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Quick Reference - What Each Answer Covers

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SURGERY UNIVERSITY EXAM - 10 MARK ANSWERS (Part 2)

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Q1. Impotence in Male: Management and Recent Advances

Definition

Classification / Aetiology

• Performance anxiety, depression, relationship problems, stress
• Characterised by normal nocturnal penile tumescence (NPT)

Investigations

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Management

A. First Line: Lifestyle Modification + PDE5 Inhibitors

• Mechanism: Nitric oxide (NO) → cGMP → smooth muscle relaxation → arterial dilation and tumescence. PDE5 degrades cGMP; inhibition prolongs erection
• Drugs:
  • Sildenafil (Viagra): 25-100 mg, on-demand, 1 hr before; duration 4-6 hrs; fatty food reduces absorption
  • Tadalafil (Cialis): 10-20 mg on-demand OR 2.5-5 mg daily (continuous use); duration 36 hrs ("weekend pill")
  • Vardenafil (Levitra): 10-20 mg on-demand
  • Avanafil (Stendra): Fastest onset (15-30 min), highly selective, fewer visual side effects
• Contraindications: Nitrate use (risk of life-threatening hypotension), severe hypotension, recent MI/stroke

B. Second Line

• Cylinder placed over penis; vacuum created by pump → blood drawn in → constriction ring applied at base to maintain erection
• Safe, effective in ~90%; suitable for patients on anticoagulants, cardiac patients
• Erection may feel unnatural (pivoting)

• Alprostadil (Prostaglandin E1): 2.5-40 mcg injected into corpus cavernosum; erection within 5-20 min; duration 30-60 min
• Bimix: Papaverine + phentolamine; Trimix: Papaverine + phentolamine + alprostadil (most potent)
• Complications: Priapism, pain, fibrosis, haematoma
• Success rate: 70-80%

• Alprostadil pellet inserted into urethra via applicator
• Absorbed through urethral mucosa into corpora cavernosa
• Less effective than ICI; compliance issues (burning sensation)

C. Third Line: Surgical

1. Semi-rigid (Malleable) Prosthesis:
   • Two bendable rods inserted into corpora cavernosa
   • Always semi-rigid; bent up for intercourse, down for concealment
   • Simple, durable, low complication rate
   • Suitable for elderly, neurological ED, manual dexterity issues
2. Inflatable Penile Prosthesis (IPP):
   • Two-piece (AMS Ambicor): cylinders + scrotal pump; no separate reservoir
   • Three-piece (AMS 700 CX / Coloplast Titan): Cylinders + pump (scrotum) + reservoir (retropubic space); most natural erection quality
   • Inflated for intercourse, deflated at rest
   • Patient satisfaction >90%; partner satisfaction >80%
   • Complications: Infection (1-3%), mechanical failure, auto-inflation, erosion

• Penile arterial revascularization (Michal-Brindley procedure): For focal arterial stenosis in young men with pelvic trauma; inferior epigastric artery anastomosed to dorsal penile artery
• Venous ligation surgery: Ligates venous leak sites; long-term results disappointing; largely abandoned

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Recent Advances

• Low-energy acoustic shockwaves applied to penile shaft
• Induces neovascularization (angiogenesis), promotes NO synthesis, regenerates cavernous tissue
• 6-12 sessions; effective for mild-moderate vasculogenic ED
• Can restore responsiveness to PDE5 inhibitors in prior non-responders
• Non-invasive, no anaesthesia; evidence base growing (ISSM guidelines 2021)

• Autologous PRP injected intracavernously
• Growth factors (PDGF, VEGF, TGF-β) promote tissue repair and angiogenesis
• Early studies promising; still investigational

• Mesenchymal stem cells (adipose or bone marrow-derived) injected intracavernously
• Aim: regenerate smooth muscle cells, endothelium, nerves destroyed by diabetes/prostatectomy
• Phase I/II trials ongoing; not yet standard of care

• Maxi-K gene therapy (hSlo) for smooth muscle relaxation: Phase I trial showed benefit at 6-month follow-up
• VEGF gene therapy for angiogenesis

• Topical alprostadil (Vitaros): 300 mcg applied to urethral meatus; approved in Europe
• MED3000 (ScopeAim): Topical GT3 formulation (glyceryl trinitrate + pentoxifylline)

• Bremelanotide (PT-141 / Vyleesi): Centrally-acting melanocortin 4 receptor agonist; acts via hypothalamic pathway, not vascular; works in patients who fail PDE5 inhibitors; SC injection

• Improved nerve identification and sparing; ED rates after RARP significantly lower than open prostatectomy

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Q2. Etiopathogenesis, Investigation and Management of Psoas Abscess

Anatomy

Classification

• No identifiable adjacent source
• Hematogenous spread to psoas muscle
• Common in immunocompromised, IV drug users, diabetes
• Organism: Staphylococcus aureus (most common worldwide; including MRSA)
• More common in developing countries

• Direct extension from adjacent infected structure
• More common in developed countries
• Sources:
  • Vertebral (Pott's disease): Mycobacterium tuberculosis - historically most common; still prevalent in developing countries
  • Crohn's disease: most common cause in developed world
  • Appendicitis/perforated appendix
  • Diverticulitis
  • Renal pathology: Perinephric abscess, renal tuberculosis
  • Infected aortic aneurysm / graft
  • Septic arthritis of hip/sacroiliac joint
  • Pelvic inflammatory disease
  • Vertebral osteomyelitis (non-TB): S. aureus, Streptococcus, gram-negatives

Pathogenesis

• Is a closed space, promoting anaerobic conditions for abscess development
• Communicates superiorly with the mediastinum (diaphragmatic hiatus) and inferiorly with the femoral triangle (below inguinal ligament)
• Thus, abscess can track to the groin/thigh (presenting as a mass or "pointing abscess" in upper thigh)

Clinical Features - Classic Triad (present in only 30%)

1. Fever
2. Back/flank pain
3. Limp / limitation of hip movement (psoas sign)

• Groin pain or mass
• Hip flexion deformity (psoas spasm)
• Referred pain to anterior thigh
• Weight loss, night sweats (TB)
• Hip held in flexion, external rotation

Investigations

• FBC: Leukocytosis (neutrophilia in bacterial; lymphocytosis in TB)
• ESR, CRP: Elevated
• Blood cultures (50% positive in hematogenous cases)
• Mantoux/Tuberculin skin test, IGRA (Quantiferon Gold) for TB
• Serum calcium (TB - hypercalcemia)

1. Ultrasound: First-line; shows hypoechoic collection in psoas region; may miss deep/small abscesses; guides drainage
2. CT Abdomen/Pelvis (Gold Standard):
   • Hypodense collection with ring enhancement within/around psoas muscle
   • Identifies source (vertebral, bowel, renal)
   • Shows extent; guides drainage approach
   • Gas within collection = pyogenic abscess
3. MRI:
   • Superior soft tissue resolution; preferred for vertebral involvement (Pott's disease)
   • T1: Low signal; T2: High signal; gadolinium enhancement of rim
   • No radiation; preferred in young/pregnant
4. X-ray spine/hip: May show vertebral collapse, disc space narrowing (Pott's), loss of psoas shadow
5. Bone scan/PET-CT: For occult source identification

• Aspirate from drainage: Gram stain, culture (aerobic, anaerobic, AFB, fungal)
• AFB smear and culture (Lowenstein-Jensen medium) for TB; takes 6-8 weeks
• PCR/GeneXpert for rapid TB identification
• Histopathology of tissue: Granulomas = TB

Management

A. Medical Treatment

• IV antibiotics empirically covering S. aureus and gram-negatives:
  • Primary: Flucloxacillin + gentamicin (or piperacillin-tazobactam in severe sepsis)
  • MRSA cover: Vancomycin
  • TB psoas abscess: Standard RHEZ regime (Rifampicin, Isoniazid, Ethambutol, Pyrazinamide) for 2 months, then RH for 4-7 months
• Nutritional support, analgesia

B. Drainage (Most Important)

• Treatment of choice for most psoas abscesses
• Real-time imaging guidance; posterior or posterolateral approach
• Pigtail catheter left in situ for continuous drainage (7-14 days)
• Aspiration alone sufficient for <3 cm well-loculated abscesses
• Success rate: 85-90%
• Preferred in: medically unfit patients, loculated collections, TB abscesses (after anti-TB therapy initiated)

• Retroperitoneal (posterior flank) approach (preferred): Patient in lateral decubitus; incision over 12th rib; extraperitoneal access to psoas; thorough drainage, debridement, wash-out
• Anterior transperitoneal approach: For abscesses extending into pelvis or when laparotomy needed for source control
• Medial (lumbar) approach: For vertebral TB with paravertebral abscess

• Crohn's disease: Resection or strictureplasty + drainage
• Appendiceal source: Appendicectomy
• Vertebral TB: Anti-TB drugs; surgery for spinal instability
• Perinephric abscess: Nephrostomy ± nephrectomy

C. Postoperative Care

• Continue antibiotics (IV → oral) for minimum 4-6 weeks (6-12 months for TB)
• Monitor WBC, CRP, ESR for resolution
• Repeat CT at 4-6 weeks to confirm resolution
• Source treatment as appropriate

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Q3. Urinary Diversion: Indications, Methods and Complications

