, definitive management is preferred to prevent adverse outcomes.)
iii. Individuals with solitary kidneys in whom attempted conservative management and
spontaneous passage of the stone may lead to an anuric state
iv. Patients with hypertension, diabetes, or other medical conditions that predispose to
renal insufficiency
d. Contraindications
i. Absolute
 Acute urinary tract infection or urosepsis
 Uncorrected bleeding disorders or coagulopathies
 Pregnancy
 Uncorrected obstruction distal to the stone
ii. Relative contraindications include the following:
 Body habitus: Morbid obesity and orthopedic or spinal deformities may
complicate or prevent proper positioning. In these situations, attempting to
position the patient prior to anesthetic induction is useful to ensure the practicality
of the approach.
 Renal ectopy or malformations (eg, horseshoe kidneys and pelvic kidneys)
 Complex intrarenal drainage (eg, infundibular stenosis)
 Poorly controlled hypertension (due to increased bleeding risk)
 Gastrointestinal disorders: In rare cases, these may be exacerbated after ESWL
treatment.
 Renal insufficiency: Stone-free rates in patients with renal insufficiency (57%)
(serum creatinine level of 2–2.9 mg/dL) were significantly lower than in patients
with better renal function (66%) (serum creatinine level < 2 mg/dL).

2018, NOTES
9. SHORT – UROLOGY
A 45-year-old male was admitted from the Emergency Department for `left renal colic ’. He had seen
a GP for severe left loin pain the previous day which was partially relieved by an injection. KUB x-ray
done showed a 7mm ‘left upper ureteric stone’. This is the second time he has had the attack. He
passed out a small stone after the first attack a few months earlier. He has a temperature of 38 oC.

Outline the management of this patient. (20marks)

Deal with pain and evaluation of patient’s condition

1. Quick clinical assessment (history and physical examination) and resuscitation if necessary.
(2 marks)
2. Analgesia-Intravenous @ intramuscular NSAIDS or opioids. (2 marks)

Confirm diagnosis and stone status

1. Look for signs and symptoms of complication associated with ureteric calculi:
a. Acute pyelonephritis / Pyonephrosis ( Fever, chills, and rigor with loin tenderness.
 b. Early signs of sepsis like tachycardia, tachypnoea and high total white blood cell.
(3 marks)
c. Renal impairment (nausea, vomiting)

2. Full history and complete physical examination. (2 marks)

3. Investigations:
a. Urine FEME, Urine culture and sensitivity
b. Blood tests: Full blood count and renal profile with uric acid and calcium.
c. Ultrasound KUB : to look for evidence of hydronephsis, pyelonephritis or pyonephrosis.
d. CT Urography without contrast – will show stone, hydronephrosis. (2 marks)

Management of patient and stone

4. If there is presence of sepsis and urinary tract obstruction (hydronephrosis):

a. Fluid resuscitation
b. Intravenous broad-spectrum antibiotic
c. Early decompression. Retrograde ureteric stenting or percutaneous Nephrostomy
tube insertion. (3 marks)

5. The definitive treatment options of 7mm upper ureteric calculi (8 marks)

a. If 5 mm or less, conservative with analgesia with or without medical expulsion
therapy.
b. No progress or >5mm
i. ESWL
ii. URS (ureteroscopy with lithotripsy)
iii. Laparoscopic or open ureterolithotomy.

6. Long term management to prevent recurrent of stone:

a. Adequate fluid intake (2- 2.5 L/day)
b. Low purine diet if stone is associated with hyperuricaemia
c. If associated with high calcium, further workout is necessary.

Write short notes on the treatment options for renal stones. (2020)

Factors to consider before deciding on the treatment options

1) Patient factors:
a. Symptoms
b. Complications e.g. renal impairment
c. Medical history
d. Social factors e.g. occupation
2) Stone factors:
a. Size
b. Site
c. Type
3) Surgeon and facilities:
a. Facilities available e.g. ESWL and intracorporeal lithotripters
b. Experience of surgeon
(6 marks)
Treatment options:
 1. ESWL
- size less than 2cm
- Type – all types possible except cysteine stones
- Site – lower pole stones lower stone clearance rate (3 marks)
2. PCNL
- larger than 2cm, staghorn calculus
- Failed ESWL
- Lower pole stones
- Cysteine stones (3marks)
3. Retrograde Intrarenal surgery (RIRS)
- Smaller stones if failed ESWL
- Lower pole stones
- Obese patients
- Horseshoe kidney (3marks)
4. Open surgery
- Complex staghorn (3marks)
5. Laparoscopy is an option instead of open but is rarely performed. (1mark)
(Bonus 1 mark for mentioning complications of any treatments)

