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MSRA Prep Series: Day 4- Urology

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Summary

Explore an in-depth hour long presentation on urology with registrar Bronte Pace. Bronte will discuss critical urology topics associated with MSRA. She'll offer a comprehensive overview on a range of subjects, starting with pediatric urology, discussing ailments like undescended testes, testicular torsion and issues concerning pediatric surgery. You'll gain an understanding about the causes, potential risks and available treatments for each issue. She'll touch on other critical topics like lower urinary tract symptoms (LUTS) frequently seen in men and delve into their causes and available treatments, including conservative management strategies and prescription medications. This presentation provides valuable knowledge for any medical professional seeking to expand their understanding of urology related medical cases.

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Description

Recap Recording

  • Day 4 (17/11/24) - Urology, Paeds, Neuro, Haem, Psych

Learning objectives

  1. To understand the pathophysiology, clinical presentation, and diagnostic approach of significant urologic conditions such as undescended testes, testicular torsion, and phimosis.
  2. To learn how to examine a patient with suspected urological conditions, including conducting proper physical examinations and interpreting clinical findings.
  3. To understand the management and treatment strategies for common urological conditions, including surgical and non-surgical interventions.
  4. To appreciate the importance and implications of early detection of urological conditions, especially in pediatric patients.
  5. To learn about lower urinary tract symptoms (LUTS) and modulation through lifestyle changes, medications, and possible surgical interventions.
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The following transcript was generated automatically from the content and has not been checked or corrected manually.

Um sorry for the delay. We had a couple of technical difficulties, so we've just put together something we have. Our next speaker um is Bronte Pace who's a urology registrar, who's gonna talk to you a bit about some of the urology topics that can come up with M sra. Um So I'll turn over to her. Thank you CJ. Um So I it's quite an extensive topic, urology. Um And I know you get examining quite a lot of stuff. So I'm gonna do a whistle stop tour of, of most of what we can in the next hour with urology. Um I was gonna start with pediatric urology. Um So we just do the torsion slide CJ at first. Um I'll talk about undescended testes first though. So, um undescended testes are um where the testicle doesn't descend into the scrotum. So, testes uh first form in the embryo in the abdominal wall and then make their descend down the abdominal wall through the inguinal canal and then into the scrotum. Um And sometimes this doesn't happen. Um This is for a variety of reasons, but the, the main thing is that we get a bit concerned of the higher risk of testicular cancer in the undescended testis. Um It's about a 3 to 5% chance, increased chance of getting a testicular cancer if you, if you have an undescended testis, and if it's not brought down into the scrotum by the first stages of puberty, so around 11 to 13 years of age, um then it, it increases further to around 6%. If you do bring it down before puberty, then it remains about AAA 2% extra risk of getting a testicular cancer. So we do when we bring the testes down, ask the patient to examine them on a regular basis. Um So how we bring it down is um we find where the testicle is. So most commonly, this is in the inguinal canal, which can be palpated, which is fine. We know where that is. Um if it is in the inguinal canal, then we open up the inguinal canal. So um like a inguinal hernia incision, you make an incision over the inguinal ligament um via the testis and then you literally just poke it down into the scrotum and then secure it down into the scrotum that's even with the Orchidopexy. So, suturing it with a three point fixation, um or you just form a Dartos pouch. So where you make a, a small hole in the dartos um pop the testis in there and then just due to fibrosis with inflammatory reaction, it, it stays there. Um So the main point we have an under understanded test is, is that we pick it up early enough. So the, uh, male baby scrotum should be examined in the NP exam. So, when they're first born and then on their first baby check as well. So by the GP, so there's two stages there where we should be examining for, er, whether the testis is undescended or not. Um, if, if it's not present, um, especially by the, by the age of 11 where they should be, they should technically be descended by the age of two years old, but by the age of 11 then we should have fixed it down into the scrotum. Um, so that's the undescended testis that, that and Formosus are the most common presentations of pediatric urology to the urologist. I know the pediatric surgeons get more. But, um, we, we deal with undescended testes and for Moses really. Um, but the, the main thing that we see and then the main thing that we worry about is, uh, testicular torsion. So this is quite common in the adolescent age. Um, it's uncommon below the age of 11 and it's really uncommon above the age of 30. So if you see a gentleman with a painful testis