Final Year Students

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Final Year Students

• Surgery and Urology
• Mr Little

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Objectives

• Standard history taking
• Physical examination
• Diagnosis and investigation
• Frequently asked questions

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FIRST SENTENCE OF ANSWER

• I will take a full history and perform a full
  physical examination.
• Examiners expect this
• Remember to say that you will do a PR, if
  appropriate.

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Abdomen

• What are the 9 abdominal quadrants called?
• How are the lines that divide them defined?

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Incisions of the abdomen

• A Pfannenstiel
• B Appendectomy
• C Battles (Pararectal)
• D Paramedian
• E Midline
• F Thoracoabdominal
• G Milwaukee (Rooftop)
• H Kochers
• I Tranverse

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Hernias

• One of the few parts of final MB where surface
  anatomy is crucial! Inguinal surface anatomy is
  used to distinguish inguinal hernias into direct
  and indirect, and to demonstrate femoral hernias.
• Most likely to get inguinal hernias, incisional
  hernias, femoral hernias, para-umbilical hernias
  and epigastric hernias.

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Inguinal surface anatomy

• A Inferior epigastric artery
• B Femoral nerve
• C Femoral artery
• D Femoral vein
• E is the most important
• THE PUBIC TUBERCLE

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Examination of the groin

• Usually means either a hernia, a testicular
  swelling or lymph nodes.
• Groin Hernias
• Either an inguinal lump or a scrotal lump you
  cant get above. If not clinically obvious, as
  the patient to stand and/or cough.
• Femoral hernias do not usually enter the scrotum.
• Try to gently reduce it.
• Surface anatomy If it is below and lateral to
  the pubic tubercle its a femoral hernia. If its
  superior or medial to the pubic tubercle its an
  inguinal hernia. Inguinal is commoner.
• Occlusion at the mid-inguinal point (i.e. halfway
  between the pubic tubercle and the anterior
  superior iliac spine, i.e. the deep ring)
  prevents an INDIRECT inguinal hernia from popping
  out. In the middle-aged male, direct is commoner.

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Other hernias

• Incisional 10 of hernias. Either reduceable or
  not.
• Para-umbilical True umbilical hernias are rare
  after childhood. Para-umbilical hernias are found
  in fat middle-aged women. Repaired using Mayo
  repair
• Epigastric hernias Fit young men
• Frequent questions
• What is a hernia?
• What are the three commonest hernias?
• Who gets most inguinal hernias? Why?
• What is the commonest female hernia?
• What are the complications of hernias?
• What hernias occur ouside the abdomen?
• What is a Richters hernia?

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Scrotal swellings (i)

• CAN I GET ABOVE IT? If you can then its coming
  from the scrotal structures.
• Common Hydrocoeles, Epididymal cysts,
  spematocoeles.
• Uncommon Tumours
• Examine as for any lump or bump
• The 3 Ss Site, Size, Shape
• The 3 Cs Colour, Contour, Consistency
• The 3 Ts Tenderness, Tethering,
  Transillumination
• The Fer Fluctulence.

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Scrotal swellings (ii)

• Hydrocoeles Surround the testis and make it
  difficult to feel. Transilluminate!!!
• Spermatocoeles and epididymal cysts Smaller, and
  arise from adnexal structures. Do not obscure
  testis usually.
• Tumours Stony hard. Arise from testis.
• Frequent questions
• What investigation is appropriate for a newly
  diagnosed hydrocoele?
• What is a hydrocoele?
• What are the risk factors for testicular cancer?
• What blood tests would you consider for testicle
  carcinoma?
• What are the common types of testicle cancer and
  how are they treated?

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Stomas (i)

• Most likely to be either an iliostomy or an
  end-colostomy.
• Less frequently, loop colostomy or ileal
  conduit(urinary diversion)
• An iliostomy is in the RIF, and protrudes from
  the abdominal wall. Most commonly fashioned
  following pan-proctocolectomy in ulcerative
  colitis, or less frequently for caecal
  obstruction, polyposis coli or severe Crohns
  colitis.
• An end colostomy is most frequently formed in the
  LIF, and sits flush with the abdominal wall. Most
  commonly formed after a Hartmanns procedure or
  some rectal excisions.

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Stomas (ii)

• Loop colostomies are uncommon, and tend to be
  formed in the epigastrium from the transverse
  colon, or the LIF from the sigmoid colon. It is
  usually a palliative procedure for carcinomatous
  obstruction.
• Ileal conduit urinary diversions look just like
  ileostomies, but the bag will contain urine, even
  if only a little. They are usually formed when
  the patient has had a cystectomy, often for
  carcinoma of the bladder.
• Frequent questions
• What is this?
• Why is it there?

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Stomas (iii)

• Complications
• ILIOSTOMY
• Metabolic High output, B12 and Folate deficieny,
  Stones, Anaemia.
• Anatomical Stoma Prolapse and retraction, less
  frequently stomal stenosis or parastomal
  herniation
• COLOSTOMY
• Mostly Anatomical
• EARLY Stomal necrosis, ischaemia
• LATE Stomal retraction, prolapse, stenosis,
  parastomal herniation etc

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Small bowel obstruction

• Intestinal obstruction is characterised by
  vomiting, abdominal distension, constipation and
  pain.
• In high obstruction, the vomiting tends to occur
  earlier then the constipation. The reverse is the
  case for lower GI obstruction. In high
  obstruction, the distension is minimal.
• The commonest causes are Adhesions (60-80 of
  cases) and Hernias (10-15).
• Others include
• Extrinsic Volvulus, Non-GI neoplastic or
  inflammatory masses
• In the wall Crohns disease, Intussussception,
  Strictures, Atresias.
• In the Lumen Meconium ileus, Gallstones, Foreign
  body, Faecolith.

