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    Surgery Notes

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    Surgery Notes

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    Surgery notes

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    Vascular surgery 121 Invoduction to vascular disease 276 1228 Aneuysms 121.1 Epidemiology ofc dase Tl eeieereenT 122 Arterial disease 277 2241 lymphedema 1221 famiaton ofthe arr sem 1232 Lymphangits 1222 Leg cess 1223 Peiera vascular dese 2.24 Acute ateralinsifceng 1225 Chonicarteta nui 1226 Amputation 1227 Cerebrovascular isuicency 124 Venous sorers 289 1241 Aratony of eri ens 1242 Examination for vais veins 1243 Varese 1244 Deep venousthombeis Vascular surgery x \eseaardies ean ince imptant cae ofriity and erat in the developed wos asa surgery dels with cases fhe vessels which itelue arteries, vers and ‘itv ena whch nls the rai ater, aboina fara and any of ts ental or dtl branches down t the Salaries of the owe ins Ves see nthe practice venous ules and venous ince ofthe lave in, Lymphatic ease ily coves Impaoedema ard dealt wth in specs ‘cents after fale of consratie Te practic of vascular surgery has change cosieraly over te lst decade with ros vascular sieges practising ease. ve venous surgery as became miniraly ase 3 endovenous ae therapy (EV is ow offered in many You should: vases eae thogh tora eamition of the flowing * Venove stem examination (wer ints) ‘= Bamiation ofan leans] + Know te epiemloy, cause, cinalfeatwes incoing carota eae 1 Abomina artic aneurysm and peripheral 1 Peripher velar sas = amputations 1 Gangrene of venus das 1 Venous isuiceny and ves 1 Varo veins = Therboembole dcae of tens with pangs anéymproedema chro) ie surge hie tare ith inal sessment risk actor strteation and eidomalog of wu eat thes conenaion an management of cmp acl problems For example ts mote mpatant fo the tent ow the resvsitation protocol urgency and matly ate of 2 ptr abomial otie arery than 2 oa Rowand ‘cambio of ering the essential topes oven ths Chapter 25 well a aring the cia sessment wil egip You for most exaination, ining the membeship ea Same tasie but esertl pdemilgy i covered belo in Section 21.3. Plt noe te leming obetes and onceitateon thee inportant pints ith ears aing | 12.14 Epidemiology of vascular disease terial disease Peripheral aerial dese acim ommany et atherosclerosis and impaied perfusion; basal, when « teatets 20% of pape wer the ge of 70 yar + reafeets 20% of pope over the age of 50 who smoke «+ Thelnience reese with agen bth sees Risk actor (gure 12 nce: * Famlyhistoy = Saokng ® fyperersion * Hyperpdaenia = Nyedera 1 best and high-fat et Comer its ae most common fected © Moray rom areal deze sma commony do to myocar ifarctn or kes Smckng season ‘Neotel ' Venous disease + Venue eee many acusin he er ibs 1 Venous thomas es: 1 Most common in os =P 1 umerus is factscvered tein section Varnes Ace 45a the population 1 reas age, psig nthe sath cade Thre sre asian with far story © ocruptoral sociation wih staang fr long periods poten post-sugeryo Ines in peonancy an with wing casts 1 Con because by pc pathology compressing veraus Lymphatic disease Uncanmon dite in he popustin 1 htaybe cased int nary lenge ripe o sxconaty (ow se re — — — — 7. 1 Pt (es ats (es) [Wit Reed aj amp Sea) (Seon) | Neeson)" 12.2.1. Examination of the arterial system A complete eximination includes. 2 full coral Carnation, stating wth fall appropiate exposure of the patient Alttongh there re veratons it examination outs. the gener! pines ofthe ater examination remain the and get comfortable with whichever ou choose o aap. General inspection the patent wel or une? 1 thee any aninetryn postr, 2, movements ising» preious Ske? ‘ 1 isthe potent mbieormmonie (has here een an apuation as result fase seas) ops fr dilaton, pall, peripheral ena 1 othe appear lately ed an el perfused white rite? on 218 Vascular surgery + Nai shape and colour might ie some clas 5 wel at rictne saning, Delayed alr reiisiterestgly oman gn of er insuenyin the loner tate. ut trees inthe ams hares Ths ‘delayed colar el inthe ands mor ky ef vasqsm or ypowlemie shock tan does inrlinalateal obstruction Severe asx, refered to 35 Raya’ resomenan oes mest frequen in wore afer exer tocol tempertues tautng bth hans to tear whe dpi The ad then become blu eo stagnant ni nd sutnegert tn ed dt reactive person. + Felfor the plsesin te uper mts swe as ehecing for aia dels hich indicate a uta seal renner «+ Ferforn blodpresurechec in oth arms you susget 3 repay between ples, Palate forthe carotid pubes an ten to them wth & ethosop to ety ay its ek he pati to ld hi ‘eats au dot canfe beat sours witha bt. [Abdomen an grain Proceed ta examination of the sbdamen ness you fel tarde era can be performed at thee ann an en Eompletres of the assessment. Ce eamintions ae important because cern conto sich a aoe trae ‘an cardi flr render the cardae pug mechanism infin Ts retin por prison gene; howeve, hen come wth pre-existing tal vsclr dese, te ties con eae the cnc tres get. + spect na glpate fr pulsations that might be nae by + The iret ofthe ot isgeneay ust elon the evel of he mbicus ae so aneurysns are general felt + Chee the rin for pues 5 wel so aneus, * Sometimes saphena vai laweling ovr the ‘sphenaferral uncon) an pesent 5 np on Standing Thi shoul be ested by placing a handover he Swen tapping the varios vein ler don he ‘ocontmthat Risa enous neling Te an appear on ing down, + Ausclatio of he abdonen ang grin shoul be done listen fr bits ater tus, The legs must be examined for sgn of chron tte 1 Skin colaur rea cynati ae 2 Shiny tin with ha ss 1 Buzrger angle abo known 35 ase aa) Dependent ro piay filing ie * Vero guteng| * Topic skn anges or ues ily refi tne Temperature cl, wer Pulses ncn femoral, pops dol pes, and posterior bal gue 123, 1 Newropty est muscles and ees) 1 Auseutation (ver main ess 1 Doppler presses shoul be obtained aswel asthe ane beachipuseindex A) Complete the exainatin with care earinton. ota Common ae story Interac artery Femoral artery ‘Supertca fomoralatary Popa! artery Anterior tba artery Peroneal artery Posterior bial artery Figure 123: Blood spay of the lee 12.22 Leg ulcers nerfed 28 ein the contin ofthe epithe surface Although there are many causes of eles, they Commonly present ove surges for ween causes of ep ler eras (pst-OV, varicose ens) tei laters) Heros ets cerebrovascular cin sia lesions) + Visalia vasspst Rayna’ poate nodes, stages) Nalgnant scl carcinoma squamous cl arcnoma mmetstora, Mayol wey, skin metsases) + Infecive ubereoss, human inmate vis) ori ase urate colt, heat ari systemic pus