---

MS GENERAL SURGERY - ANSWER BOOK PART 2

All 10-mark & 30-mark Questions - High Yield

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Q1 - Bile Duct Injuries at Cholecystectomy (30 Marks)

Types, Classification, Prevention & Management

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MEMORY TRICK for Bile Duct Injury Classification

"STEVE's BILE DUCTS" Strasberg Classification goes A to E T = Type E is the worst (Complete transection/Hilar) E = Each type treated differently (drain vs reconstruct vs stent)

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TYPES & CLASSIFICATION - Strasberg Classification (Most Important)

Old Bismuth Classification (still exam-relevant): Bismuth I-V corresponds roughly to Strasberg E1-E5

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CAUSES / RISK FACTORS

CAUSES OF BILE DUCT INJURY
├── Technical Factors (most common)
│   ├── "Too eager" clipping - misidentifying CBD as cystic duct
│   ├── Thermal injury from diathermy
│   ├── Excessive traction causing tent-effect
│   └── Laparoscopic > Open (4x higher risk: 0.5% vs 0.1-0.2%)
│
└── Anatomical Variations (Calot's Triangle difficulty)
    ├── Short/absent cystic duct
    ├── Low junction of cystic duct with CBD
    ├── Aberrant right hepatic duct (15% of population)
    ├── Mirizzi syndrome
    └── Acute/chronic cholecystitis (fibrosis, inflammation)

---

PREVENTION - "CRITICAL VIEW OF SAFETY (CVS)"

CRITICAL VIEW OF SAFETY (Strasberg 1995)
Required 3 Criteria:
┌─────────────────────────────────────────────────────┐
│  1. Hepatocystic triangle CLEARED of fat/fibrous    │
│     tissue                                          │
│  2. Lower 1/3 of gallbladder DISSECTED free from   │
│     liver bed                                       │
│  3. Only TWO structures seen entering gallbladder   │
│     (cystic duct + cystic artery)                   │
└─────────────────────────────────────────────────────┘

• Intraoperative cholangiogram (IOC) - "road map"
• Laparoscopic ultrasound
• Fundus-first ("dome-down") dissection in difficult cases
• Convert to open - "If in doubt, cut it out (of laparoscopy)"
• Bail-out procedures: subtotal cholecystectomy, cholecystostomy

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MANAGEMENT FLOWCHART

BILE DUCT INJURY MANAGEMENT
         │
         ▼
  Intraoperative vs Postoperative
         │
┌────────┴────────────┐
│                     │
INTRAOPERATIVE       POSTOPERATIVE (days-weeks)
(detected on table)  (delayed presentation)
│                     │
▼                     ▼
If small lateral     Symptoms:
injury → Primary     • Biliary peritonitis/fistula
repair over T-tube   • Obstructive jaundice
                     • Bile collections (biloma)
If major injury →    │
Refer to HPB         ▼
surgeon              CT / ERCP / MRCP / PTC
                     │
                     ▼
              CLASSIFY THE INJURY
              (Strasberg A vs B-E)
              │
    ┌─────────┼─────────┐
    ▼         ▼         ▼
Type A     Type D     Type E
(leak)   (partial)  (complete)
    │         │         │
    ▼         ▼         ▼
ERCP +    Primary    Delayed Biliary
Stent    Repair or   Reconstruction
(gold    T-tube      (6-8 weeks later)
standard)            Roux-en-Y
                     Hepaticojejunostomy
                     (GOLD STANDARD)

---

KEY FACTS FOR 30-MARK ANSWER

• Open cholecystectomy: 0.1-0.2%
• Laparoscopic: 0.4-0.6%

1. Immediate (on table)
2. Early (1-7 days) - bile leak, peritonitis
3. Late (weeks-months) - stricture, jaundice

• Best done 6-8 weeks after injury (inflammation resolves)
• Success rate >90% in specialist HPB centers
• "3 Principles": Mucosa-to-mucosa anastomosis, tension-free, adequate blood supply

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Q2 - Surgical Anatomy of Biliary Tract & Investigations/Differential Diagnosis of Jaundice (30 Marks)

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MEMORY TRICK - BILIARY ANATOMY

"CHLOE" = Cholecystectomy Hazard List Of Extrahepatic structures Cystic duct Hepatic duct (common) Left hepatic duct Own blood supply (right hepatic artery - at risk!) Extra structure = Cystic artery (branch of right hepatic artery)

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SURGICAL ANATOMY OF THE BILIARY TRACT

