URETER SURGICAL RELATIONS
Anterior to psoas, lumbar TPs
Crossed by gonadal v.
Crosses anterior to iliac bifurcation
โ๏ธ vas is anterior, crossing from lat - med
โ๏ธureter post. to ovary, thru base of broad lig, post. to uterine a. (๐ฆ๐๐) then crosses ant. vaginal fornix
๐ฃโ๐ฉ TESTICULAR TORSION - BELL CLAPPER DEFORMITY
Best photo explaining bell clapper deformity - anatomical variant predisposing to testicular torsion.
Torsion = time critical emergency.
What suture will you use for orchiopexy?
Paper by
@uro_nima
@DrAsanad
(link ๐)
PRINCIPLES OF URINARY ANASTOMOSES:
Spatulated (โฌ๏ธ mucosal surface)
Watertight (๐ซ leak)
Absorbable suture (nidus for stones)
Stented and drained (๐ซ leak)
Tension free (๐ซ ischemia)
Well vascularised, healthy tissue (๐ซischemia)
Mucosa to mucosa
What suture do you use?
You WILL be asked over & over - arterial supply of the testis?
1๏ธโฃ testicular a
2๏ธโฃa. to vas
3๏ธโฃcremasteric
Important for:
- Fowler-Stephens procedure
- Vasectomy risk might be higher in someone with previous inguinal surgery
- Laparoscopic varicocele ligation
- Epididymectomy
BRICKER VS WALLACE ureteroileal anastomosis for ileal conduit:
- Bricker - end to side - two separate anastomoses to side of conduit
- Wallace - end to end - ureters joined together and placed on end of conduit
Surgeon preference dictates the choice
Do you know the Mayo classification for IVC thrombus in RCC?
We used to use a 2 cm cutoff above the renal vein as the differentiator between level 1 and 2.
Did you know an updated classification was published in 2020? We should now use the caudate lobe as differentiator.
BLOOD SUPPLY OF THE URETER
Multiple vessels forming longitudinal anastomosis
Prox ureter from renal artery- from MEDIAL
Distal from internal iliac, inf vesical, sup vesical- from LATERAL
Mid from aorta/gonadal- from POSTERIOR
Important to preserve adventitia when dissecting
๐ฉธAAST GRADING RENAL TRAUMA
1๏ธโฃ non expanding subcapsular haematoma or normal imaging w hematuria
2๏ธโฃ parenchymal lac < 1 cm
3๏ธโฃparenchymal lac > 1 cm
4๏ธโฃcollecting system injury OR contained injury to artery/vein
5๏ธโฃshattered kidney or avulsion of hilum/devascularisation
ANATOMY OF ADRENAL
Right - ๐บtriangular, sup to R kidney
Left - ๐ crescent, medial to upper L kidney
๐ฉธArteries x 3
Superior (from inf phrenic)
Middle (from aorta)
Inferior (from renal a.)
๐ตSingle vein
Right adrenal vein - short, directly to IVC โ ๏ธโ ๏ธ
Left - enters renal v.
ANATOMY OF THE PERINEUM ๐ฆ
Colles' fascia is continuous with Scarpa's, and superficial dartos
Urine/blood extravasation limited to 'butterfly' pattern
But may track up abdo wall to clavicles.
Classic exam q's..Confused? This video is a must ๐
PROSTATITIS
Classic questions you will be asked:
How do you categorise or classify prostatitis?
What antibiotics will you use to treat?
How do you do a Stamey test?
When might you see granulomatous prostatitis?
๐งต
RENAL CYSTS ๐ต
Extremely common incidental finding on imaging.
Do they need follow up? Could it be cancer?
Use the BOSNIAK criteria to guide decision making
Note Bosniak criteria is based off CT imaging with contrast.
more info re: small renal mass -
How long do you stop anticoagulation prior to a procedure?
Guidelines in the image - but many surgeons prefer to wait longer.