erythema) «Mainz a 1 Area ended a agen) 1 Lympat infection ote Examination of eg ulcers Te flloning shoul be nes when examin nye uke. ‘is fst sero examiing an desing 3 min the bea + Site Describe the rece ste ofan uer sing retby Shape (ort crcl, rea) > ages 1 Soping heating uke enous stasis ees) Pee Use tachi of pit ces inthe eantbiotices Now mare conmonyseuropati ern pat vith ates or opie wees ~~ i 1 Ried bas clcarinma Da ae Evert ~sauamausellearcioma >>_ 7 + xe * Sloughorandationtsuekendonbonedepth of tase + Diseharge ros argues, purse * Colour + Temperature Tenderness + Fration * Sarounding tise 1 Varios eins udetatoseoss Topic ranges: shiny sinha os, uke ss of feel ples and 6M 1 Cutanaussesation dtl (eres) Ronee + Resinal mph noes * Gener! examinaton Diagnostic testing + Bod tests FEC ESR, glucose, utantbades Mrotcogl sna ofthe ver * Dupler Ooplrutasouns Ue top + Mognetiesononce nora (MRA) or CT osraphy (A) «+ fair henography 29 Vascular surgery | [ ‘Artorial nslicioney tes [let iceraing? No] é Is there malignancy or reoutrentintectan? | No Consider ona | ‘ating —__{ isthe ulcee healing? No Tnvostigat cause of nomealng ulcer Figure 12.4: goth fr inesigaton and mangement of was ee es 200 Leg ulcer Doppler investigation = | Yoo I one Management of eg ulcers (Figure 12.4) Tren thundering case fh the most important part maging ary ue! Compesion bandas ight compen in ater seas, 3-01 oer compression fr venous dase (Corie excsion ad ating or ar-eaing ves once alan and nection a ed out and any unde 12.2.3 Peripheral vascular disease Peiera vascular dene affects a sigiteantpoparton of ‘der atin inte U Inde io bth ses increases awed lke) Ua vib wcln eig hese cmpreneé Wad fo, with smaing Being the strongest fokfoctar Although tan aet any vse thie of he loner andfwcaion ofthe common femoral ater ae the mes common affected tes, The ik ctor ond eieilogy of prior vascular deat ae covered in Secon 121) Intermittent claudication ‘amping ina rue which aca on exertan (waking or running ani reese by resin that mule Tian occ in one or sometimes both lege an athough the term lasal used to describe cai pa itean eer n anymuse demands, resting in haem Ths our fer» veble distance of waking, nse patna usa few steps and Fert ancomfotate anda ruse mating tenis Siow down ater than sp. Sometimes thee 250 Tels aking, Patients fen that he quay fife impaired eave of tym continuing norma Mey Claudication distance This fused oases the sever of the disease ad isthe tance patent can walk before having to stp due to eis para to rule at spinal case (alse - Props ee atts ofthe back causes le sin when "Sanding and isnot releved by bet retng pros Reet of aio often occas by ening Forards agaist a statorry het fg te) sting ter cases fel pa such a venous caucaton, nee rts and Baer ess nee to be elaly ruled ct 25 Critica ischaemia Coletion of smptors which may osc when bad flow fal below the minima heshod to maintain i vii. Rest pin and sue les lean commaniy ce. The 691 usally es than Ot in ely haem Rest pain De atheros progresses ad he cage bcos moe seers pin may ocr te fet rest Cal the term fees opin theft which ces a elation ch 35 ying in bed) aniseed by dependency Banging he et of the end of he be rsa. The ak of grains fsisonee auc by eatin ofthe ey Cicalton tothe fet nd thus rest pan oud ot be conued with night emp, dre of rt ptn mayb ey tee Gangrene Gongrere is dened as tase mcs due to ei “Types of gangrene 1 brraanarene bina the dtl pat of he in to harm. Gangrene spreats ov upwards Ibvoxmal unt reaches he point wee the od fart ack resenbing the feo of mummy. There ‘sual 2 carne of demarcation een the ving ling of ofthe gaarenaus tse itis ot enone The cay Sans of hy gonorene at lace and sensation ealresin the rea alon with pall of ‘+ Wet gangrene Inne gente, the dead tase infected by spogeniemirarganims and becomes sae an malodorous We sunere sally evap py due 2e2 Vascular surgery tobiotage of venous allo ata led fw. The fected prt led wth oad, when favours the rai growth of bce, The tone prot fomed by tater are oboe causing he yteic ranean of etait, Mocrcopaly the ffecte patie wale, ot pute oten and dar 1 Gangrene’ est lsd int inetd and nn infects rater thon wet ard dy ganarene, thon ‘erties te caus of gangrene ad eet pproprate 1 Wet gangrene shoul te manage wth vent antbite teatment and dierent a ees. + Diabetic gangrene du tote ars 1 Trophic esngt sulting rom peripheral ert 1 Atheros esting in iehaema 1 Loner resitancein vest nection de to excess sugar Ths pes olen asad wih gasin the 12.2.4 Acute arterial insufficiency Dost aerial stir iss of pean, sual due ‘den cuptian in bod sippy of 8 parti Common causes ince: * Compression fom an eternal source ey ceva * fest thrombin ofan aneuram + Traums Fase wth rsa theres son sal ave 3 isto ofintermtent laiistion and thsacve reseiton ‘shouldbe called an aeuteancvenic' event. Cardenas edspasing to enbal cue sa fvilaton eh src at throm myoadilinfrton (ural thrombus abr diene and atl moa Very ately an embolus rgnting from the ler ig (enters the ef het via sei eet prada embod, ‘The above-mentioned cates cn ead to the acute ves insane of asaya fhe body Fo he eee too vests eg noid steno ead ttre towels ofthe gsronestinal tract (mesenteric sehen due #0 ‘eri and tins shoals ementete at emba can be of ai, at and even aot uid. Preset signs ad symptoms ary accring the ed oun tet Common obstructions due to emboli 1 Bran = the mie cerral artery aon ofits branches rests n hela 1 Retina pase of tvombus fom an atheromatous ‘ose on "amar fig Patents des is 53curtan fang oe thei jes 1 Mesentre esl can cause caer 2 angen of ‘he dome segment fetes «+ Splcen = engorgenent an opin 4 Nidneyshaematura and pin lungs ~ pulmonar enol can be fatal: can cae aemopts and dyspnea ‘cute limb ischaemia The easel ie PY pin, practi, pas, pl, puslessnes nd prising) cl abe 12. The ft ee fe nell and the last tice vascular ino, The presence of neulogal signs inate 4 need for gent treatment Somtinesnted eigen ic indestig the segment of accion In the cate of act i teal asain suger shuld be performed fo act oxo thin tas er seal eis and avoonce of apa, With longer schaemic tines, thee is higher chance a ‘putationané moray rm regen ry an as. Newel in Paraestesia Palys Vascular Palo Pesshingy cold focised stl and complete general istry Ina a6 Sehaei eg ease by aspera fora aeyenbols commonest cause, te esi resentation that of patent reveals 3, ee wich may tender o tau a as chet puss Paraesthesae ani prays ae ate sos Investigations rac ting screen * uct © Urgent anterooraphy eee Treatment 4 sustain IV fds nd oer) * Consider anniagramurgent ebalectoitrambol 10 treat eral + Conse