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For the life. Can everyone still hear me? OK. I think he's back alive. Yep. Ok. Fine. So now, now, now a case study has evolved. Now, this patient is developing early signs of sepsis as well as signs of septic shock. So, sepsis is defined as a life threatening organ dysfunction caused by this regulated host response to an infection. So they also displaying signs of shock because of hypotension. And for the purpose of your exam, there are two main score that you, you, you should know. But clinically, I don't think we use it that often the Q so far score and the score. So, you know, you have a septic patient in front of you and you, you're not too sure where the infective source is is coming from. How, what, what's your next step? And how would you further investigate? Can you guys still s uh can you guys still see this next slide? This, so the, yeah, so at this point, uh because your patient is septic, you are thinking about immediate resuscitation of the patient and this can be guided with the septic six bundle. I always remember it as give three and take three, you give the oxygen if the patient needs it, you give the IV antibiotics depending on the most likely source of infection. And this can be guided by your local trust policy. You can also, you should also give the patients a fluid challenge and monitor that. So that usually will be a form of A b of 500 M of sodium chloride. You take three, you take some bloods including blood cultures. You measure the lactate to, to ascertain your resuscitation effort and the patient's response and you put in the catheter to measure the urine's output. So in this situation, we think that, you know, lung to growing pain is probably because of the urinary tract. So we opt for IV gentamicin and let's say that's our local trust protocol. So you, now, now you have done the, now you have fully resuscitated the patient and you completed your sepsis six bundle, you give her some antibiotics, you given the stat B of fluids and you review the patient again. Now you, you found that, you know, the patient feels a bit better. They are not as, they are not as peripherally shut down anymore. Their heart rate looks better. They are not tachycardic anymore and their BP is stable and based on your blood taken just now, you know, you've noted white cell count is 20 C RP is 120 looks like in the infection or inflammatory process going on. And the patient is in obvious ak creatinine of 200 from a baseline of 70 urine dip stick demonstrated there's some blood in the urine, some nitrates and some ides so routine. No, normally um urinary tract infection doesn't make the patient that, that unwell, that you know, they're, they're not usually that septic. Given the clinical context of someone presented with the left one to groin pain and the patient septic. You think that this is likely because of some form of um stone stone, uh like an infected obstructed stone. So the next the next investigation, you you get a CT scan again. So the CT scan demonstrated something quite similar to the first patient. Once again, the left sided ureteric stone with hydronephrosis. However, the difference is that in this clinical context, the patient is quite unwell. So it means that what there's a, there's a focus of infection within the kidney, likely because of the ascending urine tract infection and the stone has caused has completely blocked up and your kidney is not able to, you know, there's a lot of back pressure on your kidney leading to the AK. So now our case, our case study number two has evolved from just a sepsis of unknown source to identifying the source, which is an infected sru stone. This is a urological emergency and the patient needs acute surgery for the compression. You can't send patient home if you are that unwell. So what do you do So at this point, you should phone up, you know, let, let your seniors know about it and idea and you should get involved the, the urologist at this point. But the options for treating an obstructed and infected stone would be some form of acute decompression. The guidance says within 12 hours. But this is also guided by how unwell the patient is. There are two options really either a nephrostomy or the ureteric stent insertion. If you look at the picture, the one on the bottom left, that's a ureteric insertion. This is done by the urologist in theater. The patient needs to be put under general anesthetic. You put a cystoscope from the urethra into the bladder and we pass a stent retrograde from the ureteric orifice into the kidney. So the stent will act as like uh it it acts as a channel for all the infective urine to uh to, to drain. And usually it's quite impressive in doing the system. And during the operation, you can, you know, you can see things like pus pouring out from, from, from the, from, from the stent around the stent. The second way of doing it would be a nephrostomy. So, nephrostomy is done by our interventional radiologist colleague, they done it um via local anesthetic, a direct puncture from the outside of the uh of of the skin of the skin into the kidney and putting in a nephrostomy back. So which one do you choose there's no clear favors, you know, which one, which modality is better than the other. It really depends on patient factors, disease factor and the local set up. So in, in terms of patient factors, if the patient are very, very unwell and they are very hypotensive leading ICU admission, general anesthetic is probably not advised. In that case, you opt for a nephrostomy insertion. But again, this is depending on, you know, local resources. not all centers in the UK has radiological. Uh I ir we don't, not all centers have IR covers a ureteric insertion. Stent insertion might be the only option that you've got. So once you put in the, the stent and the nephrostomy, you drain all the infective urine away, you leave it alone and to come back and deal with the stone at some point. But this, you can be in 4 to 6 weeks time cause at this point, your, your main, your, your main focus is keeping the patient alive and preventing from uh draining the, the infected urine or abscess away and uh make making sure the patient is safe is that that's the main priority. So you would deal with the death deal with the stone as per the elective at the elective setting. And that's going back to the few slides. You know, you can either do it with uh uh shortwave lithotripsy or lasering it or Nephro uh like a nephrolithotomy depending