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Small bowel obstruction

• Treatment
• Assess for strangulation (Localised tenderness
  pain)
• If simple (ie no strangulation)
• IV fluids, NBM, Analgesia
• FBP, UE
• Monitor urine output
• NG aspiration for vomiting, if required.
• Remember, the rule is that 80 of simple small
  bowel obstruction will settle with conservative
  treatment.

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Large Bowel obstruction

• Causes
• Colonic Carcinoma (65)
• Diverticular disease (10)
• Volvulus (5)
• Crohns disease
• Hernia
• Strictures Ischaemic, anastamotic, inflammatory
  etc

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Abdominal Masses

• Non-pathological Gravid Uterus, Faeces in colon,
  Riedels lobe of liver, kidneys in a thin person.
• Standard questiion is to distinguish a kidney
  from a spleen
• RIF
• Sore Appendix mass/abscess, Crohns mass
• Not Sore Cancer (Caecal, Ovarian, Renal),
  Fibroids and ovarian cysts, transplanted kidney.
• Epigastric
• Ca stomach, colon, liver, pancreas
• RUQ
• Liver, Colon, Right kidney, GB, Adrenal

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Colorectal Disorders

• Colorectal Carcinoma
• Important point is that the history is different
  depending on the side of the colon the carcinoma
  is
• RIGHT sided carcinomas Present insidiously
  because the colonic contents are liquid and the
  colon relatively spacious at this point.
  Presentation is with the development of anaemia
  Fatigue, malaise, weight loss, dark blood in
  stools.
• LEFT sided carcinomas present with the symptoms
  of narrowing the lumen to more solid matter,
  Altered bowel habit, alternating constipation and
  diarrhoea, brighter red PR bleeding.
• RECTAL carcinomas also have the symptoms of
  tenesmus and passage of mucus PR
• Colonic carcinomas can also perforate and
  fistulate

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Colorectal Disorders

• Risk Factors
• Longstanding Ulcerative colitis
• Polyposis Coli
• Family History
• Differential diagnosis
• DIVERTICULAR DISEASE
• Any cause of large bowel obstruction
• PR Bleeding Colorectal CA, Diverticular disease,
  Angiodysplasia, Haemorrhoids, Anal fissure
• Investigations of choice Barium enema and
  sigmoidoscopy, with CT if carcinoma is confirmed.

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Colorectal Disorders

• TREATMENT
• Surgery
• Chemotherapy with 5-Fluorouracil for tumours of
  stage Dukes C or greater. Some would also give it
  for Dukes B
• Colorectal Carcinoma Complications Bleeding,
  Perforation and Fistulation into adjacent organs
  and obstruction

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Colorectal Disorders

• DIVERTICULAR DISEASE
• The great pretender. Can mimic colorectal
  carcinoma remarkably. Both cause PR bleeding, can
  cause intestinal obstruction, can perforate and
  can fistulate.
• Related to low-fibre diet
• Chronic symptoms investigated with Ba enema and
  Sigmoidoscopy. (Arent they all)
• Often presents acutely with LIF pain and
  tenderness and rebound. Settles with conservative
  Rx and Antibiotics usually.
• Majority do not require surgery, and are
  controlled with dietary advice

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Colorectal Disorders

• Inflammatory Bowel disease Summary table

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Colorectal Disorders

• Ulcerative colitis
• Palpable masses rare, never fistulates
• Anorectal fissures and infection occur less
  frequently
• Medical Rx successful in 80
• Surgery can be curative

• Crohns Disease
• Occasionally forms inflammatory masses or
  fistulae
• Anorectal sepsis common
• Medical Rx inadequate in 80
• Surgery for complications only

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Colorectal Disorders

• Medical treatment of ulcerative colitis
• 5-ASA derivatives, such as Sulphasalazine or
  Mesalazine can be used to reduce relapse rate.
  Delivered either orally, Enemas or suppository
  form
• Prednisolone can be used topically as above, or
  can be given orally for relapses, up to 60mg per
  day. It must be weaned off, rather than stopped
  suddenly.
• Anti-diarrhoeals Codeine, Loperamide.
• Endoscopy is used for surveillance
• Surgery is used for failure of medical Rx, For
  Carcinoma, Failure of steroids to induce response
  in few days, and Toxicity gt8 bloody stools per
  day, pulse gt100, Temp gt 38.5 C, Transverse colon
  dilated beyond 5cm and hypoalbuminaemia.
• Often a panproctocolectomy and iliostomy

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Colorectal Disorders

• Crohns disease
• Usually not accessable by topical preparations,
  so generally treated with systemic 5-ASA
  derivatives or steroids where flare up occurs.
• Surgery is often used for the complications
  Abscess drainage, resection of fistulas, and
  removal of strictured segments.
• Cannot be cured by surgery. Colonic crohns is a
  contraindication for continent pouch procedures.

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Oesophagus and Stomach

• More likely to be used in the long case setting,
  as signs are uncommon, but history is usually
  detailed.
• Haematemesis and melaena.
• Use of NSAIDS eg Aspirin, Smoking, Alcohol,
  Steroids, WARFARIN
• Remember to say PR

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Stomach and Oes. History (i)

• This is actually the history of upper GI
  bleeding, Upper abdominal pain, and upper GI
  obstruction, with history.
• Upper GI Bleeding
• Was it haematemesis or melaena
• Did one start before the other
• When did it start
• How many times has it happened
• When did it happen last
• Was it precipitated by anything
• How much blood was there
• Coffee-grounds vs fresh blood
• Did it make them collapse
• Have they felt tired / easily fatigued / easily
  short of breath ANAEMIA!

