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name 3 sites of constrictions of the ureters and which is the narrowest?
- pelvi-ureteric junction
- where ureter crosses pelvic brim in region of the bifurcation of the CIA
- vesico-ureteric junction: narrowest
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what structure in the ureter prevents retrograde urine flow back up ureters?
flap valve in the bladder wall before they reach orifices at upper lateral angles of trigone
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what size stone would you wait to spontaneously pass?
up to 4mm, wait for 2 months then intervene
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name 2 contraindications to ESWL?
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describe the type of pain that ureteric calculi produce? how it this different to peritonitis?
- colicky or constant loin pain radiate to groin or scrotum
- colic cannot lie still but very still in peritonitis
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what do staghorn calculi contain and what causes them?
- G-ve bacilli Proteus makes urease which hydrolyses urea to ammonium making urine alkaline and precipitating struvite stone formation
- magnesium, ammonium phosphate and calcium
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name 4 conditions that increase stone formation?
- hyperparathyroidism (inc calcium)
- gout
- cystinuria
- UTI with proteus - staghorn calculi
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which medications increase stone formation?
- corticosteroids increase calcium absorption
- chemotherapy induces cell breakdown and release or uric acid from purine metabolism
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what are the range of modalities used to treat ureteric calculi, ranging from simple to complex?
- simple: small stone pass spontaneously, give analgesia e.g. diclofenac and antiemetic, fluids and if infection suspected give antibiotics
- ESWL: good for small stones, better for kidney rather than ureteric stones. SE haematuria, renal colic, UTI. contra in preg and coag
- ureteroscopic removal: laser, good if lower pole stone
- percutaneous nephro lithotomy: first line for STAGHORN calculi, do under US or XR guidance
- open surgery: do if anatomical abN or complex stone or other Rx failed
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do ureteric calculi predispose to TCC or ureter?
no but bladder stones increase risk of bladder tumours of SQUAMOUS CELL type
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what is hyperacute rejection due to? time scale?
- formation of preformed antibodies against the donor organ
- within minutes of transplantation
- Abs usually against blood group Ags
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how can you minimise hyperacute rejection?
Blood group matching
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what is the treatment of hyperacute rejection? and what happens if you don't?
- remove the transplanted kidney (theres no drug to reverse it)
- or SIRS will occur
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what is acute rejection? timescale?
- occurs within days to weeks
- acute CELLULAR: influx of cytotoxic T cell (CD8) against HLA antigen on renal tubular cells
- acute VASCULAR: CD4 and CD8 T cell response against HLA I and II on endothelial cells and others. this is less common but harder to treat, graft kidney looks swollen and full of blood
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what is chronic rejection? timescale?
- months to years
- antibody mediated VASCUALR damage, slow narrowing of vessel lumen, tubular atrophy, kidney gradually loses function
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which type of treatment helps reduce acute rejection?
immunosuppression especially ciclosporin
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what is graft v host disease caused by?
engraftment of donor lymphocytes into a severely immunosuppressed recipient
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when does GVHD occur?
- BM transplant eg for AML aleady immunosuppressed as had chemo
- blood transfusion
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how can you reduce the risk of GVHD?
- tissue matching
- immunosuppression
- T cell depletion with MAb
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which 2 malignancies does ciclosporin cause?
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which diseases can lead to GU fistula e.g. from bowel to bladder causing pneumaturia?
- Crohn's
- Diverticulitis
- Trauma
- Carcinoma of colon or bladder
- carcinoma of cervix
- hysterectomy
- obstructed labour and difficult instrumental delivery
- radiotherapy
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what investigation would you use for fistula detection?
barium enema to look for extra luminal barium and the underlying cause
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what type of biopsy and what type of scoring system is used for prostate cancer?
- TRUS: trans rectal ultrasound biopsy
- Gleason score
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give 2 causes of urinary incontinence in women and how to manage them
- UTI: MSU, abx
- operation for prolapsed bladder - may sew stitches around bladder neck too loose or too tight: do US to see if bladder is full and enlarged
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give a rare presentation of renal cell carcinoma
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Name 5 complications of renal cell carcinoma
- 1. tumour spread to renal vein and may EMBOLISE to lung causing PE - during handling intraop!
- 2. bony mets - osteolytic
- 3. polycythaemia due to ectopic EPO production
- 4. left varicocele: left testicular joins left renal but right joins IVC
- 5. hypercalcaemia due to PTH production
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where in the kidney does RCC arise from?
proximal convoluted tubule
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how should Any boy with a first episode of a UTI be managed?
- caution!
- do micturating cystourethrogram to look for VUR
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if there are classic loin to groin pain and haematuria symptoms but a normal XR KUB, what would be the next investigation?
IVU - would show delayed nephrogram on that side
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what is the classical history for renal cell carcinoma?
- loin pain
- haematuria
- mass in hypochondrium (upper quad)
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if suspect bladder cancer (painless haematuria), what inv would u do?
cystoscopy and biopsy
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in terms of acute testicular pain, what cause is more common in adults and what in children?
- adults: epididymo-orchitis
- children: torsion
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how do you manage epididymo-orchitis?
- antibiotic cover
- scrotal US to exclude abscess - testicular necrosis
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A 31-year-old man presents to the clinic with a 2-month history of a right testicular lump. This was mildly tender at first, but over the last month has become painless. what is the diagnosis?
seminoma: usually found in 30-40 yo
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how to treat suspected seminoma?
radical orchidectomy as tumour doubling time is only 28 days!
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how to manage testicular torsion?
- emergency surgical exploration as necrosis in 6 hrs from ischaemia!
- orchidopexy suture both down so cant tort in future
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if there is unilateral scrotal pain that you CANNOT get above and the person goes to gym.. what is it?
- inguinal hernia
- need to exclude obstruction
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if you can get ABOVE a scrotal swelling what is it?
hydrocele
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how would you treat advanced prostate cancer with no mets in a 75 yo man?
hormone therapy to suppress further tumour growth
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what investigation would you do in a man with incontinence 6 months post TURP?
urodynamics to identify type of incont
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how would you treat a 65yo man with 6month LUTS and uroflow showing mod obstruction?
- medical treatment alpha blocker tamsulosin.
- if no response TURP
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are hydroceles more common in children or adults?
children
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do hydroceles usually communicate with the peritoneal cavity?
no
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can hydroceles be caused by ascites?
yes
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would you find haematuria in BPH?
yes it may come from the enlarged gland
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what are 2 cardinal signs of BPH?
- hesitancy
- terminal dribbling
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what are symptoms of infection or detrusor instability?
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is impotence assoc. with BPH?
no
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what changes may you see in the bladder with BOO?
- diverticula
- trabeculation
- hypertrophy of muscle
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which anti hypertensive drug should you not give to asthmatics?
beta blockers
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what is the advantage of IVU over plain XR KUB?
- shows LEVEL and degree of OBSTRUCTION
- only rarely fails to identify a stone
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A 40-year-old woman presents with haematuria, malaise, fever and joint pains. She recently recovered from a sore throat. Renal function is abnormal. which investigation would tell diagnosis?
renal biopsy: symptoms suggest intrinsic renal disease such as glomerulonephritis
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bilateral loin mass, non tender, in a hypertensive…diagnosis?
adult polycystic kidney disease: rare hereditary cause for secondary hypertension
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what should any painless swelling of the testis assumed do be?
- malignancy- so do US: if solid its most likely cancer, if cystic then benign
- over 30: seminoma
- under 30: teratoma
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in which can you normally palpate the testis: hydrocele or epididymal cyst?
epididymal cyst
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