on the, the type of the stone. So there are also other indications for acute management or decompression as I mentioned. So the other indications, the first indication as we discussed sepsis, the other indications would be patients has AK I or if they have bilateral ureteric stone or you have if they have functionally on anatomically solitary kidney or uncontrolled pain. Now, the bottom four indications, they not, you do not necessarily need to put a nephrostomy or a ureteric stent. Ideally, the the consensus is that if you have local uh special specialty uh available, you have a stone surgeon and you have, you know, you have access to a definitive stone treatment. They should go for definitive stone treatment to remove the stone rather than just decompressing. This is because of the morbidity associated with putting in a ureteric stent patient often complains of sort of low to groin pain, bladder spasm bleeding in your urine or in the case of a nephrostomy, the patient is gonna have back of urine uh attached to them for about 4 to 6 weeks time. So if possible and if your local set out, you have, you have local resources to do it. Ideally, you should treat the stones acutely rather than just decompressing it. The only caveat is sepsis in terms of sepsis. You leave the stone alone, you decompress and come back, uh come back again in the future. Ok. So I think that's quite a, that's quite a short. Uh I hope I provided some context to, you know, the treatment of stones. And before I moved on to a general overview of prostate cancer, uh Has anyone got any burning questions about stone? You can let me know in the chat. Yeah. So nephrostomy and ureteric stent, it depends. It, there's, there's no right or wrong way. You can, you can, you, it, it's up to, it's up to um you know, uh the patient factors as well as local factors. In least, I believe the radiology colleagues cover all of our nephrostomy stent insertion. But in certain places, if you don't have such services, stent is your only options. So Renal colleague for antiemetic, yes, if the patients are, you know, suffering from pain, nausea, vomiting, you should give them antiemetics. But again, those are just mainly for symptom control rather than the, you know, definitive stone treatment. Ok. So a next thing that the second topic that I like to discuss about prostate cancer. So prostate cancer is an rapidly evolving space. Uh by the time you finish your revision, you know, uh uh by the time you finish your revision, probably another set of guidelines will be, will be out um at, at this point. But in general, I would like to provide you guys just a sort of overview about prostate cancer. The key facts that you need to know and how do we plan, how, how do we treat it in a wider context? There's no substitute from opening a textbook to have a proper read. And that's, and this slide is definitely not a substitute for, you know, a proper uh sit down opening textbook have to read, but this is just mainly for context. So prostate cancers are adenocarcinomas that arises from your peripheral prostate. And this is why when you are examining the patient, when you are examining the patient, uh you can perform digital rectal examination and you should be able to feel the, you should be able to feel the the prostate malignancy. It is the most common uh male malignancy with the the key things to remember for your exam is that most of the prostate cancers are slow progressing. The post current post mortem evidence suggests that in in male patients that are 50 years old, 30 patients of the 30 patients will have some form of prostate cancer. And by the time they are 80 years old, 80% will have some form of prostate cancer in the prostate. So what this tells you is that most patients die with prostate cancer rather than from prostate cancer. Hence, the radical treatment should be targeting those with the aggressive disease when the patient presents with uh you know, uh when, when a GP, let's say if you are in uh you are in GP patients uh worry about a prostate cancer. What what do you need to know? So you need to take a full urological history. So you uh this will be a lower urine tract symptoms, generally dividing between a story symptoms or voiding symptoms. You also need to know about if the patient had any risk factors for prostate cancer, such as their age, ethnicity and uh family history. So you also need to know about uh patients has any red flag features such as weight loss, bone pain and swelling and their general fitness for surgery. At the end of the consultation, you perform a digital rectal examination to ascertain the size and the consistency of the prostate. Next, if, if you are suspicious about a prostate cancer, you would like to order a psa blood test. So the key thing to remember about prostate specific antigen is that it is organ specific, it is not disease specific, meaning that it can be raised in other benign conditions such as benign prostate hyperplasia, prostatitis or recent instrumentation or catheterization of the urinary tract. This is because PSA is a normal, is a serum protein secreted by your prosthetic duct, ductal epithelial cells and its main function is to liquify your seminal coagulant. Because of that, there's no absolute cut off that we can see to predict the absence of the prostate cancer. The nice guideline, currently, they advocate for specific, as you can see on the top right corner of the slides. Other things that we can use for us to gauge, you know, the possibility of prostate cancer, uh PSA density, which take it takes into account of the volume of your prostate and psa velocity. But those are not something that you need to know at this stage for your medical school exam. So further investigation, digital rectal examination, you found that the prostate is very hard, you know, the PSA is raised like to order some MRI prostate, uh MRI prostate. And at some point, if the MRI is positive, you get a trans sample of prostate biopsy such as a transrectal or transperineal prostate biopsy. If during your consultation, you are worried about uh you know, you, you're quite convinced that the patient has metastatic disease, such as the patients developing bone pain, leg swelling, you can order a bone scan and CT staging for completeness. So going back to the first slide, the key thing of prostate cancer is identifying the patients with um aggressive disease and that's certainly something that's quite difficult to do. We have our TNM staging, which is the clinical and