BILIARY SYSTEM ANATOMY
          RIGHT LOBE          LEFT LOBE
               │                   │
     Right Hepatic Duct    Left Hepatic Duct
               │                   │
               └─────┬─────────────┘
                     │
           COMMON HEPATIC DUCT (CHD)
                     │   (2-3 cm long)
                     │ ← Cystic duct joins here
                     │
           COMMON BILE DUCT (CBD)
                     │   (8-10 cm long, 6-8mm diameter)
                     │
           ┌─────────┴──────────────┐
     Supraduodenal      Retroduodenal
        (2-3 cm)           portion
                     │
              Pancreatic portion
                     │
              AMPULLA OF VATER
                     │
            Sphincter of Oddi
                     │
              DUODENUM (D2)

---

CALOT'S TRIANGLE (Hepatocystic Triangle)

CALOT'S TRIANGLE
     ┌──────────────────────────────────┐
     │                                  │
     │  Medial border: Common Hepatic   │
     │                  Duct            │
     │  Lateral border: Cystic duct     │
     │  Superior border: Liver surface  │
     │                                  │
     │  Contents:                       │
     │   • Cystic artery                │
     │   • Cystic lymph node (Lund's    │
     │     node / Mascagni's node)      │
     │   • Sometimes right hepatic      │
     │     artery                       │
     └──────────────────────────────────┘

Memory: "Calot's triangle has Cystic artery, Cystic lymph node, and is bounded by CHD, Cystic duct, Cystic plate (liver)" = 5 C's

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BLOOD SUPPLY

• CBD upper 2/3: Right hepatic artery (3 o'clock and 9 o'clock positions)
• CBD lower 1/3: Gastroduodenal artery
• Cystic artery: Branch of right hepatic artery (80% of cases)

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JAUNDICE - CLASSIFICATION & DIFFERENTIAL DIAGNOSIS

MEMORY TRICK for Jaundice Types:

"Pre, Intra, Post" = "Before the liver, Inside the liver, After the liver"

JAUNDICE - DIFFERENTIAL DIAGNOSIS

PRE-HEPATIC (HAEMOLYTIC)           HEPATIC               POST-HEPATIC (OBSTRUCTIVE)
Unconjugated bilirubin ↑           Mixed pattern          Conjugated bilirubin ↑
Dark urine: NO                     Dark urine: YES        Dark urine: YES (tea colored)
Pale stools: NO                    Pale/dark stools       Pale/clay stools: YES
│                                  │                      │
├── Haemolytic anaemia             ├── Hepatitis A,B,C    ├── GALLSTONES (choledocholithiasis)
├── Sickle cell disease            ├── Alcoholic liver    ├── CARCINOMA HEAD PANCREAS
├── Thalassaemia                   │   disease            ├── CHOLANGIOCARCINOMA
├── G6PD deficiency                ├── Cirrhosis          ├── PRIMARY SCLEROSING CHOLANGITIS
├── Malaria                        ├── Autoimmune         ├── MIRIZZI SYNDROME
└── Gilbert's syndrome             │   hepatitis          ├── Benign stricture (post-op)
    (conjugation defect)           ├── Drug-induced       ├── Carcinoma gallbladder
                                   └── Wilson's disease   └── Pancreatitis (chronic)

---

INVESTIGATIONS FOR JAUNDICE

INVESTIGATION ALGORITHM FOR JAUNDICE

STEP 1: BLOOD TESTS (First line)
├── LFTs: Bilirubin (direct vs indirect), ALT, AST, ALP, GGT
├── FBC: anaemia, haemolysis
├── Clotting: PT/INR (liver synthetic function)
├── Serum albumin
├── Viral hepatitis screen (HAV, HBV, HCV)
├── LDH, Reticulocyte count (if haemolytic)
└── Tumour markers: CA19-9 (pancreatic/cholangioCA), AFP (HCC)

STEP 2: URINE/STOOL
├── Urinary urobilinogen ↑ (haemolytic)
├── Urinary bilirubin ↑ (obstructive/hepatic)
└── Pale stools (obstructive)