UROLOGICAL TRAUMA – RENAL, URETER, BLADDER, URETHRA

Outline the principles of management of injury to the male urethra (May 2003:S)
e. Investigation
i. CT Scan
ii. Retrograde urethrography
iii. Cystography
f. Management
i. Initial management
 These patients often have multiple injuries, and management must be
coordinated with other specialists, usually trauma, critical care, and orthopedic
specialists.
 Life-threatening injuries must be corrected first
ii. Posterior urethral injury secondary to pelvic fracture
 Suprapubic catheter for bladder drainage
 Delayed repair.
iii. Ultimate repair of the posterior urethral injury
 Performed 6-12 weeks after the event, after the pelvic hematoma has resolved
and the patient's orthopedic injuries have stabilized.
 Perineal approach - mobilizing the urethra distally to allow a direct anastomosis
after excision of the stricture.
 A urethral catheter is left indwelling to stent the repair, and the suprapubic
catheter may be removed.
 Transpubic approaches useful in men with fistulous tracts complicating a
membranous urethral injury.
 Combining a perineal and abdominal approach with pubectomy provides
maximum exposure of the prostatic apex.
iv. Early realignment of posterior urethral injuries
 This has been performed at the time of injury, using interlocking sounds or by
passage of catheters from both retrograde and antegrade approaches.
 Also, direct suture repair has been attempted in the immediate postinjury period.
 Another approach could be careful insertion of a urethral catheter under
fluoroscopic guidance by a urologist experienced in that approach.
 These approaches have the disadvantage of possible entrance into and
contamination of the pelvic hematoma with ensuing hemorrhage and sepsis.
v. Early endoscopic realignment (within 1 week postinjury)
 using a combined transurethral and percutaneous transvesical approach
  If performed 5-7 days postinjury, the pelvic hematoma has stabilized and
hemorrhage is less of a concern.
 The patient's overall condition has usually improved by this time, and sepsis is
less of a concern.
vi. Bulbar urethral injuries
 Often manifest months to years following blunt perineal trauma.
 The presentation for these injuries is often that of decreased stream and voiding
symptoms.
 The diagnosis of urethral stricture is then made with urethrography and
cystoscopy.
 These strictures may be managed with excision of the stricture and end-to-end
anastomosis via a perineal approach. Most are short (< 2 cm).
 Longer strictures may require flaps (penile fasciocutaneous) or grafts (buccal
mucosa) to achieve a tensionless anastomosis.
vii. Penetrating anterior urethral injuries
 Should be explored. The area of injury should be examined, and devitalized
tissue should be debrided carefully to minimize tissue loss.
 Defects of up to 2 cm in the bulbar urethra and up to 1.5 cm in the penile urethra
can be repaired primarily via a direct anastomosis over a catheter with fine
absorbable suture.
 This is the preferred method of repair for these injuries. Longer defects should
never be repaired emergently; they should be reconstructed at an interval
following the injury to allow for resolution of other injuries and proper planning of
the tissue transfers required for the repair.
 Urinary diversion can be accomplished with a suprapubic catheter during this
interval.

The management of suspicious urethral injury in a patient involved in road traffic accident.
(2008, NOTES)

IATROGENIC UROLOGICAL INJURY

Write short nots on Iatrogenic ureteric injuries associated with pelvic surgery including risk
factors, mechanism, presentation, prevention and principles of repair. (2013, NOTES)

1. Write short notes on iatrogenic ureteric injuries associated with pelvic surgery
including risk factors, mechanism, presentation, prevention and principles of
repair. 