assoromy i tepetson nu suspected 1225 Chronic arterial insufficiency Inthe ajay of aur patent arerioslerosisis the main use, often due t sang or betes: Muti eeurent “al emboli, Bueges ee, andre, Tokay leis important rm te ison to ascertin: The severity of the anton * Towhat dearest affecting the patents ety Ascot it factors ‘commen ates of daze ae the ori iacané super femoral regions. Chron case of the uper Ib ae Common presentations ince tertent Gaudio, st Superficial femoral artery (SFA) disease Disease ateing the SE cases nermtent caution in the cn atone dae, rest pin may ecu, mphiog ‘ta! im hoe, These patents my a ave many ter signs, including ules, gargene and skin anges Pes inthe Phare sal absent Aortoiliac artery disease Depending onthe sevety, any of the stove signs and Symptons af FA oxsuson can be sere pis interment ssueaton affecting the buttock or thigh, Dare ofthe Srtilaeseqent cin ao be asocatd with impotence ipucena are comes othe intra la) amen Lerche’ Couto, ena mptene and ae femora pues Investigations 1 FCIESR/UREluas ips 1 Tea est to ses lean stance * Doppler sts toasts ABP Tate 122} 95 wl as areas 1 Anerigapy is undertaken wheal sero anaoplsty 09-12 Normal 06-08 Mid arte! daze auton) 04-08 Mert ate alias cers clauiaton, corres in) 0.4 or Severe ditase with es pin andor gansrene ess equtes futher inesigatonaimanagement Management Isao improve riko ua snking hypeterson and on pl prof and to contel dees and improve este faces Suh aot, ners and wea. Abie on Foot ne sou ie, ‘tates: asrinelosioore ingress for agarese Mood peur contol Dit contol ood une) Statins or to eles * Tolower lester below nor iis To cecease artis infanvnaton Nasoiatas suchas posta and nairotu hich ines open pte by mes ncn been tients ursutale for surgical ierention Gstazlisa eer gen that a seve MP phashodieserace Inhibitor ar has good apt a antral ater Suga! = Galoon acl tenting thicon be intalaia or sbi + Areal bps wth autogenous enor proshteat 1 Foraartlae disease, Daan yas ae usualy ed Ipaeatoroethyenel Fora rain seas wih poor iter can be ibeutanesity tac and rasta othe ema - ily fe) boas at Endarterectomy fas gly een supers by + Lumbar smpahectomyis we wher recrstvcton unease and symptom corvol required Vascular surgery 122.6 Amputation An amputation isthe remo of 3 boy part by surgery or ‘ours. Suiealy, itis erfomedn cet of gangrene ron healing les, rest pain not amenable to sarge. and malignancies ofthe its can abe pero int that hve been rendered ices folowing aur rene * Won-furetoning nbs 1 Congenital dete Bach ples es _ i Levels of amputation (distal to proximal) (ours oF VN ce: Tonto — 55m) en Magnetic resonance agagraphy i ceasing ued as ron-inasie. technique wihoit the compstons of "adioral angiogapy, Mest sugeons wil operate othe aro rhe exo sey. Apron 1 of Cis te cad ty Management of carotid disease frost ri i cts Jase te wot cam Mica! management > ania hoa ecment > Se ar Creal fentres of carotid disease ppmetna , General points about ampatations + Trogh-inee amp + Poymptonatc aro tenes ut aul bu 0 Oa See tet ond abet diecast lee + Gath Soles upeeota) shal ee 3 Sepetacteneinisoone! tome of araiae eee mee sng + Anus ga taser tao scl marc : Ste of emmy * Fipdsacvatn say wt sueony test von Asn peer 4c er 1 pate p «msm nduie setae Seandtn azo snes lane + Tansee atack A) - ave fc neurog!_tetad fr 3 yeas shud snd gone ; inorse chance of ampstaton eto contin of In el pate, he omar mpetins ete of Fat ee ‘vlan contmed tyr ‘scl, neuropathy iain ad secondary the toes ransmettara belw-aee ond above nee, Perea achoeme neurological defi ND) ir fees revolting 25 hous ets hn Sugery for aymptnaistrss D Teste menonedanpuatins hee see ans 2D Ter i eet sit ot ty wth» et Level of amputation andarerotconmoniy se + etueiestoe A-scan ss enfarecony tsps ay oo ln rm ing ange han 2 housed wih ethene eno of ef HO en 5 " . Complications of amputation * Sins pesnatin a srsatd symptoms depends ars pce fle angey one vrs J+ Set ihr hei eta ot ply ee sition sera we han 7 : Shir onsen recy 5 thn hs ste noel ames 4 nay Sones + Ca ancy-conabtel tema dyshaso Sep + Stewhecweofin vile mains tomsinain fH (soniar renege) nln ea aa wh eet rey 1 Remon + Vereen a erg, 6 Bang, Surg for symptomatic stenosis : cmon . Sacre cetera a ss Sie stonate tens feed when sens F rons ivecofeenh(eiSAoctay —[ TO Meike sotelnceis wih he deyecofsenais Once Pvt en OR Them rhaaag Sate r ee + Poston tuna ina The i of rte sles 10% in efit em SHEP ie tht sey with ce erate = Siete ctv ascents 2 hich moma See Se Senses tons stot nen ta oe ee |= Glnical judgement is mare important, even ifit chanical injury to earginal tase ntrmmperatively ‘ontinates barat ses, Late complications Assessment of stenosis roids ran are guice tothe sei of tenes Complications of surgery ince: Indications for surgical amputation of limbs * Posten pam Iecoreatanetweenacsotdutandahaemodamialy © CVAL{ie me) pee * Sinus teton portant cari steos seared tobe betwen OR and + Taint acacia (94-9) a Seer nate chon deo wnesnsrae * Phantom ib pain ‘2 Acar murmur maybe arse tothe rec Sif, Bleing and haontama eonlaane 4 Uces rom costo pessue ofprothess Caled, oF torturous wesls may generate but inthe & Death (2) * osteoeit absence of stenosis. rts may be absent in cae severe © Neve nes * Chronister nstiercfinperable veer disease feeuret aed ater with endovasclr techniques su 3 agiopisy stents grat * Rest pin, eration, gongreras change with or chem of kn fps 12.2.7 Cerebrovascular insuffi sents ane ofthe ost seins ency + buplexutrxound carotid ansigapty 1 Glssopharngel neve * fection: averting fot sess atts, ‘nd mst inthe wav Ech yar 1 ol deaths he ssn dee Sees bt tasted th Mat ach of el ee i teomyeis UK oceur as result of ceeds ecient CV aed ‘ompliation oot anolyte placement ising ued tate i ae chiiis any more patents expense the morbiity of phi “ors of inducing arte neuolgcal vet eros. Recent studs suggest that Heres & ler + Tumours Bln” paras. Amongst patents With Soe xa "kof peanent stoke ompliaton rat with stent pacement than wih caatid * Sots, tone oseagei sarcoma) tail ao sas teense naproimatey one hal + Magnet resonance soiogreay endarterectomy sthough fre evden silanated * Sot tive sarcomas fees 1 (Train scan an carotid ees with construction 1 Metra (at Vascular surgery 12.28 Aneurysms sxymet of a ate 0 att than 1 fines nema ameter It feted 09 weakness inthe wal ofthe ood ws The commonest artery 19 We ated isthe aot, Fellowes he pope and the femora ay. An anearsm ofthe arts mandates the aration ofthe femora! and poplars to confi or exe the presence of 20 neu The cones s 60 the, that nthe presence of ‘pple or emoral artery aneurysm tees 3 