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Stomach and Oes. History (ii)

• Upper GI obstruction Oesophagus or Gastric?
• At the level of the Oesopagus Dysphagia,
  regurgitation of food
• At the level of the Stomach Early satiety,
  Forceful vomiting, Sucussion splash if youre
  lucky!
• Both give marked weight loss
• History
• Drug history NSAIDS Aspirin, Warfarin,
  Steroids.
• Smoking Amount per day, and duration. Have you
  ever smoked?
• Alcohol As for smoking.
• Family history
• Upper GI pain and differential later

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Stomach and Oesophagus signs

• Signs THINK Bleeding, Baccy and Booze.
• Bleeding Pale conjunctivae, pallor. Melaena. (ie
  more chronic signs) Unlikely to see tachycardia,
  hypotension etc, as this tends to be quite acute.
  Remember NSAIDS and Warfarin. Trap for the
  unwary Guinness or Iron tablets give you black
  stools.
• Smoking The most obvious is often nicotine
  stained fingers! Also remember the signs of COAD
  It implies a smoking history. Smoking also
  significant in the context of cancer Look for
  wasting, an LIF mass, Hepatomegaly etc.
• Alcohol This essentially means the signs of
  chronic liver disease.

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Stomach and Oesophagus

• Oral Questions relating to haematemesis /
  melaena
• What risk factors did this patient have for Upper
  GI bleeding?
• Why are they on Aspirin / Warfarin / Steroids ?
• What investigations will you do AND WHY?
• FBP, Coag, UE, LFT, GCsm 4 units, OGD.
• If the OGD is negative what investigation will
  you do (Melaena)?
• BARIUM ENEMA
• What are the commonest causes of upper GI
  bleeding
• Gastritis, Duodenitis

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Stomach and Oesophagus

• What are the causes of upper GI bleeding
• Oesophagus Oesophagitis, Oesophageal erosions,
  Mallory-Weiss tears, Oesphageal varices,
  Oesophageal carcinoma (rarely)
• Stomach Gastritis, Gastric erosions, Gastric
  ulcers, Gastric carcinoma.
• Duodenum Duodenitis, Duodenal Ulcers,
  Aorto-Enteric fistulas.
• How do you treat upper GI bleeding?
• Most settle with conservative Rx IV fluids, NBM,
  PPI. Can use endoscopy therapeutically for both
  ulcers and varices. Open resection of ulcer etc
  rare.
• What are oesophageal varices?
• What causes them?
• What are the other sites of porto-systemic
  anastamosis?

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Stomach and Oesophagus

• Difficult Question
• How would you see this?
• What is it?

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Stomach and Oesophagus

• This is a barium swallow.
• What is the likely diagnosis?
• Difficult question.

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Stomach and Oesophagus

• How would you investigate the patient with a
  tumour of the stomach or oesophagus on OGD ?
• Stage them, using a CT scan of Chest, Abdomen and
  Pelvis. If resectable then treat surgeically if
  possible. Radiotherapy is second-line option for
  oesophagus. Many Gastric and oesophageal tumours
  are irresectable, so remember to consider
  palliative care options such as bypass and
  stenting, laser resection of oesophagus.
• What is Barretts Oesophagus?
• What is its significance?
• How do you manage it?
• What might cause dysphagia?
• What drugs are associated with upper GI bleeding?

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• What kind of X-ray is this?
• What does it show?

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The Liver, biliary system and pancreas

• History features
• Jaundice, Upper abdominal pain.
• Jaundice The A to I varies from book to book,
  but I use
• Alcohol
• Blood tranfusion
• Contact
• Drugs (eg Paracetamol)
• Extrahepatic
• Family History, Foreign Travel
• Gallstones
• Homosexuality
• Infections ( HBV, EBV, Leptospirosis)

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The Liver, biliary system and pancreas

• Upper Abdominal pain
• Epigastric
• Upper GI Gastritis, Oesophageal reflux, Peptic
  Ulcer, Perforation of gastric or duodenal ulcer.
• Hepatobiliary Biliary Colic, Pancreatitis
• REMEMBER MYOCARDIAL INFARCTION
• Right Hypochondrium
• Hepatobiliary Biliary Colic, Cholecystitis,
  Cholangitis, Hepatitis, Pancreatitis,
  Fitz-Hugh-Curtis syndrome.
• Upper GI Peptic Ulcer, Perforation of Ulcer
• Other Abdominal Subphrenic abscess,
  Appendixitis, Renal Colic
• Extra-Abdominal Right lower lobe pneumonia,
  Pulmonary embolus.

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The Liver, biliary system and pancreas

• Physical examination often involves looking for
  the signs of chronic liver disease in the case of
  jaundice or pancreatitis. Cholecystitis is most
  frequently abdominal signs only, if
  un-complicated.
• Surgeons most frequently look after Cholecystitis
  and Pancreatitis.
• Cholecystitis Remember the 5 Fs! It gives the
  game away.
• Right Upper quadrant pain, aching/colicky, may
  radiate around to back, often onset at night or
  in response to fatty foods, may be associated
  with vomiting. Gallstones in the gallbladder do
  not cause jaundice unless they move into the
  common bile duct.
• Complications Jaundice, Pancreatitis.