Definition

Indications

• Radical cystectomy: Muscle-invasive bladder cancer (T2-T4), high-grade non-muscle-invasive bladder cancer refractory to BCG
• Neurogenic bladder: Refractory to conservative management
• Pelvic exenteration: For advanced pelvic malignancy
• Radiation cystitis: Refractory with reduced capacity/fistula
• Interstitial cystitis: Refractory bladder pain syndrome
• Trauma with irreparable bladder/urethra
• Congenital anomalies: Bladder exstrophy, cloacal anomalies

Classification

Urinary Diversion
├── Incontinent (Non-Continent)
│   └── Ileal Conduit (Bricker)
│   └── Colon Conduit
├── Continent Cutaneous
│   └── Kock Pouch (ileal reservoir)
│   └── Indiana Pouch (ileocaecal)
│   └── Mitrofanoff (appendicovesicostomy)
└── Orthotopic (Continent, voiding via urethra)
    └── Ileal Neobladder (Studer / Hautmann)
    └── Sigmoid neobladder

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A. Ileal Conduit (Bricker, 1950) - Most Common

1. Resect 15-20 cm distal ileum (preserving mesentery and blood supply)
2. Restore ileal continuity with end-to-end anastomosis
3. Reimplant ureters into proximal end of conduit (Wallace or Bricker technique - refluxing or non-refluxing)
4. Distal ileum brought through right abdominal wall; stoma fashioned (spout/rosebud) flush above skin

• Technically simpler; shorter operative time
• Most reliable; widely applicable regardless of comorbidity
• No reservoir complications

• External bag worn permanently (body image, QoL issues)
• Continuous urine leakage if bag fails

• Early: Urine leak, wound infection, ileus, DVT
• Late (most significant):
  • Stomal stenosis (15-20%)
  • Parastomal hernia (20-30%)
  • Ureteroileal stricture/obstruction (5-10%)
  • Pyelonephritis, urolithiasis
  • Upper tract deterioration (reflux nephropathy): 30% at 10 years
  • Hyperchloraemic metabolic acidosis (chloride reabsorption from ileum)

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B. Orthotopic Ileal Neobladder (Studer / Hautmann)

• Negative urethral margins on frozen section
• Intact urethral sphincter mechanism (external sphincter)
• Good renal function (creatinine <150 μmol/L - able to compensate metabolic acidosis)
• Motivated, compliant patient
• Suitable anatomy

1. Isolate 54-60 cm of ileum; restore intestinal continuity
2. Detubularize all but proximal 10-12 cm (proximal tubular chimney for ureteral implantation in a non-refluxing or refluxing manner)
3. Fold and anastomose opened ileum into a U/W/M shaped reservoir
4. Close the neobladder leaving a dependent pouch
5. Anastomose to the urethra (vesicourethral anastomosis)
6. Left ureter brought through mesentery (Studer afferent limb preserves anti-reflux)

• Urinary incontinence: Daytime 10-20%; Nocturnal (enuresis) 20-40% (loss of nocturnal cortical control)
• Urinary retention requiring CIC (clean intermittent catheterisation): 10-25%
• Metabolic: Hyperchloraemic metabolic acidosis (ileum reabsorbs Cl-; monitor regularly)
• Vitamin B12 deficiency (if terminal ileum used; lifelong supplementation)
• Nocturnal enuresis (absent sphincter tone during sleep)
• Pouch stone formation
• Ureteroenteric strictures

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C. Continent Cutaneous Diversion (Indiana Pouch)

• Low-pressure reservoir (detubularized bowel)
• Continence valve: narrowed terminal ileum (plicated/tapered) or appendix (Mitrofanoff)

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D. Other Methods

Summary Table

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Q4. Surgical Anatomy of the Prostate

Overview

Dimensions and Relations

• Weight: 20g (normal adult)
• Shape: Inverted cone/chestnut
• Above: Bladder neck
• Below: Urogenital diaphragm (external sphincter)
• Anterior: Puboprostatic ligaments, Santorini's venous plexus (dorsal venous complex), pubic symphysis
• Posterior: Denonvilliers' fascia → seminal vesicles and vas deferens above; rectum posterior (separated by fascia)
• Lateral: Levator ani (pelvic floor), neurovascular bundles (NVB)

Zonal Anatomy (McNeal, 1981)

Fascia and Planes

• Between posterior prostate/seminal vesicles and anterior rectal wall
• Two layers (anterior + posterior) with potential space
• Important in radical prostatectomy: dissecting anterior to posterior layer (prostatic side) protects rectum; dissecting posterior to anterior layer (rectal side) may improve oncological clearance but risk rectal injury

Blood Supply

• Inferior vesical artery (branch of internal iliac) → main supply
• Middle rectal artery (contributes)
• Prostatic arteries enter at 5 and 7 o'clock positions on DRE (posterolateral)

• Dorsal Venous Complex (DVC) of Santorini: Major venous plexus anterior to prostate between puboprostatic ligaments; communicates with deep dorsal vein of penis and pelvic veins; major source of haemorrhage in radical prostatectomy → controlled by suture ligation (Bunce stitch) before division

Lymphatic Drainage

• Obturator nodes (most important/first echelon)
• Internal iliac nodes
• Presacral nodes
• External iliac nodes
• Pelvic lymphadenectomy (PLND) removes obturator and iliac nodes for staging

Nerve Supply and Neurovascular Bundles (NVBs)

• Autonomic nerves from pelvic plexus (T10-L1 sympathetic + S2-S4 parasympathetic via inferior hypogastric plexus)
• Travel in the posterolateral "neurovascular bundles" at 5 and 7 o'clock positions
• Provide cavernous nerve innervation to corpora cavernosa → responsible for erection
• Run in the groove between prostate and rectum, then behind the membranous urethra
• Nerve-sparing prostatectomy: preserves NVBs → preserves erectile function (bilateral nerve-sparing: 70-80% potency; unilateral: 50%)

• External urethral sphincter: Striated muscle; inferior to prostate; at membranous urethra; voluntary control; most important for post-prostatectomy continence
• Bladder neck (internal sphincter): Smooth muscle; often deliberately divided in TURP/prostatectomy
• Rhabdosphincter: horseshoe-shaped at membranous urethra; preserved during radical prostatectomy

Urethra in Relation to Prostate

• Proximal prostatic urethra: Crista urethralis, colliculus seminalis (verumontanum) at posterior wall
• Verumontanum: Most important landmark in TURP; at junction of prostatic and membranous urethra; 1-1.5 cm distal to external sphincter; resection must stop proximal to verumontanum
• Ejaculatory Ducts: Open at verumontanum; arise from fusion of vas deferens and seminal vesicle ducts

Surgical Relevance

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Q5. Recent Modalities in Management of Benign Prostatic Hyperplasia (BPH)

Overview

Indications for Active Treatment

• Moderate-severe LUTS (IPSS >7)
• Failed medical therapy (alpha blockers ± 5-alpha reductase inhibitors ± PDE5i)
• Complications: AUR, recurrent UTI, bladder stones, renal impairment, haematuria

Traditional Surgical Standard: TURP

• Transurethral resection of the prostate remains the benchmark
• Bipolar TURP (saline irrigation) has replaced monopolar TURP
• Reduces TUR syndrome risk

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Recent / Minimally Invasive Surgical Therapies (MISTs)

1. HoLEP - Holmium Laser Enucleation of the Prostate

• Laser: Holmium:YAG laser (2140 nm wavelength)
• Principle: Anatomical enucleation of prostatic adenoma from surgical capsule (same plane as open simple prostatectomy), then morcellated in the bladder
• Suitable for any prostate size (30 g - >200 g)
• Advantages: Size-independent; bloodless (haemostatic); suitable for anticoagulated patients; hospital stay 1-2 days; durable results equivalent to open prostatectomy; preserves tissue for histology (unlike vaporization)
• Considered the new gold standard for surgical BPH management (EAU Guidelines 2024)
• Learning curve: 50-100 cases

2. GreenLight PVP - Photoselective Vaporization of the Prostate

• Laser: KTP (potassium-titanyl-phosphate) 532 nm or XPS 180W GreenLight
• Principle: Laser energy absorbed by oxyhemoglobin → vaporizes prostatic tissue without morcellation
• Bloodless, suitable for anticoagulated patients
• Disadvantage: No tissue for histology; limited to moderate-size prostates

3. Thulium Laser (ThuLEP / ThuVAP)

• Thulium:YAG (2013 nm) or Thulium fiber laser (TFL - 1940 nm)
• Similar to HoLEP; some data suggest better haemostasis
• TFL (Thulium Fiber Laser) is newest; continuous-wave; efficient vaporization and enucleation

4. Aquablation (AquaBeam - Robotic Waterjet)

• Principle: Real-time ultrasound imaging + robotically controlled high-velocity waterjet that ablates prostatic tissue with heat-free precision
• AQUABEAM robotic system
• Pre-operative MRI/ultrasound mapping; robotically executes customized resection plan
• Avoids ejaculatory duct zone → preserves ejaculatory function (major advantage vs. TURP/HoLEP)
• Suitable for 30-150 g prostates
• WATER/WATER II trials: Non-inferior to TURP; lower retrograde ejaculation rate
• FDA approved 2017