Our page on anticoagulants has:
- mechanisms
- VTE risk stratification
- reversal for NOACs
๐ฉ๐ฉ๐ฉธ๐ฉธ Anatomy of the CAVA
Knowledge of the tributaries of the IVC is ESSENTIAL for safe surgery in the retroperitoneum.
Torn gonadal vein can be a bad day
Torn lumbar vein can be an absolute disaster
Managing avulsed lumbar?
- pack
- oversew
- consider opening if lap
PENILE FRACTURE ๐
3 key features
Pop/crack sound ๐
Immediate loss of erection ๐
Bruising ++ like an ๐
10-20% assoc urethral injury - hematuria ๐ฉธ
USS or MRI can help localise injury prior to OT
๐ช Surgical exploration/repair good outcomes (vs observation - ED, curvature)
๐ด NOCTURIA is not always the prostate!
Independent risk factor for increased mortality โ ๏ธ
Bladder diary most important investigation: > 33 % of total daily urine output at night = nocturnal polyuria
Important to assess for all causes (before TURP!)
MEDICAL MANAGEMENT OF KIDNEY STONES
I've just published this page which summarises all of the guideline and algorithms for medical management and prevention of stones, based on metabolic workup.
Bookmark this tweet or visit the page:
Knowledge of anatomy is mandatory in surgery. ๐ซ
Flank incision = risk of pleural injury โ
Incision further posterior = more pleural attachments
Medial half of the 12th rib, and medial 3/4 of the 11th rib have pleural attachments.
I like supra-11 incision for partial - you?
โCALYCEAL DIVERTICULUM
Cystic cavity within the kidney, lined by non-secretory urothelium, communicating with a calyx or renal pelvis by a narrow isthmus.
Calyceal diverticular do not have papillae and fill with urine passively.
Management of stones:
RISK FACTORS FOR RENAL STONES
For exams, you need a way to classify risk factors for stones that will stay in your mind.
This table is how I remembered - even if you just remember the categories, you can get most.
Full page here:
PDE5 inhibitors are the mainstay of medical management of
#erectiledysfunction
.
However, many times they are prescribed without appropriate counselling.
Key tips:
- avoid having at same time as food
- still require sexual stimulation to work
- don't work immediately
๐๐Renal stone analysis should prompt an immediate thought about what can be done to prevent future stones.
e.g.:
struvite stone = UTIs
calcium phosphate stone = ?could this be renal tubular acidosis
uric acid stone = acidic urine, ?hyperuricemia
Blood in the semen is an alarming thing for patients, but usually no sinister cause is found.
Do you have an approach you use?
I tend to think about MRI prostate & cystoscopy in those over 40-50...but appreciate it is usually low yield.
What do you do?
๐ Management of the inguinal nodes in penile cancer can become very complicated, especially for those trying to understand the topic for exams.
This is my simple way to approach it based on guidelines, not only for exams, but real life.
Any doubt โก๏ธ refer hi-volume centre.
๐ 'ONE SHOT IVP' in trauma?
To confirm presence of contralateral kidney, prior to exploration/trauma nephrectomy (assume no CT prior)
โผ๏ธ 2mg/kg IV contrast, then xray in OR after 10 min
Alternatives?
-direct palpation
-ultrasound
See old
@JUrology
article
ENDOMETRIOSIS - may involve the bladder or ureter
Bladder - may present with cyclic hematuria, bladder pain, urinary symptoms, incidental on imaging
Ureter - often causes silent obstruction (โโ) and hydronephrosis, or symptoms renal obstruction
Rx - often surgical
What are your options for managing ureteric stones??
This will vary depending on your location and what resources you have.
Here is our table regarding the pros and cons of all the options.
What do you think?
AUTONOMIC DYSREFLEXIA โโ
Severe hypertension in response to noxious stimulus - usually distended or irritated bladder.
Seen in those with spinal cord injury T6 or higher.
Potential life threatening emergency - must treat promptly.
for more notes
Upper tract urothelial cancer:
Best oncological treatment is radical nephroureterectomy.
BUT - this may often be overkill, and often these patients have threatened renal function anyway.
Use
@Uroweb
guidelines to stratify low risk - may be amenable to kidney sparing surgery.
