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Hm. Right. Several months. Yeah. We're live now. Okay, fine. Um, hi, everyone. Um, my name is Wendy. I'm one of the CT T s in Manchester. Well done for being here. I know there's more exciting things going on at seven o'clock today. Um, I am going to talk you to, um, urology stuff you need for part A. Um, this talk is gonna be based a lot on M. C. Q s. I've integrated them into the talk, so it will require a little bit of integrate, uh, interaction on your part. The polls will come up as we go along. If you do have any questions or anything, just I won't be able to keep a track track of the messages to just, um if you can either, um, meat yourselves or I will try and come back to the messages at some point. Right. Um, So what we're going to cover urology is fairly a straight forward topic. As far as MRCS goes, it's It's quite it's a smaller topic as far, um, in terms of competitive sort of general surgery and trauma and orthopedics, it's fairly straightforward. The bits that come up are expected. Um so shouldn't be too complex. The bits that are a bit more complex, I'll spend a bit more time on. So what we'll do today is we'll start with a recap of some anatomy. We'll go through some acute testicular pain presentations and some differentials. Um, we'll talk about sort of lumps in the scrotum and the testicles, um, and then talk about renal stones, prostate pathologies, both benign and malignant. And then we'll finish on some bladder and renal cancer at the end. So, um, just to recap some anatomy, obviously. You can see, by the way, sorry if I keep coughing. I'm still recovering from the flu, but in time you can see the, uh, diagrams here on the right. Um, things that are relevant is the renal pelvis, which you can see here. The orientation of that sort of running anterior into posterior is that you have the renal arteries, which you can have one or two of, uh, the renal veins behind it. And then the ureter is the most posterior aspect of the renal pelvis. The renal arteries come off the aorta at L1 L2, and then the only other thing is the renal veins run obviously behind that, but the left renal vein actually runs in front of the aorta. Um, so it's a longer it's longer than the right renal vein as it goes over to the right side of the body to join the ivc in at this level anyway, because the ivc runs on the right side and posterior to the aorta. The other thing that's sort of relevant in anatomy to highlight is the ganado veins, and they're drainage. So the left and right ganado veins have different drainage, so the right one drain straight into the IBC, as you'd expect it to. But the left one drains into the left renal vein up here, which then goes into the I V C. That is relevant, um, which will come to a question which will be it will be relevant for As for the vast difference, um, it passes from the epididymal, um, in the scrotum, goes up by the inguinal canal to line the side wall of the pelvis, and it ends in the ejaculatory ducks during ejaculation. The smooth muscle in the walls of the va deference which contract it causes. Paracelsus um, which then moves the sperm into the urethra. Here it joins secretions from the seminal vesicles, the prostate, the barber urethra grands, and they're all forms semen in terms of sort of some more relevant anatomy going forward, the blood supply and the ureter is split into thirds. Um, the upper third is supplied by branches of the renal artery branches of the gonadal arteries, and then you've got some smaller sort of collateral type branches coming straight off the main abdominal aorta. The middle third is mainly by the common I'll yak artery or branches of the common iliac, as well as the gonadal arteries and then the lower third, um, our branches of the common and internal iliac arteries, especially the uterine and the superior of the cycle arteries. The ureters enter the bladder at an oblique angle. It travels through the detrusor for roughly two centimeters, which creates this one way valve. And when the the tone in the detrusor muscle in the bladder wall collapses, as in, when this tone in it, it collapses the ureters, which then prevents the reflux of your urine back into the ureters, the other sort of relevant thing, which you'll need to know when it comes to stuff like stones. And the renal tract is the narrowing. These are natural narrowings that happen in the urine to. So the first one is at the pelvis Ureteric junction up here. Then the second one is as the euro to crosses the pelvic brim. And it's sort of near where the, uh, common Eylea bifurcates here. And then because of the oblique angle, it enters the bladder at the V. U J. Is the most common site for stone formation there. So with that in mind, um, we'll go on to the first question. Um, I'll just give you a minute to read that. And I think there should be a pole going live on that somewhere. Can everyone see that? Has everyone got a poll come up? Rob? Mm. Robert, You there is the poll gone live? Yeah. The polls gone up. I can't see it. The results of that Don't worry. I think everyone else can see it. Got three responses in. Okay, just give another 10 15 seconds. If anyone else wants to answer Okay. Should we end the pole? That then? Ok, for that question, I can't actually see the results of the poll, but it's fine. I'll just go through it on the presentation. So 50% of the connective tissue of the scrotum, a couple of deep perennial space and one for lesser pelvis. That's fine. Thanks, Rob. So, um, the correct answer is connected tissue of the scrotum. So the main thing to sort of take from this question is that it's focusing on the bulb a urethra that the injuries in and to this, uh, this explanation here is straight off the MRCS where it's talking about the spit. The space it's asked after is the one between the perennial membrane and the member in a sleep part of the superficial fashion. Now, I'll be honest. When I, um, was studying for this, I found this really quite difficult to conceptualize the fashion of the perineum, so I'm just gonna spend a bit of time going through it. So, um, the urethra has three parts Firstly, the prosthetic, the membrane iss, and then the bulbous part here. And then these are the different layers of sort of fashion you get. You have deep peroneal fashion, superficial, and then you've got different pouches, and then you've got the perennial membrane. This is just a sort of a coronal section through the shaft of the Penis, and it's you can see these different layers of, um, fascia. So the way I sort of found the easiest way to remember things. But some, if you find it, is sort of challenging, as I probably did. You probably do just need to go spend a little bit of time, get wrapping your head around it. So in the abdomen