Surgery Long Cases 3
Chief complaint
Flank pain
Differential diagnosis
Investigations
Complete blood count
ESR
Serum creatinine and BUN
Serum electrolytes: for serum levels of calcium, phosphorus and uric acid are done to rule out
hypercalcemia, hypophosphatemia and hyperuricemia.
Urine analysis
Pregnancy
Abdominopelvic ultrasonography
KUB: allows for diagnosis of both radio-opaque and radiolucent stones with the exception of indinavir
stones.
Non contrast CT: is the investigation of choice for ureteric colic.
Triphasic CT scan: for RCC
MRI: can be used to define the level of stone obstruction. can be superior at detecting tumour infltration
into the vein wall and the level of thrombus in RCC.
Nephrolithiasis
Pathophysiology and clinical principle
The recognized risk factors for the development of kidney stones include: age (men in the fourth to sixth
decade and women have a bimodal peak in the third decade and the postmenopausal period). Men are
twice as likely to form stones, white people, a family history, hereditary forms like cystinuria or type I
renal tubular acidosis and primary hyperoxaluria, people living in hot arid climates, prolonged
immobilization, gout, myeloproliferative disorders, recurrent UTIs, nutritional defciency in vitamins A and
B6, magnesium and phosphate, a reduced protein–carbohydrate ratio and drugs like corticosteroids and
chemotherapeutic agents.
There are two types of stones: calcium containing (calcium oxalate (60-85%), calcium phosphate) stones
and non-calcium containing (uric acid stones, infection stones, and cystine stones, indinavir stones,
xanthine stones, matrix stones, silica stones).
Complications
Urinary tract infections, pyonephrosis, renal abscess and septicemia, xanthogranulomatous
pyelonephritis (bearpaw sign), pyeloenteric or cutaneous fistula bilateral stones may lead to anuria and
AKI and chronic renal failure. UTIs can be classified as uncomplicated (occurring in a healthy patient with
a structurally and functionally normal urinary tract) or complicated (occurring in a patient with an
anatomical or functional urinary tract abnormality, in an immunocompromised patient or with more
virulent or resistant bacteria). An isolated UTI is one in which there has been an interval of at least 6
months between infections. A recurrent UTI (rUTI) is defined as ≥2 episodes in 6 months or ≥3 episodes
in 12 months. Infections can also be classified based on their site (urethritis, prostatitis, cystitis,
pyelonephritis).
Staging
Therapeutic approach
NSAIDS and paracetamol are usually effective for small 3-5mm calculi causing ureteric colic. Emergency
urinary decompression may be done either with ureteric stenting or with PCN. However, in the absence
of infection, in a certain select group of symptomatic but surgically ft patients, removal of stones may be
possible by ureteroscopy.
Non-surgical management
Watchful waiting: Patients with small (<5 mm), non-obstructive, asymptomatic, lower pole renal calculi
with preserved renal function may be kept on follow-up. Up to 90% of 4-mm stones and 50% of 6- to 10-
mm stones pass spontaneously.
Medical expulsive therapy: Tamsulosin is an ˜1-adrenergic adrenoreceptor blocker that causes smooth
muscle relaxation of the distal ureteric muscle. It can be used for distal ureteric stones larger than 5 mm
and to assist passage of fragments following SWL.
Extracorporeal shockwave lithotripsy
Endourologic procedures include: Urethrorenoscopy(most commonly used in our setup), retrograde
intrarenal surgery and percutaneous nephrolithotomy or miniaturized PCNL.
Indications for retrograde intrarenal surgery (RIRS)
Renal stones <2 cm.
Lower pole calculi.
Obesity.
Musculoskeletal deformities (e.g. kyphoscoliosis) and renal anomalies (HSK or pelvic kidney).
Bleeding diathesis
Indications for percutaneous nephrolithotomy
Renal stones >2 cm.
Lower pole renal stones with anatomy that is unfavourable for SWL.
Failed SWL or RIRS for renal calculi.
Staghorn calculi.
Contraindications to percutaneous nephrolithotomy
Pregnancy.
Untreated UTI.
Bleeding diathesis.
Current anticoagulation.