DUTASTERIDE/FINASTERIDE AND PROSTATE CANCER
PCPT:
25% reduction in CaP - mostly Gleason 6
Higher prevalence Gl 8-10 w finasteride
?Reduced prostate size = more ca found
15 yr f/u - no survival difference
REDUCE:
23% reduction in CaP
Small incr risk Gl 8-10
EAU guideline:
POST OBSTRUCTIVE DIUESIS
All emergency department practitioners, urologists, renal physicians and inpatient doctors should have an appreciation for those at risk of POD
I've seen patients lose 10+ litres in 24 hours.
Can you share your preferred management strategy?
URETHRAL DIVERTICULUM
Classic presentation is "3 x Ds" - dysuria, dyspareunia & (postvoid) dribbling
Reality=rare to have all 3
Other sx- palpable mass, storage LUTS, hematuria, UTIs, discharge.
Best scan=MRI
Cysto may identify ostium - use 0 degree
MRI image from Campbell:
DIETL'S CRISIS
Refers to episodic severe flank pain associated with nausea/vomiting, classically after an intake of alcohol or other diuretic.
Usually associated with PUJ obstruction (or UPJ obstruction depending which country you are in!)
DDx - renal colic
Who are the best candidates for a SLING for post-prostatectomy incontinence?
- mild-moderate incontinence
- non obese
- no XRT
- dry overnight
50-60% cure
20-30% better
Mechanism - repositioning and support prox urethra, โฌ๏ธfunctional urethral length (NOT compression)
FEMALE UROLOGY is often neglected during study because of a lack of understanding and exposure.
Can you articulate the relationship between pelvic organ prolapse and stress incontinence?
Further info on POP for exams and practice here
MARTIUS FLAP
(labial fat pad)
You may have heard about this but never seen it.
The principles are straightforward and you never know when it may be useful.
It's also common to get asked about in exams.
Check my page but also the article below ๐
PROSTATITIS
Classic questions you will be asked:
How do you categorise or classify prostatitis?
What antibiotics will you use to treat?
How do you do a Stamey test?
When might you see granulomatous prostatitis?
LYNCH SYNDROME
Upper tract urothelial cancer is 3rd most common cancer in these patients.
Germline mutation in one of 4 mismatch repair (MMR) genes -> "microsatellite instabiity"
Cumulative lifetime risk of 2.9 % for UTUC in Lynch patients (14 x relative risk)
How to screen?
โโConsent process for vasectomy ... sounds straightforward but really really important in both practice and exams...
Check my page for lots of detail -
Autosomal dominant polycystic kidney disease - indications for nephrectomy:
1. Uncontrolled pain
2. Refractory bleeding or infection
3. Troublesome stone burden not amenable to usual treatment
4. To make room for transplant
5. Solid enhancing suspicious renal mass
โโTip for commonly examined hereditary syndromes in urology:
It is usually a safe bet to guess AUTOSOMAL DOMINANT for the mode of transmission.
This works for vHL, Birt Hogg Dube, tuberous sclerosis, adult polycystic kidney disease.
the main exception - cystinuria!!
XGP KIDNEY (Xanthogranulomatous pyelonephritis)
Rare, severe, chronic kidney infection characterised by destruction of renal parenchyma.
Also - a favourite scan to be shown to residents and trainees to be grilled on.
Pathophys?
Histo?
Presentation?
Imaging?
Management?
(1/9)
๐ฉ๐ฉ UTI & PREGNANCY
4-7% pregnant women have asymptomatic bacteriuria.
Normally we don't treat asymptomatic bacteriuria.
But in pregnancy - 20 - 40% may progress to pyelonephritis - which can lead to adverse fetal outcomes.
Which ABx are safe?
Penicillins, cephalosporins
VON HIPPEL LINDAU (vHL)
What are the urological manifestations of vHL?
What are the non urological manifestations?
What is the genetics and how does it relate to RCC?
Don't they just need a nephrectomy?