you've got two layers of superficial fashion. One is the fatty campers layer, and then underneath that you've got a member anus. Scarpa's fashion layer. The Scarpa's layer actually extends into the scrotum, so Scarpa's if the more superficial those layers is sorry. So Scarpa's extends into the scrotum, one as a superficial fashion of the Penis and also the dartos fascia, which then covers the scrotum and the Penis. And then it has a second sort of deeper, more membrane. It's layer called collies fascia, um, which is the same Scarpa's fashion that extends into the Parini Um, and then, underneath colleagues fascia. You've got the perennial membrane. The colleagues fascia itself attaches to the posterior sort of border of the perennial membrane, so it's not actually continuous posteriorly. It's only sort of anteriorly and super, uh, superior early and then between colleagues, fashion and that perennial membrane. You have your superficial perennial pouch now that in males have only covered males because that's most of the questions will be about that in males. The superficial peroneal pouch contains both the root of the Penis and the bulbous urethra. So this penile part of the urethra, the deep perennial pouch, is underneath that. So where the perennial membrane forms the upper part and then the deep fresher underneath, which I'll come to in a minute, which is called Bucks Fashir, that contains the membranous urethra, which is found sort of just underneath the prostate. Bucks fascia is the deeper layer of fascia that you have, so that's separate from these layers, and it's continuous with the external spermatic fascia in the scrotum it has. It's it's sort of you can appreciate it a little bit here. It splits, um, and forms its own sort of separate compartments. Um, as sort of described here, so sort of going back to this this question, um, the Bulba urethra is almost entirely in the superficial, um, fascial layer up here and it's in the superficial peroneal pouch, which means that if you have rupture of this member sorry, the bulb is part of this urethra. You'll get extra extra visitation of both blood and urine into the superficial layers here, but also into the scrotum. And if if sort of that continues to build that continues to leak, it could spread all the way up to the abdomen. Other sort of smaller, sort of less relevant. If you like parts of the perennial fascia is, you might have heard of Dennen Villiers fascia, which can be found between the prostate and the rectum and the war. There's fashion, which can be found between the rectum and the sacrum. This in particular award is fracture in particular is relevant, um, in terms of malignancy and seeding onto the sacrum, and there's lots of nerves and things affected there as well. It's not particularly relevant, so if you want, you can look it up at your own time. But I didn't I didn't think, um, it's come up in any questions before. So, um, the next question, um, is about a pelvic fracture, so if you want to just take sort of a little bit of time reading that and access at the pole. Any answers on the pole? Yeah. We have responses coming in. I don't know if you can see them One. I can't see any of these. I don't know what's happening. We've got a split between bladder rupture and membranous urethra rupture mainly. Okay, fine. All right. Sorry. All right. I don't know why I can't see these. Um, okay, so, um, answer is the membranous urethra rupture. Um, that kind of goes back to what I was saying before about the fact that the membranous urethra is within, uh, deep, uh, disco. That's that, um, is within the deep perennial pouch. So if you've got on on examination, you've got peritoneal edema. That doesn't really narrow things down. But if you've got prostate, that's not palpable. That suggests that there's a Dema quite deep in the prostate. And based on sort of where, um, that's, uh, if you if you look back at that diagram, where that's coming up, too, that's that's around here. Really? Which is your deep perennial pouch? Um, so and they said if you've got any any high leads or displaced prostate. You should be worried about Member. And as you breathe or rupture. So next question. Um, I'll just let you read that as well. We have a unanimous decision. Yeah, almost unanimous decision for posterior urine for valves. Okay, good. So you guys all know your stuff then. So, um, posterior, you eat your vows? Um, there's a lot of questions. Almost all questions about hydrogen process in young infant type boys are almost all possibly we thought valves. It's the most common cause of blood outlet obstruction. Um, if in terms of like what it actually is, it's obstructive developmental abnormalities. Almost. Actually, I think it only affects males. Um, and it's where you get an obstructive membrane on the posterior aspect of the urethra. Um, and it's all you need to know about. It is it happens in neutro. It's an abnormal. It's sort of developmental abnormality in neutro. Um, but it causes hydronephrosis and hydroxyurea to, and you get a thick cord, uh, bladder. Basically. So Yeah. Well done. Um, so that's sort of the first little bit. We'll go onto acute testicular pain now. Um, so next question is about some sudden onset testicular pain. I'll give you a second to read it, and then I'll start the whole No, it okay? Do we have some answers? Sorry. Yeah. It seems to be a bit of a split between the first three answers at the moment. First three. Okay, fine. So, um, I'll explain this in a little bit more then. Um, so the answer is testicular torsion of the hydrated. It's either testicular hydrated or hide. It'd of macagni. Um, so, um, things in sorry things in the question to sort of help with this is, um it's obviously unilateral. Um, it's a sudden onset, which kind of rules out the epididymal chi itis. Although you can get fairly sort of quick, um, onset of symptoms, it's not usually sudden. It still takes, you know, a good good couple of hours to days, usually for epididymal chi itis. Whereas a torsion of some sort is sudden onset. The superior pole of the test is being tender. Also sort of supports a more of a sort of appendage testicular hydrated. Um um, answer. And but the main sort of thing in this question is the fact that there's a cremasteric reflex It says it's particularly marked i e. It's present in a testicular torsion in, um, there would be an absent cremasteric reflex. So in, Whereas, if you have just the appendage that storted that would still the reflex would still be present. All right, So next question is about another testicular pain. I'll try and move through these questions. Sort of, uh, 30 seconds to one minute, sort of, uh, kind of frame consist. We have, uh, option threes. The favorites with a few going for option, too. Ok, great. Thanks. So, um, correct