5. Rezum (Steam Therapy / Water Vapor Thermal Therapy)

• Principle: Radiofrequency energy converts water to steam (103°C); steam injected into prostatic transition zone → convective thermal damage → cell death → tissue resorption over weeks
• Office procedure under local anaesthesia
• 10-minute procedure; catheter for 3-7 days
• Best for small-moderate prostates (30-80 g)
• Preserves sexual function (ejaculatory and erectile)
• IPSS improvement: 50%; Qmax improvement: 50%
• Durable results at 5 years; FDA approved 2015

6. Urolift (Prostatic Urethral Lift)

• Principle: Small permanent implants (nitinol clips + suture) retract and hold the lateral prostatic lobes away from the urethra under cystoscopic guidance
• No tissue removal or heat; preserves ejaculatory and erectile function
• Office procedure; immediate improvement
• Not suitable for: obstructive median lobe, >80 g prostate
• L.I.F.T. trial: Significant IPSS and Qmax improvement; 5-year durable results
• Ideal for sexually active men with lateral lobe obstruction

7. iTind (Temporarily Implanted Nitinol Device)

• Nitinol device inserted and left in urethra for 5-7 days; reshapes urethra; then removed
• Single outpatient visit essentially; preserves ejaculation
• Early data encouraging

8. Prostate Artery Embolization (PAE)

• Interventional radiology procedure
• Super-selective catheterization of prostatic arteries (bilateral); microembolic particles (polyvinyl alcohol / bead embolics)
• Reduces prostatic blood supply → infarction → volume reduction (25-40%)
• ROPE registry; IMPACT trial (non-inferior to TURP in selected patients)
• Advantages: No anaesthesia; preserves ejaculatory function; suitable for large prostates, anticoagulated, frail patients
• Disadvantages: Technically demanding; post-embolization syndrome; less durable than TURP; non-target embolization risk

9. Convective RF Ablation (Optilume BPH Balloon)

• Drug-coated balloon delivering paclitaxel to urethra + mechanical dilation
• Investigational

10. Focal Laser Ablation / HIFU for BPH

• Emerging; limited evidence currently

Medical Management (for completeness)

• Alpha blockers (tamsulosin, silodosin): First-line; rapid symptom relief
• 5-ARI (finasteride, dutasteride): Reduce prostate volume over 6 months; best for large prostates (>40 mL); combination therapy superior
• PDE5 inhibitors (tadalafil 5 mg daily): Improves both LUTS and ED
• Beta-3 agonist (mirabegron): For OAB/storage symptoms
• Anticholinergics: Storage symptoms (caution - AUR risk)

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Q6. Recent Advances and Modalities in Prostate Cancer

Staging and Risk Stratification

• TNM staging; Gleason grading (now Grade Groups 1-5 by ISUP 2016)
• Risk groups: Low (PSA<10, GG1, T1-2a), Intermediate (GG2-3 or PSA 10-20 or T2b-c), High (GG4-5 or PSA>20 or T3)

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Recent Diagnostic Advances

1. MRI-Targeted Biopsy (Fusion Biopsy)

• mpMRI (Multi-parametric MRI): T2W + DWI + DCE sequences; PI-RADS v2.1 scoring (1-5)
• PI-RADS 3-5 lesions targeted with biopsy; reduces over-diagnosis of low-grade cancer
• MRI-TRUS Fusion Biopsy: Real-time MRI-TRUS fusion overlay; targeted cores from PI-RADS ≥3 lesions + systematic biopsies
• In-Bore MRI-guided biopsy: Highest accuracy; expensive/time-consuming
• PROMIS, PRECISION trials: mpMRI-targeted biopsy superior to systematic TRUS biopsy for clinically significant cancer detection

2. PSMA PET-CT (Prostate-Specific Membrane Antigen)

• Gallium-68 PSMA PET-CT: Supersedes conventional staging (CT + bone scan)
• PSMA overexpressed on prostate cancer cells; radiolabeled ligand binds with high specificity
• Superior sensitivity for: nodal metastases, bone metastases, biochemical recurrence (PSA >0.2 post-prostatectomy)
• OSPREY, CONDOR, proPSMA trials established superiority
• Lu-177 PSMA (Theranostics): Same PSMA ligand; radiolabeled with lutetium-177 (beta emitter) → targeted radiotherapy to PSMA-expressing metastases; VISION trial: significant rPFS/OS benefit in mCRPC

3. Liquid Biopsy

• ctDNA (Circulating tumour DNA): Detected in plasma; mutation profiling; treatment selection
• AR-V7 splice variant: Detected in CTCs; predicts resistance to enzalutamide/abiraterone → direct to taxane chemotherapy

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Treatment: Recent Advances

A. Radical Prostatectomy

• Da Vinci system (Xi/SP); most radical prostatectomies now robotic
• 3D visualization, wristed instruments, tremor filtration
• SP (Single Port) robotic prostatectomy: Single incision; improved cosmesis; reduced port-site complications
• Outcomes equivalent to open; lower blood loss, shorter catheterization

B. Radiation Therapy

• 5 fractions (1 week) vs. conventional 40 fractions
• PACE-B trial: Non-inferior to IMRT at 5 years; fewer patient visits
• MRI-guided radiotherapy (MR-Linac): Real-time MRI during radiotherapy; adapts plan to organ motion; spares bladder/rectum

• LDR (low dose rate): Iodine-125 seeds permanently implanted; for low/intermediate risk
• HDR (high dose rate): Temporary Iridium-192 catheters; single/few fractions; combined with EBRT for high-risk

C. Focal Therapy (for Localized, Low-Intermediate Risk)

• Focused ultrasound waves → focal thermal necrosis of prostate
• Ablatherm (EDAP), Sonablate (SonaCare) systems
• Whole-gland or focal (hemi-ablation) treatment
• Preserves continence and erectile function (vs. radical treatment)

• Laser fiber placed in lesion under MRI guidance; thermal ablation of focal lesion
• Minimal tissue loss; preserve function

• Argon gas probes freeze prostate tissue to -40°C → ice ball formation → cell death
• Primary or salvage after radiotherapy failure
• Side effects: ED (50-60%), sphincter injury, urethral sloughing

• Non-thermal electrical pulses create permanent pores in cell membranes → apoptosis
• Spares collagen, vessels, nerves → low risk to urethra and NVB
• True "nerve-sparing" focal therapy; results awaited

D. Systemic Therapy - Recent Advances

• Next-generation androgen receptor pathway inhibitors
• ARCHES, TITAN, ARAMIS trials: Significant OS benefit in mHSPC and nmCRPC
• Apalutamide + ADT: standard of care for mHSPC (TITAN trial)
• Darolutamide: Fewer CNS side effects (does not cross BBB)

• CYP17A1 inhibitor → blocks androgen synthesis from adrenal/tumor
• LATITUDE, STAMPEDE trials: OS benefit in mHSPC
• Combined with enzalutamide: ENZAMET, ARASENS trials

• Olaparib, Rucaparib, Niraparib, Talazoparib
• For mCRPC with BRCA1/2, ATM mutations (Homologous Recombination Repair - HRR gene defects)
• PROfound trial (olaparib): Significant rPFS benefit in HRR-mutant mCRPC
• BRCA testing now standard before second-line mCRPC treatment

• Sipuleucel-T (Provenge): Autologous dendritic cell vaccine; FDA approved for asymptomatic/minimally symptomatic mCRPC; modest OS benefit (IMPACT trial)
• Pembrolizumab: For MSI-H / dMMR prostate cancer (tumour-agnostic approval)
• PD-1/PD-L1 inhibitors generally have low activity in prostate cancer (immunologically "cold" tumor)

• 177Lu-PSMA-617 (Lutetium Vipivotide Tetraxetan / Pluvicto): VISION trial; FDA/EMA approved 2022; for PSMA-positive mCRPC post-ARSI and taxane
• Actinium-225 PSMA: Alpha emitter; early trials very promising; higher cell kill

• AMG 160 (PSMA × CD3 bispecific): Redirects T-cells to kill PSMA+ prostate cancer cells
• Phase II trials ongoing

• ADT + Docetaxel + Darolutamide (ARASENS): mHSPC; significant OS improvement
• ADT + Abiraterone + Enzalutamide: Combinations under investigation

• BRCA1/2 germline/somatic testing for all mCRPC
• Decipher, Oncotype DX Prostate, Prolaris: Genomic risk classifiers for adjuvant therapy decisions

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Q7. Laser Ablation of the Prostate

Introduction

Physics of Laser-Tissue Interaction

• Absorption: Tissue absorbs laser energy → heat → vaporization/coagulation
• Vaporization: >100°C → explosive steam; tissue destruction
• Coagulation: 60-100°C → protein denaturation without vaporization
• Wavelength determines absorption coefficient by tissue chromophores (water, hemoglobin, melanin)

Types of Lasers Used

1. Holmium:YAG Laser (Ho:YAG) - 2140 nm

• Gold standard laser procedure; equivalent to open simple prostatectomy
• Anatomical enucleation at surgical capsule plane
• Three-lobe technique or two-lobe
• Morcellation required (Karl Storz/Wolf morcellator)
• Suitable for any prostate size; anticoagulated patients
• Disadvantage: Learning curve; dedicated morcellator required

• Pure vaporization of smaller prostates
• No morcellator needed; no tissue for histology