STEP 3: IMAGING (by escalation)
│
├── USG ABDOMEN (First line imaging)
│    → CBD diameter >8mm = obstructive
│    → Dilated IHBR = obstruction above
│    → Gallstones, liver texture
│
├── CT ABDOMEN with contrast (2nd line)
│    → Level of obstruction, lymph nodes
│    → Pancreatic mass, vascular involvement
│
├── MRCP (gold standard for duct anatomy - non-invasive)
│    → Choledocholithiasis, strictures, PSC
│    → Level and cause of obstruction
│
├── ERCP (therapeutic + diagnostic)
│    → Stone extraction, stenting, biopsy
│    → Risk: pancreatitis 3-5%
│
└── PTC (percutaneous transhepatic cholangiography)
     → When ERCP fails or proximal obstruction
     → Can provide biliary drainage

STEP 4: TISSUE
└── Liver biopsy (hepatic causes), FNAC (mass lesions)

---

USG FEATURES - Obstructive vs Non-Obstructive:

• CBD >8 mm (or >10 mm post-cholecystectomy) = obstructive
• Intrahepatic biliary radicle (IHBR) dilatation
• "Double-barrel shotgun" sign on USG = dilated CBD alongside portal vein

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Q3 - Renal / Ureteric Calculi - Modalities of Treatment & Latest Management (30 Marks)

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MEMORY TRICK

"ESWL PCNL URS" = "Extremely Smashing WaVeS Pulverize Calculi NonStop Until Renal Stones"

• ESWL = Extracorporeal Shock Wave Lithotripsy
• PCNL = Percutaneous Nephrolithotomy
• URS = Ureteroscopy + Laser

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TYPES OF RENAL STONES

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PATHOPHYSIOLOGY FLOWCHART

STONE FORMATION
     │
     ▼
Supersaturation of urine
     │
     ▼
┌────┴───────────────────────────┐
│  Nucleation (crystal formation) │
│  Promoters > Inhibitors         │
│  (Promoters: high Ca, oxalate,  │
│   urate, infection)             │
│  (Inhibitors: citrate, Mg,      │
│   nephrocalcin, pyrophosphate)  │
└────────────────────────────────┘
     │
     ▼
Crystal aggregation & growth
     │
     ▼
Calculus formation

---

CLINICAL FEATURES

• Flank pain (dull ache)
• Haematuria (microscopic or gross)
• Recurrent UTI (especially struvite)
• Incidental finding

• Sudden, severe, colicky loin-to-groin pain (worst pain ever described)
• Radiation to scrotum/labia, inner thigh
• Restlessness (patient cannot lie still - differentiates from peritonitis)
• Nausea, vomiting
• Haematuria 85-90% of cases

Memory Trick for Ureteric Pain Radiation: "Loin to Groin" = "Stone moving down the line"

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ANATOMICAL NARROWINGS - Where Stones Get STUCK

3 POINTS OF NARROWING IN URETER
     KIDNEY
        │
        │ ← PUJ (Pelvi-ureteric junction) - NARROWING 1
        │
        │ (Abdominal ureter)
        │
        │ ← Pelvic brim where ureter crosses iliac vessels - NARROWING 2
        │
        │ (Pelvic ureter)
        │
        │ ← VUJ (Vesico-ureteric junction) = NARROWEST - NARROWING 3
        │
     BLADDER

MOST STONES GET STUCK AT VUJ (narrowest point)

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INVESTIGATIONS

1. CT KUB (non-contrast) - Gold standard - detects all stones, sensitivity 95-98%
2. USG KUB - First line (no radiation), good for renal stones, poor for mid-ureter
3. X-ray KUB - Simple, misses uric acid stones (radiolucent)
4. IVU/IVP - Older gold standard (now replaced by CT KUB)
5. Urine R/E - Haematuria, crystals, infection
6. 24-hour urine - Metabolic workup (Ca, oxalate, uric acid, citrate, creatinine)
7. Serum - Ca, PO4, uric acid, creatinine

---

TREATMENT MODALITIES (Latest Management)

TREATMENT ALGORITHM FOR URINARY CALCULI

RENAL STONE
     │
     ├── Asymptomatic, < 5 mm → Conservative (80% pass spontaneously)
     │                           Medical Expulsive Therapy (MET):
     │                           Alpha-blockers (Tamsulosin 0.4 mg OD)
     │                           Pain: NSAIDs (Diclofenac), Opioids
     │
     ├── 5-10 mm → ESWL (Extracorporeal Shock Wave Lithotripsy)
     │               FIRST LINE for renal pelvis stones
     │
     ├── > 10 mm or ESWL fail → PCNL (Percutaneous Nephrolithotomy)
     │
     ├── > 20 mm (staghorn/large) → PCNL (gold standard)
     │
     └── Special situations → Flexible URS (FURS) / Robotic PCNL