Introduction : (2 marks)

 Incidence : 1 to 10%
 gynaecological procedures most common, followed by urological, colorectal and
vascular

Risk factors : (4 marks)

 prior pelvic surgery

 intraoperative hemorrhage
 inflammatory bowel disease
 extensive or large neoplasm (locally advanced, locally infiltrating)
  intraabdominal infection
 unrecognized congenital anomalies (eg duplicated ureter, horsheshoe kidney)
 pelvic radiotherapy
 retroperitoneal fibrosis

Mechanism / type : (4 marks)

 laceration (total or partial laceration)

 avulsion
 crushing
 ligation/clipped
 devascularization
 thermal injury from electrocautery

Presentation (4 marks)

 intra-operative recognition –
 squirt of urine 
 exposure of stent 

 post-operative diagnosis
 flank pain or mass
 fever and sepsis
 fistula
 prolonged drain output
 urinoma
 prolonged ileus
 renal failure due to ureteric obstruction

Prevention (3 marks)

 awareness of the risk 

 ureteric stenting/catheterization preoperatively aids identification but DOES NOT
prevent ureteral injury
 visualization is crucial during all surgical steps
 adequate exposure
 preserve periureteric tissue (adventitia) to avoid devascularization
 avoid using energy sources when dissecting close to ureter

Principles of repair of ureteric injury (3 marks)

  debridement of non-viable tissue to a bleeding edge
 adequate mobilization to allow for tension free anastomosis
 spatulated ureter
 absorbable suture
 indwelling ureteral stent
 placement of surgical drain at area of repair

Question 3 (2019, NOTES)

SHORT URO
A 45-year-old lady underwent laparoscopic hysterectomy for uterine fibroid. Post-operatively she
complained of suprapubic pain and abdominal distension. She also had reduced urine output.
She has a past history of appendicectomy for a perforated appendicitis 30 years ago.
On abdominal examination, the abdomen was distended and tender with sluggish bowel sounds.

Q1. What is your differential diagnosis ( 3 marks )

 Ureteric injury
 Bladder injury
 +/-Bowel injury

Q2. How would you manage this patient initially ( 7 marks )

o Resuscitation
o IV antibiotic
o Analgesic
o Diagnostic investigation
 IVU and Cystogram
 Contrasted CT Abdomen, Urography and Cystography
 +/-Cystoscopy
 +/-USG Abdomen

This was one of the investigations done.

Q3. What is the investigation and what does it show? ( 2 marks )
CT Cystogram film
showing extravasation of contrast from the bladder

Q4. What is the definitive management for this patient? ( 8 marks )

Damage control management - Percutaneous drainage of abdominal collection

Definitive treatment:
In this case: It is intraperitoneal injury as presence of contrast around the bowel loop

Surgical treatment (standard of care)

Identification of the site by
a. Direct visualization
b. In difficult case
i. Methylene blue, intraoperative cystoscopy
Evaluation of the size of defect

2 layers repair of the bladder injury watertight absorbable suture

Urinary catheter and +/- suprapubic catheter
+/- Abdominal drainage

IF conservative management mentioned – No marks for this section

TESTICULAR TORSION
Differential diagnoses of unilateral scrotal swelling (May 2004:S)
a. Epididymitis
b. Orchitis
c. Hernia
d. Hydrocele
 e. Varicocele
f. Testicular torsion
g. Testicular cancer

Management of painful scrotum in young adults. (2015, NOTES)

Management of Painful Scrotum in Young Adults

Differential Diagnosis:

i. Torsion of testicles
ii. Torsion of testicular appendages
iii. Epididymo-orchitis, Isolated Epididymitis, Isolated Orchitis
iv. Testicular tumour
v. Varicocele

Testicular torsion

Definition :
- Twist of spermatic cord resulting in strangulation of blood supply to testes and epididymis

History :

 -  Sudden onset, severe pain in hemiscrotum

 -  May radiate to loin/groin
 -  May have similar history in the past, with spontaneous resolution of pain
(torsion/spontaneous

detorsion)

 -  May be preceeded with history of mild trauma to testes

Examination :

 -  Tender ± swollen testes

 -  High-riding
 -  Horizontally lying
 -  ± scrotal erythema

Management

 -  Urological emergency
 -  Diagnosis by history and examination
 -  Colour Doppler ultrasound only if readily available
 -  If in doubt -> scrotal exploration + 3 point fixation (or subdartos pouch) + fix contralateral
testes

Torsion of testicular appendages

Definition
 -  Torsion of appendix testes (hydatid of Morgagni) or appendix epididymis