• Resection in chips (like TURP); antiquated

2. Potassium-Titanyl-Phosphate (KTP) / GreenLight Laser - 532 nm

• 80W KTP → 120W HPS → 180W XPS systems (progressive evolution)
• Tissue vaporized instantly with laser fiber in non-contact mode
• Excellent haemostasis (can be used on anticoagulated patients)
• Coagulation zone 1-2 mm deep
• Limitation: No tissue for histology (vaporized); retrograde ejaculation still common; limited to moderate prostate sizes

3. Thulium:YAG Laser (Tm:YAG) - 2013 nm

• Newest generation; diode-pumped fiber laser
• Continuous-wave or pulse-modulated
• Efficient at lower powers; delivered through thin flexible fibers (180 μm)
• Suitable for flexible ureteroscopy AND prostate
• TFL-HoLEP equivalent outcomes; potentially less thermal spread

4. Diode Laser - 940/980/1470 nm

• Compact, portable, low-cost
• Vaporization and coagulation modes
• InterStim, Biolitec systems
• Adequate for smaller prostates
• Less established than HoLEP or GreenLight

5. Nd:YAG Laser - 1064 nm

• Poor absorption (deep penetration 10 mm); primarily coagulative
• VLAP (Visual Laser Ablation of Prostate): Lateral firing fiber; coagulative necrosis of prostatic tissue; significant post-treatment retention period (weeks of sloughing); historically important; now largely replaced by above

Comparison Summary

Advantages of Laser over TURP

• Lower blood loss; reduced transfusion rate
• Shorter catheterization time
• Day surgery feasible
• Safe in anticoagulated patients
• Lower TUR syndrome risk (saline irrigation in HoLEP)

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Q8. Cystoscopy

Definition

Types of Cystoscopes

• Stainless steel; available in 17-30 Fr; 0°, 30°, 70° lens systems
• 30° lens: most used (general inspection, most of bladder)
• 70° lens: bladder base, trigone, dome inspection
• Superior optics; requires lithotomy position under anaesthesia

• Fibre-optic or digital chip-on-tip (Karl Storz FLEX-XC)
• Deflectable tip (210° range)
• Performed under local anaesthesia (intraurethral lignocaine gel)
• Outpatient, no stirrups
• Smaller working channel (2 mm); less therapeutic capability

Indications

• Haematuria (painless frank haematuria - MUST exclude bladder cancer)
• Recurrent UTIs
• LUTS - assess bladder outlet, trigone, trabeculation, diverticula
• Follow-up surveillance: Bladder cancer, urethral stricture
• Ureteric orifice assessment (duplication, reflux workup)
• Suspicious urine cytology with negative imaging
• Fistula assessment (vesicovaginal, vesicoenteric)
• Foreign body
• Interstitial cystitis (Hunner's ulcer)
• Failed ureteral catheterization under fluoroscopy

• Bladder tumour biopsy and TURBT (transurethral resection of bladder tumour)
• Bladder stone fragmentation (litholapaxy, laser)
• Dilatation of ureteral stricture / ureteroscopy
• Ureteral stent (JJ stent) insertion/removal
• Haematuria management (diathermy of bleeding vessels)
• Bladder neck incision (BNI)
• Urethral stricture dilatation / internal urethrotomy (Otis urethrotome, Cold knife)
• Botulinum toxin injection (OAB, neurogenic bladder)
• Hydrodistension (interstitial cystitis)
• Retrograde pyelogram
• Placement of suprapubic catheter (Trocar cystostomy)

Procedure (Flexible Outpatient)

1. Patient supine; intraurethral lignocaine gel (2%) instilled; 3-5 minutes wait
2. Flexible cystoscope inserted with gentle irrigation of normal saline
3. Urethra inspected: Strictures, false passages
4. Bladder neck and prostate (in males) inspected
5. Bladder distended with 200-300 mL saline
6. Systematic inspection: trigone, both ureteral orifices, lateral walls, dome, anterior wall (tilt head down)
7. Document findings; biopsies/interventions as needed

Findings and Significance

Complications

• UTI (most common; antibiotic prophylaxis: trimethoprim or nitrofurantoin)
• Haematuria
• Urethral trauma/false passage
• Perforation (rare)
• TUR syndrome (with monopolar electrocautery + glycine irrigation)
• Failure to complete/poor visualisation

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Q9. Endoscopy (General Principles and Types)

Definition

Classification

Endoscopy
├── Upper GI (UGI)
│   ├── OGD / Gastroscopy (diagnostic + therapeutic)
│   ├── ERCP (biliary + pancreatic)
│   └── Enteroscopy (small bowel)
│       ├── Push enteroscopy
│       ├── Double-balloon enteroscopy (DBE)
│       └── Capsule endoscopy
├── Lower GI
│   ├── Colonoscopy
│   ├── Flexible sigmoidoscopy
│   └── Anoscopy/Proctoscopy (rigid)
├── Respiratory
│   └── Bronchoscopy (rigid or flexible)
├── Urological
│   ├── Cystoscopy
│   ├── Ureteroscopy (flexible/semi-rigid)
│   └── Nephroscopy (PCNL)
└── Other
    ├── Laparoscopy (surgical endoscopy)
    ├── Thoracoscopy / VATS
    ├── Arthroscopy
    └── Hysteroscopy

Components of an Endoscope

1. Control head: Angulation controls (up/down, left/right), suction, air/water buttons, working channel port
2. Insertion tube: Flexible; contains light bundles (fibre-optic or LED light guide), image transmission (CCD chip or fibre-optic bundle), air/water channels, suction/working channel
3. Light source: LED (modern) or Xenon; 300W
4. Video processor: Image processing, enhancement (NBI, BLI, LCI)
5. Monitor: Full HD or 4K
6. Universal cord: Connects scope to processor and light source

Image Enhancement Technologies

• NBI (Narrow Band Imaging, Olympus): Uses 415nm + 540nm wavelengths; enhances mucosal vascular pattern; improves polyp/early cancer detection
• BLI (Blue Light Imaging, Fujifilm): Similar principle; enhanced vascular contrast
• LCI (Linked Colour Imaging): Enhanced colour differentiation for flat lesions, H. pylori gastritis
• Chromoendoscopy: Dye spray (indigo carmine, methylene blue) for pit pattern assessment
• Magnification endoscopy: 100-150x; combined with NBI for early cancer characterization
• AI-assisted colonoscopy (CADe - Computer-Aided Detection): Real-time AI polyp detection; reduces adenoma miss rate by 30%

Endoscopic Hemostasis Methods

• Injection: Diluted adrenaline (1:10,000) + fibrin glue/thrombin
• Thermal: Argon plasma coagulation (APC), heater probe, bipolar electrocautery
• Mechanical: Endoclips (Resolution 360, Instinct), over-the-scope clips (OTSC/"bear claw"), endoloops
• Combination (most effective): Injection + thermal/clip

Endoscopic Resection Techniques

• Polypectomy: Hot/cold snare; <10 mm → cold snare; >10 mm → hot snare
• EMR (Endoscopic Mucosal Resection): Submucosal injection → lift → snare; for flat/sessile lesions <20 mm
• ESD (Endoscopic Submucosal Dissection): En-bloc resection of any size flat lesion using needle knife; Japanese origin; allows R0 resection of early GI cancer without surgery; steep learning curve
• EFTR (Endoscopic Full-Thickness Resection): Full-thickness excision using OTSC + snare; for subepithelial tumours, non-lifting polyps

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Q10. Oesophagogastroduodenoscopy (OGD): Diagnostic and Therapeutic Uses (20 marks)

Introduction

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Instrument

• Flexible videoendoscope: 8-11 mm diameter; 100-125 cm working length
• 2° angulation (up/down 210°; left/right 100°)
• Working channel 2.8-3.7 mm
• Suction, air/water irrigation
• Standard gastroscope / therapeutic gastroscope (wider channel) / ultra-thin (transnasal)

Patient Preparation

• Nil-by-mouth: 6 hours food, 2 hours clear liquids (elective)
• IV access; pulse oximetry monitoring
• Sedation: IV midazolam ± fentanyl (conscious sedation) or propofol (deep sedation with anaesthesia); OR topical pharyngeal lignocaine spray only
• Antispasmodic (IV hyoscine butylbromide / glucagon) if needed to reduce peristalsis
• Patient left lateral decubitus position; bite guard inserted

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Diagnostic Uses

1. Oesophagus

• Reflux oesophagitis / GERD: LA classification (A-D); Barrett's oesophagus surveillance (Prague classification - C+M criteria); biopsies
• Barrett's Oesophagus: Metaplastic columnar epithelium; dysplasia grading; risk of adenocarcinoma; surveillance every 3-5 years (non-dysplastic), annual (LGD), 3-monthly or ablation (HGD)
• Oesophageal cancer: Squamous or adenocarcinoma; staging, biopsy, assessment of involvement
• Achalasia / Dysmotility: Dilated oesophagus, food residue, "puckered" gastro-oesophageal junction (GOJ)
• Strictures: Peptic, malignant, post-caustic; can be dilated
• Varices: Grading (Grade I-IV); treatment with band ligation
• Webs and rings: Schatzki ring, Plummer-Vinson web
• Hiatus hernia: Type assessment
• Diverticula: Zenker's, epiphrenic

