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DAMS Visual Treat

Urology

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AfraTafreeh.com • Identify the instrument
• Uses

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 AfraTafreeh.com

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• Identify the red arrow
• Important points about the
structure
• What are the black and blue
arrows indicate?

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 Verumontanum
• Embryological remnant of Mullerian duct
• Ejaculatory duct open
• External sphincter present around it
• TURP done proximal to verumontanum to avoid injury to Veru
• PUV located distal to Veru

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Revision Prostate
• Three zones
• Peripheral zone
• Carcinoma
• Forms pseudocapsule
• Central zone
• Median lobe
• Causes BOO
• Transitional zone
• BPH

Mandatory investigations for TURP

• Urine R/M & C/S
• Serum creatinine
• Flow rate
• USG for PVR

Investigation of choice for BPH

Transabdominal USG
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 Cystoscopy in a 60-year-old man with BPH

• What is the arrow denoting?

• What symptoms arise due to these
bladder changes?

BOO
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Obstructive symptoms
Early and reversible

Detrussor hypertrophy
Autonomous incoordinated contractions
Irritative symptoms
Late and persistent

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 TB BOO UTI

Irritative symptoms

Neurogenic causes CIS Bladder

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Symptoms

Obstructive symptoms Irritative symptoms

• Hesitancy • Frequency
• Intermittent stream • Urgency (Awake)
• Decreased flow • Nocturia (Sleeping)
• Retention • Urge incontinence
• Nocturnal incontinence

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 Cystoscopy in a 55-year-old lady.
Answer the following questions.
• What should be the next step?
• What investigation should have
been done before cystoscopy in
this patient?

Painless hematuria
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Urine for cytology

NMP 22 (Better)

USG
Systemic MVAC
MRI

Intravesical
BCG/Mitomycin
Ta T1 TURBT T2 Radical
cystectomy

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 Identify this instrument?
• Most common use in
urology?

AfraTafreeh.com

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 Prostate biopsy
• Transrectal route
• Under antibiotic coverage
• TRUS guided
• How many cores?
• 12
• Alternate route
• Trans-perineal

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 Prostate biopsy
• Gleason’s score
• Two separate scoring from 3 to 5 and adding them 6 to 10
• Why in prostate carcinoma Gleason’s score important
• Heterogeniety

AfraTafreeh.com Xray KUB done in a 25-year-

old man with left flank pain

• What is the possible

diagnosis?

• What are the differential

diagnosis?

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• Opacities on plain radiograph confused with renal calculi
• Calcified mesenteric lymph node
• Gallstones / concretions in appendix
• Tablets / foreign body in bowel
• Phleboliths
• Ossified tip of 12th rib
• Calcified TB lesion in kidney
• Calcified adrenal gland

2 cm lower calyx?
• PCNL / RIRS / ESWL
• RIRS
• RIRS will be the answer if
• Ectopic kidney
• Fused kidney
• Obese patient
• Bleeding disorders
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 5 cm lower calyx?
• PCNL / RIRS / ESWL
• PCNL
• Why not ESWL?

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3 cm upper calyx?
• PCNL / RIRS / ESWL
• ESWL

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 Xray KUB
• What is the next investigation?
• What is the preferred treatment?

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 Staghorn calculi
• Treatment of choice
• PCNL

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 9899664533
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 Micturating cystogram in 30-year-
old man with sterile pyuria. What is
the diagnosis and management?

• Diagnosis
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• Management

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 Right pelvis

Right reflux
AfraTafreeh.com Fecolith

Small bladder

Management of small capacity high pressure

bladder
• Augmentation
• Small capacity → Large capacity
• High pressure → Low pressure

• Price for augmentation

• CISC
• Artificial channel using appendix conduit

•MITROFANOFF

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 Complication of augmentation
• Metabolic
• Hyper Chloremic Metabolic Acidosis

• Bone growth problem

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Complication of augmentation
• Bowel related
• Bowel dysfunction
• Diarrhea due to ileal / colon resection
• Anemia
• Due to?
• Vit B12 deficiency due to ileal resection
• Gall stones
• Due to deficiency of bile salts
• Stone formation
• Mucus in colon can cause stones
• Infections
• Tumor
• Adenocarcinoma
• Perforation

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 • Identify investigation?

• Diagnosis?
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• Identify investigation?
• NCCT or CECT
• NCCT
• How?

• Diagnosis?
• B/L Renal stones
• B/L Lower ureteric stone
• Left mid ureteric stone

Which side to be operated first?

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 65-year-old man with left
flank pain.

• Diagnosis?

• Treatment?

• RCC common > 64

years
• Risk factors
• Old age
• Male
• Obese
• Hypertension
• Smoking
• Commonest type
• Clear cell

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 • Hereditary
associated with?
• VHL
• Lung metastasis
• Cannon ball lesions
• Other malignancy?
• Nephrectomy
• First to identify?
• First to ligate?
• First to cut?

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• RCC is a chemo and
radio sensitive tumor
• False

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 Identify the investigation?
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• Normal value?