Non-endourological surgeries include pyelolithotomy, anatrophic nephrolithotomy.
Patients are also advised to increase fluid intake of more than 2.5 liters per day, dietary calcium should
not be restricted; supplemental calcium, if necessary, should be taken at meal times, reduce intake of
animal protein and salt.
Complete removal and long-term antibiotics are important to prevent the recurrence of infectious
stones.
Follow-up
Renal cancer
Pathophysiology and clinical principles
It may be sporadic or familial. von Hippel–Lindau (VHL) syndrome is the most common familial syndrome
associated with RCC. Cigarette smoking, obesity and hypertension are the major risk factors associated
with RCC. Others include diuretics, occupational exposure to petrochemicals and dyes and ARCD in
patients on long-term hemodialysis. The most common presenting symptom is haematuria.
Complications
The most common paraneoplastic syndrome is an elevated erythrocyte sedimentation rate (ESR)
followed by hypertension, anemia and hypercalcemia. The most common site of metastasis is the lung
and is classically described as cannon ball metastases. Metastases may occasionally present as
pathological fractures.
Staging
Staging of renal cell carcinoma is based on size, position and lymph node involvement:
Stage I: tumor <7 cm in the largest dimension, limited to the kidney.
Stage II: tumor >7 cm in the largest dimension, limited to the kidney.
Stage III: tumor in the major veins or adrenal gland with intact Gerota’s fascia, or regional lymph
nodes involved.
Stage IV: tumor beyond Gerota’s fascia.
Therapeutic approach
Radical nephrectomy remains the gold standard treatment for localized disease. Partial nephrectomy
should be the treatment of choice in tumours less than 4 cm, in well-selected tumours between 4 and 7
cm, in bilateral tumours, in tumours in solitary kidneys and in patients with pre-existing renal
dysfunction. Alternative techniques such as surveillance, cryoablation or radiofrequency ablation of
small renal tumours may be offered in patients with high surgical risk (e.g. elderly patients, patients with
multiple comorbidities).
For palliative therapy in patients with metastatic RCC Cytoreductive nephrectomy may be beneficial in
good and intermediate-risk patients. Palliative nephrectomy may be considered for intractable
hematuria, pain and symptomatic PNS. Angioembolization of renal tumor can be performed in medically
unfit patients with intractable hematuria.
Chief Complaint
Hematuria
Differential diagnosis
Investigations
Urine analysis
Urine culture
Cystoscopy
CT
MRI
Bladder cancer
Pathophysiology and clinical principles
The commonest type of bladder cancer is transitional cell (urothelial) carcinoma. Squamous cell
carcinoma occurs secondary to chronic inflammation (e.g. indwelling catheter, stone, schistosomiasis),
and primary adenocarcinoma usually originates in the urachus (dome of the bladder) or in those with
bowel in the urinary tract (augmentation enterocystoplasty, bladder exstrophy repair). Histological
variants (e.g. micropapillary, sarcomatoid, plasmacytoid, nested variant) can coexist with urothelial
carcinoma and generally signify aggressive tumours with poorer prognosis than pure urothelial
carcinoma. Patients most commonly present with painless hematuria (in 85%).
Complications
Staging
Tis: urothelial carcinoma in situ
Ta: non-invasive papillary urothelial carcinoma
T1: invasive into lamina propria
T2a: invasive into inner half of muscularis propria
T2b: invasive into outer half of muscularis propria
T3a: microscopic invasion in perivesical soft tissue
T3b: macroscopic invasion in perivesical soft tissue
T4: invasion into adjacent organs
Approximately 70% of tumours are non-muscle invasive bladder cancers (NMIBC/ Tis, and T1) at
presentation, whereas 30% are MIBC (stages T2, T3, T4) or metastatic.
Therapeutic approach
The initial management of bladder tumours consists of TURBT for accurate staging purposes.
Early radical cystectomy should be discussed for high-risk patients as they are at high risk of tumor
progression. An alternative is intravesical bacillus Calmette–Guérin (BCG) (given weekly for 6 weeks,
followed by a 3-weekly treatment every 6 months for 3 years. Side efects include transient fever, dysuria,
rarely BCG sepsis and BCG cystitis necessitating cystectomy) to reduce the risk of tumor progression.