2. Stomach

• Peptic ulcer disease: Gastric/duodenal ulcers; Johnson classification (GU); biopsy from ulcer edge (4-6 quadrant) to exclude malignancy; H. pylori testing (RUT - rapid urease test)
• Gastric cancer: Early gastric cancer (EGC) vs. advanced; Paris classification; biopsy for histology; staging for ESD eligibility
• Polyps: Hyperplastic, fundic gland, adenomatous; resect or biopsy depending on type
• MALT lymphoma: Associated with H. pylori; biopsy + RUT
• Gastritis: H. pylori gastritis (Sydney classification); Atrophic gastritis; autoimmune gastritis (corpus-restricted, anti-IF antibodies)
• Subepithelial tumours: GIST (gastrointestinal stromal tumour), leiomyoma, carcinoid; EUS assessment
• Bezoar: Trichobezoar, phytobezoar; fragmentation and removal
• Foreign body: Ingested objects; extraction if in oesophagus/stomach

3. Duodenum

• Duodenal ulcers: D1 most common; H. pylori biopsy (CLO test)
• Coeliac disease (Sprue): D2 biopsies (4-6 samples); villous atrophy (Marsh classification); scalloping, mosaic pattern
• Ampullary lesions: Adenoma, carcinoma; biopsy; may block biliary/pancreatic drainage
• Duodenal cancer: Rare; biopsy and staging
• Crohn's disease: Cobblestone mucosa, aphthous ulcers

4. Post-Surgical Assessment

• Anastomotic leaks, strictures, marginal ulceration after gastrectomy, gastric sleeve, Roux-en-Y
• Stent patency assessment
• Feeding jejunostomy assessment

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Therapeutic Uses

A. Haemostasis (Upper GI Bleeding)

• Ia: Spurting - urgent endoscopic + surgical standby
• Ib: Oozing - endoscopic treatment
• IIa: Non-bleeding visible vessel - treat (re-bleeding 50%)
• IIb: Adherent clot - treat or wash
• IIc: Flat spot - no treatment needed
• III: Clean base - discharge possible

1. Injection therapy: Dilute adrenaline 1:10,000 (4 quadrant injection, 1mL each) for tamponade + vasoconstriction; alone insufficient - combine with thermal or mechanical
2. Thermal coagulation: Heater probe (15-30J); bipolar BICAP electrode; APC (500-750 kHz argon gas coagulation; 40-60W)
3. Mechanical - Endoclips: Quickclip (Olympus), Resolution (Boston Scientific), Instinct (Cook); apply to visible vessel or ulcer base; gold standard for visible vessel haemorrhage
4. Over-The-Scope Clip (OTSC/"Bear Claw"): For difficult-to-clip lesions, full-thickness closure, fistula closure, recurrent bleeding
5. Haemostatic Powder (TC-325 / Hemospray): Spray applied to bleeding point; forms physical barrier; used as bridge therapy; acute severe haemorrhage
6. SEMS (Self-Expanding Metal Stent): For malignant bleeding or Dieulafoy's if other methods fail

• Band Ligation (EVL): Standard of care for oesophageal varices; rubber bands applied to each varix above GOJ; repeat every 2-3 weeks until eradicated
• Injection Sclerotherapy: Ethanolamine oleate or sodium tetradecyl sulfate; largely replaced by band ligation but still used for gastric varices inaccessible to banding
• Histoacryl (Cyanoacrylate) Injection: For gastric varices (fundal); glue injection obliterates varices; risk of embolism
• TIPSS (Transjugular Intrahepatic Portosystemic Shunt): Radiological procedure for refractory/recurrent variceal bleeding

B. Dilatation

• Balloon Dilatation (TTS - Through-the-Scope): For peptic, anastomotic, or post-caustic strictures; water-filled balloon; Graded up to target diameter
• Bougie Dilatation (Savary-Gilliard): Tapered wire-guided polyvinyl dilators; over guidewire; for fibrotic strictures
• Pneumatic Dilatation: 30-35-40 mm balloon across cardia; for achalasia; 70-80% remission; risk of perforation 2%

C. Foreign Body and Bezoar Management

• Foreign bodies: Coins, bones, dentures, button batteries (URGENT - alkali leakage), magnets
• Devices: Rat-tooth forceps, Roth net, polypectomy snare, overtubes, protector hoods
• Button batteries: EMERGENCY; hydroxide injury within 2 hours; remove immediately
• Bezoars: Fragmentation with snare/forceps + irrigation; enzymes (cellulase for phytobezoars)

D. Enteral Access

• PEG (Percutaneous Endoscopic Gastrostomy):
  • Endoscope-guided placement of feeding tube through abdominal wall into stomach
  • Techniques: Pull technique (Gauderer-Ponsky), push technique, introducer (Russell) technique
  • Indications: Dysphagia (stroke, head/neck cancer, motor neurone disease), nutritional support
  • Complications: Buried bumper syndrome, leakage, bleeding, aspiration, tumour seeding (with PEG through pharyngeal cancer)
• PEJ (Percutaneous Endoscopic Jejunostomy): Extension tube through PEG into jejunum; for gastroparesis, aspiration risk
• Nasojejunal tube placement: Under endoscopic guidance into jejunum

E. Tumour-Related Procedures

• Stenting (SEMS):
  • Palliative treatment for inoperable oesophageal/gastric cancer
  • Self-expanding metal stents (uncovered, partially-covered, fully-covered)
  • Relieves dysphagia within 24 hours
  • Complications: Migration (FC > UC), ingrowth (UC), pain, perforation, fistula
  • SEMS also for colonic obstruction (bridge to surgery or palliative)
• APC (Argon Plasma Coagulation): Ablation of tumour tissue, Barrett's metaplasia, radiation telangiectasia, watermelon stomach (GAVE)
• PDT (Photodynamic Therapy): Photosensitizer + laser light → reactive oxygen species → tumour necrosis; for Barrett's HGD, early oesophageal cancer; largely replaced by RFA
• RFA (Radiofrequency Ablation - HALO system):
  • Circumferential (360°) or focal (90°) electrode balloon
  • For Barrett's oesophagus with HGD or LGD
  • AIM Dysplasia trial: 80-90% complete eradication of dysplasia; 75-80% complete eradication of intestinal metaplasia
  • Combined with EMR for nodular Barrett's

F. Endoscopic Resection

• EMR: Oesophageal/gastric lesions; inject → lift → snare; piecemeal for large lesions; for early cancer staging
• ESD: En bloc resection; larger lesions; early oesophageal squamous cell carcinoma (SCC), early gastric cancer; suitable for lesions not amenable to EMR
• EFTR: Full-thickness resection (subepithelial tumours)
• Endoscopic submucosal tunneling resection (STER): For submucosal tumours arising from muscularis propria (cardia, oesophagus)

G. Biliary and Pancreatic (ERCP via Duodenoscope)

• Sphincterotomy: Opening of ampulla of Vater for stone extraction
• CBD Stone Extraction: Balloon/basket retrieval; Cholangioscopy-guided laser/ESWL for large stones
• Biliary Stenting: Plastic stents (short-term); SEMS (malignant strictures); for benign strictures (multiple plastic stents sequentially)
• Pancreatic duct stenting: Chronic pancreatitis, stone, stricture
• Cholangioscopy (SpyGlass): Direct visualization of bile duct; biopsy of biliary strictures; laser lithotripsy of large stones

H. Anti-Reflux and Bariatric Endoscopy

• TIF (Transoral Incisionless Fundoplication): Creates gastroesophageal valve using EsophyX device; for GERD refractory to PPIs
• Stretta Procedure: RF energy to LOS; improves competence
• Endoscopic sleeve gastroplasty (ESG, Overstitch): Suturing stomach wall to reduce gastric volume; BMI reduction ~10%; less invasive than surgical sleeve
• Intragastric balloon: Orbera, Spatz; temporary volume-occupying device; 6-12 months; ~10-15% weight loss

I. Other Therapeutic Uses

• Dilation/treatment of Zenker's diverticulum: Endoscopic septotomy (ZD stapler / Draf / harmonic)
• Peroral Endoscopic Myotomy (POEM): Submucosal tunnel → myotomy; for achalasia; covered in Q15
• G-POEM (Gastric-POEM): Submucosal pyloromyotomy for gastroparesis
• Closure of perforations: Endoclips, OTSC, suturing systems (OverStitch)
• EUS-guided drainage: Pancreatic pseudocyst drainage, walled-off necrosis (WON), hepaticogastrostomy

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Q11. Etiology and Management of Male Infertility

Definition

Etiology

A. Pre-testicular (Endocrine/Hypothalamic-Pituitary) - 2%

• Hypogonadotropic hypogonadism: Low FSH, LH, testosterone
  • Kallmann syndrome (GnRH deficiency + anosmia; KAL1 gene)
  • Pituitary tumours (prolactinoma most common - hyperprolactinaemia inhibits GnRH)
  • Cushing's syndrome, hypothyroidism
• Androgen resistance syndromes

B. Testicular (Primary) - 75%

• Varicocele: Most common correctable cause of male infertility (35-40% of primary, 75-80% of secondary infertility); Left > bilateral > right
• Cryptorchidism (undescended testis): Impaired spermatogenesis from heat exposure
• Orchitis: Mumps orchitis (post-pubertal) - 30% bilateral atrophy; bacterial; granulomatous
• Klinefelter's syndrome (47,XXY): Azoospermia, small firm testes, gynaecomastia; most common genetic cause of azoospermia
• Y-chromosome microdeletion: AZFa, AZFb, AZFc regions; azoospermia or severe oligospermia
• Idiopathic oligoasthenoteratozoospermia (OAT): Most common diagnosis
• Chemotherapy/radiotherapy: Alkylating agents particularly gonadotoxic
• Testicular torsion: Bilateral if contralateral ischemia
• Medications: Sulphasalazine, testosterone supplementation (suppresses endogenous spermatogenesis - "anabolic steroid infertility")