History

 -  Pain mimicking testicular torsion, usually at superior pole of testes

Examination

 -  Testes usually not tender

 -  Blue dot sign (only in 21%)
 -  Normal vertically lying testes

Management

 -  Colour Doppler ultrasound

 -  Can be managed conservatively
 -  Surgical exploration if uncontrolled pain (excision of appendix testes)

Epididymo-orchitis

Definition

 -  Inflammation of epididymis and testes due bacterial/abacterial causes

 -  Organism : E coli (coliform bacteria), C trachomatis (STD)

History

 -  Gradual onset of pain

 -  May have UTI symptoms
 -  History of STD
 -  Nausea, fever

Examination

 -  Tender epididymis and testes

 -  Erythematous scrotum
 -  Reactive hydrocele
 -  Scrotal abscess

Management

 -  Urinalysis, Urine C&S, WBC, STD workup if necessary

 -  Colour Doppler Ultrasound – thickened and enlarged, locate abscess
 -  Analgesics
 -  Antibiotics – eg fluoroquinolones for 2 weeks
 -  Review patient again after 1 week

Testicular tumour

History
  -  Testicular mass is present
 -  Risk factors – cryptorchidism
 -  20% have pain

Examination

 -  Supraclavicular nodes
 -  Lungs
 -  Abdomen
 -  Testicular mass

Management

 -  Tumour markers : alpha Fetoprotein, beta HCG, LDH

 -  US Scrotum and testes
 -  CXR
 -  Radical Inguinal orchidectomy

Varicocele

Definition

 -  Dilatation of veins in pampiniform plexus of spermatic cord

History

 -  Rarely painful, only if large varicocele

 -  infertlity

Examination

- “bag of worms”

Management

 -  Ligation – inguinal, scrotal, retroperitonal (high ligation)

 -  Embolization.

Acute painful scrotum in a 20-year-old male. (2007, NOTES)

Surgery for testicular torsion (May 2001:S)

h. Introduction
i. Testicular torsion refers to the torsion of the spermatic cord structures and
subsequent loss of the blood supply to the ipsilateral testicle.
ii. This is a urological emergency; early diagnosis and treatment are vital to saving the
testicle and preserving future fertility.
i. Surgery
i. Incision
 Either a midline raphe incision or bilateral transverse scrotal incisions
  Enter the ipsilateral scrotal compartment, incise the tunica vaginalis, and then
deliver the testicle for examination.
ii. The spermatic cord is then untwisted.
iii. Evaluate the testis for viability.
 If viability is in question, place the testicle in warm sponges and reevaluate after
several minutes.
 If the testis is necrotic, perform an orchiectomy to avoid prolonged, debilitating
pain and tenderness.
iv. To prevent subsequent torsion
 Fix viable gonads to the scrotal wall with 3-4 nonabsorbable sutures.
 A dartos pouch can be made, into which the testicle is placed.
 Always perform contralateral orchiopexy when testicular torsion is confirmed
intraoperatively, in order to prevent future torsion of that testicle.
v. Signs of a viable testis after detorsion include a return of color, return of Doppler flow,
and arterial bleeding after incision of the tunica albuginea.
j. Testicular prosthesis placement
i. Patients requiring an orchiectomy because of a nonviable testis may benefit from the
placement of a testicular prosthesis.
ii. Delay this placement, usually for 6 months, until healing is complete and
inflammatory changes resolve.
iii. Perform the prosthetic placement through an inguinal incision

RENAL CANCER
The various surgical options in the treatment of renal cell carcinoma taking into accounts the
factors influencing your decision (May 2010:S)
a. Nephron-sparing surgery (partial nephrectomy)
i. Small T1a renal tumours
ii. Bilateral disease (familial renal cancer syndrome)
iii. Tumour in a solitary functioning kidney
iv. Pre-existing renal insufficiency
v. Approach
 Open partial nephrectomy
 Laparoscopic partial nephrectomy
b. Radical nephrectomy
i. Standard, often curative, therapy for localized renal cell cancer
ii. Remove kidney, adrenal gland, perirenal fat, Gerota’s fascia, regional LN dissection
iii. T1 T2 tumours of lower pole – ipsilateral adrenal gland can be left in situ
iv. Open radical nephrectomy
 For larger tumours (>7cm) and renal vein/IVC involvement
v. Laparoscopic radical nephrectomy
 Now the first-line surgical approach for radical nephrectomy
 Cure rate equivalent, reduced blood loss, analgesia, length of hospital stay and
earlier return to normal activities
 Can be perform
1) Transperitoneal
2) Retroperitoneal
2.
A 59-year-old female patient presented to the Emergency Department, with persistent
“bloatedness” of abdomen, and generalized nonspecific body ache. There was also recent
pigmentation of her armpits with painful veins over the abdomen. She had loss 20kg within
2 months with significant constitutional symptoms. Among various test results which was
done in private hospital, the calcium level was 3.1 mmol/L. An image of the CT scan is as
shown (IMAGE 1). (2016, NOTES)

