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Urology 1 Clinical Fellow in UrologySocial Medias Case 1 Question 1 A 56 year old man is admitted via ED with right sided flank pain. He has a background of quadriplegia following a C-spine injury and has had recurrent UTIs for several years. The abdominal X-ray from ED is shown next. What is the main chemical composition of the shown abnormality? A/ Patent E/ B/ RR 20 Sats 96% C/ BP 110/56 D/ CRT 3 secs BM 155 HS I + II + 0 Temp 38.7 Case 1 Question 1 A 56 year old man is admitted via ED with right sided flank pain. He has a background of quadriplegia following a C-spine injury and has had recurrent UTIs for several years. The abdominal X-ray from ED is shown next. What is the main chemical composition of the shown abnormality? A/ Patent E/ A. Calcium oxalate B/ B. Cysteine RR 20 Sats 96% C. Struvite D. Calcium phosphate C/ HR 101 D/ E. Urate BP 110/56 GCS 15 CRT 3 secs BM 15 HS I + II + 0 Temp 38.7 Case 1 Answer A. Calcium oxalate Staghorn calculi are composed, primarily, of B. Cysteine struvite. This is often mixed with calcium C. Struvite phosphate/oxalate to make it radio-opaque. D. Calcium phosphate E. Urate Struvite, on its own, is radio-lucent and forms due to recurrent infections. • Calcium stones are the most common form of renal calculus, followed by urate. • Both have predisposing conditions, but most commonly dehydration or spontaneous • Check calcium and urate in all patients with ureteric calculi • Cysteine stones are the result of a genetic condition… • …called cystinuriaCase 1 Explanation Type of stone Causes Calcium oxalate/phosphate Dehydration Hypercalcaemia (hyperparathyroidism) Uric acid Dehydration Elevated urate (gout) Struvite Recurrent UTIs Cysteine Cystinuria Case 2 Question A 25 year old man is admitted with suspected renal colic. He had a single episode of right sided pain in the night that has now subsided. His CTKUB shows a 5mm mid-ureteric stone with mild-moderate hydronephrosis. He has no comorbidities and his bloods and observations are shown below. What is the most appropriate management? A. Ureteric stenting Observations: B. Extracorporeal shock-wave Bloods: lithotripsy HR 89 Hb 136 BP 112/78 WCC 12.5 C. Nephrostomy RR 18 CRP 15 Sats 98% on air eGFR 67 D. Primary ureteroscopy and laser Temp 37.2 K+ 4.2 lithotripsy E. Discharge with follow up Case 2 Answer A. Ureteric stenting Most stones 6mm or under will pass B. Extracorporeal shock-wave lithotripsy spontaneously without intervention C. Nephrostomy D. Primary ureteroscopy and laser Follow up imaging can confirm that is has lithotripsy passed spontaneously, and if not E. Discharge with follow up intervention can be planned non-urgently • NICE guidance states that acute intervention for uncomplicated is indicated if the stone is unlikely to pass or causing ongoing pain • Emergency treatment is indicated for pain, renal failure and sepsis • An infected obstructed system can only be safely managed with drainage, either stent or nephrostomy • Medical-expulsive therapy (alpha blockers) shows minimal benefit but can be safely used as an adjunctCase 2 Explanation Emergencies: -Fulminant renal failure -Intractable pain Case 3 Question A 72 year old gentleman is admitted from haematology clinic. He was referred with an abdominal mass (?lymphatic) but his pre-clinic bloods showed significant renal failure with an eGFR of 2 and he has come to MAU for assessment. The patient reports chronic mild LUTS, specifically poor flow, urgency, and occasional bed wetting. He has had some dysuria and malodourous urine for one week. Half an hour after catheterisation for monitoring you notice his urine has become quite red. You check his blood and his PSA (done by the admitting SHO) was 18. What is the cause of his renal failure? A/ Patent A. UTI E/ B. Prostate cancer B/ RR 18 C. Multiple myeloma Sats 91% on air xxxxx D. Acute urinary retention C/ HR 95 D/ E. High pressure chronic retention BP 104/62 GCS 15 Minimally tender mass CRT 3s BM 6.2 Dull to percussion HS I + II + 0 Temp 37.0 Case 3 Answer High pressure chronic retention is a common A. UTI cause of obstructive uropathy. The high B. Prostate cancer pressure causes back pressure on the kidneys C. Lymphoma with free light chains and, eventually, renal failure. The red flag D. Acute urinary retention symptom is nocturnal enuresis. After E. High pressure chronic retention catheterisation, decompression bleeding is common. An elevated PSA can be an artefact of retention. • This gentleman likely did have a UTI, which is very common with chronic retention, but his symptoms weren’t indicative of sepsis with