C. Post-testicular (Obstructive) - 20%

• Vasectomy (deliberate obstruction)
• Vas deferens obstruction: Congenital bilateral absence of vas deferens (CBAVD) - associated with CFTR mutation (cystic fibrosis gene); Young's syndrome (sinopulmonary disease)
• Epididymal obstruction: Post-gonococcal/chlamydial infection
• Ejaculatory duct obstruction: Congenital (Mullerian duct cyst) or acquired; transrectal US shows dilated seminal vesicles; treated by transurethral resection of ejaculatory ducts (TURED)
• Retrograde ejaculation: Diabetic autonomic neuropathy, post-TURP, post-retroperitoneal lymph node dissection, alpha blocker use; sperm in post-ejaculate urine (>15 sperm/HPF)

Investigation

• Azoospermia: No sperm in ejaculate (post-centrifuge pellet)
• Oligospermia: <16 million/mL; Severe <5 million/mL
• Asthenospermia: Low motility; Teratospermia: Low morphology
• OAT: Combined deficiency (most common)

• High FSH + small testes = primary testicular failure
• Low FSH + low T = hypogonadotropic hypogonadism

• Karyotype (47,XXY for Klinefelter's)
• Y-chromosome microdeletion (AZF regions): For non-obstructive azoospermia (NOA)
• CFTR mutation: If CBAVD suspected

Management

A. Medical Treatment

• hCG (LH analogue): Restores testosterone; 2000 IU SC 3x/week for 3-6 months
• FSH (hMG or recombinant FSH): Added after adequate testosterone; stimulates spermatogenesis
• Prolactinoma: Dopamine agonist (cabergoline/bromocriptine) → normalizes prolactin → restores spermatogenesis

• Sympathomimetics: Pseudoephedrine, imipramine - increases internal sphincter tone → antegrade ejaculation
• If fails: Alkalinization of urine (sodium bicarbonate) → collect sperm from urine → IUI/IVF

• Antioxidants (CoQ10, vitamin E, vitamin C, selenium): Some evidence for sperm parameter improvement

B. Surgical Treatment

• Most commonly performed procedure for male infertility
• Indications: Clinical varicocele (Grade II-III) + abnormal semen analysis + female partner normal or with treatable infertility + couple failed to conceive ≥2 years
• Approaches:
  • Microsurgical subinguinal varicocelectomy (Goldstein): Gold standard; lowest recurrence (1-2%), lowest hydrocele rate (<1%); uses operating microscope
  • Inguinal (Ivanissevich): Common, reliable
  • Retroperitoneal (Palomo): High ligation of internal spermatic vein at L4; high recurrence; rarely done
  • Laparoscopic: Similar to Palomo; general anaesthesia; rarely used
  • Percutaneous embolization (radiological): Retrograde catheterization of internal spermatic vein; occlusion with coils; outpatient; no incision; suitable for recurrence
• Outcomes: 50-70% improvement in semen parameters; 30-40% spontaneous pregnancy rates

• Vasovasostomy: Reanastomosis of vas deferens; indicated if no epididymal obstruction; success 90% if <3 years, 60-70% if 3-9 years, 30-50% >9 years
• Vasoepididymostomy: Anastomosis of vas to epididymal tubule; indicated if intravasal fluid on intraoperative inspection contains no sperm or sperm heads only (suggests secondary epididymal blockage)
• Both done under operating microscope (microsurgery)

C. Assisted Reproductive Techniques (ART)

• IUI (Intrauterine Insemination): For mild OAT, cervical factors; 10-15% success/cycle
• IVF (In Vitro Fertilisation): Moderate OAT; <5 million sperm/mL
• ICSI (Intracytoplasmic Sperm Injection): Single sperm injected directly into oocyte; for severe OAT, azoospermia with retrieved sperm; 40-50% fertilization rate per injected egg; revolutionized treatment of male factor infertility

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Q12. Fracture of Penis and Management

Definition

Anatomy

• Tunica albuginea: Dense fibro-elastic sheath surrounding each corpus cavernosum; 2 mm thick when erect (thinned from 2 mm flaccid); Type I collagen (outer longitudinal) + Type II collagen (inner circular); resists intracavernosal pressure up to 1500 mmHg normally but vulnerable to acute bending
• Corpus spongiosum + urethra: Separate from corpora cavernosa; spared in 80% of cases but may be injured

Mechanism

• Sudden buckling of erect penis (forced bending)
• Most common during: sexual intercourse (female superior position most common), masturbation, rolling over in bed on an erect penis ("Fajr fracture" in Middle East)
• Fracture typically occurs at the point of maximal stress (usually ventrolateral mid-shaft; proximal shaft 30%)

Clinical Features

• Sudden cracking/popping sound ("crack sound") at time of injury
• Immediate detumescence (penis loses erection)
• Rapid swelling, bruising, deformity - "Eggplant deformity" (diffuse haematoma + ecchymosis)
• "Rolling sign": Penile haematoma lateralizes to side of tear when patient stands (contained by Buck's fascia)
• Marked pain (usually moderate; less than expected - tunica tears rapidly)
• If Buck's fascia also torn: Haematoma extends to perineum, scrotum, inner thighs ("butterfly haematoma" - Colles' fascia distribution)
• Urethral injury (20%): Urethral tear/complete urethral disruption; features: frank haematuria, blood at meatus, inability to void, urinary retention

Investigations

• Clinical diagnosis in most cases (history + examination is pathognomonic)
• If diagnosis uncertain: MRI penis (gold standard; identifies exact tear location and extent); rarely needed
• Retrograde urethrogram: If urethral injury suspected; MUST be done before catheterization if blood at meatus
• Ultrasound (Doppler): Can show haematoma + flow disruption; less sensitive than MRI

Management

Immediate First Aid

• Ice packs (reduce swelling)
• Analgesia
• Urethral catheterization ONLY if no blood at meatus; otherwise RUG first

A. Surgical (Immediate) - Treatment of Choice

• Subcoronal degloving incision (most versatile): Circumferential skin incision just below corona; degloving of entire penile skin to base; allows access to all potential sites of injury; preferred
• Direct incision over haematoma: For definitive single-side injury; quicker; risk of missing contralateral or urethral injury
• Penoscrotal or infrapubic approach: For proximal injuries

1. Penile/regional block + GA or spinal
2. Circumferential subcoronal degloving incision through Buck's fascia
3. Evacuate haematoma; identify tunica albuginea tear (usually 1-2 cm transverse tear)
4. Irrigation
5. Primary repair with 2-0 or 3-0 absorbable suture (Vicryl or PDS) using horizontal mattress or interrupted stitches; ensure watertight closure
6. Inspect urethra (urethral sound/Foley catheter manipulation); if urethral injury found → primary repair over Foley catheter 14 Fr or suprapubic cystostomy + staged repair
7. Skin closure

• Incomplete (contusion): Suprapubic catheter for 2-3 weeks
• Complete tear: Primary urethral repair in same setting OR suprapubic diversion + delayed urethroplasty (3-6 months)

B. Conservative Management (Rarely Used)

• Ice packs, pressure dressing, anti-inflammatory medication, anti-erectile agents (diazepam, estrogen patch)
• Higher complication rates: ED (29% vs. 3% surgical), penile curvature/Peyronie's (50% vs. 5%), fibrous plaque formation, abscess, urethrocutaneous fistula
• Only considered if patient refuses surgery or fitness precludes GA

Complications

• Penile curvature: Fibrotic scarring → Peyronie's-like deformity (5-10% surgical, 50% conservative)
• Erectile dysfunction: More common with delayed repair
• Urethrocutaneous fistula (if urethral injury missed)
• Urethral stricture (at site of urethral repair)

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Q13. Ectopic Testis

Definition

Embryology of Normal Testicular Descent

1. Testis arises from genital ridge (7th week)
2. Gubernaculum forms; testis attached via cranial suspensory ligament
3. Transabdominal phase (8-15 weeks): INSL3 + testosterone → gubernaculum swells → testis moves from posterior abdominal wall to internal inguinal ring
4. Inguinoscrotal phase (25-35 weeks): Gubernaculum shrinks; testis passes through inguinal canal into scrotum
5. Complete by birth in 97% term males; 3% born with undescended testis; 80% descend by 3 months; at 6 months only 0.8% remain undescended (hormonal surge)

Sites of Ectopic Testis (after passing through external ring)

Difference: Ectopic vs. Undescended (Cryptorchid) Testis

Clinical Features

• Empty scrotum on affected side (unilateral or bilateral)
• Palpable lump in perineum, inguinal region, or base of penis
• NOT palpable in scrotum
• Indirect inguinal hernia: 90% of undescended/ectopic testes associated with patent processus vaginalis
• May have testicular torsion (rare; more common in undescended than ectopic)
• Puberty: Normal hormonal axis but spermatogenesis affected

Diagnosis

• Clinical examination: Key; in infant/child; both testes examined
• Ultrasound: Palpable or superficial ectopic testis location confirmation
• MRI / Laparoscopy: For impalpable testis (true cryptorchid in intra-abdominal position)
• If bilateral and not palpable: Hormonal profile (FSH/LH/testosterone); hCG stimulation test; karyotype (46,XX DSD?)