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The Liver, biliary system and pancreas

• Physical examination usually only shows subcostal
  tenderness and murphys sign. Rarely palpable. 5
  Fs
• The investigation of cholecystitis is essentially
  the investigation of upper abdominal pain.
• FBP, UE, AMYLASE, LFTs, Erect Chest X-Ray,
  Abdominal film.
• Initial Rx IV Fluids, Nil by mouth.
• Cefuroxime for infection. Most add Metronidazole
  as well. Cholangitis is Jaundice, Fever and
  Rigors. This is known as Charcots triad.
• Investigation Ultrasound of abdomen. OGD if its
  normal.
• Treatment Laparoscopic cholecystectomy or open
  cholecystectomy. (Dont use laparoscopic surgery
  if there are adhesions, or a common bile duct
  stone)

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The Liver, biliary system and pancreas

• Stones in the common bile duct may produce
  jaundice and pancreatitis. They are suspected
  when ultrasound detects a dilated common bile
  duct, or visualised duct stones.
• An ERCP can the be carried out to prove the fact,
  and the sphincter of oddi divided to allow the
  stones to pass harmlessly into the duodenum.
• They are not removed by a laparoscopic
  cholecystectomy. At the time of open surgery, an
  intraoperative cholangiogram is performed to
  ensure that none are present. If there are, then
  they are removed with specialised forceps.

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The Liver, biliary system and pancreas

• Pancreatitis
• Presentation is similar to Cholecystitis, but
  pain is more centralised and is more severe,
  possibly radiating to the back. Classically the
  patient lies still with their knees bent. They
  are generally more unwell. May be shocked,
  jaundiced.
• Physical signs are often absent or very scanty!
  Consider the signs of chronic liver disease,
  Cullens sign and Gray-Turners sign. Abdominal
  tenderness to palpation can be poorly localised
  and hard to define. Pyrexia, Tachycardia.
• Initial investigations are the same as for
  cholecystitis FBP, UE, LFT, Amylase, CXR, AXR.
  Amylase is considered diagnostic for pancreatitis
  if it is greater than 1000 u/ml. Abdo Xray may
  show a sentinel loop or loss of psoas shadow.

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The Liver, biliary system and pancreas

• Causes Gallstones and Alcohol most common. Also
  GET SMASHD Trauma and Surgery, Steroids, Mumps,
  AI, Scorpions, Hyperlipidaemia and drugs.
• Treatment
• Once diagnosis is established do an arterial
  blood gas and a serum calcium glucose. Treat
  any hypocalcaemia.
• IV fliuds, nil by mouth. Aim to keep urine output
  above 30 mls per hour. Consider central line in
  elderly or CCF patients.
• Opiate analgesia
• NG tube
• Monitor
• Hourly urometer, Pulse and BP
• 12-hourly arterial bolld gases
• Daily FBP, UE, Calcium and amylase

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The Liver, biliary system and pancreasYou must
learn the Ranson criteria, as it is a measure of
severity. 0-2 2 motality, rising to 100 for 7

• AT PRESENTATION
• Age gt55
• WCCgt16
• Glucosegt11
• LDHgt350
• ASTgt60

• DURING 1st 48 HOURS
• Haematocrit falls gt10
• Urea rises gt10
• Serum Ca2 lt2
• Base excess lt-4
• PaO2 lt8 kPa
• Fluid sequesteredgt 6 litres

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Jaundice

• Most surgeons look after post-hepatic jaundice.
  This type of jaundice is charcterised by dark
  urine and pale stools. This is because bilirubin
  products are not allowed to pass into the GI
  tract via the biliary tree, but conjugated
  bilirubin is water soluble and so darkens the
  urine.
• Jaundice is divided into pre-hepatic, hepatic and
  post-hepatic aetiologies.
• Pre-Hepatic Haemolysis, Heriditary eg Gilberts
• Hepatic Cirrhosis, Carcinoma infiltration,
  Viral, Autoimmune, Paracetamol and other drugs.
  Halothane is no longer used.
• Post-Hepatic (Obstructive) CBD gallstones,
  Pancreatic carcinoma, Nodes in the porta-Hepatis,
  Cholangiocarcinoma. Complication of lap chole?

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Jaundice

• The physical signs of chronic liver disease is a
  gob-standard exam question. Remember to start at
  the hands and work up!
• Hands Finger clubbing, Leukonechia, Palmar
  erythema, Dupuytrens, Asterixis
• Skin Bruising, Spider Naevi, hair loss
• Face Head Jaundiced sclera. Constructional
  apraxia, Foetor hepaticus.
• Chest Gynaecomastia
• Abdomen Enlarged liver or spleen, Ascites, Caput
  Medusae. Remember to ascertain the nature of the
  liver edge, consistency, tenderness. Bruits etc
  astronomically rare.
• Legs Peripheral pitting oedema from
  hypoalbuminaemia.

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Jaundice

• Investigation of the jaundiced patient
• FBP, UE, LFT, Coagulation, Hepatitis
• Remember Macrocytosis as a sign of alcoholism
• In obstructive jaundice, the Alkaline Phosphatase
  will rise out of proportion to the transaminases
  (These may be slightly up), and the bilirubin is
  conjugated.
• Hepatocellular jaundice is characterised by
  marked transaminase rise, and a mix of conjugated
  and unconjugated bilirubin.
• Prehepatic Jaundice is unconjugated, (so not
  present in urine)
• Ultrasound This will tend to separate the
  Hepatic and Post-hepatic jaundices quite nicely
  also.