above the age of 30 there's a less than 2% chance that it's going to be torted, it's going to be infection or something else. Um, but, um, as the image shows here, this is the the testicle and this is how it twists on itself. So a torsion is when there is more than a 360 degree twist around the spermatic cord. So thoracic cord, obviously, it holds all the blood vessels. So the testicular artery which supplies the testicle um as well as the venous system. So you get both the lack of blood supply and congestion. When it twists on itself, there's two types of testicular torsion. So there's extravaginal torsion. So outside the tunica vaginalis, that's the most common in the adolescent. Um and the intravaginal torsion um which can be seen in the neonates. Um So they're both shown there. Um The a common predisposing factor to um having a torsion is a bell clapper deformity, which is shown on the far right there. So it's where the epididymis lies um on top of the testis. So it's a 90 degree lie than it should do um as you can see in the other pictures. Um So the treatment for a testicular torsion is a scrotal exploration. So this should technically be done within six hours of when the pain first started. Um They, they do have a 12 to 24 hour window where it's likely to remain viable though, but six hours is the aim after six hours, then then there's tissue that that dies. Um But you take him to theater. So it's an urgent procedure, take him to the theater. Um And then open up the scrotum. So you go through the layers of the scrotum um and then deliver the testicle. If it looks like a normal testicle, you pop it back in, you don't do anything. If it's a torted testis, then you have to un tot it. So twist it back in the other direction and then do a three point fixation. So um that's either side, left and the right lateral, medial and then at the bottom. So the inferior end, so then it can't twist again. Um We do also if it looks like a normal unor twisted unted testicle, but it has a bell caper deformity. Um It, it is um advised to fix both sides because as I said earlier, it makes it predisposes you to having a torsion. So if you see a bell clapper, you fix both sides, both testicles are delivered and fixed. Um So that's torsion. Um It's pretty self explanatory. The testicle twist, you need to untwist it. Um The other thing as I say, which is common in pediatric surgery is a phimosis. Um So that is a type foreskin. It's different to a paraphimosis which older gentlemen get, which is where the foreskin gets trapped behind the glans penis and then forms a swelling around it. So that is different to a phimosis. Um but the treatment for phimosis, um uh so we could just leave it. Um If the patient isn't having any issues, then we just, we just leave it in particular, if the patient is before adolescence, they're very likely to, it's very likely to stretch back when they reach puberty. So we don't, we don't usually do circumcisions before puberty. Um If, if it becomes bothersome for them or they're getting lots of, um, balanitis, zero obliterans of BXO and then we can perform a circumcision at that point. Um But mostly it is conservative management management of um uh salt water bar. So that helps um and uh just put Vaseline around the area um to stop it, causing any abrasions. If that, if it's still causing bother after this conservative management, then we can use a low dose steroid cream. So this is either hydrocortisone or betnovate. Um And if that's not working, if it's becoming bothersome still or they reached adolescence and it's still tight, then it's a circumcision to treat the formosus. The circumcision is removing the distal end of the perfuse um and then suturing it to the corona. So the base of the Glans penis um so that the head of the penis is exposed. Um So that's it for pediatric urology when it comes to urologists, as I say, uh there are other pediatric that comes under P ES like cus spadius uh and other things. Um So we move on to lots now CJ. So there's a, a lot section. So lots of really, really common mainly in men, but women do get them as well. Um So that stands for lower urine tract symptoms. It's the main thing that a urologist see, there's that we, we divide lots into two types. So storage lights, I always remember with the acronym Fun. So frequency, urgency and nocturia, they've added their urgent continence, but that comes under urgency. So urgency is either wet or dry. If it's wet, they're incontinent with it. If it's dry, they're not. Um So this is where the, where the bladder holds more than it than it wants to. Really. So that's, that's the storage part of it. Um Usually in men to do with the prostate and then there's wooing Ls. So this is hesitancy, poor flow, terminal dribbling and feeling of incomplete emptying. So again, this can be due to the prostate but can also be influenced by obstructing features further down in the urethra like a stricture. Um to note as well, these are non neurological lots. So, um those that have had spinal cord injuries or have neurological um issues do have lots, but that's in a different context. Um So the most common ones we see in men are the storage lots. This is because their prostates get bigger as they get older, which is inevitable. Um The prostate tissue continues to grow. Um As long as the man has testosterone, which in men, they don't go through menopause. So they continue to have hormones until they, until the end of their days. So they