chance of soi aneryam bing present Common classifications ‘Antonia (9 infrarenal ort, sprarenh ila femora, popliteal = Popites Pathologie 4 ue re byl ve jes of rte wall «Face: fored inthe adventitia er onal ous the fncuyans, ae testment modes may fer A fabe onimaton wth he amen of the ates tan by & feos capsle and usualy results rom erauna, 9 ena false aneurysm acuing ater a earl puncte for eda Aetlogca 1 Ateroscleratiedegeneratie > Post-trumati: Congenital in oscar, bey neu Inlamation: evdence of pe-vetil inarary ney Eve event of infammatio, ith thik Serio als which ave been row compress ajacent sructures sich a5 the inert vera a the Defect aso wth theres, hypertension Nartars ome, una Connective tse dards: Marfan, hear, Tatas’ arteritis tteroin clers Infection: Salmonella Treponema epi ntvenas rag user eal infective endocris any ciferent combinations of te above can be wed to see an aneurysm, ot ay be an infomation int Complications of aneurysms General * thyprotemi shock ve ta rupture + Arteral emboli * lsufentciulation past the aneurysm Specifet site ine ale eter rect effector due to embol © yor infrtion * Stoke * forte desecton + Fatuaton ‘Abdominal aortic aneurysm (AAA) Defined as foal widening ><) commonest in > 60 yeas MF =: © Most inrarer95%) with 208 nosing ac arses sk actrs aresare a the for peer asc diese Plain fr: ra calations 80%) Can show sizeof the ancy a eran bras (10) whieh can cause weer osrction = Sig acuay in with easement fap a tut nab to how Row andumenaecratey ogingrams able to show ian lumen cae cae ural toms presenti a eases Common suse heros © Connect tive dare of menage 65-76 yeats Symptonsgns 1 Seer soe, pessteat a constant 1 Hooley or spasnatic 1 aya to ack groin ito oes “+ Putte tonal mass oil eneres and ity if uptued 1 Sever sen or persistent in in he lone back Shock wth pd pulse or eartrat sensations Embossing ate in seaea wash foo Examination + General urelabe to asses 2 by examination alone * Predictably af neu dety proportional tse: 29m secur for Ads of 10-19. 1 So acer for AAS of 40-491 1 Tm aces for BAS of SO em eater + Redon obesty dese the Sens of aatin Investigations © Ax cae wal operative measurements The requeey of Sars depends onthe size ofthe 1 For ancurms between 9 em and ma yea cans rete 1 Far aeuryms beeen 4 em an m.2 -manthy 1 Foraneurens that re more han Sm marth ‘nce the aneurin sage han Sma apetaton shoul te offered and» Caan rusts to tine he natn ented spec theretonshp tothe renal ater) Surgery * Inieae patent symptomatic ori these of te Options + baron gat (apron) * dover rea tent va eral atria) 1 Poe orate ethan St moray for ete epi 1 Bev surgery hasa mat fs than 0 sa 70 Inmet compiestions 1 Hoemornage Perineal enbottion * taey compton: Myocardial infrtion 1 Rena ure 1 Disseminated intavsclar oogultion deve resitr dst snrome = Colne iehariaigina cod ichaeria 2 Stoke 1 Deep venous thmbasspuimonary etl, te corpations * Spontaneois clson of arta 1 fortoenter stla Popliteal artery aneurysm Thiet the seca moet conmon ste for aterosserote Som of cee ate asters [thd ave an ected AMA ‘cesonaly presen with plsatle masia te bak of the nee bt ae commony ago with anes thrombosis dt mal ising to peripheral nckaemia Rupe rate Aneuryn reaterhan 2m regarded Snot “+ toesigat wth dupe utascunlT ar angiogram to 1 rears of 25 em or greater a vty tated surgical Smale nes re srened every 2 months et common surgi treatments gation othe ery ar ops witha ein gate Femoral artery aneurysm Mos ou a pat of generalised atl distin rate tha i tion (ae rey uptureorensesptoms Repay rote rat or reves vn bypass Dito eatin Wg abuse 5 chron netons can 123.1 Lymphoedema lymphoedema is the radal sweling of iB du 10 rages ‘alu of the pac syste (Box 121. is Vascular surgery ympondena nity Primary lymphoedema congenital ane <1 yaa be fai or on fel Tres oe yeas canbe fail ora a) Secondary lymphoedema * Surgery: srg or in secon * Racotheragy * Infection: prs arias) Pathology A proprtin of tients hve Tani story Miko’ {varie poses resin subareas {Frei can be worsened by secondary infston Management The as of testment a Conservative treatment Skin care wl ede rk of nfecton + Prpsiterapy and manual yh einage may hep + Exterralpeeamaicompresion wl ako ap reduce 1 Once sveting reduced compres stocings shoul be + Aeibitiesshau be en athe est dan of ineton * Drag endures) area ro proved bene * Debuting operation omar proceeding of sutevtaneous Chars procedure: debaking of suestaeous sere bie: terminal le ymphatic 1 Bath aio produce soa into «osm isften po fr dein precedes 123.2 Lymphangitis Lymphangs fe inlamaton of imate chanel aris infecton. Reionl Iymphadenopathy is common. The relate 0 te angering infection. Athaugh na pei dita ue avaible for mpgs, two-thiés of cen wth ‘Srmptoms ard signs Fea ted Sets inten of phates from he causes Group A Behacmohte Stepicacus (GAS) most iat wth perineal pres. ymphadeits may ‘ol tara nade tote ste Parental antbiesmybe sritifonmatory cups, sou be en fr pal vith reduction of elng oo 12.4.1 Anatomy of lower limb veins 33 Siperfiilenous tem Long saphenous ven "em atv othe mdi males hans breath malo the patel femoral ein tthe saphenefemorl junction ter to and em ow he uber Short saphenous vein eeeteten a eee eee) Saperapoplteal nein gol hind the ter males» dine of a» dep faa popes vena the Sinzoids Deep venous5ten Corso visa Suis ath snc of the deep and super syste ain it the deep vers touch proaing (communicating vis which tree the deep fi They have ves to revert backow ino the supe em (Ye supatcal apigsatie vein crestor] patel esa ue en el sagen vin ecesory ven | ("oy fo Ap tse \4 VS Tennasien ) «imate Peat vin Figure 12.5 Antony of oner in ens 289 Vascular surgery | Figure 12.58: Deep and super venous tems Requirements for efficent venous drainage Patent vrau uti ts Effient muscle ung Competent ates Ao, enous eur is inne by arity an verarcar 12.4.2 Examination for varicose veins + Expose the patent ater inotuting youself and + Inspection ~ start wth patent standing 1 Distauton: diated ad otucus ees in eg osha saphenous rib of ther drton 1 Venous tars venules tend uch vss that may be plate 1 Supertia! dvambophibits ely shows sinfames 1 Haemcsiserst eeema, scab check or satng from pevousulertons = Upadermatoerass: hone venus hypterson ‘he sin ard sutra nthe pier Hain | co 1 Arie slingloedema (iting uate er bine, atowteow he knee = Prevous ugey eats oronary artery bypass ating sua equies saphenous venous gas, fekting obvious dpariy nim length TEDS Palate varices long the complet gh of the veins foray ineglaries = notches amps perfil tombs tenderness rd hardness tcmbopheis an the sapheofeoral junction