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Jaundice

• Questions
• What are the causes of Cirrhosis?
• Alcohol and Hepatitis are the first things to say
• If pressed
• Primary Biliary Cirrhosis, Autoimmune hepatitis
• Haemochromatosis and Wilsons disease
• Drugs eg Methotrexate
• Budd-Chiari syndrome (Hens tooth), Cong Cardiac
  failure.
• Alpha-1-antitrypsin deficiency
• How would you prepare the jaundiced patient for
  surgery?
• Basically this means correcting any coagulation
  abn with FFP and/or Vitamin K, and giving
  perioperative IV fluids to maintain a good urine
  output (Hepatorenal syndrome more likely in the
  dehydrated)

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Breast lumps

• Common Breast Lumps
• Young Women Fibroadenoma / Abscess
• Pregnant / recent sprog Galactocoele / abscess
• Middle aged and elderly women Cancer higher up
  the differential diagnosis list.
• Investigation IN THIS ORDER
• Clinical examination
• Mammogram (USS if premenopausal)
• FNA aspiration

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Breast Cancer Treatment

• Local treatment
• Usually lumpectomy/partial mastectomy if feasble.
  Not feasable for central tumours, large tumours
  or tumours in small breasts etc.
• Systemic treatment
• Premenopausal usually chemotherapy
• Postmenopausal usually Tamoxifen. (Remember risk
  of uterine CA)

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Vascular Cases

• Likely Cases
• Aneurysm (AAA)
• Ischaemic lower limb
• Ulcer
• Varicose veins

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Aneurysm

• Mostly Aortic (Within abdo) Next most common is
  splenic artery aneurysm. Think of Elderly male
  hypertensive smokers with family history.
• Usually need repaired if greater than 5
  centimeters in diameter (Risk of bursting
  increases above this)
• Inv FBP, UE, ESR (?Inflammatory), CT scan,
  Chest X-ray and ECG
• Need emergency CT if painful aneurysm has it
  burst?
• Now can be repaired with endoluminal stenting in
  some cases.

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Chronically Ischaemic lower limb

• Signs
• Absent pulses
• Colder than other limb
• Thin, Shiny skin
• Hair loss on leg
• Ulcers
• gangrene

• Symptoms
• Claudication
• At what distance.
• How long does it take to disappear at rest
• On the flat or just uphill
• Rest pain?
• Relevant PMH
• Smoking
• Diabetes
• Hypertension, Stroke, MI, etc

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Investigation

• Ankle-Brachial pressure index
• Take systolic BP at brachial artery using doppler
  USS, and compare it to the systolic BP at
  posterior tibial or dorsalis pedis artery.
• Divide the ankle value by the arm value. Should
  be the same. 0.5Claudication, 0.3Rest pain,
  0.2 impending gangrenous changes.
• Definitive main investigation is arteriography.

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Whats this?
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Ulcers

• Usually
• Venous Medial malleolus, Venous excema, varicose
  veins, skin pigmentation. Surprisingly painless!
• Arterial Black, sloughy, painful. Look for other
  signs of limb ischaemia.
• Neuropathic. Sensory loss. Often diabetics with
  good pulses
• Vasculitic. Sharp, punched out lesions.

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Urology in a nutshell
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Causes of Haematuria

• PRE-RENAL Coagulation disorder, Sickle-cell,
  Vasculitis
• RENAL Glomerular disease, Carcinoma, Cystic
  disease, Trauma, A-V malformations,
  Emboli
• POST RENAL Stones
• Infection (Bladder / Prostate / Urethra)
  Carcinoma (Bladder / Prostate),
  Traumatic bladder catheterisation,
  Inflammatory Cystitis

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Investigation of Haematuria

• Painless haematuria is carcinoma until proven
  otherwise
• Initial investigation (For Anything) is full
  history and examination.
• PR!

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Investigation of Haematuria

• Blood Investigations
• FBP Anaemic? White cell count raise indicative
  of infection?, Enough platelets?
• UE Are their kidneys working? (Crude test)
• Coagulation screen Haemophilia?, Warfarin?
• In Men PSA
• REMEMBER MSSU Direct microscopy and culture.

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More Investigation

• Urinary Cytology
• Not very sensitive, but an unequivocally
  positive cytology is quite specific for TCC
  bladder.
• RADIOLOGY
• IVP
• Ultrasound
• Both are very sensitive and specific, but USS
  better for small peripheral renal lesions, and
  IVP better for renal pelvis and ureters.
• FLEXIBLE CYSTOSCOPY

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Bladder Cancer Incidence

• Males outnumber females by about 2.7 to 1
• Average age at diagnosis is 65 years.
• 85 confined to bladder at time of presentation.
• 70 will recur after treatment, and 30 of these
  will progress
• Risk Factors
• SMOKING
• Chemical carcinogens chemical, dye, rubber,
  petrol, leather and printing industries are at
  increased risk. Also Cyclophosphamide
• Not Coffee

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Initial diagnosis and treatment

• Most are diagnosed using flexible cystoscopy
  under fresh air, and haematuria investigations.
• Non-invasive tests such as PCR analysis, and
  Matrix-metalloproteinase-9 are yielding some
  results with high specificity and sensitivity,
  but remain research tools at present.
• IVP Make sure there are no TCC in the renal
  pelvis or ureters. For every 50-60 bladder
  carcinomata, there are 3 Renal pelvis TCCs and
  one ureteric TCC
• TURBT Curative for early disease, also provides
  histology.