continue to have a larger and larger prostate as they get older. Um So treatment of lots. So I'll go go over male lots. First, some male arts, we give conservative management as the first option. So of any, any management process that we go through, we, we start with conservative. So um reducing caffeine. So caffeine causes diuresis. So reducing caffeine alcohol for the same reason. Fizzy drinks because that actually irritates the bladder as well as Black Curran. Um, so things like ribena, we, we say to avoid because that can irritate the bladder. Um uh and then a decrease in smoking as well. Again, that's another irritant of the bladder. We advise to drink clear water during all clear fluids during the day, 2 L and then to cut their fluid intake down after 4 to 6 p.m. Um Other conservative measurements are, we could advise the patient to double void. So go for a wee wait five minutes and then even if you don't need to try and pass urine again afterwards, um just because they're likely if they've got these storage lights to have residual volume in their bladder. Um, so next on the Miralax is um, er, medication. So, er, the two main medications that we use uh and is evidence based by quite a few studies, er, is an alpha blocker, um, and a five alpha reductase inhibitor. So alpha blocker, the most common one we use is tamsulosin. Um, there's other ones as well. Aaos doxazosin, but tamsulosin is uh what is licensed for LUTS. So Tullos is uh an alpha blocker and this causes blockade of um stimulation of the muscles in the prostate. So, it's a muscle relaxant of the prostate. Um and the bladder neck. So it basically relaxes things to open things up to allow the bladder to empty through the prostate through your urethra. Um This works pretty, pretty instantly within the 1st 48 hours, they should have some effect. Um And if it does, then we ask them to continue to take that pretty much lifelong, the adverse effects. Um because it is a adrenal blockade is um hypotension. So if they suffer from dizziness or they're frail uneasy on their feet, then, then you need to counsel them on this. Um Because of this as well, I tend to e even if they're younger for some men advise them to take it at night. Um Because if they get an instant um hypotension or dizziness then and then it's at night or in bed. Um So that's the one we start with first. Um There is evidence that having the both medications together work better, but I always start with just Tullos first and then move on to adding the five alpha reductase inhibitor. So most commonly that is finasteride, there's also others including dutasteride. Um But the point of these five alpha reductase inhibitors is to inhibit the pathway of forming testosterone. It actually inhibits the formation of DHT a precursor of testosterone. Um A and this, this it stops, it, well, basically shrinks the prostate. Um because as I said earlier, it's testosterone testosterone that drives prostate growth. Um So the aim of Finasteride and dutasteride is to shrink prostate. Um the side effects of Finasteride are because of its decrease in testosterone effect. Um So it has some good things like hair growth which men do take recreationally for hair growth. Um, but it has other effects due to this decrease in testosterone, uh, like hot flushes, like what menopausal women get, um, breast tenderness, mood swings and also erectile dysfunction, which the younger man may not want. Uh, so this is sometimes reserved for, for the older gentlemen that have gone past their, past their erectile function anyway. Um, less medication and then, er, moving on to surgical, uh, surgical method. So we can catheterize the patient. We can have a long term catheter. Um, this isn't a favorable option if they're older. If they, if they've tried, um, they've tried the medication, uh, and they're not fit for surgery, then they could have a long term catheter or if they can, they can do intermittent self catheters. So that's where we give them disposable catheters to use from twice a week to twice a day, depending on how much residual they have in their bladder. Um, and then there's surgical options. So with the prostate, there's, there's loads of loads of surgery now and then it's evolving. The gold standard is a transurethral resection of the prostate. So a turp this is where the middle part of the prostate is cored out using diathermy. So we we cut away that middle part by going in through the urethra. Um Other options are resumed. So that's where we use aqua ablation. So you go through the urethra, stick a needle into the prostate and then inject steam in there. So that causes denaturation of the cells and then it eventually shrinks over a period of, of about six weeks. Um There's hole where you can take the middle part of the prostate out with a laser. Um And there's uli as well where you basically staple the prostate out of the way. So you go in through the urethra and then five staples either side and it, it brings the prostate out. Um But the gold standard and I think, which is best to know for the M sra level is uh transurethral resection of prostate for, for surgical options. Um So that's, that's lots to do with the prostate. So some of these lots as well could also be due to uh overactive bladder symptoms. So the detrusor muscle could be uh could be contracting uh when, when you don't want it to. So, uh we call it overactive bladder. Um The two types of medication that we use for that are a um anticholinergic. Um