answer is option three. So I've done for, uh, you guys who got that? So this is the slower onset I was talking about in the Sorry last question. So it's 48 hours, um, onset of sort of testicular pain. He's got systemic signs of infection. Um, this fits more with an epididymal mark itis than a acute testicular torsion. Um, therefore, that also goes with the fact in the last question we're talking about the fact that you still have a cremasteric reflex, as opposed to in a torsion where you wouldn't, um So epidural mark itis is usually treated with antibiotics, Testicular inspection Vyron Englander approach, which I think some of you had said that would be more. Um so So a testicular inspection by an inguinal approach generally is for more of a malignant cause. Because you're trying to avoid the scrotal approach to, uh, sort of contam avoid contaminated lymphatic fields. The only way you'd go for an inguinal approach to look at the testicle is for a sort of a malignant, um, cause scrotal expiration virus. Scrotal approach is obviously what you do in a testicular torsion. But I don't think that this is obviously not that, um I will talk on the next slide a little bit more about how we treat this. So, um, this is kind of a summary of acute testicular pain and things. So before I so go into the actual pathologies, I thought I'd talk a bit About what? I'm sure you all know this but the actual signs. So the Chromos tarik reflex is obviously elicited by scratch, stroking sort of the medial, um, upper aspect of the thigh. And normally you get contraction of the chromosome muscle, which then causes the testes to be sort of retracted up in upwards into the into the body, and an absent cremasteric reflex is what you get in a in a torsion praying sign is, um, diagnostic if you like. Um, for epididymitis has very high sensitivity to very high specificity, and it's essentially when you lift the sort of affected or tender swollen testicle, and it either relieves or completely, um, usually just relieves the the amount of pain, because that is a sign of epididymitis. So you're basically relieving the pressure on the epididymis, which is up here at the top superior aspect of the testes, so test sort of going from top to bottom. Testicular torsion generally is when you have a mobile testis, which then rotates on its spermatic cord, which then occlude is both the testicular and the cremasteric artery, which then causes a ski mia. You get venous congestion, a Dema, and then eventually you'll get infarction of the testes it presents. As we said, sudden onset, severe unilateral pain, and the test is usually associated with nausea and vomiting. They'd be very, you know, very, very sick with it, Um, and then in terms of on examination, they'd be unilaterally tender. They would have a high riding testes might have a horizontal lie and you'd have the absent cremasteric reflex. As we've said, management in that situation is absolutely. To take the patient to theater, you have to urgently surgically explore them within 4 to 6 hours, usually six hours. Um, is your normal so viability window and depending on what you find is what you do. So if it's a viable testes, you would fix it. So orchidopexy and you typically fix both testes so that the other one doesn't tour as well. If the testes is not viable, then you would take it out, sew orchidectomy. And when you consent someone for, um, their procedure, you have to tell them there's a risk that you could proceed to orchidectomy. All right, um, and then, in terms of torsion of the hydrated of morgue agony, um, it's a remnant. It's the sort of testicle appendage you get. The top of the test is it's a remnant of the malaria duct. Um, on examination, it's you you don't cause it doesn't really give you very much erythema. Um, it's the testes is a normal lie. It's not high riding, and you might get this blue classical blue dot sign, Um, on the upper half of the Hemi scrotum, which is basically, um, it's it's the infarcted hydrated, basically coming up as blue on the on the top. It might present similar in a similar way to the testicular torsion. But as as we sort of discussed in the previous question, there are some differences and then in terms of epididymitis epididymo-orchitis orchitis so they're also put under the same bracket of things. Um, there's a bi modal presentation for these. Um, it's either split into young males, which are classified as under 35 or older males over 35. Younger males are the sort of mechanism, if you like. Uh, the organisms, um, involved tend to be S t I s, um, so gonorrhea, chlamydia and older men tend to be the enteric organisms from UTI s. They have a slower presentation. As I mentioned before, you'd still get a unilateral severe scrotal pain. And to be honest, I have seen some patient's, um that have presented that I've been referred to me as a query torsion. But the history is what tells you it's epididymitis. Um they'll be swelling. There'll be erythema. The patient will be sort of systemically showing signs of infection like fevers. You'll have some urethral discharge or dysuria. Remember that the younger patient's will may also have concurrent S t i s, um you will have a cremasteric reflex in that, um, in that patient with Epididymides itis and a positive praying sign. Management is largely with antibiotics again based on trust guidelines. But usually they have two different antibiotics, depending on whether they're targeting the SDI, Popular young males, population or the older enteric organisms. And classically, they tend to give doxycycline, Vesti eyes and ciprofloxacin. Um, for the enteric organism. If it's an S t. I remember that they need to have sort of re thel swabs and referral to Garden Clinic for contact tracing and all that. So, yeah, um, fine. So we'll move on to sort of scrotal testicular lumps, and we'll start with a question about a four year olds. Some of these questions I won't go into sort of huge amounts of talking about it because it's just pattern recognition of what comes up. So once you've seen so these types of questions before, you just know the answer. There's not a whole lot of background knowledge to it, but there you go. Anyway, Uh, you have some answers. Option one is the winner at the minute. Okay, great. You already know that one. Fine. So, um yeah, any sort of child that presents with hydra, uh, hydrocele, which obviously, this is because it trans illuminates, um, is usually due to patent processes. Vaginal ease. Um, sometimes that tends to sort of resolve by itself, but by two years, if it's not, you have to go with surgical X sort of surgical management. And usually you do it via an inguinal approach and not a scrotal approach because you're trying to identify and then litigate the processes. Vaginal honest. So yeah. Fairly