Surgery Of GUS.

❖ Dr/ Abdallah Al_Sakaf

❖ Done by. Sala Al_Najdi

❖ Urolithiasis Summary

Definition Formation of
calculi in the
urinary tract
(kidneys,ureters,
bladder, urethra.
Epidemiolog -10_20%
prevalence.

- ♂ > ♀ (4:3 for

renal stones, 8:1
for bladder
stones).

- Peak age:
30_50 year
1/Diet: High
oxalate (spinach),
calcium (dairy),
uric acid
(meat/organ
meats).
2/Dehydration:
Concentrated
Main Causes urine.
3/Infections (e.g.,
*Proteus* →
struvite stones)
4/Metabolic:
Hypercalciuria,
hyperoxaluria,
cystinuria.

Stone Types 1-Calcium oxalate

(70-80%): Spiky,
radiopaque.
2- Struvite (15-
20%): Large
("staghorn"),
infection-related.
 3 - Uric acid (5-
10%): Smooth,
radiolucent.
4 - Cystine (1-3%):
Yellow-green,
hexagonal
crystals.
Symptoms -Renal:
Flank pain,
hematuria.
-Ureteral colic:
Severe pain (loin
to groin), nausea.
-Bladder:
Dysuria,frequency,
interrupted
stream.
Diagnosis -Urinalysis: RBCs,
WBCs, crystals
(e.g., cystine).
- Imaging:
- *KUB X-ray*
(80% visible).
- Non-contrast CT
(gold standard).
- Ultrasound (for
hydronephrosis).
Treatment Conservative:
- Fluids (2L/day),
analgesics
(NSAIDs), α-
blockers (for
ureteral stones).
Surgical:
- *ESWL* (for
stones <2 cm).
- Ureteroscopy (for
impacted stones).
- PCNL (for
large/staghorn
stones).
Complications - Pyelonephritis,
sepsis.
- Hydronephrosis
→ renal atrophy.
- Chronic kidney
disease.
Prevention - Hydration (dilute
urine).
- Diet mods (limit
salt/oxalate/animal
protein).
- Medications
(e.g., thiazides for
calcium stones,

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 allopurinol for uric
acid).

❖ Chronic Pyelonephritis Summary

Definition Chronic inflammation of renal tubules and

interstitium, leading to scarring and calyceal
deformities.
Main Causes 1/Obstructive: Urinary outflow blockage (e.g.,
stones, tumors).
2. Reflux Nephropathy: Vesicoureteral reflux (VUR)
+ UTI (most common cause).
Risk Groups -Infants/children (congenital anomalies).
- Spinal cord injury patients (neurogenic bladder).
-Females (higher post-infancy risk).
Pathology - Gross: Uneven scarring, blunted papillae, dilated
calyces.
-Microscopic: Thyroid-like tubules ("thyroidization"),
lymphocytic infiltrate.
Complications - ESRD (end-stage renal disease).
- Glomerulosclerosis.
- Papillary necrosis.
- Perinephric abscess .
Diagnosis Urinalysis.
- IV pyelography.
- Ultrasound.
Treatment Antibiotics.
- Relieve obstruction (e.g., surgery for stones).
- Pain management.
- Prevent recurrent UTIs .
Rare Variants XGP
(xanthogranulomatous pyelonephritis).
- EPN (emphysematous pyelonephritis; diabetic
patients) .

Notes

- Reflux Nephropathy: Caused by congenital VUR → urine backflow → renal scarring .

- Tuberculous Pyelonephritis: Hematogenous spread from lungs → caseating granulomas in kidneys

❖ Benign Prostatic Hyperplasia (BPH) Summary

Definition Non-cancerous prostate

enlargement due to
stromal/epithelial
hyperplasia.

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 Epidemiology - 50% of men >60 yrs;
90% >85 yrs.
- Rare before age 40.
Risk Factors - Age (primary)
- Androgens (DHT)
- Family history
- Metabolic syndrome.
Symptoms -Obstructive: Weak
stream, straining,
incomplete voiding.

-Irritative: Frequency,
urgency, nocturia.
Diagnosis -IPSS (0-35 score)
- DRE: Smooth,
enlarged prostate.
- Tests : Urinalysis,
PSA, PVR,
uroflowmetry.
Treatment -Mild (IPSS ≤7):
Watchful waiting.
-Moderate-Severe (IPSS
≥8)
- *Medical*: α-blockers
(tamsulosin), 5α-RIs
(finasteride).
- *Surgical*: TURP (gold
standard), laser
enucleation.
- *Minimally invasive*:
TUNA, TUMT.
Complications UTI, retention, CKD.
-Acute urinary retention
- Bladder stones
- TURP syndrome
(hyponatremia)
- Erectile dysfunction
(rare).

Notes
LUTS:
- *Irritative*: Frequency, Urgency, Nocturia (FUN). - *Obstructive*: Hesitancy, Weak stream, Incomplete
voiding (HWI).

Prostate Zones (McNeal's):

- Peripheral (70%): Cancer-prone.
- Transitional (5%): BPH origin.
- Central (20%): Rarely involved.

*When to Refer*:
- Refractory retention
- Recurrent UTIs/hematuria
- Renal insufficiency
- Failed medical therapy.