There's, there's a few anticholinergics, the most commonly used in urology are oxybutynin, Solifenacin and Trospium. Um as with anticholinergics, which we were taught at med school, they have quite a lot of side effects. So, dry eyes or dry mucous membranes, dry eyes and mouth. Um and they can um cause memory issues as well, especially if the patient has dementia, then that can worsen the dementia. Um So you don't want to overload, so you don't want a, a um, anti mascarin burden. Um, if they already have, um, if they already have dementia. So the, the one that we tend to pick, if, if they've got any signs of this is trospium because it doesn't, doesn't breach the, um, blood brain membrane, uh, blood brain barrier. Sorry. Um, so is the one to use the older population. Um, so they're the antimuscarinics after that are beta, three agonists. So, um, so beta three receptors in the detrusor muscle. So the muscle of the bladder, um, they cause, er, er, they cause relaxation of the bladder. So, um, by using an agonist, we can, we can, um, cause relaxation of the bladder. So that's, um, mirror is the most common one we use. Um, so there are lots of men, lots of women, um, are usually overactive bladder symptoms. We only have a short urethra in men. It, it's a lot longer, 11 centimeters in us. It's, it's 3 to 4 centimeters. Um, so it's unlikely that there's going to be an obstruction. Um, from bladder emptying. So it, it is usually due to overactive bladder. Um, so we go down the line of, um, overactive bladder. So those two medications, antimuscarinic and a beta three agonist. Um, with women as well, you really want to rule out any neurological course or do a full neurological examination as part of the workup and they need APV exam. Um, so that's a bimanual exam and pass by the speculum exam. They can have some obstruction if they've got a vaginal prolapse. Um So that's lots. CJ I think we're gonna move on to cancers now. Any anyone's five. But yeah, we do testicular cancer. Yeah. So this ties in with the unscented testis as well, I suppose. So, um we move on to cancers now. So in neurology we we look at so our systems, we do kidneys, bladder prostate and then male external genitalia. Um So I'll start with the male, external genitalia. So, testicles is the, the most common one we see of the external genitalia. Um This has a bimodal distribution of presentation. So it's either in the, in the, in kids and adolescents or in over 40 years old. Uh It's uncommon to see it in between. Um there's two types of testicular cancer. So they either germ cells uh or, or they're stromal cells. So, stromal cells are the cells that line the reproductive cells. So the lady cells, the soto cells, um and, and you can, you can get the granulosa cell tumors but extremely rare. Um but the most common are germ cell tumors. So, the tumors that produce sperm are involved in production of spermatozoa. Um So the germ cell tumors are um then further subdivided into seminoma and nonseminoma, a seminoma just as it is, is seminoma and then non seminoma is further subdivided into embryonal yolk sac and choriocarcinoma. Um What, what type it is um can help the oncologist after it's been removed in uh the further chemotherapy of it's metastatic. Um But for a surgical side of things, it doesn't matter too much at the stage that we look at the cancer because our aim is to chop the testicle off. Um There are uh there's some benefits to knowing what type of tumor it is though. So the we we use three tumor markers to look for testicular cancer. Sometimes people have, have a massive testicular cancer and have completely normal tumor markers though. But um there's beta HCG. So that's raising in a male. I would be concerned of embryonal or a choriocarcinoma tumor. Um alpha fetoprotein AFP. So that's producing yolk sac tumors and then LDH, which is just a marker of tumor burden is not a specific tumor indication. Um So when working out for testicular cancer, so a patient would present with a mass in their testis. Um So history examination, um the, the gold standard of imaging is actually a ultrasound within 24 hours. So, if you see them in clinic, you should really send them straight down to the sonographer for an ultrasound of their testes in the NHS. It's obviously not, not doable a lot of the time but a two week wait, ultrasound testes should be ordered straight away. Um So the ultrasound is done, um and uh will show either a, a tumor or not a tumor if it shows a tumor. Um Then at that point, we will do the tumor markers. So, before surgery, you want those tumor markers, then you list the patient for um an orchidectomy, so that tumor needs to come out and that testicle needs to come out via an inguinal approach. So we don't go for the scrotum to take the testicle out. It has to go via the inguinal canal. Um that there's, there's evidence that there, there could be seeding. Um if you accidentally breach the testicle and make the incision into the scrotum. Um but you, you find the cord via the canal, you clamp the cord, you fix it, you try and fix it. Um and then take the testicle out that gets sent to histology. Um So after this surgery, you want to do staging as well. So this most commonly used to be a chest X ray, but we tend to ii, if the patient is I is an adult, we tend to do a, a CT chest, abdomen pelvis. Um But the um the point of a, a chest X ray is that the most common metastases is to the lung and they look like cannon ball metastases. So they