Flow rates
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• Normal
• > 15 ml/sec Minimum urine?
• Decreased
• < 10 ml/sec 200 ml
• Equivocal
• 10 – 15 ml/sec

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Pressures at voiding
• Normal
• < 60 cm H2O

• Increased
• > 80 cm H2O

• Equivocal
• 60 – 80 cm H2O

BOO AfraTafreeh.com

• Pressure
• > 80 cm H2O

• Flow
• < 10 ml/sec

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 Diagnosis?

• Treatment of asymptomatic
patient?

•Horse shoe kidney

•Fused at lower end
•Always ectopic
• L4/5
•Flower vase appearance
on IVP
•Asymptomatic
• No treatment

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 • Diagnosis?

• Name of the sign?

• Diagnosis?
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• Retrocaval ureter
• Extramural obstruction
• Only on the right side
• Name of the sign?
• Reverse J sign
• Treatment
• Pyeloplasty

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 • Identify?

• Treatment?

•Exstrophy epispadias
complex
• Lower abdominal wall
defect
• Anterior wall of bladder
open
• Pelvic diastasis
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• Incontinence
•Treatment
• Staged repair

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 •Timing of surgery
• Bladder and abdominal
wall closure neonatal
period
• Epispadias repair
• 6 m to 1 y
• Bladder neck repair
• 5 – 7 years

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• Identify the investigation?

• What are its uses?

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 • Urodynamic study
• Also called the pressure flow study
• Investigation of choice for diagnosing and
management of neurogenic bladder

•pDet = pVes – p Abd

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 • Identify this device.

• How to prevent this complication in

which this instrument will be used?

AfraTafreeh.com

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 • Artificial sphincter
• Indicated in post external sphincter
injury during TURP
• TURP dissection should
be done proximal to
verumontanum

60-yer-old man with narrow stream

of urine with back pain. Xray
attached.
• Diagnosis
• Treatment

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 • BOO + Bone / Pelvic pain
• = Carcinoma prostate
• Prostate is the most
common source of bone
metastasis and not breast
• Metastasis can be both
osteoblastic and osteolytic
but more common is
• Osteoblastic

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 • Identify the investigation?
• Name of the sign?
• Diagnosis?
• Treatment?

AfraTafreeh.com

• Identify the investigation?

• Micturating cystourethrogram
• Why not RGU?
• Name of the sign?
• Key hole sign
• Diagnosis?
• Posterior urethral valves
• Treatment?
• Cystoscopic fulguration of the
valves

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 AfraTafreeh.com

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• Diagnosis

• Appropriate age to operate?

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 • Diagnosis
• Hypospadias
• Appropriate age to operate?
• Can start anytime after 6 months
• All stages should be complete before 18
months
• Why?

• The defects in a
hypospadias
• Hooded prepuce
• Meatus proximal
• Defective urethra
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• Abnormal ventral curvature
• Chordee
• Defective glans
• Bifid scrotum

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 Diagnosis?

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 • Diagnosis?
• Epispadias
• Isolated epispadias is less common
than exstrophy – epispadias complex
• Everything opposite of hypospadias
• Two varieties
• Continent
• Incontinent
• Surgery
• Modified Ransley technique

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• Diagnosis

• Treatment

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 • Diagnosis
• Paraphimosis

• Treatment
• Reduction / circumcision

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• Diagnosis ?

• Treatment

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 • Diagnosis ?
• Drooping lily sign
• Duplicated pelvis with upper
calyx nonfunctional

• Treatment
• If asymptomatic then no
treatment
• If symptomatic then partial
nephrectomy
• Usually, which pole is the
problem?
• 99% upper pole

• Diagnosis
• Treatment in an asymptomatic
patient?
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 • Diagnosis
• Left incomplete duplication
• Treatment in an asymptomatic
patient?
• No treatment

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DUPLICATION

URETERS FUSE URETERS REMAINS SEPARATED

COMPLETE
INCOMPLETE
DUPLICATION
DUPLICATION

MORE COMMON

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 • Identify the image and the sign

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 •Identify the image and the sign
• Blue dot sign
• Testicular appendix torsion

• Treatment
AfraTafreeh.com
• Testicular appendix torsion don’t need
exploration
• If diagnosis unsure and testicular torsion
cannot be ruled out
• Scrotal exploration

• Metabolic complications of this procedure

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 Blocks Cl
NH4+ channels of
intestines

Absorbed by intestine
Hyperchloremia
Portal circulation

Liver
H+ NH3

Metabolic acidosis Detoxified by Liver

• What is the investigation of

choice?

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Management

Testicular mass suspicious USG Tumor markers

on clinical examination scrotum if suspicious

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High inguinal High inguinal incision
Biopsy orchidectomy if and delivery of testis
malignant

Surveillance by CECT
Stage 1 Sem & Non Sem
and tumor markers
CECT abdomen +
chest

Rest of stages BEP regimen

Sem & Non Sem

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