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 ❖ Prostate Cancer Summary

Definition Malignant adenocarcinoma (95%) arising from

prostate gland epithelium.
Epidemiology - Most common male cancer (1 in 6 lifetime risk).
- Median age at Dx: 68 yrs.
- African-Americans at highest risk.
Risk Factors - Age (>50 yrs)
- Family history
- African descent
- High-fat diet
- Lynch syndrome
Clinical Types -LUTS (frequency, weak stream).
- Occult: Mets symptoms first.
- Incidental: Found during TURP.
Zonal Distribution -Peripheral zone (70%
- Transition zone (20%)
- Central zone (10%)
Diagnosis PSA: >4 ng/mL (but BPH/prostatitis elevate PSA).
- DRE: Nodule/asymmetry.
- Biopsy: TRUS-guided (12-core).
- MRI: For staging (T3/T4).
Grading Gleason Score
- 6 (Low grade)
- 7 (Intermediate)
- 8-10 (High grade)
Staging (TNM) - T1-T2: Organ-confined
- T3: Extracapsular extension
- T4: Adjacent organs
- N1: Node+
- M1: Mets (bone=common)
Treatment Localized**:
- Active surveillance (Low risk)
- Radical prostatectomy (Gold standard for T1-T2)
- Radiation (EBRT/brachytherapy)
*Advanced**:
- ADT (LHRH agonists/antagonists)
- Chemo (docetaxel)
- Immunotherapy (sipuleucel-T)
Complications - Post-RP: Incontinence (5-20%), ED (30-70%)
- ADT: Hot flashes, osteoporosis
- Bone mets: Pain, fractures
Screening Controversial:
- USPSTF: Individualized for 55-69 yrs.
- PSA + DRE: Annually for high-risk men.

Notes

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PERIPHERAL: Zone where 70% of cancers arise.
- GL70: Gleason 7 = Intermediate risk

*When to Biopsy*:
- PSA >10 ng/mL
- PSA 4-10 + abnormal DRE/free PSA <25%
- Rising PSA velocity (>0.75 ng/mL/yr)

❖ Prostatitis Summary:

Definition Inflammation of the prostate gland

Classified as - Acute bacterial
- Chronic bacterial
- Chronic pelvic pain
Epidemiology - Affects 10-15% of men
- Most common urologic diagnosis in men <50 yrs
Risk Factors - UTI/STIs
- BPH
- Catheter use
- Dehydration
- Immunosuppression
Pathogens - E. coli (80%)
- Other Enterobacteriaceae
- Chlamydia/Gonorrhea (in younger men)
Symptoms Acute:
- Fever/chills
- Dysuria
- Perineal pain

Chronic:
- Pelvic pain >3 months - Voiding symptoms
Diagnosis - DRE: Tender, boggy prostate (avoid in acute) -
Urinalysis: WBCs, bacteria
- Culture: Pre- and post-prostatic massage
- NIH Chronic Prostatitis Symptom Index
Treatment Acute Bacterial:
- Fluoroquinolones (4-6 wks)

Chronic Bacterial:
- ABx (6-12 wks)

CPPS:
- Alpha-blockers
- Anti-inflammatories
-Physical therapy
Complications - Prostatic abscess
- Epididymitis
- Sepsis (acute)
- Infertility (chronic)
Prevention - Hydration

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 - Regular ejaculation
- Proper hygiene
- Prompt UTI treatment

Notes:
1. "HOT PROSTATE" mnemonic for acute bacterial prostatitis:
- High fever
- Obstructive symptoms
- Tender prostate
- Pyuria
- Rigors
- Over 50 yrs
- Systemic symptoms
- Toxic appearance

2. NIH Classification:
- Type I: Acute bacterial
- Type II: Chronic bacterial
- Type III: CPPS (A: inflammatory, B: non-inflammatory)
- Type IV: Asymptomatic inflammatory

3. Diagnostic Tip:
- 4-glass test (localization cultures) for chronic cases

❖ Testicular Torsion Summary :

Definition Twisting of spermatic cord causing vascular

compromise (surgical emergency)
Epidemiology - Peak incidence: 12-18 yrs (puberty)

- Neonatal form (rare, <1 yr)

Types 1. Extravaginal (neonates):
- Entire cord+tunica twists

2. Intravaginal (adolescents):
- Bell-clapper deformity (abnormal fixation)
Symptoms - Sudden severe unilateral scrotal pain
- Nausea/vomiting (50%)
- High-riding testis
- Absent cremasteric reflex
- Negative Prehn's sign
Diagnosis - Clinical diagnosis (don't delay!)
- Doppler US (if immediately available)
- Gold standard: Surgical exploration
Time-Sensitive - Orchial salvage rates:
90-100% (<6hrs)
50% (6-12hrs)
<10% (>24hrs)
Management Emergency surgery:

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 1. Manual detorsion (if OR delayed)
2. Surgical detorsion+fixation (bilateral)
3. Orchidectomy if non-viable
Differential Dx** - Epididymitis (Prehn's sign +ve)
- Torsion of appendix testis
- Incarcerated hernia
Complications - Testicular necrosis
- Infertility
- Infection

Notes:
Key Mnemonics 👉"TEST TORSION":
T - Testicular pain
E - Emergency
S - Sudden onset
T - Teenage peak
T - Time-sensitive
O - Orchidopexy needed
R - Reflex absent
S - Salvage window <6hrs
I - Irreversible after 24hrs
O - Only exploration confirms
N - Nausea common

**Critical Points:**
1. "Time is Testicle": >90% salvage if treated within 6 hours
2. **Bell-clapper deformity**: Anatomic predisposition where testis lacks normal fixation
3. **Always fix contralateral testis** due to bilateral risk (40-80% cases)

………......................
Daughter Of Scientists