pre-renal AKI • Although prostate cancer can cause obstructive uropathy, this would more likely be asymptomatic ureteric obstruction and the bladder would not be affected • Haematological malignancies can cause renal failure, however this would not have any • AUR is always painful, relieved by catheterisation Retention Acute retention Chronic retention -Painful High pressure Low pressure -Acute -nocturnal -nocturia -Relieved by catheterisation enuresis -urgency -renal failure -frequency BPH -bilateral -incomplete +-precipitant hydronephrosis voiding Clot retention Bladder outlet UTIs, stones Neurological Medications obstruction Constipation BPH Etc…. Detrusor failure StrictureHigh Pressure Chronic Retention • Ongoing drainage is required to relieve pressure on the kidneys • In the short term this could be • An indwelling urethral catheter • A supra-pubic catheter • Intermittent self-catheterisation • In the long term this could be • Any of the above • TURP (if fit) • Medical management (ie. Tamsulosin, Finasteride) does not provide long term safety • Sometimes none of the above are appropriate for a patient, in which case renal failure may be inevitableAcute urinary retention • Causes • Investigation (in men) • BPH • DRE (+- PSA) • UTI • Treat cause • Medications • Trial tamsulosin • Neurological • TWOC • Constipation • Investigation (in women) • Pelvic masses • Neurological examination • Urethral stricture • Pelvic exam and imaging • Clots • Treat cause • Prostate cancer • TWOC Case 4 Question A 6 month old boy is brought in to paediatrics by his father. When changing his son’s nappy he noticed that the left side of his scrotum was quite swollen compared to the right. The child’s mother was looking after him in the week and didn’t notice anything. On examination the left hemi-scrotum is swollen and minimally tender. There is no induration of the skin and the swelling is fluctuant. What is the underlying anatomical abnormality? A. Patent processus vaginalis B. Posterior urethral valve C. Bell-Clapper deformity D. Dilated pampiniform plexus E. Indirect inguinal hernia Case 4 Answer A. Patent processus vaginalis Patent processus vaginalis is a common cause B. Posterior urethral valve of hydrocele in infants, which often presents C. Bell-Clapper deformity as a painless, unilateral swelling. PPV can also D. Dilated pampiniform plexus cause inguinal hernias and can cause any E. Indirect inguinal hernia intra-abdominal pathology to track into the scrotum. • Posterior urethral valves are rare and cause high pressure retention in children, which can lead to UTIs • Bell-Clapper deformity is related to PPV, but this patient is not presenting with torsion • A dilated pampiniform plexus causes varicocele, which examines as a “bag of worms.” • The examination is not consistent with a hernia, which would not be fluctuant Case 5 Question A 25 year old man had an orchidectomy for suspected testicular cancer. The macroscopic appearances show a malignant lesion with several differentiated tissue types including some muscle fibres. His staging CT shows some para-aortic lymphadenopathy. What is the most likely type of tumour? A. Mature teratoma B. Mixed non-seminomatous germ cell tumour C. Leydig cell tumour D. Testicular seminoma E. Pure testicular choriocarcinoma Case 5 Answer A. Mature teratoma Mixed NSGCTs are the most common type of B. Mixed non-seminomatous germ cell tumour NSGCTs, with individual components rarely developing alone. C. Leydig cell tumour D. Testicular seminoma Composition of tumours can be highly E. Pure testicular choriocarcinoma variable. • A mature teratoma resembles a dermoid cyst and can have a variety of tissue types. They are usually benign and do not metastasise, but are more frequently seen with other cell lineages involved • Leydig cell tumours have a single tissue type and no malignant potential • Testicular seminomas make up ~50% of testicular malignancies but present a little later in life and have one cell lineage Case 5 Explanation Tumour type Markers Malignant Classification Proportion Age of potential presentation Seminoma HCG High Germ cell ~50% 35-50 years Embryonal cell HCG/AFP High Choriocarcinoma HCG Very high Non-seminomat Children, young ous germ cell ~50% adults Yolk-sac tumour AFP High Teratoma Variable Variable Leydig cell None Benign Young adult tumour Stromal <5% Sertoli cell None Benign 35-50 years tumour Lymphoma WCC Variable Lymphoma >50 yearsAny questions? O O F Feedback & Instagram + 3C N O Please complete feedback to receive CF slides and cheat sheet!Follow our Instagram page for MCQs! NH O Cl CH 3 CH OH CH 3 3 CH OH 3 3HC CH3 HC O 3