straightforward. Next question. Trauma case You like. Okay, this one should be fairly straightforward. Well, do we have some answers? Yep. Tomato seal is, um, almost unanimous. Favorite. Good. All right. Um, so, yeah, that's the right answer. So, anywhere you've got sort of trauma to, uh, trauma to the scrotum is there's going to be blood. Um, it's the only thing with this is blood. Once it's sort of sat there. It forms a clot. It forms a hard mass around the testis which usually sometimes cut off. If it's been a little bit of time, you can't actually separate it from the testing. So it might seem like quite a, uh, tumor like structure, So that will need sort of surgical exploration. Um, but yeah, that's all you really need to know about the hematocele. Um, this is about a left sided varicocele, All right? The benign Squirtle swellings are fairly straightforward, So hopefully you guys know about this already? Uh, h Okay. Oh, I figured out how to see my own answers so I can see them myself. Don't worry, Rob. Right? So most of you have gone with option one. Actually, it's been a actually three ways. Split between 12 and five. Interesting. Okay, so the main one is so the correct answer rather is abdominal ultrasound. So at the beginning, when I was talking about the drainage of the gonadal or the testicular veins, there's a difference between the left and right side. Um, there is a significance of the left sided varicocele. So because the left testicular vein drains into the left renal artery rather than the IV, see if there's any obstruction in the left sort of kidney. If there's any tumor's, it will compress very easily the left testicular vein, which would then cause backpressure and cause a varicocele. So in that sort of setting, you cannot safely discharge the patient. Um, without having done an ultrasound to look for a renal mass, and it's you wouldn't, uh, the reason sort of one isn't The best answer is because normally for a varicocele, you don't do anything. So it's sort of a standard, um, sort of a benign varicocele, if you like, unless it's causing significant amount of, um, sort of quality of life problems. And the patient's really struggling with it, which it shouldn't do. If it's sort of a just a benign varicose, see, or you don't actually take, you don't actually surgically manage them. You just leave them. Um, so the only time you'd manage the left side of various e or is if there's actually compression of it because of another um, another reason. And therefore you'd actually deal with that problem and not the varicocele. All right, So, uh, this next one is just, uh, uh, a weird one, if I'm honest, but I'm worried. Okay. Something. All right, So 50% of you said Leydig cell tumor and then 25% 25 between the first two. So yeah, this is a Leydig cell tumor. Um, there's not a whole lot I can say about the reasoning for it. It's just some people who have Leydig cell tumors. Apparently present first with kind of capacity of the before, they even have a nodule on their left testis. It's one of those things you're just going to have to store away is a little nugget for part A. That sometimes comes up. There might be a few of those. Um, it's not. It's just like random facts that you need to remember. So this is just one of those. And then I think the last one for this section, um, is about a painless lump. Okay, just stop in about five seconds, so this is okay, So there's been a sort of a split across all of these, so I'll just go through this a bit more. So, um, correct answer is, um, orchidectomy via an inguinal approach. So from this sort of questions, then you know he's got a testicular cancer. Um, so in any sort of suspected cancers. Um, especially of the testes. You should avoid doing biopsies. Um, it's just you don't You don't biopsy. Um, f n a nothing, Um, for the test is because usually you have to put a needle through the scrotum into the testes, which means, on the way back out your seeding it. So this and that and then your scrotum is actually drained by a different inguinal. Sorry. Different lymphatic channels than your testes would be. So your test is goes to your para-aortic nodes and your scrotum goes to your inguinal lymph nodes. So you try and avoid contaminating, um, those lymphatic channels. So the best thing you do in terms of investigating is an ultrasound and bloods, as this question stem have already told you, and then in terms of what you're doing in terms of management is you're just removing it. So it's orchidectomy, and the same principle applies, um, as I mentioned earlier between England and scrotal scrotal approach because of the scrotal approach. You're then contaminating lymphatic field. So you're contaminating two different lymphatic fields, whereas if you go in via an inguinal approach, you're basically going down the inguinal canal, and that is its own channel. So that is your best way to get proximal control of vessels, lymphatic channels, all of those things. And you do not want to contaminate, um, the scrotum and seed, um, cancer cells onto the scrotum. All right. Okay. So I'll do a little bit about testicular cancer before I start on sort of testicular cancer. I'm just going to do a bit on cryptorchidism. Sorry if I said that in a really awkward way. So cryptorchidism or understanded? Milder standard testes, um, are massive. Massive risk factor for testicular cancer also increases the risk of infertility in the mail. Um, classically associated with preterm birth, low birth weight, positive family history. If you've got hormonal abnormalities, other sort of developmental disorders, and normally you let infant because they would have they would have noticed a sort of understanded testes at birth or within their first sort of, uh, baby checks. Um, but you normally let the test is naturally descend until about six months of age, after which they're just the chance of them descending back and sort of naturally is very low. So usually you set them up for an orchidopexy anywhere between six and 18 months if they have a delayed presentation of understanding or milder Standard test is so I'm talking like in their teenage years, early adulthood. You wouldn't just, um, fix those test is because there's a really, really high chance that those are now, uh, that there are increased risk of testicular cancer. So it's just safer now that this the testes have been sort of either anywhere in the abdominal wall or the, you know inguinal canal or anything that it's just safer for them to be removed. So that's if you have a 20 year old who presents with amounts. Undescended test is the answer is orchidectomy. Um, this is sort of where you'd find the testes, if you like in a either a sort of a true mild descended testes. So this is a long the inguinal canal on on. It's sort of natural route down