URETERIC STONE
     │
     ├── < 10 mm → MET (Tamsulosin) → Wait 4-6 weeks
     │
     ├── Upper ureter < 10 mm → ESWL or URS
     │
     ├── Lower ureter < 10 mm → URS (Semi-rigid) ← First line
     │
     └── > 10 mm or failed → URS + Holmium Laser Lithotripsy
                              (GOLD STANDARD for ureteric stones)

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MODALITIES COMPARISON

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ESWL - HOW IT WORKS (For Exam)

"Shock waves generated outside, focused on stone, fragmented into sand-like particles passed in urine"

• 1000-3000 shocks delivered per session
• Contraindicated: Pregnancy, coagulopathy, AAA, distal obstruction, pacemaker
• Best for: Renal pelvis stones, < 2 cm, low density on CT (Hounsfield units < 900)

---

STONE PREVENTION

TYPE OF STONE → PREVENTION
Calcium Oxalate → ↑ fluid intake, low salt/protein diet, thiazide diuretics, citrate supplements
Uric Acid → Allopurinol, alkalinize urine (K citrate, NaHCO3)
Struvite (infection) → Treat infection, antibiotics, acetohydroxamic acid
Cystine → ↑↑ Fluids (>3L/day), alkalinize urine, D-penicillamine

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Q4 - Carcinoma Prostate: Surgical Anatomy, Staging, Clinical Features, Investigations & Management (30 Marks)

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MEMORY TRICKS

"ABCDE of Prostate Zones": Anterior fibromuscular stroma, Big central zone, Central zone (transition zone), Ducts (peripheral zone drains), Enzyme PSA comes from all zones

Gleason Grading: "G1 G2 = Good, G4 G5 = God help you"

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SURGICAL ANATOMY OF PROSTATE

PROSTATE ANATOMY
     ┌─────────────────────────────────┐
     │         PROSTATE GLAND          │
     │    Size: Walnut (20-30 gm)       │
     │    Level: Below bladder neck    │
     │                                 │
     │  ZONES (McNeal):                │
     │  • Peripheral Zone (PZ) - 70%   │
     │    ← Most cancers arise here    │
     │    ← Posterolateral, palpable   │
     │    ← on DRE                     │
     │                                 │
     │  • Central Zone (CZ) - 25%      │
     │    ← Surrounds ejaculatory      │
     │       ducts                     │
     │                                 │
     │  • Transition Zone (TZ) - 5%   │
     │    ← BPH arises here            │
     │                                 │
     │  • Anterior Fibromuscular       │
     │    Stroma (AFS)                 │
     └─────────────────────────────────┘

RELATIONS:
- Superior: Bladder neck
- Inferior: Urogenital diaphragm
- Anterior: Pubic symphysis (retropubic space of Retzius)
- Posterior: Rectum (separated by Denonvilliers fascia)
- Lateral: Levator ani

NEUROVASCULAR BUNDLE:
- "NVB" = Posterolateral to prostate
- Contains cavernous nerves (erection)
- At risk during radical prostatectomy

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STAGING - TNM & Jewett-Whitmore Classification

TNM STAGING (Most Important for Exam)

T STAGE (Primary Tumour):
T1 - Clinically inapparent (not palpable, not visible)
     T1a: ≤5% of resected tissue (incidental TURP)
     T1b: >5% of resected tissue
     T1c: Detected by needle biopsy (elevated PSA)

T2 - Confined within prostate (palpable)
     T2a: ≤ half of one lobe
     T2b: > half of one lobe
     T2c: Both lobes

T3 - Extends through capsule
     T3a: Extracapsular extension (ECE)
     T3b: Seminal vesicle invasion

T4 - Fixed or invades adjacent structures
     (bladder neck, sphincter, rectum, levator ani)

N STAGE:
N0 - No regional lymph nodes
N1 - Regional lymph node metastasis (obturator, iliac)

M STAGE:
M0 - No distant metastasis
M1a: Non-regional lymph nodes
M1b: Bone (MOST COMMON SITE - OSTEOBLASTIC mets)
M1c: Other organs

Memory for BONE METS: "Prostate is the Only cancer that gives Osteoblastic (sclerotic) bone mets" - except breast which can give both. Spine, pelvis, ribs, skull most common.

