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Hello, everyone and sorry for the it issues. Can you guys hear me and see the slides? Ok, just let me know in the chat box, please? Cool, cool, cool. So, uh thanks, thanks for joining for the talk today. And thank you for the organizing committee for having me to uh pro provide uh to give a talk on basic urology. 101 for me, me medical school exams. My name is uh my name is who, I'm currently the ST three U Urology Registrar. I'll be commencing my post in Shrewsbury Hospital in this coming October. So the main aim for uh the main aim of this talk. Something that like, uh hopefully you can take home with is to provide you with some context regarding some common neurological topics because I felt that it's not a topic that's being taught uh properly in medical school because it is quite a new specialty. It's not gonna be a deep dive into, you know, deep, a deep dive into all the information they need for exams. But hopefully this will provide you with a general concept and context to what you read on the textbook. So if I change the slide to the second one. Can you guys still see the second slide? OK. Should be on the learning outcomes. OK. Fine. So the as I mentioned, these are learning outcomes. Uh just a great overview about urology as a specialty. What do we do day to day presentations of, you know, common ureteric stones? Ureal stones is management as well as a basic understanding of pros prostate cancer in general. So, topic number one. So what, what is urology? So, urologist, we are a group of surgeons that specialize in diagnosing and treating the disease of the urinary system. So the main organs that we dealt with would be your two kidneys, your ureter bladder, urethra, as well as male reproductive organs. There's a little bit of overlap with the gynecological surgeons such as there's a specialty called which which we won't be going into today. And urology as a specialty offers you wide variety of procedures that you can, you can do. We have endoscopy procedures and we play with lasers. There's also open laparoscopic and robotic surgery that's available to you as well. In general. I think urology is a great specialty that you should, can consider and for medical school because uh you know, there's not a lot of emergencies compared to our general surgeon colleagues and it's better for work life balance and you can, there's so much things that you can do and I'm sure there will be something in the specialty that suits your interest. So how in the UK? So how do you become a urologist? The first thing is after you completed your five years of medical school, you should have done your foundation year program, which is F one and F two. And at that point, you'll be eligible for the national selection for your core training. So core training last, usually two years can be extended up to three years. And during that time, you are expected to pass your MRC S exam. And after you've done your course as you get training for two years, you go for another round of uh national selection. And it's that point that you decide what sort of surgeon do you want to be. You can, you can apply for urology, orthopedics or generic surgery and for urology, the training program last 5 to 6 years. And before you are awarded the CCT certificate and you became a consultant, there's a bit of change in the training program recently. Uh when I applied the run through training, meaning that after you applied for from your foundation year to you used to be uh we used to have a run through training where you get you, where you get your training number and you, you don't have to reapply and go for another interview up to the point U CCT, but that has to be spread. So as it is now, there will be two national selection to that you have to go through first right after uh uh right after F two and the second one after your course surgical training. So any questions, uh any anything uh questions about the career progression so far? I feel like it's pretty straightforward. But of course, if there's any questions, let me know in the chat and we have a, we, I will look at the, at the end of the slide. So the first topic that um I would like to talk about uh is about urinary tract calculi. So a calculi is basically a crystal aggregates that forms in the urinary tract. And these regions can be formed anywhere in the urinary tract from your renal for your kidneys and your ureter and your bladder. But for the purposes of the the topic today and your exams, I will focus meeting on the renal and the ureteric stones. So the lifetime risk is higher in men, 10% in men and 7 7% in women. With the peak incidence around 20 to 50 years old. Once you've developed stone one time in your life, that's 50% of it recurring in the future. Again. Now, the common size of stone obstruction leading to symptoms, there are mainly 33 places and this is reflected on the narrowing parts of your normal ureteral anatomy. There will be at your pelvic ureteric junction, the pelvic brain where it crosses the vessels as well as your Vesico ureteric junction where it uh it joins to your bladder. So how would uh so keep in terms of the stone compositions, there are different type of um stones. There's a, there's a different type of stones, uh you know, composition. But those, there's a few key effects that you need to know about a few of them. I think that can be quite nicely summarized in the picture on your top right side. But you know, the the main thing, the key things are that the most common type of stone is calcium oxalate stones, about approximately 80% of the kidney stone out of this composition. The second thing would be a struvite stone, a struvite soon consists of magnesium ammonium phosphate stones and it is associated with urinary tract