Those with solitary low-grade Ta tumours have the lowest risk of recurrence and progression and so the
management of this group consists of regular cystoscopic surveillance alone. For intermediate-risk
tumours, a 6-week course of intravesical mitomycin C can be considered to reduce the risk of recurrence.
For those with high-grade or T1 tumours, a repeat TURBT 2–6 weeks after initial TURBT should be
performed to identify any residual tumor. Upstaging to MIBC is found in up to 40%.
The management of MIBC is neoadjuvant chemotherapy followed by radical cystectomy. Options for
urinary diversion include ileal conduit, orthotopic bladder substitute, heterotopic bladder substitute or
ureterosigmoidostomy. The choice of diversion is dependent on patient factors, tumor factors and
surgeon experience.
Chief complaint
Voiding symptoms
Differential diagnosis
BPH;
bladder neck stenosis;
bladder neck dyssynergia or functional bladder neck obstruction;
bladder neck hypertrophy;
prostate cancer;
urethral stricture;
functional obstruction due to neuropathic conditions.
Investigations
Urine analysis
Urine culture
RFT
Pressure–flow urodynamic study
ultrasound measurement of postvoid residual urine.
Cystourethroscopy
Urethrography: for strictures
PSA: range is 4–10 ng/L, >10 ng/mL is suggestive of cancer and >35 ng/mL is almost diagnostic of
advanced prostate cancer, in the absence of active urinary tract infection. a free-to-total PSA ratio of less
than 15% should be suspicious of malignancy.
PSA density <15% is for benign conditions.
Prostate velocity > 0.75 goes for malignancy
Prostetic biopsy: If there is suspicion of prostate cancer, because of local findings, a raised PSA or
metastatic disease. Either transperineally or rectally.
Multiparametric magnetic resonance imaging (mpMRI) should be done, which may show a suspicious
index lesion.
Transrectal ultrasound (TRUS)-guided or transperineal biopsies should be considered.
Bone scan
gallium-labelled prostate-specific membrane antigen (PSMA) positron emission tomography scan
Benign prostatic hyperplasia
Pathophysiology and clinical principles
Non-modifiable risk factors include: age, black race, family history of BPH and bladder cancer, a high
estrogen to testosterone ratio.
Modifiable risk factors include: obesity and metabolic syndrome, greater coffee or total caffein intake,
lower levels of physical activity, alcohol consumption, diet difficient in vitamin A, beta carotene, or
lycopene.
The international prostate symptoms score:
Total score:
0-7 Mildly symptomatic;
8-19 moderately symptomatic;
20-35 severely symptomatic
Therapeutic approach
Strong indicators for treatment include:
Acute retention
Chronic retention and renal impairment
Complications like stone, infection or diverticulum formation
Hemorrhage
Elective prostatectomy for severe symptoms not responding to drug therapy with a low
maximum flow rate (<10 mL/s) and an increased residual volume of urine (100–250 mL)
Conservative measures include watchful waiting in conjunction with fluid manipulation (avoid fluid binge
and late-night intake) and a reduction in caffeinated and alcoholic drinks
Drug therapy is with α-blockers (alfuzosin, silodosin, tamsulosin, doxazosin, terazosin) or, in men with a
large prostate, a 5α-reductase inhibitor, or both; combination therapy has a better outcome in glands
bigger than 35 g. Blood pressure should be monitored in patients who are started on alpha-adrenergic
receptor blockers due to the risk of hypotension.
Interventional measures include transurethral resection of the prostate (TURP), which remains the gold
standard; consider HOLEP (holmium laser enucleation of the prostate), open/ robotic simple
prostatectomy for large glands; new minimally invasive treatment options that are available to patients
include prostate artery embolisation (PAE), water vapor prostate treatment (Rezum), prostatic urethral
lift (Urolift) and water jet treatment (Aquablation).