I have a page on Malacoplakia which comes from 'soft plaque' in Greek
abnormal macrophage function & inflammatory reaction in response to infection - often history of repeated E.coli infections.
Michaelis-Gutmann bodies are classic Histo ๐๐
Malakoplakia of the urinary bladder with histiocytic infiltrate and MG bodies (concentric basophilic inclusions)- one of the highest number of MG bodies I have seen in any case!
#bladder
#Pathology
@UMichPath
SHOCK
Definition - acute circulatory failure, with inadequate tissue perfusion causing cellular hypoxia
4 types of shock:
1. Hypovolemic
2. Cardiogenic
3. Obstructive
4. Vasodilatory (distributive)
Can be multiple in same patient - e.g. septic patient also dehydrated
Do not perform simple circumcision if phimosis is associated with other penile anomalies such as buried penis, congenital penile curvature, epispadias or hypospadias.
#PedsUro
#EAUguidelines
Congratulations and welcome to all those matching to urology in USA. Look forward to helping you all over the coming years!
#UroMatch2024
#UroSoMe
#AUAMatch2024
๐๐ฅ๏ธCT SCANS
Med students keen on surgery - must know what phase CT you are reading and why
๐ชจNon-con - stones, โฌ๏ธeGFR
๐ฉธArterial - bleeding, vascular anatomy
๐ฆPortal venous - inflammation, abdo organs, staging
๐นOral - GIT pathology
๐ฐDelayed - hematuria, urine leak
Fluoroquinolones have the most favourable pharmacokinetic properties for penetrating the alkaline prostatic fluid. (ciprofloxacin, norfloxacin)
Trimethoprim is the next best alternative.
PARKINSON'S DISEASE - NEUROLOGY OR UROLOGY?
35 - 70 % of patients with Parkinson's may have urological dysfunction.
What are the common urinary symptoms?
What is seen on urodynamics?
How can we treat these patients?
Should I do a TURP?
WTF is MSA?
@Uroweb
'Sir, your PET scan shows an L1 vertebral met, avid pelvic nodes and a pre sacral node. But because the CT and Bone Scan are OK, we will perform radical prostatectomy'
A 30 year old lady is referred to your clinic with an incidental finding of a dilated ureter on ultrasound.
What is your definition of megaureter?
How do you classify it to help guide your management?
SEPSIS
Were you taught about SIRS? Definitions of sepsis vs severe sepsis?
These are now historic and not recommended.
New guidelines suggest the use of SOFA, or more commonly, qSOFA
๐
BALANITIS XEROTICA OBLITERANS (BXO)
Now correctly known lichen sclerosis et atrophicus
Incidence - about 1 in 300
Appearance - white patches, skin thickening, cracking and bleeding of foreskin
Management - topical steroids or surgery (circumcision)
HIGH YIELD POINTS: (1/2)
๐ฆ A 38 year old man presents with urinary symptoms - poor flow and hesitancy.
Don't always blame the prostate!!
The differential diagnosis for LUTS are wide, and one must be aware of all possible contributors - potentially in younger men.
There are many options for treatment for chronic pelvic pain syndrome - current guidelines suggesting using the UPOINTS framework to help guide management based on patients symptoms + phenotype
There is no silver bullet - but we can help these patients improve quality of life!
The Kelly clamp was named after Howard Kelly, an American gynaecologist. Did you know that he discovered a way to identify the ureters during surgery by gently squeezing them, inducing peristalsis? This is also known as โKellyโs signโ.
ABx for prostatitis:
Prostate capillary bed lacks active transport โ penetration dependent on passive transport
3 factors determine ability to penetrate โ lipid solubility; pKa and protein binding
B-lactams - low pKa / poor lipid solubility
Antibiotic with best properties?
Mural calcification of the bladder wall is the hallmark characteristic of schistosomiasis on imaging.
Other organs โ prostate, SVs, distal ureters, colon and gynae organs may also show calcification.
Ureteric dilation may also be apparent.
PRIAPUS is the Greek God of fertility and farming. What a combination.
We will keep posting useful information every day.
Check out our website for further notes on priapism or all things urological, available anytime