radiological extent of the disease and your biopsy will provide you the histological type of the disease. So the histological type can be scored by Gleason pattern. Sorry, the Gleason score, which is 1 to 51 being well differentiated and five being lack of differentiation. So it's a combination of two scores with the first score being the most predominant and the second being the second most predominant. So you write it down as let's say a decent three plus four if three is more common than four, for instance. So having all those information and current nice guideline divide the patients out into five different groups based on the Cambridge pronoun group. So group one to group five, group, one being the low risk group and group five being the high risk group, you don't have to. There's, there's no point in memorizing all these specific subgroups. But the key things to take away are the prognostic of prostate cancer. At the moment, there are three main factors would be the Gleason score, your psa level as well as your staging. But of course, you also need to take into account of the patient factors such as their overall fitness for surgery and their life expectancy, treating prostate cancer generally. Again, this is a rapidly evolving space, you know, uh it's probably outdated at this point. But for, for, for your exam, the patients can be divided into three different groups. So for patients that are unfit for surgery, their life expectancy is less than 10 to 15 years and significant medical comorbidities, you put the patient on watchful waiting with the aim of avoiding any treatment unless the patient becomes symptomatic. And this is usually from some, some form of metastasis. In that case, you can treat the patient with hormonal treatment because prostate cancer is androgen dependent. And by suppressing the amount of androgen you have in your system, you can lead to the prostate ca uh cancer to go through apoptosis and shrinking in size. Now, what is the difference between active surveillance and watchful rating, active surveillance? The main aim is to delay any treatment unless it's necessary where there are signs of disease progression. This is reserved for the patient that fit for radical treatment. And if there's any signs of disease progression, the patient should have medical treatment. You follow these patients out with, you know, regular psa level repeated MRI and biopsy. And that's again, depending on the local setup, the radical treatment that's available at the moment. Uh for, for exams, you need the, you can, there's a radical prostatectomy or removal of the prostate. This can be performed open quite uncommon to see. And now it is laparoscopic or robotic assisted. The complications from a prostatectomy includes things like hematuria, rectal injury, needing a stoma formation and importance. The other thing would be uh the other options are will be radical radiotherapy. However, the complication and risk includes again, hematuria, cystitis, proctitis and secondary pelvic cancer. Because of the radiation. There is also use of brachytherapy, which is the implantation of small radioactive seeds directly into the prostate and causes local destruction of the prostate. However, if the patient has any sort of existing low, low in tract uh track symptoms such as difficult to pee and weak stream, and this procedure can essentially worsening their low in uh lower in track symptoms. So that's, that's the sort of a quick summary of the uh uh prostate cancer. So, but as as I said, uh the main, the prostate cancer is a rapidly evolving field. It changes almost every day. But in general, these are the concept that you need to know. The first thing would be uh you know, prostate cancer is most of it is slow progressing. The key things is to identify which patient you should treat because of the possible complications from the surgery. So I'm happy to take any questions and I'll have a look at the chart at this point. Mm. So can stone present with penis hematuria? Yes. Occasionally patients do present with uh asymptomatically with an incidental finding of ureteric stones on ba based on your routine abdominal ultrasound or CT scan. What's the difference between CT scan and ultrasound? And I think that really depends on your local set up CT CT scan without contrast is certainly the gold standard because it tell you this but not just the location of the stone, but also you know, any stone burden and the anatomy of the, the anatomy of the uh of the of the urinary tract. Uh I II think you II think that's, that's the main difference really in terms of the resources available. So uh if the patient is more than 50 years old, CT S is preferred to exclude other positive. Yes. In any patient undecided patient, especially if they are old back pain, going to groin pain. The key facts to rule out would be a abdominal aneurysm that's ruptured because if you miss those on presentation, you can the patient, you know, the patient has basically high risk of death if you miss if you miss it on initial presentation. Yeah, with the slides we sent in these um teaching sessions we recorded. I think that's something that the moderator is able to answer. Yeah. So otherwise, sorry, sorry Mr Who uh I'm, I'm one of the facilitators as well. Um Before we get on to that, do we have any more questions for Mr Hu today? Just pop it in chat if you have any? Ok. So uh thanks. It doesn't seem like anyone has any more questions. So thank you all for coming today. As um doctor has said, we will be putting all these recordings on the meal page. So feel free to go back and watch it whenever you have the time for your vision. Um Before we finish, I would just like to remind everyone to make sure you fill up the feedback form to be able to get your certificate and don't forget to sign up for our next session, which will be next Monday and that will be covering vascular surgery if I'm just gonna share the poster. Now, um if you can see. So this is the poster for next week. If you want to sign up and you're interested in angle to talk again, you just scan a QR code and sign up, it's the same thing. It's all metal. Again, it will be recorded similar to this one. It's gonna cover, you know, vascular surgery, vascular access and also painful limb. So I think that will be very interesting and helpful for exam purposes. The link is also in the chat box if that's easier for everyone. So thank you all for coming today. I hope you all found it useful and thank you so much mister for speaking.