Complications

• Infertility: Spermatogenesis impaired by heat; bilateral > unilateral
• Malignancy: Risk of testicular cancer 3-14x higher than normal; risk reduced but NOT eliminated by orchidopexy; tumour surveillance important
• Torsion: Increased risk (especially if undescended)
• Hernia: 90% have associated patent processus vaginalis
• Psychological: Cosmetic concerns; testicular self-examination education

Management

Timing

• Current recommendation: Surgery at 6-12 months of age (no later than 18 months)
• Early surgery: Maximizes fertility preservation; reduces but does not eliminate cancer risk
• hCG or GnRH therapy (to stimulate descent): Limited role; 20% short-term success; high relapse; not recommended as primary therapy (EAU/ESPU guidelines)

Surgery: Orchidopexy

• Standard approach for ectopic and inguinal undescended testis
• Incision: Small inguinal crease incision (2-3 cm)
• Open external oblique aponeurosis along its fibres
• Isolate spermatic cord; identify and ligate patent processus vaginalis (indirect hernia sac) at internal ring (herniotomy)
• Free cord (vessels and vas) from surrounding tissues; careful not to injure vas
• Create dartos pouch in hemiscrotum (subdartos pouch technique)
• Place testis in pouch under no tension; close Scarpa's fascia over cord
• Critical: Adequate length must be gained - if short, lateral release behind inferior epigastric vessels (Fowler-Stephens maneuver)

• For intra-abdominal testis or when not palpable
• Diagnostic laparoscopy first: confirms testis location
• Laparoscopic single-stage orchidopexy: Mobilize vessels/vas + bring testis to scrotum
• Two-stage Fowler-Stephens (for high intra-abdominal testis with short vessels): Stage 1 - clip internal spermatic vessels laparoscopically; wait 6 months (collateral circulation via vasal and cremasteric vessels develops); Stage 2 - orchidopexy

Orchiectomy

• For atrophic or post-pubertal undiscovered testis (puberty onwards; risk vs. benefit of surgical preservation)
• Prosthetic testis insertion at time of orchiectomy for cosmesis

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Q14. Preperitoneal Anatomy of Inguinal Hernia in Relation to Laparoscopic Surgery (20 Marks)

Introduction

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Anatomy of the Inguinal Region

Bony Landmarks

• Pubic symphysis: Midline anterior
• Pubic tubercle: 1 cm lateral to symphysis; insertion of inguinal ligament medially; key landmark
• Anterior Superior Iliac Spine (ASIS): Lateral landmark
• Iliopubic tract: Thickening of transversalis fascia from ASIS to pubic tubercle; parallel to inguinal ligament but posterior; critical landmark in laparoscopic surgery

Myopectineal Orifice (Fruchaud's Orifice)

• Single large opening in the posterior abdominal wall through which all groin hernias pass
• Bounded by: rectus muscle medially, iliopsoas laterally, Cooper's ligament below, inguinal ligament inferiorly, transversus abdominis above
• Contains: indirect inguinal hernia (lateral to IEV), direct inguinal hernia (medial to IEV), femoral hernia (below iliopubic tract)
• All groin hernias can be repaired by covering this entire orifice with mesh - principle of laparoscopic repair

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The Preperitoneal Space

• Between pubic symphysis/bladder and peritoneum
• Avascular (with careful dissection); entry point for TEP

• Lateral extension of Retzius space; between psoas/iliac vessels and peritoneum
• Site of lateral dissection in TEP/TAPP

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Anatomical Structures in the Preperitoneal Space (Surgeon's View from Behind)

1. Cooper's (Pectineal) Ligament

• Dense fibrous structure on the superior pubic ramus (pectineal line)
• MUST be identified; mesh is stapled/tacked here medially in laparoscopic repair
• Continuous with transversalis fascia and lacunar ligament

2. Iliopubic Tract

• Condensation of transversalis fascia; runs from ASIS to pubic tubercle
• Parallel to inguinal ligament but 1-2 cm posterior
• Inferior boundary of the "safety zone"
• Critical: Tacks must NOT be placed below the iliopubic tract laterally → risk of injuring lateral cutaneous femoral nerve and femoral branch of genitofemoral nerve → lateral thigh numbness/pain

3. Inferior Epigastric Vessels (IEV)

• Arise from external iliac vessels; run medially and superiorly within the posterior rectus sheath
• Key landmark: Divide direct (medial) from indirect (lateral) inguinal hernias
• Must be identified and preserved; damage → haematoma

4. "Triangle of Doom" (Surgical Danger Zone)

• Bounded by:
  • Medially: Vas deferens
  • Laterally: Spermatic vessels (internal spermatic artery and vein)
  • Inferior apex: At the internal ring / peritoneal fold
• Contains: External iliac artery and vein (life-threatening injury if damaged)
• Rule: NO staples/tacks in the Triangle of Doom

5. "Triangle of Pain" (Lateral Danger Zone)

• Bounded by:
  • Medially: Spermatic vessels
  • Laterally: Iliopubic tract
  • Inferior: Peritoneal fold
• Contains: Lateral cutaneous femoral nerve (LCFN), femoral nerve, and femoral branch of genitofemoral nerve
• Rule: NO staples/tacks lateral to the spermatic vessels and below the iliopubic tract = Triangle of Pain

6. Spermatic Cord Structures

• Vas deferens: Runs inferomedially; crosses over iliac vessels; must be identified and preserved
• Internal spermatic vessels: Run laterally; course through internal ring; must be preserved
• Together they form an inverted "V" frame around the internal ring

7. Internal Inguinal Ring

• Opening in transversalis fascia; site of indirect hernia
• Lateral to IEV; spermatic cord traverses
• In females: Round ligament passes through

8. Femoral Canal / Femoral Ring

• Medial compartment of femoral sheath; below inguinal ligament and iliopubic tract; medial to femoral vein
• Site of femoral hernia; covered by mesh in laparoscopic repair (important - open anterior repairs may miss femoral hernias)

9. Nerve Anatomy (Critical for Pain Avoidance)

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Laparoscopic Approaches

A. TAPP (Transabdominal Preperitoneal Repair)

• 10-12 mm umbilical (camera)
• 5 mm right iliac fossa
• 5 mm left iliac fossa

1. Peritoneum incised 2-3 cm above hernia defect from median umbilical ligament (MUL) to ASIS
2. Preperitoneal space developed by blunt dissection
3. Cooper's ligament, IEV, indirect/direct hernia defect, triangle of doom and pain identified
4. Hernia sac dissected from cord (complete for indirect; just reduced for direct)
5. Mesh (15 x 10 cm minimum) placed flat; covers internal ring, direct space, and femoral ring; medial edge overlapping midline
6. Mesh fixed with staples/tacks: Cooper's ligament medially; above iliopubic tract laterally (NO tacks in triangle of doom or triangle of pain)
7. Alternatively: glue fixation (fibrin glue - Tisseel; cyanoacrylate - ProGrip self-fixating mesh) - reduces chronic pain vs. tacks
8. Peritoneum closed over mesh (prevents adhesion between mesh and bowel/cord)

• Easier learning curve than TEP
• Better visualization initially
• Can simultaneously inspect peritoneal cavity (diagnose contralateral hernia)
• Easier for bilateral simultaneous repair
• Can be done after previous pelvic surgery (relative advantage)

• Peritoneal cavity entered → visceral injury risk
• Peritoneal closure required (if inadequate → mesh-bowel contact)
• Higher port-site hernia risk vs. TEP (umbilical port)

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B. TEP (Totally Extraperitoneal Repair)

• 10-12 mm infra-umbilical (camera; through anterior rectus sheath; dissection between posterior rectus sheath and rectus muscle)
• 5 mm 5 cm below umbilicus (midline)
• 5 mm 5 cm further down (midline/pubic area)
• OR: 2 pararectal ports

• Inflated in preperitoneal space (under direct vision) → creates space by blunt dissection
• Balloon path: behind rectus, then caudally into Retzius space
• Alternatively: blunt fingertip or 10 mm scope head used to develop space

1. Posterior rectus sheath incised; balloon dissector inserted; inflated (800-1200 mL)
2. Ports placed under vision in preperitoneal space
3. Cooper's ligament, pubic symphysis, IEV identified
4. Hernia sac dissected (complete parietalization of spermatic cord - 5 cm from ring)
5. Mesh placed (same size); fixed with Cooper's ligament tack ± glue; no peritoneal closure needed
6. Deflate CO2 → mesh held by intraperitoneal pressure

• Peritoneal cavity NOT entered → less risk of visceral injury, adhesions, bowel obstruction
• No peritoneal closure needed
• Lower port-site hernia rate
• Faster recovery (less postoperative ileus)
• Preferred for previous lower abdominal/inguinal surgery (relative)

• Steeper learning curve
• Limited working space (balloon space)
• Risk of peritoneal tear (enters TAPP territory if peritoneum breaches)
• Cannot evaluate contralateral side easily
• Not suitable after previous Retzius space surgery (radical prostatectomy, pelvic fracture repair)

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C. ONSTEP (One-stage Needlescopic Extraperitoneal Patch)

• Single 2 cm skin incision; two mini-ports; partial peritoneal fixation of mesh
• Newer technique; limited adoption