**Image: Contrasted CT image of a large heterogenous right renal mass extending

into right renal vein and IVC with tumor thrombus seen within. Multiple paracaval
and paraaortic nodes. A single hypodense liver lesion seen. **

a. Describe the CT findings. (2 marks)

b. What is your diagnosis? (1 marks)

c. How do you explain the cause of constitutional symptoms in this patient?

(4 marks)

d. What is the pathophysiology and management of hypercalcemia in the

absence of bony pathology in this case? (7 marks)

e. Discuss the definitive management of this patient. (5 marks)

BLADDER CANCER – NON-MUSCLE INVASIVE AND MUSCLE INVASIVE

Painless hematuria relevant Clinical information for haematuria. 14 marks. Photo of bladder
tumor. Dx. 1 mark (2019, NOTES)
management for bladder ca as general surgeon 5 marks

QUESTION 7 – SHORT – HAEMATURIA

A 50-year-old male was referred for painless haematuria of 2 weeks duration. This was his first
episode. The referral came with an ultrasound scan picture of the urinary bladder as shown below.
He is otherwise quite well.

a. What is the most likely diagnosis. (2 marks)

Most likely diagnosis : Ca bladder superficial
Reason : Painless haematuria, growth on bladder wall on ultrasound

b. Discuss the management for this patient. (18 marks)

Management:
Treat acute problem – Haematuria with clots, insert 3-way CBD and irrigate till clear (3 marks)
Pallor or symptomatic anaemia – resuscitate, transfuse

History:
Symptoms
Of Anaemia – from prolonged blood loss
Of Ureteric obstruction – loin pain
Of co-existing medical conditions – HT, DM
Occupation – contact with carcinogens e.g. dyes
Examination:
General fitness
Anaemia
Renal impairment
Prostatism – DD

INVESTIGATIONS (3 marks)
Ultrasound – KUB, look for other bladder lesions, hydronephrosis,
Liver for 2ries
CT TAP - staging
Cystoscopy – Biopsy – lesion and rest of bladder,
Resection (TURBT) – Curative and diagnostic

TREATMENT
Depends on Stage, Grade, available facilities and Condition of patient

SURGERY (3 marks)
Transurethral Resection of Bladder tumour (TURBT)
- Maybe adequate and curative for small superficial T1, T2
- Resection must include adequate margin and depth
Partial cystectomy
 - Larger tumour localised to dome or side, bladder can be closed without problem
- Where TUR facility not available

ALL patients undergoing TURBT or partial cystectomy requires regular cystoscopic surveillance of
the bladder.
Recurrences may either be treated by a repeat TURBT or changed to radical cystectomy. (2 marks)

Radical cystectomy (3 marks)

- For multicentric lesions
- Multiple recurrences
- High grade
- With ileal conduit or neobladder reconstruction

CHEMOTHERAPY (2 marks)
INTRAVESICAL CHEMOTHERAPY (MITOMYCIN)
- Reduce likelihood of recurrence
- Given after resection
- Other drugs used - valrubicin, docetaxel, thiotepa, and gemcitabine
SYSTEMIC CHEMOTHERAPY
- Usually for invasive tumours or secondaries
- Adjuvant to cystectomy

IMMUNOTHERAPY (1 mark)
- Intravesical BCG – role similar to intravesical mitomycin
- 6 weekly or 3-6 monthly
- Prevent / reduce recurrences