forasaptera vari 1 Tap test: prominent ees in the cre pe. there isan incmpten he, he venous oe ominous ard the tape at the ote end 1 Cough test wen ater ough, feel at he “Tourniquet testIerthes tet os 122) = Tap. til ough ets have a low cere or detection of comgetet vee * Gian ump? Palate to distinguish ten) saphera vari thespkenefemara junto, (2) hema. (3) mph nae = compares 1 Caf tenes: undrhjing deep enous thrombosis (Womars sgn not relate Temperate ofboth gs Disa ples 8 sereton oases tri and tiated ofthe Foot Ping ote Tumiquet test raw utd a the Dope rates sed seas 1 As patient e down 2 Fase yan empty vis 2: Tie turnique rund the mid-igh- holy itin oston ask patient to stand incompetence aoe the ounquet When ou release the ouriquet the vs wl det he ‘olunn of eo fein down the ecompetent File a bond ping the arte tem Pertes est (assess the dee venous ste) + Emping of susace weirs insets iat deep Full abdominal and pelvic examination shoul be performed because te patent may have apie ass Describe a mentioned below Tnodermatoscleros venous fates, exe swelings 2 Desert inspection ining oe desert, sarin dtbvton - shat or long saphenous or reithe 3 Where the incompetent valves) at: based on lel aes and pec ess Complains: tenderness infection Further asessment findings: pec an abdonina Plan of further investigation and manapement lan dlr safes change compeson Stoke, potent soe A us euayipartant asses patents dee venous ster as its the spel stem Thiam be ‘chive ya comtnation of lncl eset ad ‘adlgia sans The reason fr isso itor the lian ofthe potential eof the vac eas a ‘we ao le aption forthe dierent reatrens rail Varcose ven sure onthe supercal System cannot be urderakn i gents wth 30 competent orotate deep vera str 12.43 Varicose veins veins The mast ami affected wis te the log 3d fan obstructed stem leg pec mass or deep venus Demographic Aes of population ovese 1 cevptons longstanding requited e geo ‘= Primary or isiopathe (ati eto vei- wa ty ‘eating in ditaton and abe sage 1 Secondary:otstuciontvauna 1 Furciorat incompetent aes norma emanation beeen te dep and super ins 1 Hgn ress: areovenous stasis ncompetenc easing pusting vaste) Signs and symptoms Varco nse generally aries, with mst tens eiog symptomatic for mary. years Being ursigny 1 the ‘commonest compat fam patents. Patents may compli ‘of aching ep, ching, are sling night remp peri thrombophei, atmesrape de to venus hypetenson lecems and ukeraton, stn dscloaton due to Ipaseratosleeis and saphena vari promitet dation Vascular surgery esrb ete bursting pin on wang that reve yrs and lation of he Note cnetion betwen ss and smpams & gue Occasional patents an pesent with varias ens duet congenital traraty sch 5 Rippe-Tenauay syndrome The conse of + congenital rise ens Porewine sine 1 bone sso tisuehyertophy 1 Deep venous shemales, ‘Types of veins that maybe mistaken or aos eins Athletic veins Nona enlarged ins on muscu eps Dilated ine Kno beter thread ns nd spies, These are de toa harmon effect on soft tin. Commonly appear at menarche, daring pegnancy and he menopause _Spheraferaiaptenopopiel uncon Sqn the calfean augment a ral anda biphasic siga head Incompetence presen easing retogade fom + Duplex sreenng:inestiatian of choice as ts ecuate ‘and can dagrore vlan perforatorincopetenc Isao nr-imuasve ard quik to psior \enograhy: a vey acute bur mre invasive and rary equies Conceetve mesures Ease staking (dusted compression) Beato of xs Ressurance “Therapeutic management The indestions for surgery depend primaiy onthe patent’ bat to cope Any ofthe sigas ar sya can ereset Abzlte incor wold be + Upademstoclesehenous es © Recent super tronbophiebis eng romped sar Therapeutie management mds: = Suoery Injection sclerotherapy: adm tetrad! sulphate Sothys best ape a Sra varicosities Lage ins are unlely 0 respond adequately a shold be Wate Asal amount of sclerosant placed in he lumen fin hich en compreses with banding The sleront sequent foes to otras the lone ofthe nT an ao be safely combined wth surgery t ahve beter rls, Te scorn eed uly ction of adm Sletherapy rarely gives lng-lsing rests i te competence iether in the gin oa the back ofthe te, Surgery i tesfore advised fn such pliers om ‘arcs est above the ke. Foam maybe wed sn atertive o stotheray Laser therapy and aotequeny station Endovenous er therapy (EVI sow standard in mast soa fr vet are wins Tis has replace sting a the reste are beter, wth ever complications of ene damage compared with sgn, Eugen is expensv and thee a ering cuve to tain he surgeons. Mos hospi raring tier teapy wl cantin ts Sting ded asin bow, [AT sims toe sro congue ack he amen fhe ‘in lng its enh, This elerate infomation ofthe ven 1st alow teing by Fas (dase endoteium adheres to ise) and subiequentobteratin of the venus amen ATs rately flowed by compression bandaging dung he en pe a ewe. aciteauency ablation ofthe ven follows the set same procedure a rnp ae ergy exept tat i 5 Faorequenyeneray or coagulation stead fase ean be use in theates rot equipped to perm ser suey “Surgery ims a daconec the incompetent yt from the vera crultion. The commonest procedure f= ligation (aptenofenoal or saphenopoplies junction) ard Sipping fhe longo Shr sapbenous ees combined with Ins essential bef pefoming any surgery onthe superia venous stem tO ensue that the dep Yenous sem 1 ompetent Remeing the super stem, nthe presenee ofa damaged deepsysten, canbe dsastous tthe pain, Complications arising fom arose veins « Supetiil omtopebiis * Lpodematocers- pigmentation de to haemierin * Hoematge Majo ker ian) Camplin of aioe vein sway + Recurence * Bleesin and haematoma © Deep venous tombass + sor, 12.4.4 Deep venous thrombosis Deep venous tvamtas [VT and pulmonary emboli (FE) are the erg cause of preventable hospital moaty in te Westen wor Although PEs ci ten mee retools, i must be emphasised that tf & primary 3 complain oF. reno ria fistful he primary mesa forthe denen of trombrisalhouh he mpartance of «hac shighl eet The trad consis of 1 Chanesin ves! ow enous tas 1 changes inves! wal vse! wally) * change inlond convents ypecoagastle state) ‘There maybe osymptms eating tothe location ofthe DV, tut the classe eymptams of ONT inde pin, swing and redness ofthe eg an tation ofthe sure veins In up a 2% ofl hoped patents, there may be some frm of DMT hich fen remain napparent There ate several teas diag phil examination to Incase he detection of OM. eating the ckcamfrence of te atectes nthe contralateral ib ated point an be hp Phsieal examinations general ulti fo ecuding a diagnosis of Hloma's sgn: somo in the calf muces or forced Ahoritlexan of the fot with the ingest has boen 3 historical