74
Staging of TCC bladder
CIS Ta T1 T2 T3a
T3b
mucosa sub-mucosa detrusor muscle Peri-vesical
fat
75
Staging Continued

• Also Stage T4a, where the prostate is invaded,
  and T4b where there is pelvic structure invasion.
  T3b has a worse prognosis than T3a.
• Lymph nodes status, and presence or absence of
  metastases.
• Tumour Grade i.e. degree of preservation of
  cellular architecture, mitotic figure number etc.
• Why bother staging? Treatment is tailored to
  stage of disease

76
Treatment Options

• Ta Single, G1-2, Not recurrent TURB
• Multiple, recurrent, or high grade TURBIntrave
  sical chemo
• T1 G1-2 TURBIntravesical chemo
• G3 TURBBCG
• CIS TURBBCG
• T2-T4 Radical Cystectomy
• Radiotherapy
• N or M ?Chemotherapy - MVAC

77
Surgery and Radiotherapy

• TURBT
• Radical cystectomy Major intra-abdominal
  procedure. Can divert urine either to an ileal
  conduit, or make a new bladder from bowel or
  colon. Incidental lymph node mets found in 20-35
  5 year survival a bit better than DXT 65 for
  T2-T4 disease.
• Pelvic Radiotherapy 20-40 5 year survival, but
  15 get local complications, e.g. radiation
  cystitis or proctitis.

78
Chemotherapy

• Intravesical
• Mitomycin response rate 40-50. Consider single
  dose intravesically post surgery rather than 6
  week course. Occasionally produces chemical
  cystitis.
• BCG decreases recurrence from 80 to 40, and
  decreases progression from 35 to 7. Cystitis in
  90 and haematuria in 33
• Systemic
• MVAC (Methotrexate, Vinblastine, doxorubicin,
  cisplatin) 13-35 response rate, but median
  survival rate is only one year
• Difficult to convince oncologists to give!

79
The bottom line

• Five-year survival
• Stage
• Ta 94
• T1 69
• T2 40
• T3 31
• T4 0
• Worse with increasing grade, and increased grade
  and stage associated with increased risk of
  metastatic disease.

80
Why Is a Spleen Not a Kidney?

• Very common exam question!
• Kidneys do not move with respiration
• Kidneys enlarge up down, not to the RIF
• Kidneys are resonant to percussion
• Kidneys are ballottable
• Kidneys do not have a notch
• You can get above a kidney

81
What Causes Big Kidneys?

• Unilateral
• Carcinoma
• Renal cell, transitional cell in adults
• Nephroblastoma (wilms tumour) in kids
• Hydronephrosis
• Tend to be chronic e.g. PUJ obstruction, reflux
• Simple cysts
• Compensatory hypertrophy

• Bilateral
• Polycystic kidneys
• Bilateral hydronephrosis
• Amyloid hens tooth

82
Renal Cell Carcinoma

• Synonyms hypernephroma, clear-cell carcinoma.
• Incidence 2-3 of all adult cancers.
• Renal cell carcinoma is roughly 85 of all renal
  tumours, the remainder being things like
  transitional cell carcinoma of the renal pelvis,
  and renal sarcoma.
• Age peak of 40-70 years old.
• Males outnumber females 21
• Risk factors
• Smoking.
• Others Von-Hippel Lindau syndrome, horseshoe
  kidneys, adult polycystic kidney disease,
  acquired renal cystic disease.

83
RCC Aetiology and Presentation

• Arises from the cells of the proximal convoluted
  tubule.
• Presentation classically
• Haematuria
• Flank pain
• Loin mass
• 50 diagnosed as incidental findings in 1995,
  during USS or CT for other problem.
• 30 present with metastatic symptoms
• Bone pain, dyspnoea, cough, etc.
• (Often to liver, lungs, bones, brain and adrenal
  glands)

Only true in 15
84
Why Physicians Like It

• Paraneoplastic syndromes
• Erythrocytosis (3-10) from increased
  erythropoetin production.
• Hypercalcaemia (3-13) either from a PTH-like
  substance, or from osteolytic hypercalcaemia.
• Hypertension (Up to 40)
• Deranged LFTs Stauffers syndrome, from
  hepatotoxic tumour products.
• Sundry others Rarely produces ACTH (Cushings
  syndrome), enteroglucagon (protein
  enteropathy), prolactin (galactorrhoea),
  insulin (hypoglycaemia) and
  gonadotropins.

85
Diagnosis and Staging

• Initial diagnosis
• FBP, UE, LFT.
• IVP and ultrasound.
• MSSU direct microscopy.
• Staging
• CT scan chest, abdomen and pelvis /- head.
• Isotope bone scan.
• Rarely
• Renal arteriography.
• Biopsy.
• Cavogram.

86
Pathological Staging (1)

• May be different than your textbooks. The TNM
  people revised this in 1997, and it may not be in
  older versions.
• Tumour
• T1 lt7cm, intra renal
• T2 gt7 cm, intra renal
• T3 tumour extends into major veins or perinephric
  tissues, but not beyond gerotas fascia
• T4 tumour beyond gerotas fascia

• Lymph nodes
• N0 no nodes
• N1 single lymph-node lt 2cm
• N2 single lymph node 2-5cm or multiple nodes lt5cm
• N3 any nodes gt5cm
• Metastases
• M0 no metastases
• M1 distant metastases (often to liver, lungs,
  bones, brain and adrenal glands)

87
Pathological Staging (2)

• And after all that
• Stage 1 T1 N0 M0
• Stage 2 T2 N0 M0
• Stage 3 T1-2 N1 M0
• T3 n0-1 m0
• Stage 4 T4 any N M0
• Any T N2-3 M0
• Any T any N M1

88
Treatment

• Get rid of the primary tumour
• Radical nephrectomy
• Open or laparoscopic? Laparoscopic has faster
  patient recovery, but is time-consuming in
  theatre.
• Partial nephrectomy for small polar tumours, less
  than 4 cm diameter.
• Embolisation.
• Consider small tumours below 2cm in unfit
  patients for watching?