into the scrotum. And then these are sort of topic locations where you can find, uh, the test is as well. Um, and you'd explore all of those. But you obviously, you have a scan first, so you probably know where you're aiming for in terms of testicular cancer. It okay as a sex called gonadal struggle Tumor's um So the vast majority is either seminoma zor teratoma as seminoma as tend to our most common. And they tend to because you buy testicular counts also has sort of a by model. Um, presentation. Seminoma is tend to be in the older age group of 30 to 40 years, where it's teratoma. So, um, tend to be in younger 20 to 30 year olds. I've highlighted the tumor markers that are relevant for both, So you'd always get beta hcg um, alpha feta protein. More common territo, HMAS and LDH is typically in seminoma is, but it's not massively specific. You can other things like L P, but again, not specific the type of, um at all. Um there were a couple of questions. Um, I noticed about the histology of seminoma. As again, it will be one question. So not a massive deal if you don't know it. But the majority of seminoma czar classical i e. They have limb Pacific, um, infiltrates. Um, therefore, that would be the most common histological type you see for a seminoma. The others are less really rare, actually, um, other forms of semi non-seminomatous germ cell tumor are things like yolk sac, tumor's choriocarcinoma and embryo and carcinomas. Again, those are far, far less common in terms of how you invest. It can become. So, as I said before you do initially a scrotal ultrasound, and then you'd want as you would face, so at m d t hold it. You know, markets, etcetera, exercise of lung, colon, a lot of pancreas, Uh, and to avoid cross contaminating the field. All right, so now we'll move on to renal, uh, stones. Basically, it's there's about five. M. C. Q s in. This should be fairly straightforward. Um, okay, that's about 30 seconds. So I'm just going to stop. Yeah. Okay, so most of you've chosen the first two. So most Commons calcium phosphate, which is the correct answer. So, um, most radio dense, Um, on a plain X rays, calcium phosphate, Um, followed by calcium oxalate. Um, and then your kassid is the most radio lucent type of stone. I've just put the percentages up of, like, most, um, common composition of stones, if you like. So majority of, um, renal stones are calcium oxalate. Um, and then fast or below that is or the other 16 stones in particular are the least common. Um, I just wanted to mention a little bit about struvite stones because there have been a couple of questions, uh, about staghorn calculi and the composition of that. So staghorn calculi almost always struvite zones because of the chronic infection. And you get these urease producing enzymes, you get ammonia, and then you basically get struvite. So just I don't want to put a whole separate question on that, so I just mentioned that in that. All right, next question. I'll just give you a second to read that. Um All right, guys. Okay. Should be a fatty, quick one. So I stopped that one there. Um, so have a bit of a split between the middle three. So, Proteus, Klebsiella and E. Coli, um, correct answers. Proteus. Um, I don't have a whole lot of, uh, background knowledge as to why staghorn calculus is a so the Proteus. It's just one of those things. Um, so, yeah, it won't. Yeah, it's just it's Proteus. Um, it'll be one of these questions. It will be. There's a lot of questions about this, actually that come up. So, um if you just remember that, that gives you a lot of stones. So, Proteus and staghorn calculus, which are struvite stones so that you can cover all your staghorn calculus questions. Next question is a little bit longer read, so I'll just give you a little bit of time, Okay? All right. That one. So, um Okay, 80% of you said insertion of the nephrostomy. 20% said you're a tear extent. So, uh, yeah, it's insertion of Neff. Um, this question is essentially about a septic obstructed. Um, you're sort of septic obstructed urinary system, if you like. So the priority in this, um, scenario is not to remove the stone. It's to relieve the obstruction and relieve the cause of the sepsis. So you have to just It's just decompressing the system. Basically, it's not about removing the stone. Um, yeah. So yeah, fine. Um, another little. Another question. I think there's two in. This might be the last one actually about on this topic, and more than that. All right. Okay, so, um, majority of said extra corporal Shockwave lithotripsy, so Yeah, correct. Any stones under 10 millimeters? You can try for, um, Shockwave Lithotripsy. Basically I will, at the sort of end in a couple of slides time go through sort of the full management as personal millimeter of stone and what you would do, Um, if, for example, with this size of, um, a stone, you cannot do lithotripsy, then you would sort of goes for your a Tosca p. Um And then sorry. This is the last one on sort of renal tract calculi and stuff. Okay, right. So we've had a 60% of you say TCC and 40% of you said squamous cell. So So I understand why the majority of you said transitional cell carcinoma because it is the most common, um, type of sort of renal cancer and most euros or urinary tract. However, the part of this that you need to, um, focus on here is this longstanding staghorn calculus, which basically means they have had a chronic irritation and a chronic inflammatory process going on. Um, likely chronic chronic infections, recurrent infections, which basically pro owns, uh, predisposes the patient to squamous cell carcinoma and not transitional cell carcinoma. I will touch on this when I come on to the bladder cancer section. But essentially, if it was. If it didn't have a staghorn calculus there, the answer would have been transitional cell carcinoma. But because there's a sort of a focus of infection that's chronic and there's an element of chronic inflammation, the more likely, um uh, sort of causes squamous cell carcinoma. All right, so just to recap a little bit, um, I just wanted to sit highlight here at the top. So if there's a you're a Terek obstruction. So an obstructed Sepp infected system, that's a urological emergency. Which means you, as I said in the previous sort of one of the questions, it's not about sort of retrieving the stone. It's about decompressing the system. So you can either use the nephrostomy or you're a tear extent, um, in an acute setting when you've tried other things, Um, a stent is probably not the best way to go. Um, you could go with the nephrostomy because you know, your decompressing that system as you put that nephrostomy in, whereas with a stent, you you're still sort of waiting. It may may not work, and you have to still get it around the stone. All right. In a non emergency