have, they have a hollowed out middle when you're seen on a chest X ray. Um So if it, if there's no medicine on follow up imaging, then uh we're happy that we've, we've treated the, the cancer. Most likely we do uh refer to the oncologist in case they want to give a one off dose of chemotherapy. Um If it's metastatic, then again, they get referred to the oncologist because they'll need a longer course, course of um of chemo or radiotherapy depending on where the metastases are. Um So that is testicular cancer. Yeah, please do. Put any questions I'll answer at the end at the, on the um on the chart there. Um So I think uh I'll just go over penile cancer quickly as we're on the external genitalia. Anal cancer is really, really rare. Um doesn't say that it doesn't happen though. But um it, it is, it's a squamous cell carcinoma. Most commonly, you can rarely get a transitional cell carcinoma. So, a TCC in the urethra because the urethra is made up of transitional cells. Um That then that then um moves through the penis. So people don't notice it and it will grow outside of the penis. And at that point, we would call it a penile cancer and they'd go to a tertiary penile cancer center. Um But but the main one is a squamous cell carcinoma. Um the treat well. So the management is identifying it, you image it. Um So we use MRI pelvis and penis. So the penis, uh lymphatic drainage is to the um the inguinal nose. So you want to have an MRI to see if there's any nodal involvement. Um And then you want to biopsy as well just to confirm it's a penile cancer because then unfortunately, the most common management for penile cancer is, is, is a penectomy, either partial or full penectomy. Um So, and that's done in only a few centers around the UK. Um It's a, it's a super regional MDT. So they'll get referred to one of these specialist centers where they'll have that dealt with. But um main points about penile cancer is that it's most commonly a squamous cell carcinoma and, and the management is to excise the tumor somehow either, but if it's a small tumor excising that tumor or with a partial or full. Um, so I think we just go up so we'll go to prostate, please. CJ. That's the bladder. Do you want me to do? Bladder? I think that's just the staging of prostate cancer, which I think does it quite nicely. And yeah, that's, that's, that's it. That's it. Um, so prostate cancer is really common, has quite a lot of media around it as well. There's big charities that you see lots of football players wearing a badge. Um It, it, it's common affects a lot of men. Um And there's a statistic out there that 100% of men by the age of 100 will have prostate prostate cancer cells in their prostate. Um There's also another phrase that urologists like to use is most commonly, a man will die with prostate cancer rather of prostate cancer. However, unfortunately, some men do die of metastatic prostate cancer. Um, so the, the prostate cancer we see is, is adenocarcinoma. There's very rare different types of cancers within the prostate. But in the M sra the, the answer is adenocarcinoma. Um of, of what the type of prostate cancer is. Um the, the way it's picked up is is if the man has issues like lower urinary tract symptoms. So lots we should be doing AD R so digital rectal examination. Um And at that point, we might pick up an abnormal feeling prostate. Um So they should be, they investigated for a prostate cancer. Um or some men asked for a PSA um uh or in their well man check will have a, a PSA psa done and that will pick up a prostate cancer. Um When, when it's quite advanced, some men will have it picked up when they've got metastases in particular bony mets into the spine. So they'll come in with bone pain, back pain, um or lower limb symptoms, neurological symptoms. Um So on ad um we should be feeling for the size, texture and consistency of the prostate. So, um, size, uh doesn't really make a difference to the prostate cancer. The consistency does. So, um, if it's a firm prostate all over and we would be sus suspicious of a prostate cancer. Um And then in particular, if there's nodules, we'd be very suspicious of a prostate cancer. So at that point, they should be referred to a urologist or if they're already at the urologist, then we should be doing a PSA. So, um PSA is prostate specific antigen. So this is AAA serine protease, which um is normally used to uh liquefy the, the semen to allow the, the spermatozoa to, to go through the cervix. Um So it does have a, it does have a role normally, but when there's um increased growth of prostate tissue due to the cancer cells and it increases i in the amount that's found in the bloodstream. Um So PSA is the only blood test we use to detect the prostate cancer. Um at that point, if the PSA is raised and we do an MRI of the prostate. So, imaging of choice is MRI um this gives us uh indication to if there is or not a prostate cancer and if there is the extent of it and where it is, um this imaging then allows us to target prostate biopsies, which we do transperineally. So, um the perineum, the, the area of skin between the scrotum and the back passage. We, we use a needle to penetrate the prostate that way and get biopsies. Um uh And then that is, that's used to give us a histological diagnosis of prostate cancer, which is we use the Gleason scoring system. So, um I think you probably come across Gleason scoring from med school, but we use two numbers of Gleason scoring. So um the first