infection in particular because of your proteus and clap bacteria. This is because they naturally produces which hydrolyze the urine into ammonia, increase the ph and causes a precipitation of the stone. And the last things that the last thing that I want you to take away from this slight is UI stones are radiolucent. Uh CT stone are sort of semi opaque and everything else fairly radio opaque and you should be able to see on x- or CT scans. So the top and the bottom right uh of the presentation is just a sort of like a, you know, uh for the reaction of U ure and urea. It's not something that I don't think you need to memorize for exam. Is there just for context purposes. So how would kidney stones present? It depends on the location. So, if the, if the stone is just within your renal pelvis where it sits in the renal pelvis, most of the time patients are asymptomatic and you will be incidental finding on abdominal ultrasound or CT scans. However, when the stone dislodge itself from the renal pelvis into the ureter, that's commonly where the pains, uh the patients start to experience pain. When you're approaching patients with any sort of pain, you need to take a proper pain history and the approach of a crates approach. I'm sure you guys know by now in the site on set character and particularly for renal stones or Ureteric stone, the pain is often described as a quality spasm type pain radiating from the l to the groin. The patients often they are quite restless. They are not able to get into any sort of comfortable position associated with some nausea and vomiting. Occasionally patient can also experience hematuria blood in the urine, although this can be visible or nonvisible as demonstrated on the urine dipstick. So the principles of management of um Ureteric stone is largely divided into acute or elective management really because they can present it in different ways. And this is where I think I would like to provide some context to what you've been reading on textbook so that it, you know, it brings everything together. So I think this is best discussed over two sort of case study. So case study number one. So imagine yourself, you are f one doctor in the emergency department. You have just seen a 30 year old man who presented with left sided one to groin pain. You've taken a history and examined the man. So he told you that his pain is, you know, it is quite restless, this pain. So from from radius, from your left side down to his groin is very uncomfortable with it. And otherwise, you know, his observation are fair, fairly stable. You think that, you know, having attended the teaching today, you think that, you know, it sounds like a kidney stone or ureteric stone. So you, so just in your mind, 10 seconds, what how would you further investigate this? Just get a piece of paper and write a few things down that so you go through, you know, you, you see these all these patients as per any other emergency patient, you need to have a form of baseline investigations. So in this scenario, the important things are full blood counts and C RP, you would like to get a urine dipstick, you know, for any, for any source of urine tract infections, for any suggestive of urine dipstick, hematuria that could uh more consistent with a kidney stone. At some point, you would like to get a form of imaging to confirm your diagnosis. Now, in a 30 year old man, you know, you might convince yourself that, you know, you don't need the imaging. I you don't, you don't need any form of imaging. But let's say this is a 60 year old man with left sided one to groin pain. The other differential that you need to consider would be like a ruptured abdominal aneurysm. So if someone above, let's say 5050 years old, always advocate for at least a CT scan in the A&E and the imaging of choice would be a non contrast CT scan, which is the gold standard is very specific and very sensitive for stone diseases. But in younger patients or in pregnant woman and ultrasound abdomen is another consideration. Ultrasound, abdomen will not always picked up on small stones, particularly, it's very difficult to track, you know, to track the whole length of the ureter, but you are able to pick up on things like um hydronephrosis or very swollen ureters on the ultrasound. So you've got some blood, you've got some results from from from all your investigation. This patient, you know, he he looks very well aside from his pain, of course, he has normal blood tests. CRP is normal kidney functions are fine. His kidney cell is compensating and you've got the CT scan. And if you look at the images there, you can tell that on the CT scan, the left kidney is obviously more swollen than the right kidney. This is called hydronephrosis. And there's a radio opaque um calcification of sorts just around the um pelvic ureteric junction. It's uh it's the, it's all like the bright spot, bright spot within the uh within the left ureter. So with all these investigation, you know, the key thing is remind you need to remember that this is a stable patient. So the diagnosis would be this is a assuming a left 4 mL P dose with no signs of complications. Now, if you look at the chart um on the left side, this is II believe this is uh uh this is taken from mimic study that was done in Sheffield, I believe. So this basically is a probability of um stone passage, I think in 2 to 3 weeks time. So in our case, uh a left four millimeter P UJ stone we have in the upper ureter, you have approximately 71% of spontaneous passage uh in, in 2 to 3 weeks time. And if you look at the table as the size of the stone gets bigger, the chance of the chances of spontaneous patches decreases as well as and the lower it goes the easier it is to pass. So for patients with, you know, uh no early signs of complications, their