setting, all of these, um, things I mentioned on the side. So extra corporal Shockwave Lithotripsy, the percutaneous nephrolithotomy and the ureteroscopy are all first line options of what you do. So most stones under five millimeters will pass spontaneously within a couple of weeks. You normally give the patient some analgesia, you could give them tamsulosin, and it should pass by themselves, and they should have no problems. If it's a renal calculi and it's sort of somewhere between five and 20 millimeters, you could do extra Corporal Shockwave Lithotripsy. Um, I'm actually Do you know what? I'm just gonna go, Uh, you might. You guys can't tell me, but I'm just going to go through what all of these things mean, because I'm not sure everyone understands that. So, um, extra corporal Shockwave lithotripsy is where you've got your you're generating shockwaves external to the patient, so there's no sort of needles or anything put in the patient. It's generated outside. And then the air bubble bubbles and the mechanical sort of stress of the, uh, shockwaves fragment the stones and then those fragments are then collected. Um, either they just pass out sort of past the stones themselves or they go and sort of fished out if you like. Percutaneously This nephrolithotomy is where, as you suggest, percutaneous So you pop a needle straight into the renal pelvis or some kind of drainage system. Um, and you're then doing an intra corporal generation of shockwaves, if you like. So the same thing you're fragmenting, um, stones, but you're sort of directly doing it. Um, instead of doing it sort of external to the patient. Ureteroscopy is when you put a scope in retrograde so through the urethra bladder up the ureters into the renal pelvis. Um, and you're using either, um, I think it's pneumatic or laser to fragment. Um, the stones again, the fished out, um, or they passed spontaneously. So yeah, sorry. Going back to this, um, you'd either use that and then renal calculi if they're really big, so more than 20 millimeters or it's a staghorn calculi you. There's no point even trying to do the the extra corporal way, because already it's a quite painful process for patient's. They suffer a lot during it. They have to have a lot of analgesia, so it would be very tiresome to do that for such a big Stone or even a staghorn calculus. So you do the percutaneously method, Um, and then a Euro Terex calculate is obviously much easier if it's bigger to fetch out via ureteroscopy. All right, so moving onto prostate, this part of the presentation vegetations the next sort of last bit that's left is a bit quicker than what we've been through. So hopefully shouldn't be too long now. So, um, first of the I think there's only three questions. Prostate. So let's go ahead. Okay. All right. Well, all of you said prostatitis. Good. Um so I won't talk too much about that. Basically, you can tell it's a distal problem, because, um, there's hematuria at the end of his urinary stream. So it suggests there's a distal problem. And there's some puss at the meatus as well. And obviously, his classic sign of prostatitis is a tender prostate on P. R. Normally needs about four weeks, um, of antibiotics. I think they normally give ciprofloxacin. Next question about BPH. Okay, I'm going to start that one there, actually. Okay. So had a bit of a split between the posterior and the media lobe. Good thing, because those are the only two lobes of the prostate. You actually need to know anything about, um but in this case, it's the median lobe. So, um, the rest of these, right? Left, anterior. You just ignore those. The nothing significant happens in them. Um, bph happens in the median lobe, and prostate cancer happens in the posterior lobe. So some way of remembering that. But that's essentially the only two loads you need to know. And Yeah, All right. And then this is the last question. Um, um, sort of prostate because they usually do have a couple of questions about the the meds, actually. Okay, so, um, 60% of you said finesse to ride 40% said tamsulosin. So, Yep. Those are the most two common drugs used for BPH. So, uh, that basically takes out the other three. Um, with this, with the reduction of your urinary retention, it is finasteride. So finasteride or alpha five alpha one reductase inhibitors essentially work by acting to reduce dihydrotestosterone. Um, and that because of the reduced amount of hydro testosterone, you reduce the volume, um, in the prostate, which therefore means that your risk of urinary retention is much, much less because you've actually got a smaller prostate. Um, tamsulosin or alpha blockers generally actually work on the smooth muscle around in the prostatic urethra, um, to prevent sort of spasm and sort of relaxes that smooth muscle. So patient's tend to get faster symptoms with symptom relief with that, because they act fairly quickly. But it wouldn't necessarily reduce your risk of urinary attention. Vanessa Roid. Um, they takes about three months to work, so it has a slower onset, but it has a better long term, Um, because of the fact that it's reducing the volume of the prostate has longer, better long term outcomes. Right? So I'll talk a little bit about BPH, um, and then prostate cancer. So etiology of BPH is really not well understood. The reason we use finasteride and things is acting on DHT is because it's supposedly be the cause of BPH is because you've got increased levels of DHT, DHT, um, or even just simply a higher estrogen testosterone ratio. So, um, symptoms can be split into filling or voiding symptoms. You'll know that you can get frequency urgency nocturia, um, or, you know, your terminal dribbling and things. How you assess patient with BPH is a full examination. Full history. You do A D r a. Um, you're in debt to rule out any urine. Uh, UTI, you do a P s A. Even though it's obviously quite pours marker but can be used for, uh, surveillance. If you are concerned about the prostate on a Dre, you would send the patient for transrectal ultrasound and plus minus biopsy. Um, that would give you sort of a definitive idea. You typically don't do that for BPH. You'd only do if you're concerned about malignancy. Um, you could do a voiding charts, your inflammatory. All of these things. Management for BPH can be split into conservative medical and surgical. Um, conservatives like standard things like lifestyle. So, um, increased exercise, improving diet, um, stopping, smoking, obesity and all of those kinds of things. You can also work on bladder training. So usually a lot of patience with BPH um, suffer with nocturia at night, um, and sort of polyuria during the day so you can do go on bladder training courses that sort of help with that and sort of keeping a diary and things like that. We've already talked about the medications that