number is the most common grade and then the second number is the second most common grade and we use both those to add them up to give the final grade. Um So the final grade is uh from 6 to 9. Um This is a staging of prostate cancer, which I've got up in here. I think this does it quite nicely and, and, and shows how prostate cancer grows. Um So, so the stage one of prostate cancer is um something that's been clinically picked up, but we didn't feel it on ad ra. So the prostate felt normal. Um uh Stage two is that it is palpable. Uh And then that's subdivided into how much of it is palpable. Um And then T three is that, is that it is palpable in both sides. And then T four is that it has spread. Um So the point of the staging is that prostate cancer can be very small within the prostate tissue itself, grow on one side, grow to both sides and then grow outside the prostate. Um T four is is metastatic disease. It, they, they've got t four cancer, then they won't be able to have their prostate removed. Um, so the treatment of prostate cancer, um, it, it depends on the staging and it depends on the PSA and then the health of the gentleman. Um, we have two types of conservative management for men with prostate cancer. So we have watchful waiting and active surveillance. Watchful waiting is um, us seeing a patient every 6 to 12 months, doing their psa feeling their prostate every year. Um And then if they become symptomatic of a diagnosed prostate cancer, then we will treat their symptoms at that point. Um So, and then there's active surveillance which is different. Um So active surveillance is, we're not doing anything yet, mainly because they're younger men that want to preserve their erectile function. Um We again monitor their PSA and do ad R every 6 to 12 months and if there's any changes in there, so if they have a rise in PSA or they suddenly have a abnormal feeling dr which would mean they have a higher stage of the prostate cancer, then we will treat them at that point. So what we awaiting is treating symptoms and then active surveillance is treating the cancer. Um The options for treatment of cancer or uh prostate cancer or chemotherapy radiotherapy and prostatectomy. Uh Prostatectomy is removal of the prostate. Um So I think that is it for prostate cancer. I can see, I'm kind of running out of time as well. Am I, am I on to? Half 11 CJ? Yes, half, 11, half, 11. Ok. Um, so she move on to bladder cancer. That's a picture of the TR BT. So, bladder cancer. Um, so bladder cancer and prostate cancer are the two main ones that we see in urology. Uh, bladder cancer is, um, picked up when someone is referred to visible hematuria. So we don't use the term frank hematuria anymore. Um So it's visible hematuria or non visible hematuria, visible hematuria is when they see blood in the way. So this could be a rose color up into a Merlo color with clots in it. That that's all visible hematuria. Um non visible hematuria is when it's picked up on the urine dipstick. Um So they, so hematuria is when they get referred into va two week, wait to to the hospital. Um at that point, um our investigations include upper tract imaging. So, if there's non visible hematuria, we'll do an ultrasound. If there's visible hematuria, we'll do a CT urogram. So ct urogram is a CT where um the contrast dye is left for the urographic phase. So we can see the, the emptying of the kidneys to see if there's any filling defect, one in the kidneys and two in the ureter. Um So the purpose of that is that you can have visible hematuria from the upper tract. So, from a, a kidney cancer from a ureteric cancer. But you can also get it from stones as well, which would be picked up on the CT. Um So once we've done imaging, we also do a flexible cystoscopy. So that's a camera test inside the bladder. Um We do it with the patient awake. There's a flexible instrument. It, it's a bit like it, it's the same size of a 16 French catheter going in. So it is tolerated mostly. Um and on there that we can directly see the whole lining of the bladder. Um So we see an abnormality. So, as shown here, this is a um transitional transitional cell carcinoma. So a TCC, that's the most common type of cancer of the bladder lining. Um It's papillary in nature. So as you can see here, uh a and it, it has that really distinct look of it. So when you see that, that that's inevitably gonna be a, a bladder TCC. Um there's another type of bladder cancer that we uncommonly see, uh which is S CCC squamous cell carcinoma, which is most commonly due to um irritation of the bladder. So this could be with a long term catheter. So technically, those with long term catheters should have cystoscopy surveillance. Um They've got a catheter for more than 10 years um or from schistosomiasis. So that, that's a parasite that you, you get in some waters of um endemic countries. So, North Africa and part of the Middle East Um So you have a patient that's been there or lived there, then you'd, you'd want to think about schistosomiasis as well causing a sec. Um So treatment of bladder cancer uh is most commonly than not is resection. So, I it's, it's a relatively quick procedure. Um We deal with endoscopic techniques, so there's no incisions made. Um So most people can have it done. If they're really, really unwell, then they'd be the best supportive care. But if someone's fit enough to undergo a 30 minute procedure, then we will take them to theater to take that cancer out. Um So the aim of this