pain is well controlled. It can be treated with a watchful waiting. You give them some painkillers such as analgesia. The most common would be a diclofenac suppository and maybe some you losing for muscle to relax their, to relax their ureter. And if the patient's pain is settled, you can send them home with the outpatient stone clinic follow up. So if the context is when you bring the patient back in the clinic in, let's say 4 to 6 weeks time, what you do at that point is to ascertain that the first patient is asymptomatic. If the patient has passed the stone spontaneously, you can request further repeat investigation such as an X ray or a CT scan to make sure that the stone has passed. And you can also perform some baseline investigation if not already done in A&E to determine the cost of stone formation. So blood test like, you know, repeating un U calcium and phosphate, just a general screen for any metabolic diseases such as hypoparathyroidism. You can also do a 24 urine collection such as P and stone analysis to, to further help guiding, you know, the cost of the stone, most of the time stones are caused is idiopathic. You don't really find any causes, but these are sort of gene, good gener screen for any underlying metabolic diseases. So if let's say in your exam, you know, the the the context of and the location is very important. If in the exam ask you, you know how this patient is the A&E they presented now with pain. What's your first line investigation? ABCD? E you're not gonna choose a 24 hour urine collection P for PH you know, and and stone analysis in the A&E that is something that you do further on at some point to investigate the cost of the stone formation. And that's not something that you do acutely in the A&E that's just a clarification that I like to, to point out because I found myself being quite confused by, by, you know, the the chronological order of investigation when I was still a medical student. So four weeks has passed, you see the patient in repeat in in the clinic at this point by uh by, let's say if your urologist and the patient has not passed the stone, you know, they're still symptomatic, you repeated your X ray and your imaging, the stone is still there. So what now for exams, you don't need to know, you know all the details about when to use what and what all the options. But generally, um these are just a few things that, that you should be aware about. The first will be a shock wave lithotripsy to use. It can be ultrasound or xray guided, using a shock wave to break the stone apart. But this come at the these all options usually are guided by the patient choices as well as the stone factors and the location. For instance, shopping little tripsy. Most of the time patient needs to come back for multiple sessions to get it to to to break the stone completely. Any patients that are pregnant or if they have abdominal known to have abdominal aneurysm. Those are the contract indications to have a short wave lithotripsy. In that case, you might opt for a urethroscopy with a laser fragmentation of the stone. But of course, this is done under general anesthetic. And occasionally when the stone is huge, you might need to have, you know, multiple sessions done as again with uh leaving behind a ureteric stent which might cause some discomfort to the patient. Percutaneous nephrolithotomy is mainly reserved for complex stones, stones more than three centimeters or stor stones. So, stones as if you go back to the slight from before the struvite stones, the magnesium ammonium phosphate stones, which is associated with urine tract infections. They have the possibility to to evolve into a ST one calculus, meaning that you, you fill up most, most of the pelvis, the renal pelvis and on the CT scan or X ray, it looks like the horn on, on the deer basically. So those sort of complex stones, it depends on local setup. But recommendation is to be to be treated with a percutaneous nephrolithotomy. So the two images, the one on the top is basically a uh is AU RS procedure with laser fragmentation. You pass the scope from the urethra, you trace it up to the ureter and you break the stone apart under under direct vision with a laser fiber. The second one, the one below is a percutaneous nephrolithotomy where you use a scope nephroscope and you puncture the skin directly to break the stone, to break the stone and suction and uh the stone, which is obviously more invasive. So this uh for this is just for mainly for uh you know, context purposes. And in the nice guideline, generally speaking, they divide it in the treatment into renal stone or ureteric stone. And that's again, depending on the size of the stone as well as any uh any other co uh patients, choices or any contract indications for each different procedures. Ok. So you've seen the first patient, so you've seen the first patient who presented, you know, uncomplete um with the uncomplicated um stone pain as well. Pain pain is ok. And you send him home, you decided to manage him as an elective problem. So that's, that's not an issue. Coincidence. Second patients, you know, coincidentally you saw another patient after that, which is a 30 year old man again who presented with left sided L to groin pain. But this time he tells you he feels terrible. He's been feeling a bit feverish. You know, he's been vomiting, he just felt generally lethargic. You've taken a history, history, the pain is consistent with the L to groin pain. And you examine the man at this point, you realize that, hey, this man is not very well, you know, his observations, he's 98% on air. Not too terrible, but he's tachycardic. He's hypotensive and he has a temperature of 38.5 with respiratory at 22. So just in the chat box and just tell me what signs is the patient currently displaying.