Follow-up
Men undergoing prostatectomy need to be advised about the following:
Retrograde ejaculation or anejaculation: occurs in about 65-85%
Erectile dysfunction: in 5-10%
Risk of reoperation: in about 15% of patients in 8-10 years
Morbidity with sepsis
Incontinence
Hemmorhage, TURP syndrome and bladder perforation may occur intraoperatively while doing
TURP.
Bladder neck contracture
Prostatic cancer
Pathophysiology and clinical principles
About 10–15% of younger men who develop prostate cancer have a positive family history of the
disease, but the etiology is unclear. Serial sections of prostates obtained at routine necropsy
demonstrate prostate carcinoma in 25% of men between 50 and 65 years of age. The incidence in men
over 80 years is in the region of 70%. The natural history of prostate cancer depends on the stage and
grade of disease:
T1 and T2 The progression rate of well-differentiated T1a prostate cancer is very low: 10–14% after 8
years. For moderately differentiated tumours, the rate is about 20%. For T1b and T2 tumours, the rate is
in excess of 35%
T3 and T4 (M0) About 50% progress to bony metastases after 3–5 years
M1 The median survival of men with metastatic disease is about 3 years
Complications
Local spread to involve the seminal vesicles, the bladder neck, trigone and the distal sphincter
mechanism
Hematogenous spread occurs to the bones (the pelvic bones and the lower lumbar vertebra, femoral
head, ribcage and skull), breast, kidney, the bronchus and the thyroids in order of frequency.
Lymphatic spread to (i) lymphatic vessels passing to the obturator fossa or along the sides of the rectum
to the lymph nodes beside the internal iliac vein and in the hollow of the sacrum and (ii) lymphatics that
pass over the seminal vesicles and follow the vas deferens for a short distance to drain into the external
iliac lymph nodes. From retroperitoneal lymph nodes, the mediastinal nodes and occasionally the
supraclavicular nodes may become implicated.
Staging
Therapeutic approach
Low risk disease. For men in their seventies, conservative treatment would usually be the correct
approach. Radical surgical treatment might be considered in younger (<70 years) men with this form of
the disease and/or with a family history, although, even in this group, some men will elect to pursue a
conservative course (active surveillance) when counselled about risks versus benefits (impotence/
incontinence).
Intermediate risk disease. In younger (<70 years), fitter men, this may be treated by radical
prostatectomy or radical radiotherapy. Active monitoring remains an option, particularly for more elderly
patients towards the lower end of the risk spectrum. In elderly patients with outflow obstruction,
transurethral resection with or without hormone therapy is indicated. The benefit of radical treatment
over a conservative approach is likely to be about 25%, given that progression to metastatic disease is of
this order of magnitude after 10 years.
High-risk disease. These patients are at significant risk of disease progression. They need multimodal
therapy. Early androgen ablation is favored if close follow-up is not possible. For the sexually active, a
careful conservative approach with the adoption of androgen ablation when symptoms arise is
reasonable. Androgen ablation coupled with radiotherapy, perhaps with surgery (radical prostatectomy
plus salvage radiotherapy) as part of a multimodal approach, is standard treatment for younger men
with T3 disease.
Metastatic disease. Once metastases have developed, the outlook is poor. For patients with symptoms,
there is no dilemma; androgen ablation will provide symptomatic relief in over two-thirds of patients.
For patients with asymptomatic metastases, the timing of treatment is less clear. Systemic chemotherapy
with docetaxel should be considered in younger, fitter men.
Follow-up
Urethral stricture
Pathophysiology and clinical principles
The common causes of urethral stricture are: lichen sclerosis (LS), iatrogenic (post catheter and/or
instrumentation), sexually transmitted diseases (gonorrhea), post radiation, traumatic, idiopathic, and
congenital. Symptoms are usually hesitancy, poor flow and prolonged voiding time.
Complications
These include recurrent UTI, retention of urine, upper tract dilatation, bladder stones and periurethral
abscess.
Therapeutic approach
Include urethral dilatation by using serial plastic dilator, direct visual internal urethrotomy using an
optical urethrotome or a holmium/thulium laser fiber, self-dilatation/clean intermittent catheterization,
or urethroplasty either anastomotic in bulbar stricture or augmentation via buccal or lingual patch
(graft).