is mostly to get a diagnosis. Um but it is also to try and treat the cancer. A lot of these cancers are superficial. So by resecting it, we can take most of it away if it's muscle invasive, then that's a different story. But at that point, we can tell whether it's muscle invasive or not because we've got that histology sample. So this picture here is of a transurethral resection of a bladder tumor. So, tur bt, so you can see there's um we either use monopolar or bipolar diathermy to resect. Um And the purpose is to just swipe through that and then take it out and send it off. Um So as I say, it's either a superficial non muscle invasive bladder cancer or an invasive muscle, invasive bladder cancer. Um If it's a non muscle invasive, then we will just, um, likely just keep them on surveillance. So they come back for, um, 3 to 12 monthly depending on the stage of that superficial cancer, um, for flexible cystoscopy. So we keep an eye on things. We do that for five years. If it's a muscle invasive cancer, um, then they will be referred on to a cystectomy to see whether they're fit enough to have their bladder removed. Um, this is quite big surgery. So we remove the bladder. Um, and then we, uh, also involve the bowel. So we need a section of bowel to form a stoma where we implant the ureters to allow the urine to drain. So they do end up with a stoma. Um, so as I say, quite big surgery. So the patient needs to be fit enough to, to undergo that and to, to deal with a stoma afterwards as well. Um, I should probably, I should have gone over the risk factors as well. So risk factors of bladder cancer, which we are taught at med school, but it is, um, the main ones are smoking. Uh, most people with bladder cancers are smokers, but there, there's also occupational risk of a mean dyes. If they've worked in factories where they, they, they've used dyes, then you want to think of, you want to think of a bladder cancer with them as well. Uh, there's also certain chemo drugs that, uh, predispose you to, uh, bladder cancer. But, um, Yeah, I think that's probably beyond the M sra um Okie Doke, then the last cancer or I should say with this as well. So you can get T CCS in the ureter and the urethra. So that whole lining, the lining of the first bit of the ureter, which is within the kidney, the pelvis of the kidney, the whole ureter and the urethra is all lined by transitional cells. So they can all undergo changes that result in a TCC. So there are all places where we can get this. If it's in the ureter, it is a lot more difficult. Um You need to resect that bit of ureter out and reimplant the ureter or they need to undergo a nephro uretectomy where we remove the whole kidney and ureter. Um right. Can you go into the renal? So it, it's just a staging cure. Yeah, that's prostate. The other one. Yeah, that's it. Yeah. Um So uh moving to the top end of the urological system. So the kidney, so kidney cancer, um it is quite common. Um we do see it and a lot of people do undergo big surgery for it. Um It's this is cancer within the parenchyma of the kidney. So as I say, if it's within that collecting system, then it's likely to be a TCC. Um So it's, it's slightly different. So, but renal cell carcinoma is, is within the parenchyma. Um this can present as visible hematuria can present as a palpable mass or can present with flank pain. Um It's not as easily picked up. So by the time we find them, they're often on the larger side. But um but the most common presentation is visible hematuria. Um So there's different types of renal cell carcinoma. Uh The most common is clear cell RCC. There's also uh papillary, chromophobe and collecting duct. But as I say, the most common that we see which is a good 50 plus percent is clear cell renal cell carcinomas. Um And these are staged on one, the size of it and then to the extent of which it's which it's moved out of the, of its primary organ. Um So in a stage, one, cancer is less than seven centimeters. A stage two, cancer is larger than seven centimeters. Stage three, cancer is where it's um moving its way out of the kidney and involving the surrounding vasculature but still remains within garos fascia. So garos fascia is the lining of the kidneys. So the kidney is surrounded by its own fat called garos fascia. Um and then T four is when it's moved outside of the kidney, uh and outside of burro fascia. So it's likely to be metastatic at that point. The um where we image renal cell carcinoma is with a triple phase CT. So we ideally want um a plain CT which we get with all CT S and then um arterial venous and urographic phase. So, it gives us a clear indication of the vasculature of this, of the, the renal mass. Um And to see if there's any um issues with the uh drainage of the kidney as well, if there's any um filling defects as we call it. Um, the, the purpose of this is that there's, there are benign tumors of the kidney. Um And we also see cysts a lot. So renal cysts um are most commonly simple cysts and a lot of people have simple cysts and we don't do anything about these. But if a cyst becomes more complex, if the, if it does have a blood supply, then we would consider this as high risk of a cancer. So that would need to be removed and then obviously a solid vascular lump in the kidney is very likely to be an RC. So that needs to be removed. Um So the way we treat, uh, uh kidney cancer is by removing the cancer most commonly. Um So this is either a partial or a radical nephrectomy. So, uh