sign of OV pesece This gn is pesen in ewer than on-hire of patient with aime OWT an oun in tare than So of patents without OMT Ie very rt Spec sgn at not reared 5 it may doe the Many rk factors for DVT fave been mentioned in ‘pieriniag stiles Some of the armen ek foe ate ‘Mentoned teow Most patents usilyhave a conbinaton Ae over 40 * best 1 Preous ory of OT 1 Femi story flood cos in veins + Haemsolg:poeythaeia aba ver, tromboctss, inherte src of extn nithombin I efleney, ote Cetin, roti Aecieny,ctor eden dafivinapeaeis and disorders of plasinegen vation Malignancy 1 Vascular dss het flue sue uti systemic lug erytemntons St ar he ups antcoaquon, dee ynstome anes 4 Immo: oe suger or an nur especialy neo hip suger longa gts + Droplets V dug ase, rl eontacpties, estore harbayopenia Te sof OV ko cena in woren wo # Toes convaceptie pil that ots estrogen Take harmon element therapy HT 1 Haverecenty a3 baby Iisa hat ne rel asessment ao invests features fora potenial unary emboli sthismay warantarter investigation, Acne istry as tbe ae considering rk factors ncuing the we of oestoger-contning metres of rons contre, eto al hig, and istry 280 Vascular surgery of miscaige hich is ete of seal ase aa caze tambo) family story an ee aheretay Factorin te development of OM, presentations of OVI inde hiegasia ato dle Phlegnsia cers doers and got-trombote syndrome ‘These frm aii spectrom ofthe same dade lee Prlegmasia abe doen hit le) ‘is ambos nvoves ony mor dep venous chanel of the exemiy, therefore sparing eater! veins The venous Pricgmasia creas dates (ue ea) Tis is severe thambophiebis with exam pal, oedema, ‘jaccis and pose etbaemic neces phlegm ‘olson of he ene extent atin nclcng the ie ‘nd femal vei The es uly pein yaoaed and londenstous Venous gangrene maysupeere Post-trambatie syndrome Tis happens if OV damages he vas inthe deep ens, 50 leg Thi can eventual Tea to lenge pain venaus ation, suelo, potermataseos a in severe ‘FBC ltin,thomopiseren duplexes Prevention = TeDstetng 1 Ey post-op 1 fst ator ositeation non. topo cenacepties) + Medea Inia ancoagulaton with hepato I ne contindatons ‘ist and ten warfarin they The dain of waa fete by lc protocols nd infeed by fa recurent or par OMS the presence of pulmorary en nd ote thrombai rit Fae. Poplte ine era avait placement maybe perfonmedin pains ater high eo quips severe ose hea inj) thse she ae seinen er or of op event umonary enbaism rot ference Chiu tH, one Bare Canna, Kubert, Gabriel ‘Gowan, 1985 The pealence of rnherl ater diese ina defined populaton Creator, 715, 10-515, Urology elo 13.1 Urological assessment 296 13.11 Ula istay 13.12 Uloglexaminaton 1313 Hemauia 132 Renal traumaand benign urological conditions 298 1321 Real tauma 13.22 Stone dese 1323 Benign pastaticand weal disease 13.24 Benign penile condtons 1825 Thescotum and undescended testis 133 Urological malignancy 306 1 Baer cancer 3.3.2 Prostate cancer 3.3.3 eal tunous 1334 Testicular cancer 1335 Penlecancer Urology logy els with surgi! contns ofthe uiay system from he lines downto the util les, th penis Strum ad prostate ate ale deal with yogis and this ‘ten mates upaarge bul any woloists worl Ath Of he loi este nade to a basc knwo the commen bern si malignant soos is equa Congenital logis sods ate dea wih by specs in peat wlogy and are beyond the stope of this revson tea These conditions along with a eion af he reeant broly shoul we td during the pea Km, You shout: + Knowhow tn pvr 2 woogie assessment lacing ht aig, amination and oreing revatio slated tthe ical ‘nin «Koon the ifr aus of hae ard how tomestgate further + Beaware of he asain of eal aura and iterelerance to management + Know the cate estetn,asessment and management ofr toes + Ko the causes main iia feature nd rmaogement of eign ual! dieses «+ Kon the ferent ase, cin etre and management of tl amps «ow the eaves, eieminay, eal and patloi feature of ea der poste, Peri ard estilo cacer 13.1.1 Urological history Urls assessment conte of @ geneal ard aged Fist in dition to faced examination an investigations. Inaction to he stand questions ané earn, thee fe same spesife questions and temindogy retin © rags conton The word potato! sp ange se ty urls bt emai acannon used term Toe track symm fr UTI the prefered term 35 296 these symptoms an cern men and women nd a recessed a he petted, rs ewe How often do you re ood hung te dy? Do you itt ol on? ctr How often do yeu have toast gpa thea Dye Do you hae pin on psng ing estan Do yesh to wef yo a tov? string Do you have sain oval? ersteam How is you fowisveam? reminlJibling Do you a that you dhe ai Inemiteney Do youstop and start ding aur Incomplete ing Do you have the serio ofa cemting your Bader? UTS may be bs split ito wo main seg of Sams Obstructive symptoms may indicate some dence af ‘stucion within the wry rat and neice: * Sting * toate voting Tomi ding titative symptoms ray ince sone denice of deat stably sutra involuntary contactonsot edie blader, Tes spans all may Ye c=crated by way tract infections (UT * Frequeney © troeney Noe Other urological symptoms Tis my e cue roc Mos sate pin shh {>be eal col tu 5 of pens wt ae poms reve psastone lt ont ave lon on ear eotole 1 eta untan oben (UD) E Urological assessment Tester tson {rama tthe ide There many on-uoagia causes, the most important of isch is lating anal atc aneurysn. the presence nom! inaging othe causes soa be investigated + onic pain un Liar incontinence Itisdened a an nluntaylesage of wie Icon be an tiarasingsymatom, hich neds tobe characterse tod Stresincontinence_eatage of wine with asd abdominal presi such 2 cough, saene ing LgeincominenceLetage of rine peed yor wit feeling of urgency ied inconinence combination of tess and uge Noctua ene lanier while sep caniaous Orato incontinence lero retention) Permanently wet imple a sta o epic ureter Functions Incontinence wth norma ‘eeu tori Noemataria Se Section 13.1.3) + Moco sie tote rales ee 1 hcoseope tected an sti oh 13.1.2 Urological examination the presen of 2 ver aes. Tne supa region shoud ‘ho een by palpation ard pecsion fran eiged ‘rainatonof he eanallmnp ndes ard exter genta inal The exorinaton shal be carlos wit ita + Serta 1 Poston of estes 1 Peres stings 1 astlurinte or oc Cough imple Fer rin eri + Penis Usha opening 1 Hipospais presence Forest ‘+ Digital etal examination 1 Sa of prstte 1 noc pesence Pan 413.1 Haematuria Thsisoreo the oman presenting symptomsin lay Teismacrsope oor fan i te patent hs een ood Airoscpi cr sc hematula is eects by iciosapy fr psi testing ad is vary defined 53-10 re ood his pe high-power fed Mesosene haematura& often fsymponatic and found inital, ists detec haem ith pero Flr pth