RADIOTHERAPY (1 mark)
- More of a palliative role for those not fit for surgery

PROSTATE CANCER
Write short notes on the investigations in the diagnosis and the planning of the management of
prostate cancer patients (May 2009:S)
a. Established tissue diagnosis by Trans-Rectal Ultrasound (TRUS) biopsy of prostate
i. Indications for TRUS biopsy
 Suspicious nodule in prostate on digital rectal examination
 High prostate specific antigen (PSA) > 4ng/ml
ii. Gleason grade and scores
 Is based on the architectural pattern of the glands formed by the tumour
 Grade 1 to 5: Grade 1 resembles normal prostate gland and Grade 5 shows no
differentiation into gland structures
iii. Gleason score
 Is a sum of 2 Gleason grades
 Most common grade + second most common grade
 Minimum 2, Maximum 10
b. Staging of Prostate cancer
i. Imaging modalities
 CT scan of thorax, abdomen and pelvis
 Or MRI
 Bone scan – for evidence of locally advanced disease, lymph node mets and
distant mets

1. 60yo w LUTS 6/12 and PSA 30ng/ml (2015, NOTES)

 1. - what can cause raised PSA besides Prostate Ca (3m)
2. - how would u advise this pt/counsel him
3. TRUS biopsy done and confirm Prostate Ca, staging is localised to prostate
4. - what is the treatment options for him

75-year-old man with history of difficult passing of urine associated with intermittent
hematuria. He had a swelling at right inguinal region which is reducible. He had history of
COPD which is controlled by medication. He had an abdominal us done as shown below. (Us
of well distended bladder, Stone? extension of prostate into bladder) (2017, NOTES)

a. Describe the ultrasound findings. (4marks)

b. Discuss the investigation you would do for this patient. (4marks)

c. Discuss the management of this patient including surgical and medical

management. (12marks)

TESTICULAR CANCER
Teratoma (May 2008:S)
a. Definition
i. Germ cell tumour, may occur in both gonadal and extragonadal locations
ii. Include components derived from all 3 embryonic layers: ectoderm, endoderm and
mesoderm
b. Location
i. Sacrococcygeal – 40%
ii. Ovary – 25%
iii. Testicle 12%
iv. Brain -5%
v. Others (neck, mediastinum) – 18%
c. Presentation
i. Sacrococcygeal teratoma – prenatally diagnosed, occur in infant large for age,
premature or infants with fetal hydrops. More than 5cm may ruptured.
ii. Ovarian mass – abdominal pain, masss, distention
iii. Testicular tumour – scrotal mass with or without pain
d. Treatment
i. Sacrococcygeal – en bloc resection with coccyx
ii. Ovarian – ipsilateral oophorectomy or salphingo-oophorectomy
iii. Testis – radical inguinal orchidectomy

You were called by MO who is doing left inguinal hernia surgery. It turns out the hernia is a
huge left testicular tumor. On examination, the right scrotum is empty and the right testis
like structure palpated at the external inguinal ring. (2018, NOTES)

a. What is your next course of actions? (4 marks)

b. Outline your subsequent management and follow up. (12 marks)

c. What are the steps you can take to prevent this from happening again in future.
(4 marks)
RENAL TRANSPLANT

VARICOCELE
A 30 years old man came for infertility, and the test show low spermatic count. The only
abnormality found on examination is that left scrotal has a lesion described as a bag of
worms. (2017, NOTES)

a. What is the provisional diagnosis? (1 mark)

b. Explain the reason how your diagnosis is can lead to infertility. (4marks)

c. Discuss the surgical and non-surgical management of this patient. (10marks)

d. List down the complications of the surgical managements. (3marks)

e. How would you follow up for this patient? (2marks)

LONG CASE

SHORT CASE

PATHOLOGY
Retrograde pyelography
Testicular maldescent, torsion and biopsy
Scrotal swellings and infections
Obstructive uropathy
Bladder outlet obstruction 
Benign Prostatic Hypertrophy
Carcinoma of the prostate
Haematuria and bladder tumour
Urinary tract calculi
Renal tumour
Testicular tumours
Neurogenic bladder
Andrology –erectile dysfunctions and inferlility
Female urology – Urinary incontinence
Renal transplant

OPERATIVE TABLE
Suprapubic bladder drainage
Vesicolithotomy
Cystoscopy – Rigid and flexible
Exposure of kidney, nephrectomy and ureterolihotomy
Drainage of perinephric abscess
Tenckhoff catheter insertion
Vasectomy
Urinary diversion
Circumcision
Endourology