D. Robotic Inguinal Hernia Repair (rTAPP)

• Robotic-assisted TAPP; increased precision of dissection and mesh placement
• Particularly advantageous for bilateral repair in single position
• Da Vinci; emerging evidence comparable to laparoscopic TAPP

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Mesh in Laparoscopic Inguinal Hernia Repair

• Size: Minimum 10x15 cm (EHS guidelines) to cover entire myopectineal orifice with 2-3 cm overlap
• Type: Polypropylene (standard); partially absorbable; lightweight mesh (reduce chronic pain and foreign body reaction)
• Fixation: Fibrin glue / cyanoacrylate (reduced nerve entrapment vs. staples); self-gripping mesh (ProGrip); tacks/staples only on Cooper's and above iliopubic tract
• Non-fixation: For medium-small defects; intraperitoneal pressure holds mesh; comparable recurrence

Comparison: TAPP vs. TEP vs. Open (Lichtenstein)

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Q15. Technique and Complications of Laparoscopic Heller Myotomy

Introduction

• Failure of LOS (Lower Oesophageal Sphincter) to relax with swallowing
• Loss of peristalsis in the oesophageal body
• Pathology: Degeneration of inhibitory neurons (VIP + NO) in Auerbach's myenteric plexus
• Consequence: Functional obstruction → progressive dysphagia, regurgitation, weight loss

Investigations Before Surgery

• OGD/Barium swallow: Confirm diagnosis; "rat-tail" tapering at GOJ; dilated oesophagus
• High-Resolution Manometry (HRM): Gold standard diagnosis; Chicago Classification (Types I, II, III)
  • Type I: Classic (aperistalsis + IRP >15 mmHg)
  • Type II: Pan-oesophageal pressurization (best surgical outcome)
  • Type III: Spastic (worst surgical outcome; consider POEM)
• Timed Barium Swallow: Baseline; follow-up
• CT chest: Rule out pseudoachalasia (malignant infiltration of cardia)
• Endo-FLIP (Endoluminal Functional Lumen Imaging Probe): Measures distensibility index of GOJ; increasingly used

Patient Selection

• All fit patients with confirmed achalasia
• Type II best outcomes with Heller myotomy
• Type III: POEM preferred (longer myotomy on oesophageal body)
• Recurrent/failed pneumatic dilatation: Myotomy indicated

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Laparoscopic Heller Myotomy - Technique

Position and Setup

• Patient supine, slight reverse Trendelenburg (15-20°)
• Surgeon stands between patient's legs (French position) OR right side
• Monitor at patient's head
• Oro/nasogastric tube decompresses stomach; removed before myotomy

Port Placement (5-port technique)

• 10-12 mm umbilical (camera port; 30° scope)
• 5 mm left hypochondrium (retractor for liver)
• 5 mm right hypochondrium (surgeon's right hand)
• 5 mm left iliac fossa (surgeon's left hand)
• 5 mm epigastric/left flank (assistant retraction)
• Nathanson liver retractor (single-use) often used to retract left lobe of liver without a port

Operative Steps

• Pneumoperitoneum 12-14 mmHg
• Left lobe of liver retracted with fan retractor (5 mm port) or Nathanson hook
• Omentum and stomach retracted inferiorly

• Incise gastrohepatic ligament (lesser omentum); expose right crus
• Identify and open the phrenoesophageal ligament (phreno-oesophageal membrane)
• Mobilize anterior vagus nerve (identify and PROTECT) and posterior vagus nerve
• Mediastinal dissection: Mobilize distal oesophagus 6-8 cm above GOJ to gain adequate myotomy length

• Oesophagus encircled with a Penrose drain or tape for traction
• Crural dissection around the oesophagus
• Identify GOJ anteriorly (fat pad - "epiphrenic fat pad" - excised or swept)

• Extent:
  • Oesophageal portion: 6 cm above GOJ (on oesophageal body musculature)
  • Gastric portion: 1.5-3 cm below GOJ onto gastric cardia (onto stomach)
  • CRITICAL: Adequate gastric extension (≥2 cm) prevents dysphagia recurrence; but excessive extension increases GERD risk
• Technique:
  • Hook electrocautery used to incise outer longitudinal muscle layer first
  • Then circular muscle divided in layers
  • Gentle spreading with closed dissector to complete mucosal dissection
  • Mucosa should bulge through ("fish mouth" appearance of completed myotomy)
  • Low or no energy at mucosal level to prevent delayed perforation
• Intraoperative Endoscopy: Simultaneous flexible gastroscopy strongly recommended:
  • Identifies incomplete myotomy (residual circular fibres visible endoscopically)
  • Identifies mucosal perforation (air leak test with scope; stomach submerged in water)
  • Allows transillumination to identify mucosal exposure

• Dor (Anterior 180° Fundoplication): Most widely used with Heller myotomy
  • Anterior surface of fundus folded anteriorly over the myotomy
  • Sutured to left then right cut edges of myotomy
  • Protects mucosa (especially if mucosal injury occurred), reduces GERD
  • Does not require posterior hiatal dissection
  • Advantage: Covers exposed mucosa; lower risk of dysphagia recurrence
• Toupet (Posterior 270° Fundoplication):
  • Posterior wrap of fundus; sutured to both cut edges of myotomy from behind
  • Keeps myotomy edges apart (prevents scar contracture = less dysphagia)
  • Requires more posterior hiatal dissection
  • Some prefer this for better anti-reflux (270° wrap)
• Nissen (360° Wrap): Generally AVOIDED with Heller myotomy due to high dysphagia recurrence (tight wrap over denervated oesophagus)

• Posterior crural sutures to close crural defect
• Prevent postoperative paraesophageal hernia

• Ports removed under vision; fascia closed at 10-12 mm port sites
• OGD performed before port removal to confirm adequate myotomy (EGJ opens with retroflexion, air insufflation)

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Postoperative Management

• Liquid diet for 24 hours; soft diet for 2 weeks; resume normal diet
• Discharge day 1-2
• PPI therapy (omeprazole 20 mg BD) initiated; continued for 6 months
• Timed barium swallow at 3-6 months: Assess oesophageal emptying; document

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Outcomes

• Symptomatic success: 87-92% at 5 years (Type I), 93-96% (Type II), 70-80% (Type III)
• Superior to pneumatic dilatation at 5 years (RCT: POEM/Heller equivalent at 2 years; long-term POEM data accumulating)

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Complications

Intraoperative

• Incidence: 5-15% (most recognized and repaired intraoperatively)
• Cause: Inadvertent entry during myotomy (especially at GOJ where mucosa adherent)
• Prevention: Intraoperative endoscopy; careful sharp dissection; low energy near mucosa
• Management: Primary repair with 3-0 or 4-0 absorbable sutures; reinforce with Dor fundoplication flap (anterior) over repair; if perforation large/unrecognized → convert to open
• If unrecognized → postoperative mediastinitis, pneumothorax, effusion → high mortality

• DVC of gastric vessels; short gastric artery injury
• Usually controlled laparoscopically; conversion if major vessel injury

• Anterior vagus most at risk; identified and preserved
• Injury → gastroparesis, dumping syndrome

• Pleural entry during mediastinal dissection; CO2 pneumothorax
• Usually resolves spontaneously; may need chest drain intraoperatively

Early Postoperative

• Presents: Fever, chest/epigastric pain, tachycardia day 1-5
• Investigation: CT chest/abdomen with oral contrast (Gastrografin)
• Management: NPO, IV antibiotics, PPI; endoscopic clipping; surgical repair if large; rarely SEMS

• Pre-existing oesophageal retention; risk in massive dilatation
• Peri-operative antibiotics; NGT decompression pre-operatively

• Post-mediastinal dissection; conservative management; drain if large

Late Complications

• Incidence without fundoplication: 30-60%; with Dor/Toupet: 15-30%
• Presents: Heartburn, regurgitation; pH monitoring confirms
• Management: PPIs; POEM for failed Heller; re-do fundoplication
• Long-term consequence of untreated reflux: Peptic stricture, Barrett's, adenocarcinoma

• Causes:
  • Incomplete myotomy (most common): Gastric extension <1.5 cm; residual circular fibres
  • Tight fundoplication (Nissen > Dor)
  • Scarring/fibrosis of myotomy edges
  • End-stage mega-oesophagus (non-responsive)
• Assessment: Manometry, timed barium swallow, EGD
• Management:
  • Repeat pneumatic dilatation (short-term relief)
  • POEM (ideal salvage procedure - can address both oesophageal and gastric components, avoids old scar tissue anteriorly by posterior approach)
  • Repeat Heller (technically difficult; risk of mucosal injury in scarred field)
  • Oesophagectomy (last resort; end-stage mega-oesophagus)

• Peptic stricture: Dilatation ± PPIs
• Barrett's oesophagus: RFA/surveillance

• Hernia (at 10-12 mm ports)
• Wound infection

• Rate: <2% (experienced centres)
• Indications: Uncontrolled bleeding, large perforation, dense adhesions, inability to complete myotomy safely

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POEM vs. Laparoscopic Heller Myotomy

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References: Smith and Tanagho's General Urology 19th Ed; Campbell Walsh Wein Urology; Bailey & Love's Surgery 28th Ed; Harrison's Internal Medicine 22nd Ed; Schwartz's Principles of Surgery 11th Ed; current EAU/SAGES/ESGE guidelines (2024-2026).

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