aeposiblen the presence ‘tmyobin, povidone ad hypotiite Seventy percent oF potent with microscope Naenaturis have no signet Painless macroscopic hema sould be eared 3 ng (used by3malnarey unl proved hers tsa critson fer briny seen within the Zoek rule, 35% smptomat rsp Pert in patents 250 yess ol, though is sow of much dete ang wos Te ase of haematite stedn Boe 131 Investigation of haematuria Most hoemsturio referals ae rected 1 2. one-stop Pacman This ins omc repeatapoinimens fer sora essa ena rapid lagna fr the patent vith faster eatmert ines Te falloningivestiations at {sual aaa nthe are slop enone * sine aay High specticiy but lw entity for wanstonal ell cero TCC) Eouvcs etsin the peserceof infection o Urological causes Cancer = Ber 2 Ktney Prostate * Renal pis and ureter 4 lfotion of ype or loer act, = Baceralintting TO 1 Paasiienschistorories Fung + Stones Renal Mader, wretha 1 iey-arinry-ter UB fi 1 ay reve Sane dase eral msec der mses >. Low pic yprate for upper tact C0 1 exblegstosopy ater tumours toe dae, claves fla eb estoscopy i the mainstay ofthe ie ar laws detieaton of very smal tows ot detected USS ter maging maybe quite wth an inten rogram ‘or MU, fallimesaations re arma an there high index ef asso fun crey spt te ee ofa IMs ate beter at intl detecting upper TS CT maybe requed to further characters el meses, Although MUS ‘nent eared as agnosie of upper et Ta lrg Select sean nets further invesiton with revoprade yagrphyané weterscopy, hich weld low oa sue Sages a inesgatns aerate patient may te refered tak the GP with ow eso for eer there soul be rte eig 132.1 Renal trauma ‘The jority of real aua i the developed wor is bt fore vauma [Europe 97%, with the remain beng erating, The son fr ths lasiton that 958 of bunnies can be managed cosenatily, wheres 76 of ursht wounds and SO oft wound equte suger. As © Benon prostatic hypertrophy © Heprlcieal 1 Ta nephropathy pone olomerlonahits Coagulation disorders = Maran, © Congenital latrogenic Radiotherapy > Cyloposstamise Thoms the ines ae retropetones aga, they a ltl el protected ard a sigan amount of aura is equi a Aamage then Co-esting eran damageicormon, epi Solent injuries on the lehand ie The Fdnee are 20 surounded by tough cps which tmporaes the aloty of teding ond alos or cnstvatve eaten. Surgery of Trauma organ severty Sse AST ate! Contson or steps haematoma Grasell—> Figure 13.2: Staging of der cancer eae ae confine tothe epithe ae canbe very sores with 5 4F- 80% chance fhe tur becoming mash Te commonest preseting symptom is ales macroscopic hematuria (85) Mrescopc Haematui Is 2 es labe pt though it requis ies, eens rinary oeny an freqtry canbe cased bya malignant ests forty tumor mass fect. Ul can acu sconday 10 tumour colisatin. etastaedsease can present with veh los, lower ib oedema, oactve real are ot Diagnosis ‘Thema of umoursareagrosed with exe cystoscopy ‘isa quick and easy pocedue tat fms he bacon of ‘one-stop haematuri ce Unie etlogy cn be lp a itis er pee ut not tg erste, ene in lamer ‘yae mous Utrscund can pik pete small tomo Sound (Simm in sae, but wabeoated des can be riseaing.Hstlgy is abtained by tarsuetiva esecton TURE, and for superfal turaurs ths also euaie treatment Staging requires» chest, abdomen and pis CT Superficial unos are maraged by TURBT ard avant invavsieal chemotherapy vith mitonyse C, which istied ino tear or our allowing resestion Tisha een shown to rede recuence rates The ae i fled Up for 1 yeas wth equa ele stoscpy any recrences te raed with TURBT muti recreres may be Weed by acourse ofinravescacemheapy ove 3 Get period Inrvescal AC can alo te used nd fs moe effect han mitomycin apreventingecurencestworsbyupreauiaiog the immune response Invasive tumous requie radial pstectony, with posse reoasjant chemotherapy Ue Is verted ito an le ‘anduitra eonstucte baer, Patents who are ot tor surgery who donot ws to Rae stoma con fae aca rabetherey 1332 Prostate cancer Since heaven of prostates antigen (FS tsi in 109, hencdece of prstat cancer has mare tan doles Ie is the commonest male malignancy ard the second commonest case of anes deste aes. There has een Tite ehane in the mortaty rt oe the st 30 yeas. The rajoty of prostate cances. donot become ically signa Aetiology and epidemiology The greatest kata fr deoping adencelno ofthe prostate age: 75 of prostate ones are apnosedn en ‘mer the age oS It emre cmon in the West: iran from Asia and Japan ae up o 2 ines mre ie to develop Tis implies an envcnmetal acto, pohly dt. A Carnbean resins inthe USA atthe highs group. Fe toten percent of prostate cancers aul be heey Prostate romoed by testosterone an dinyrotestoserone and removal of testosterone leads to 2poptss of unour ces This proies the metas fr the Pathology from the crt or cal eth Some 7 are od in the pesgheral zone of the prsate and 20% from the traptonl ae Gt we 131) The wasn ze the ate iced nbenign hyperopia spread obs the Sxl veces an the tase ofthe ae hich on ret inure abstction The commonest ite for metas s one they ar usually sera Lg aban messes ne pt unoninan A Gleason gaa 1-5 iene wo redomiant ses in boy, whch ae combined t ie Seoreof2-10Incuren practice snes of 610316 eeeay seen Ascreof 343 the commanet he ghee score Presentation A stages of prostate cance can present ayptomaticly with a raed FSA or abnormal inde digital eta ‘aration Canmonpresetngsymptonsincudeworsing Tomer inary et tos LUT), heat ad eine eonfot alof whic oud ao eu om benign dae Pavone de con ese with Yer fire seronstyt0 Ute bructon, lower limb oedema, bone pin ot pottloiea facture, abd neva gs Secanary to Diagnosis ay leat PSA isthe commonest es fer considering 2 ‘ages of ance. tia sine protease detetbe nse, Normal age-spece vues ae shown in Tebe 131 Urology PSAs oi acta) as sos ae coe 65 no-79 PSA Is prostatespeciie but not cancer-specife. Other endo such 5 BPH, UT, prostatitis way reenon ad inerunenaton can all leate readings Digital eta ‘ante, though an nec sence an moat ol 95 the mjrty af tunaus af inthe pie 0%, ic posterie an therefore glpable via the retam Dagrosis cones by arse ultasund TUS) and ion. Curent guidelines reared a est ten gsies ogy soul nat be performed ty a is nat witout Tite for dognss may 380 te otaned allowing TURP, although the maory of ue removed inthis poste rom the taster one not he peripheral Zane. CMRI and one cans ar sed toe stage te dese, but ‘hey aren substi oristologyin mating» anes. Amie of options ex and chcsog the bes opin fr the patent can be a lengthy roe. Treatments can te Sepuate ito cai, alate and conenatve. The appropriateness depends ota numberof actors, incding FA, Gleason sco, linia stage, o-moriiy and Ite pecan, Crate