alpha blockers like TAMSULOSIN or, um, finessed a roid surgery. Typically, almost all nowadays is to u R P um, there are sort of complications of T u r p um, that may come up in the exam. So specifically, t u r t u turps syndrome. Um, I may talk about that. If not, I'll mention it a bit later. Um, open prostatectomy knees are almost never done these days. So not really. It's never really going to be the answer to any other questions that you get prostate cancer. Um, risk factors, wise eyes fairly straightforward. Um, increasing age. As I'm sure you all know, people die with prostate cancer, not with, uh, because of the African Africa rib Ian Ethnicities are increased risk. As with anything family history, obesity, diet, smoking, things like that. Things you could get asked about for prostate cancer is usually about the Gleason score, which is a history histological grading system for prostate cancer. So, on a biopsy, what happens is they would take your most common histological pattern that comes up in that biopsy and give it a score between one and 55 being sort of the more severe, less well differentiated if you like, and then they take the second most common pattern and also score it one out of five. And then you'd get a total score out of 10 to the higher the score, um, out of 10. That the worst. The prognosis more sort of the poorer. The differentiation and such management as with any cancer, will always be via an M D t approach with prostate cancer. There's lots and lots of options. What you do so you could do watchful waiting and active surveillance. That would be based on sort of if you've got no metastasis, um, of small, like a fairly, um, small, localized lump and, um, one if the patient is maybe a bit frail and not fit for anything much, or if it's just small enough and, incidentally found, and you could sort of take it like that. But it's not often done in a prostate cancer situation. Other options are radiotherapy. Brachytherapy Um, which is brachytherapy, is essentially inserting like seeds or something I can't fully remember. But it's seeds into the prostate, and it works from internally hormone therapy, so people you'll see, I'm sure in hospitals as well. Got people on Gaza really in, which is an LHRH agonist. Um, surgical management. You could do it to U R P Often the margins aren't great. Depend again. It would depend on how big the cancer was. Um, or you could do a radical prostatectomy. Chemo. You can't treat prostate cancer specifically with chemo. It has very poor, um, sort of. It's not very effective for prostate cancer. Radiotherapy is better, but you could use chemo for mets. Um, I mentioned a couple of the T. U R P complications that could come up in the exam. So standard things are bleeding urinary retention, which is why you often leave a catheter in situ and patient's comfort to u R P. Um, because you don't have a prostate or reduce volume prostate. There's risk of retrograde ejaculation and erectile dysfunction. T u r p syndrome has come up in exams before, So essentially it's caused by these, um, glycine rich hypotonic, um, irrigation fluid. The other alternative to doing that is, if you've used more 0.9% normal saline if you have, if you think your procedure is going to be longer than an hour, then you should not really use the guy seen, um, which, um, irrigation fluid. You should use hypertonic saline or just try and keep it under an hour. You get a severe dilution of hyponatremia as a result of this, um, and then you get all the symptoms associated with hyponatremia. Um, but yeah, that's essentially, uh, t u R p syndrome. And then we've just got a couple of slides left on, uh, bladder and renal cancer. Bladder cancer is more of a bulky one than renal cancer. So there's only two questions, guys. So, um, last two questions on this. Okay, so we'll stop that there. Yeah. So you've always had polycystic kidney disease. Good. Again. There's not a whole lot. Um, I can say about this. It's one of those pattern recognition type questions. Um, but family history of subarachnoid hemorrhage. Um, and basically having renal disease, Um, polycystic kidney disease, fed, straightforward there. And then this is the last, um, last question here, which again should be fairly straightforward. All right. Okay. So we've had mostly transitional cell carcinoma. A couple of people said nephroblastoma. Few people said, Andrew, my life Homa. Okay, so, answering this is transitional cell carcinoma. Um, this is a fairly sort of standard presentation of bladder cancer, so sorry, Um, any sort of kidney ham. So if you like, so hematuria textile industry left flank. Um, mass. That's transitional cell carcino. It's got all the risk factors, whichever, but I'll go through in a minute. Um, the other ones will have. Uh, yeah, it's This is just bog standard. Um, textile. Don't overthink it. Um, textile industry hematuria transitional cell carcinoma. I'll go through a little bit more about bladder cancer in a minute. Um, just quickly the bladder anatomy because, um, I realized I didn't cover that in the first bit. Um, the blood supply of the bladder is against split, so the upper part in both male and females are, uh are supplied by the superior cycle artery. The know apart in males are inferior. The cycle artery, which is obviously easy to remember. But in the lower part of females is the vaginal artery. The nerve supplies, the bit that sometimes comes up in exams. So you have a parasympathetic and sympathetic innovation, um, of the bladder, which there's a dual innovation. So there's one part that innovates the the muscles of the bladder wars, the detrusor and then the internal sphincter. So the parasympathetic, um, fibers are essentially in charge of emptying your bladder. So yeah, so it's emptying your bladder, whereas your sympathetic fibers are about contracting your internal sphincter, um, and inhibiting the truth. They're allowing it to distend. So it's not contracting. It's it's sort of distending allowing the urine to fill. So that's your flight flight moment, because you obviously don't want to work yourself when you know you're you're running away. So that is how you remember that. So parasympathetic allows you to make sure it, whereas your sympathetic flow inhibits it. They're both under involuntary control. Your external sphincter is the only one that's under voluntary control. Um, whereas and then that supplied by the Pew dental nerve. Um, fun fact, um, the, um, women are the only ones that actually have an external sphincter. Um, so men are don't have, uh, you know, control under voluntary control. But I doubt that's gonna come in, have been an exam, but yeah, there you go. Um, bladder cancer. So, as I said before, um, in the Western world, transitional cell carcinoma is the most common 90% Um, but