89
Chemotherapy?

• Renal cell carcinoma has a track record of being
  unresponsive to chemotherapy.
• Immunotherapy
• Only works for clear cell type, the largest
  pathological group of RCC.
• Only used if lymph-node metastases, or metastases
  to solid organs. Cerebral metastases are a
  contra-indication.
• Combination regimens based on cytokines
• Interleukin-2 19 response rate alone
• Interferon-a 11 response rate
• Together 25-30 response
• Combinations of interleukin-2, interferon-a and
  5-fluorouracil have produced response rates of
  39 in one series.
• The main problem with immunotherapy is that it
  has a lot of side effects, such as fever,
  hypotension, tachycardia, oliguria. You can end
  up in ICU from it, but this is rare.

90
The Bottom Line

• Responses to immunotherapy tend to be
  short-lived, i.e. Months.
• Relapsers tend not to respond to more
  immunotherapy.
• 5-year survival
• T1 88-100
• T2 t3a 60
• T3b 15-20
• T4 0-20

Tumor stage T3 can be subdivided into 2 groups
T3a can invade the adrenal or perinephric tissue,
but remains within gerotas fascia, and T3b
invades the Renal vein or IVC.
91
Other Renal Tumours (Adult) Uncommon

• Sarcoma females outnumber males by 21. Surgery
  only effective therapy. Prognosis poor.
• Transitional cell carcinoma of the renal pelvis.
• Haematologic tumours (lymphoma deposits etc)
• Metastatic tumours (In order of frequency)
• Lung
• Breast
• Stomach
• Non-tumours that masquerade as such
• Oncocytoma
• Angiomyolipoma
• Others leiomyomas, haemangiomas

92
Symptoms of BOO

• Irritative
• Frequency, Urgency, Nocturia gt 2 times per night
• Obstructive
• Hesitancy, Poor flow, Terminal dribbling.
• Others
• Recurrent urinary tract infections as a
  consequence of impaired bladder emptying
• Haematuria rarely.
• Can be scored using IPSS system

93
Causes of impaired bladder emptying(i)

• Detrusor failure, i.e. weak bladder
• Think of the bladder with its nerve supply. Any
  disorder of nervous control may impair emptying.
  For example
• Spine Injuries, Disc prolapse, Spina bifida.
• Nerves Diabetes, Multiple sclerosis.
• Bladder Myogenic failure.

94
Causes of impaired bladder emptying(ii)

• Outlet Obstruction i.e. blocked bladder
• Mostly a male phenomenon. Can be any cause from
  bladder neck to outside world. For example
• Prostatic enlargement
• Bladder neck hypertrophy (Often post TURP)
• Urethral strictures (Often post instrumentations,
  also STD)
• Meatal stenosis (As for strictures, also after
  botched circumcisions and a condition called
  Balanitis Xerotica Obliterans)
• In male infants Posterior urethral valves

95
Investigation of BOO symptoms

• History and examination
• Dont forget to do PR!!!
• FBP, UE, Glucose, MSSU
• Prostate specific antigen (PSA)
• Currently best blood-test for separating benign
  prostatic disease from prostate cancer. It rises
  in cases of cancer. It can also rise with urinary
  tract infections, and following episodes of
  urinary retention or urinary instrumentation.
  Also slowly rises with age.
• Ultrasound of bladder (Is it emptying? If
  creatinine abnormal then also ultrasound kidneys,
  looking for obstructive uropathy)
• Urinary flow rate

96
Benign Prostatic Hypertrophy

• PSA should be within normal range or biopsies
  have shown no carcinoma.
• Usually treated medically, unless there is an
  absolute indication for surgery
• Refractory retention
• Recurrent UTI
• Bladder stones
• Obstructive uropathy
• Recurrent or persistent haematuria
• Symptom control is only a relative indication!

97
Obstructive Uropathy

• Basically this is renal impairment caused by
  chronic bladder outlet obstruction.
• It produces a detectable rise in creatinine, and
  eventually can be seen on ultrasound as thinning
  of the renal cortex.
• It means that the best treatment is operative
  relief of obstruction.

98
Acute Urinary Retention

• This is the end-stage of urinary outflow
  obstruction.
• Preceding outlet symptoms, with the straw that
  breaks the camels back often being an
  intercurrent UTI, an episode of constipation,
  immobility or post-operatively.
• Provided there is no obstructive uropathy, can be
  started on medical treatment and catheter removed
  after a day or two.

99
Medical management of prostatic obstruction

• Two broad groups of drugs
• Alpha-blockers These produce smooth muscle
  relaxation within the prostate, and so widen the
  outflow tract. Older generation drugs have been
  associated with postural hypotension, but newer
  drugs such Tamsulosin have minimised this.
• 5-alpha reductase inhibitors blocks testosterone
  metabolism to produce a 25 decrease in prostate
  volume. Better for large fleshy glands. 5 of
  patients get hot flushes, and can also cause
  gynaecomastia. Finasteride is the only drug in
  this group.

100
Surgical management of prostatic obstruction

• A variety of operations has been tried, such as
  prostatic microwave, cryoablation, and
  transurethral incision of the prostate.
• However, none has replaced TURP (Trans-urethral
  resection of prostate), which remains the gold
  standard.
• TURP is not always successful, however. The most
  common early complication is failure to void
  after catheter removal (6). There is also a
  small risk of incontinence from external
  sphincter damage.
• And finally After TURP erectile failure may be
  produced, and ALWAYS retrograde ejaculation is
  caused.