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GLEASON GRADING

"Gleason = Grade 1 to 5 (two areas added = Score 2-10)"

---

CLINICAL FEATURES

SYMPTOMS OF CARCINOMA PROSTATE

EARLY (Localised):
├── Usually ASYMPTOMATIC (PSA screening)
├── LUTS: Hesitancy, poor stream, frequency, nocturia
│   (similar to BPH!)
└── Haematuria, haematospermia (occasionally)

LOCALLY ADVANCED:
├── Ureteric obstruction → Hydronephrosis, uraemia
├── Bladder invasion → Haematuria
└── Rectal compression → Altered bowel habits

METASTATIC:
├── BONE PAIN (most common) - back, hip, pelvis
│   Pathological fractures
├── Cord compression (emergency!)
│   → Paraplegia, bladder/bowel dysfunction
├── Lymphoedema (pelvic node mets)
└── Anaemia (bone marrow infiltration)

DRE FINDINGS:
├── T1: Normal
├── T2: Hard, irregular nodule, within capsule
├── T3/T4: Hard, fixed, loss of sulcus, seminal
│          vesicle involvement

---

INVESTIGATIONS

INVESTIGATIONS ALGORITHM - CARCINOMA PROSTATE

BLOOD:
├── PSA (Prostate Specific Antigen):
│    Normal: < 4 ng/mL
│    4-10 ng/mL: Grey zone (25-40% risk of Ca)
│    > 10 ng/mL: High risk (>50% risk of Ca)
│    PSA Density, PSA Velocity, Free:Total PSA ratio
├── FBC, LFTs, RFTs
└── ALP ↑ (bone mets), LDH ↑

IMAGING:
├── USG Abdomen/Pelvis: Hydronephrosis, liver mets
├── TRUS (Trans-Rectal Ultrasound):
│    → Hypoechoic lesion in peripheral zone
│    → Guides biopsy
├── MRI Prostate (mpMRI):
│    → GOLD STANDARD for local staging
│    → PI-RADS scoring (1-5)
├── Bone Scan (Tc99m): Most sensitive for bone mets
│    → Indicated if PSA > 20, Gleason ≥ 8, T3/T4
├── PSMA PET-CT: Latest - most sensitive for staging
└── CT Abdomen/Pelvis: LN assessment

BIOPSY:
└── Trans-rectal or Trans-perineal 12-core biopsy
     → Under TRUS guidance
     → GOLD STANDARD for diagnosis

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MANAGEMENT FLOWCHART

MANAGEMENT - CARCINOMA PROSTATE

                    DIAGNOSED PROSTATE CANCER
                              │
               ┌──────────────┼──────────────────┐
               ▼              ▼                   ▼
         LOCALISED      LOCALLY ADVANCED      METASTATIC
         (T1-T2, N0, M0)   (T3-T4)           (M1)
               │              │                   │
    ┌──────────┤              │           Androgen Deprivation
    │          │              │           Therapy (ADT):
    ▼          ▼              ▼           - Bilateral orchidectomy
 Active     Radical      RT + ADT         (surgical castration)
 Surveillance Prostatec-  (Standard)     - LHRH agonists
 (low risk)   tomy                        (Leuprolide, Goserelin)
              (Robotic/                  - Abiraterone + Prednisone
              Laparoscopic)             - Enzalutamide
              or EBRT                   - Docetaxel chemo
              (External Beam            - Radium-223 (bone mets)
               Radiotherapy)            - Sipuleucel-T (vaccine)
              or Brachytherapy
              (low-risk only)

ACTIVE SURVEILLANCE criteria:
- PSA < 10, Gleason ≤ 6, T1c-T2a
- Monitoring: PSA q3-6 months, biopsy at 1 yr then q3-5 yrs

RADICAL PROSTATECTOMY complications:
- Urinary incontinence (10-20%)
- Erectile dysfunction (30-80% depending on nerve-sparing)
- Anastomotic stricture

---

HORMONE REFRACTORY / CASTRATION-RESISTANT PROSTATE CANCER (CRPC)

When PSA rises despite castrate testosterone levels (<50 ng/dL) Treatment: Abiraterone, Enzalutamide, Docetaxel, Cabazitaxel, PARP inhibitors (Olaparib for BRCA mutations)

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Q5 - Extradural Haematoma: Clinical Features, Investigations & Management (10 Marks)

---

MEMORY TRICK

"TALK and DIE" - The classic triad Lucid interval → Artery ruptures (middle meningeal) → Transient LOC → Koma (coma) follows

"TEMPO" of EDH: Transient LOC → Euphoric recovery (lucid interval) → Mounting headache → Pupil dilation (ipsilateral - 3rd nerve compression) → Obstructed (contralateral hemiparesis)