worldwide squamous cell carcinoma of the bladder is the most common, and that's usually due to persistent inflammation and worldwide's, and not not in Britain or any western country. It's caused by schistosome Oh, a huma to be, um, and it basically causes a squamous metaplasia because of the chronic information in the UK If you have squamous cell carcinoma, it's because of the same mechanism where you get chronic information. But the causation of that is usually things like staghorn calculus or a long term capita causing that persistent sort of inflammation. Um, as I mentioned before, these are the standard risk factors male sex, smoking and an occupational exposure. Those are your bits that you will find in the stem of any question that will try and tear you towards transitional cell carcinoma. Painless hematuria is the most common, Um, presentation. It's your red flag symptom that you'd get on a two week wait. How you'd sort of proceed with that is you do your almost initial work up, but in terms of diagnostically, the patient would go for a two week wait. Flexible cystoscopy plus minus biopsy. Um, and then they would have a CT urogram to visualize the entire sort of urinary system to see if there's anything if it's not in the bladder. Is it something else? Where, um, renal cell carcinoma. So there's Sorry this is slightly worthy. Um, slide, But I just couldn't find a whole lot of questions that I thought encompass things. Very well. Um, renal cell carcinoma is, um, the most common form. You get adenocarcinoma of the actual renal cortex. Um, and you typically get them in the upper part of the kidney. Um, sometimes they might ask you about the histology or microscopic appearance, which is a pol a he DREl clear cells. So clear cells renal. Um, uh, in renal cell carcinoma and you can get this dark stain in nuclei and you get, uh, lipid, lipid rich, um, and glycogen rich side to plasma. All right. Other parts, um, other things. A nephroblastoma. I think that was one of the answers in the previous questions Is a Wilms tumor in Children? Um, so you'd only get that as part of a will Sort of a renal mass and a child will be a Wilms tumor, for example. Um and then we already talked about sort of SEC because of chronic information. Spread of our CCS are usually because spread directly into the perinephric, um, tissues, adrenals, um, and the new local sort of, um, renal vein and the ivc. Um, the renal cell carcinoma is one of the few that can spread to bone. It's one of the five that can spread to bones. It's important to remember that. And then, as I said, all you know trust, um, anywhere in the urine, no system the presentations fairly, um, symmetrical. With hematuria, you'll get lethargy, weight loss, and you can get masses as well in the kidneys. All right, um, management is typically divided on whether it's localized or metastatic. I don't think there'll be a whole lot of questions about this if I'm honest. Um, but, um, there's you can, either. If it's a localized cancer, you you can either do a partial or radical nephrectomy, depending on how big the tumor is. If it can be sort of a segment of the tumour, uh, segment of the kidney can be removed, or if it's involved in multiple segments or the sort of renal pelvis, it might be that the whole radical whole kidney has to be taken out. Um, these sort of less, um, surgical management. I've not really seen that done, but apparently you can do that. If you've got hemorrhagic disease, you could do a renal artery. Embolization via i r chemo, Um, is as same as prostate ineffective. Um, even for metastatic disease, sir. Typically, you do a nephrectomy with immunotherapy. Um, you can use biologic agents, and you can also remove sort of individual mets. So, for example, if there's renal, um, Mets to the to the lungs, you can just take out that segment that that met. If you like to call the meta step to me. Um, so, yeah, I think that was pretty much everything. Um, I don't have anything more to had. If there's any questions, I'm happy to take them. If not, that's the end. Please do put your kind of questions for her ending the comments. But thanks for everyone for coming. I've put two forms ones the feedback form. So please give her into some feedback for her presentation and a link for next week's event, which is going to be trauma. A. T. L s So Yeah. I'll stick around so that everyone can put fill the feedback form out. Thank you very much for Wendy. Okay. I think you managed to watch a better football. It's two nil for those who are interested. England. Yeah. Yeah. Next week's session does not clash of any home nations. Especially now Wales are getting knocked out. I should have thought about that when you scheduled it. I really should have got some. Thanks. In the chat, some people are still logged in, so I assume you're doing your feedback form, so keep the session running like I can't see anything a little while. Uh, there's just some people telling you that you did a wonderful job. Oh, thanks, but no question. So you obviously have covered everything. Okay. Sorry. I realized how to get the whole thing up, but it wasn't coming up initially, so but it's fine. I figured it out so that you could have some uninterrupted time. A tree? Um, where is it? You could see it. So essentially, when you start it, you have to close it, and then it comes up at the bottom once it's closed, but it comes up under two tabs you've got, like, an open and close and then the actual question. So you have a lot of scrolling up and down. Okay? I initially I didn't see it because it just came up with zero. It's not like a live. You can't see it when it's open. You have to close it in order to see the Okay. I'll, uh, I'll pass it on to the next presenters. So for me, I can just see it on messages. It comes up and fills up. Those people are answering. So for you, you can't see it unless they close it. Yeah, so it's everything zero, and then you close it and then the results are there, so you can't tell like how many people have answered and stuff. So that's why I was just paying a time on it, because I just didn't know how many people had answered. I see. I see. I still have some people logged in, so I'll stay in for five or 10 minutes to give people a chance to fill out the feedback form. But we don't have any questions in the chat. Excuse me. I hope you haven't caught your cough over over the Internet. Yeah, Yeah. Mhm. Mhm. Okay, just a few more people around now. So I think, um, I think I'll stop the session, but people can still fill it out. Um, and I can email it out to everyone, and then we've got We've got eight feedback so far. This is still should be a few more. Who? I haven't done it. No. Okay. Well, thank you very much. No, that's okay. All right. See you. Uh, see your work. Good bye, then. Bye.