101
Prostatic carcinoma

• 4th commonest cancer death, after lung,colon and
  breast.
• Rare before age 40, peak incidence in 70s.
• 70 arise in the peripheral zone of the prostate.
• Most often found on PR or PSA testing
• 40 have metastases at the time of diagnosis.

102
Prostate Carcinoma

• Suspected on digital rectal examination or a
  raised PSA.
• Diagnosed by BIOPSY, or found at TURP.

103
Further investigation

• Is the prostate cancer
• Metastatic ( Only treatable with Hormones)
• Locally advanced (Hormones or radiotherapy)
• Confined to the prostate (Hormones, Radio or
  Surgery)
• Staging of prostate cancer requires an isotope
  bone scan. In patients under 75 years, where
  surgery or radiotherapy are being considered, a
  CT scan is also required.

104
Staging (TNM)

• T1a Tumor in lt5 TURP specimen, incidental
  finding.
• T1b Tumor in gt5 TURP specimen, incidental
  finding.
• T1c Tumor non-palpable, diagnosed on biopsy.
• T2a Palpable, half a lobe or less
• T2b Palpable, half to all of one lobe
• T2c Palpable, involves both lobes.
• T3a Unilateral extracapsular extension
• T3b Bilateral extracapsular extension
• T3c Tumor invades seminal vesicles
• T4a Invades bladder neck, external sphincter or
  rectum
• T4b Invades levator muscles, or is fixed to
  pelvic side-wall.

• N0 No lymph node metastases
• N1 Single node metastasis, below 2cm in size
• N2 Mets to a single node between 2 and 5 cm, or
  multiple nodes less than 5cm.
• N3 Lymph node metastasis gt 5cm
• M0 No Metastases.
• M1 Metastases

105
Treatment - Surgery

• For prostate cancer without metastases, which is
  confined to the prostate, PSA is below 15, and
  age below 70, consider RADICAL PROSTATECTOMY.
• Major intra-abdominal procedure, with significant
  morbidity. Almost inevitably produces total
  erectile failure, and a variable degree of
  incontinence. Incontinence tends to improve /
  resolve with pelvic floor exercises.
• 5 year disease-free survival for T2 cancer with
  surgery is 80

106
Treatment - Radiotherapy

• Consider in males with disease that has spread
  locally outside the prostate below age 75. Also
  for prostate confined disease in men below 70
  years, unfit for surgery, and without metastases.
• Can be given as external beam or brachytherapy
  (implanted radioactive particles within the
  prostate)
• Complications
• Bladder Frequency, Urgency, Haematuria.
• Bowel Diarrhoea, Tenesmus, PR bleeding.
• Skin Rash
• Rarely, fistulas may be caused.
• 5 year disease free survival for T2 disease is
  70 (Slightly lower than for surgery)

107
Treatment - Hormones

• Prostate carcinoma is dependant on testosterone
  to survive. The medication used attempts to block
  testosterone synthesis. They are used in cases of
  metastatic disease or age gt75 years or unfitness
  for either surgery or radiotherapy for localised
  disease.
• Gonadotropin analogues Goserelin, Leuprolin.
  Often given as monthly or 3-monthly injections.
  Initially produce a tumour flare, so can only be
  started after several days of an anti-androgen.
• Anti-androgens Flutamide, Bicalutamide,
  Cyproterone acetate. Tablet form once daily.
• Both of these medication groups produce
  significant side-effects most often hot-flushes,
  erectile failure, loss of libido, and
  gynaecomastia.
• Treatment can be combined, using both a GNRH
  analogue and an anti-androgen. On average a
  2-year response is achieved until the development
  of Hormone-resistance. Alterative drugs for
  advanced disease include Oestrogens and
  Estramustine.

108
Ooh, Controversy!

• In elderly men, i.e. age greater than 75, there
  is an argument for not investigating an
  asymptomatically raised PSA.
• The reason is that at this age, there is a
  significant chance they will die of something
  else, and the only treatment would be Hormonal
  manipulation anyway. Some argue that treatment
  should be witheld until the development of
  outflow symptoms or metastatic discomfort, and
  then instituted.
• The idea is to avoid needlessly treating and
  worrying elderly men

109
Urinary tract Calculi

• Ureteric Calculi Most pass without difficulty,
  especially if below 5mm in diameter. Above 7mm
  they are unlikely to pass.
• If calculi are not passing, or if they are
  causing blockage of the kidney as shown on IVP,
  then they can be removed endoscopically using a
  Ureteroscope and either Laser or EHL or basket
  extraction. If theres a lot of ureteric swelling
  then a stent can be left in for 4-6 weeks and
  then removed.
• Ureteric calculi can be a symptom of a raised
  serum Calcium, so remember to check it!

110
Urinary tract Calculi

• Renal Calculi
• Generally present either as a cause of recurring
  infections or a cause of pain in the loin or
  flank. If large enough, they can seriously
  compromise renal function. This can be detected
  using a DMSA scan.
• In a functioning kidney, stones up to about 2cm
  can be fragmented with ESWL sessions, which may
  be multiple. Larger stones or multiple stones may
  be dealt with operatively using PCNL, where a
  tube is inserted though the flank into the renal
  pelvis, and the stones surgically fragmented and
  removed. Very large stones may need to be removed
  using an open pyelolithotomy.
• If the kidney is non-functioning then it can be
  removed.

111
Okay brain, its all up to you.(Homer J Simpson)