sual treatment wth 2 ada prostatectomy only 3. pssity in owan-onfnes dsase The mala complications of surgery are exesle dysuncton and incrtinence. Suga ecrique& constant ting rene rerowascula-tunle-spaing Suge hes led 19 improved toes Lparosopc and abt ehiquessebeomng increasingly opr an im owe eomplston ates. Radiotherapy can cause ete datnetion espe since it is often combined with Romana manipution. Bowe! end blader site-fesareaioconmonteseinudehaeat a ard poets therapy, the implantation of rao seein 125) nto the prostate fe peer technique which edees towel completions and allows fra hight ration dose to he pent Uni weteton ous nu to 208 of ig-itersiy forse uteasoune MF and eoterpy ae tras Some patients th potenti curable cease chee o 0 under active selon, whch conte of requ SA testing, git vcs evamiation and repeat bos. This _70u tends to have low PSA apd Gleason tumor, which are slow to progres. They ae ually Aen 0 od rene side-effects of ofa tenent ut can sith to tabla treatment fs ter eases progressing Simplamatc or ih-rade lol advanced and metatatie seas is ual ested by ronal manipula, with 3 Iueasng homeoe-easing hormone (HRI naan. In ost aes hs wl eng the FSA takin the norma ange for an werageof 18 months, Chem! etation fad a4 ruber of sdefiects:ectle sturction, hot fuse fatiue, wight gin mood sera, graeomastia sd xs 0 Ibid. After tat the PSA care the tumour caso be dependent on tetsterne for futher gow, This ead a ‘Geese progresion and worsening cl and metastatic ‘mgt Asymptonati aents with FSA lus fess tan 30-40 na canbe managed by PSAs, mate wating + curate 1 Radial adathespy sternal bacytheapr = sev + Paiive itera ea to posta or meta depois ' Hoeneral manipulator Chem etration wth LHRH analogues = Baphoptonstes + Consenative Pete suveance Regular PSA teks ow tesa fring 1 P5Aand symptom martin, termona manipulation 13.33 Renal tumours Renal cell carcinoma ‘eraarinaras of te Hdrey ay be refered t by many ras: eal el excinama IAC, hyperneptvona, Grits raaigances, idence continues to incase det Improwementsin a inerened acess o USS an CT a Ee ieiruene ‘Aetoogy an ris factors Age 60-80 yas 1 Enionental- sai, dass atest a Anum, poheabos phenacetin Geant = on Hipp! (0, ator dominant, 0 deep real tumours 2 pects adams pin and macoxopc «Theme oye weeny ie ng + Inspire Roma oO se onan Dine yt of ets dese cha wht + Lomein cme rare cod oc sea fuente fom a rrp {FC pote or anseia 1 Ue retnine eal ure hyperaeaenia USS stain chest sbomen ad pes = Renagram, DTPA or MAG scan to determine split ‘uncon Siopys rarest dt url ests an the rik of hemeerage ad uur seeing, Pathology and staging Renal cel ctcinomae are adenocarcinomas ang rom the proximal eonolted tial Tey ae mlocl in 18-20% eases, 25% contain ess ae est nate They an ‘eral or into the elven (10), inferior vera cv an ccasnal into thet au Lymph spreads othe para-aortic an ir odes Lng vy, tome ad bain ae the ‘common tes for haematgenas pe. Histolgia subepes + Conventional (70-20) - so inown a crcl ue the Nistlogal process hat removes the fa fom he cele euting on te character penance + Pap (19 - mutica a + Chromopobe + Calletng duet rae, por prognss, our patents Medullary cel - rar, oun, iodo, Sele poor preanass Tumours af graded 1-4, 1 biog wel teenies and ‘ing poor, withthe Fran yer, Staging isi the TM ster, Se Box 12. Tia ten, ited tidy 12 S7em lnted tise 73. Bterson outs teiney but within Gets fase Tas Areal or perinp ie fat imolemet 12) _terson nto eal ven oe VC bel phragm ae Berson ino MC above phragm “Tumour made beyond Gero asa No Nonodes 2 More than one ode inated Mo Nodstantmetatases MI Dstan metastases presen ‘The maj of renal magnons ae treated wth sey Laproscopie real sugey& bearing mare commen, but uety ope ase peahecomy rena the commonest Proce nthe UX Managements tated 2 number of Factors icing age, o-morbiies, moc ard the Condit ofthe contrat, Nephron spring sie) tha pari mephvecomy ithe feted opon ates with trou ot arena to pat nepectamy and wha have anormal contra Kney may be ete ‘chan opens nephrectomy aparscpic nephrectomy if aes Sral tumours maybe sete withthe ie in ‘8, Parl regietomy & wsualy perfumed open but laprseopy ise in sore centres Dtrer opons for sl ard exsionay multiple fons include ether and aateqaency baton. shoul ot te fgten that maine foundeonsia the ety may oy rue testent I Bey become symgtomatic oematurican be dealt with ty see emboatio of he Metastatic dese uually managed ty ones. Sinae rnetastses aye ested rm tees og I posse na this inches ban metastases I syste they eal 309 Urology Hane analogs olen est he emo f he piary toed oud Imuraheapy wth nefro-e and interes used tobe ‘has sunita and sore re no being sed cic Benign renal masses Renal sts are pee in >of the population oe he {ge of £0, is was union ut the advent ef widespread Feral at USS. Simple ys make p 70% the benign ral Ina and seldor equ eaten Salt venign masses include oncoytaas 3nd anion Fpomes Oneoetomas are ifiat to distinguish fom rmabgnant tumours and ar teeoreusualy remove fund ‘ngiomyolipamas occur peasy bt 20% ae assoested with tubeous Seas. They ae composed of Bod veel, Siooth muse ad at Wen they Become >4m, there is tmbolsation or rescon 13.3.4 Testicular cancer Primary testa cancer accounts fr 1-2 ofall mae cancers tha fete rk of Vin 50. isthe ost curate ‘ony deh rately crs efor he age of 15 o ater the ge 62 Batra deze ocirs in 10-2 of eases 95% aregem el unaurs OCT) andthe reniing sre stoma tumours hmphon Epidemiology and setioogy #39 Tena 20-35 yeas Whites ave four tne the incidence compared othe AtoCathean population + Undescened tests rpc ies is by 10-1 1% of tumours oct in descended es: also rcreanesn anormal oni ests Erty ‘eidopery, faatan af the ests in the Serta, does ot remo risk bt alos fr set-eaminton a ease Intattlr gem cl neoplasia [TGEN) ithe quent of excita fal eases develop + Hv, geneti actors and maternal oestrogen ingestion ste eas ik Teseusr tumours are csiieg ty the Word. Heath Cranston HHO ito ger cell tumors, sexed tumours nd other ee abe 112, Dey ae tage bythe THM ter Tes yearsuvhalin atts who present witoutmetastss (ans 0m; for thse with metastases [10] the Se "sil f 2%. Pogo for ron-seminomats gem ‘uous SECT) sao excelent ‘erm cal tuo 95) Seninona 48%) ter uous (6) Lymer es ccd Spemocyie assat rapasie 128) Teton Yolk sac tumour Choices Mea SGC oroorsnoma of rete eis Nesta) Serta Mie Second strma tours 10 Urological malignancy Np setgrotin XP) fale in 7% of erates an yoksa tumours Pa ite 3-5 ays Norma <0 an Human chron gonadotropin (AC) Crovicrenen 100% Terataa 4%, seminoma 10% faite 24-26 nous Nora

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