removing part of the kidney to leave some of the parachma left, if the other kidney isn't working as well as we'd like to, um, or just removing the whole kidney if we're happy that the, that the contralateral kidney is working sufficiently. Um If the patient's not fit enough for this surgery, it's a big surgery. We do it with a robot or laparoscopically mainly. Um, but it is a big surgery and, and can take over an hour. Um We can also use radio frequency ablation. So this is a procedure that's done a local anesthetic um where we inject a probe, uh and then use radio frequency to try to ablate that tumor. Um that can only be done in tumors less than four centimeters in size. But it is an option if patient is not fit for a general, a long general anesthetic. Um I think that's it for renal cancer. I mean, the main things about renal cancer is that it the way it presents. So, hematuria, uh mass and pain and that, that it is subdivided into those. The most common is clear cell and the treatment is to remove the cancer. Um I think that's it. Then is there anything else you want me to go over? CJ? I think that's all right. Um Do you want to look at questions? Is there any? Yeah, yeah, we can do that for me. So we have one from uh Shahana Yasmin. What resources do you recommend for accessing basic information on surgical urology and the content that you have spoken about today? Um So for this is foundation level, isn't it really? So there's a really good book by um Ricky Ellis. Um I, I'll find it and put it in the chart. Um But it's, it's called um Urology for um medical students and junior doctors. I used that before my core training interview um and it, and did my urology job as A, as an F one and it was really, really good, really clearly set out and just to the level that it needs to be my content today, I use um the European um Association of Urologists. Um So E au which I find really useful I use for my speciality training interview. It's probably a bit beyond the M SRA but if you want to know extra bits of detail, um they have really nice um little tables and um flow charts when you go to their condensed guideline section. So that's e au let's put you on there. I think that's it for questions. Mhm. Oh, did you find it? CJ? Yeah, sorry. That's just, that's the book by Ricky Ellis, the urology book. OK. Ok. Uh Another question, uh Vanessa Alti, what's the lifestyle like for a urology training? Just a moment? Our speak seems to have their call seems to have dropped. They're gonna try and rejoin. I think my head's back. Perfect. Um The question, there was a question from Vanessa. What's the lifestyle like for a urology trainee? Um uh It, it's, it's better than, it's better than a general surgical training. Like, like a, a lot better. It's still odd at times. But um uh yeah, it, it, it's better than general surgery. CJ. Your general surgeon CJ. Is that what you want to do? Vascular? Oh, do you, of course you do of course you do. But, um, I don't want to put any general surgeons down, but urology is less competitive. So you, you're stepping on less people's toes, which I much preferred. Um, the consultants are really, really nice people, which is one of the main reasons that, that drew me to urology in the first place is that they're nice, they're approachable, they're friendly. You can ask them anything, they'll come in when you need to. They don't have that God complex which a lot of other surgeons do. Um, you need to come in and they on calls are non residents at night again, which is really nice. So you can technically go home. Um, you do need to come in and there's a torsion and I ended up staying until 3 a.m. on Wednesday because there was a fourniers, but I've never seen a fa before. So that was, that was good for my learning. But there's, there's about three things you need to come in for overnight, which, which can happen. Um, it, it's quite busy during the day. There, there's quite a lot of admissions and it's really annoying when people call you about catheters, but generally it's good and I would recommend it. They've added a followup, which is, I hear some have on calls and some don't. Yeah, that's which I think so. Technically you, if you're a trainee, you have to be on the on call rota cos it's not good for your learning otherwise. But yeah. No, I, I've heard that as well. Um There are some places in the east midst that, that don't like Burton and, and Mansfield now. So yeah, but as I say, all in all I would recommend it if you don't mind. Especially I get a lot of because I'm a woman, I get a lot of why you're doing this because you end up putting your finger into men's bottoms and looking at a lot of penises and testicles. But um it is generally a really good speciality. I think that's it for the questions so far. Yeah. So thank you very much for coming to this talk today and I appreciate those technical difficulties. So you very grateful that you improvised and managed despite not having your slides available to get through everything. So, thank you so much. Thank you. Do you want me to? I'll put my just because there was no slides. If I, if anyone's got any question or wants to be a urologist and um I want some advice on that. Then I'll put my NHS email on the chart. Yeah. Thank you so much. All right, thanks guys. Thank you. All right, bye. Take care. Yeah, that's perfect. So folks, we'll just take a five, a 5 to 10 minute break just for our next B to arrive and get set up and then