---

DEFINITION & PATHOPHYSIOLOGY

• Most common: Fracture of squamous temporal bone → laceration of middle meningeal artery (branch of maxillary artery entering skull at pterion - thinnest point)
• Pterion = Junction of frontal, parietal, temporal, sphenoid bones = THINNEST part of skull

PATHOPHYSIOLOGY OF EDH

HEAD INJURY
     │
     ▼
SKULL FRACTURE (temporal - pterion region)
     │
     ▼
MIDDLE MENINGEAL ARTERY RUPTURE
(arterial bleed - rapid expansion)
     │
     ▼
TRANSIENT LOC (concussion)
     │
     ▼
LUCID INTERVAL (patient wakes up, talks normally)
Compensation by:
- ↓ CSF volume
- ↓ Cerebral blood volume
     │
     ▼
HAEMATOMA EXPANDS
Monroe-Kellie Doctrine exceeded
     │
     ▼
↑ ICP → BRAIN HERNIATION (Uncal herniation)
     │
┌────┴────┐
▼         ▼
IPSILATERAL    CONTRALATERAL
PUPIL DILATION  HEMIPARESIS
(CN III compression  (Pyramidal tract
by herniating       compression before
uncus)              decussation)
     │
     ▼
DECEREBRATE POSTURING
→ DEATH if untreated

---

CLINICAL FEATURES

1. Transient LOC (initial concussion)
2. Lucid Interval (minutes to hours - hallmark of EDH)
3. Deterioration - headache, vomiting, confusion, coma

• Ipsilateral fixed dilated pupil (CN III palsy)
• Contralateral hemiparesis/hemiplegia
• Cushing's Triad: Hypertension + Bradycardia + Irregular breathing (late sign)

---

INVESTIGATIONS

1. CT Head (Non-contrast) - Investigation of CHOICE
   • Lenticular (biconvex/lens-shaped) hyperdense collection between skull and brain
   • Does NOT cross suture lines (dura adherent at sutures)
   • Midline shift, mass effect
   • Skull fracture visible on bone windows
   • Mixed density = active bleeding (acute on chronic)
2. Skull X-ray: May show fracture line crossing middle meningeal groove
3. MRI: Not first choice in acute setting (slow, no bone detail)

---

MANAGEMENT FLOWCHART

EXTRADURAL HAEMATOMA - MANAGEMENT

SUSPECT EDH (head injury + lucid interval/deterioration)
          │
          ▼
URGENT CT HEAD
          │
          ▼
RESUSCITATE: ABC, IV access, O2
Neurosurgical consultation IMMEDIATELY
          │
     ┌────┴────────────────────────────────────┐
     ▼                                         ▼
SURGICAL (EMERGENCY)              CONSERVATIVE (selected)
Indications:                      Criteria (all must be met):
• Volume > 30 mL                  • Vol < 30 mL
• Thickness > 15 mm               • Thickness < 15 mm
• Midline shift > 5 mm            • Midline shift < 5 mm
• Deteriorating neurology         • GCS > 8, neurologically intact
• Comatose patient                • No pupils abnormality
• Any patient with signs          Serial CT scans + ICU monitoring
  of herniation
          │
          ▼
   EMERGENCY BURR HOLE / CRANIOTOMY
   + EVACUATION OF HAEMATOMA
   + Control of bleeding vessel
          │
          ▼
   EXCELLENT PROGNOSIS if operated early
   (Mortality <5% if before coma, >20% if in coma)

---

ICP MANAGEMENT (Pre-op stabilization)

• Head elevation 30 degrees
• Hyperventilation (PCO2 target 35 mmHg) - temporary
• Mannitol 20% (0.5-1 g/kg IV) - osmotic agent
• Avoid hypotension, hypoxia
• Anti-epileptics (Phenytoin/Levetiracetam)

---

KEY POINTS (10-mark emphasis)

---

Q6 - Carcinoma Urinary Bladder: Types, Etiopathology, Clinical Features, Investigations & Management (10 Marks)

---

MEMORY TRICKS

"TRANSITIONAL is TYPICAL" = Urothelial (TCC) = 90% of bladder cancers

Risk Factors: "SOAP SCUM" Smoking (most important, 3x risk, 50% of cases) Occupational chemicals (aniline dyes, benzidine, beta-naphthylamine) Arylamine exposure (rubber, paint, printing industry) Phenacetin (analgesic abuse) Schistosoma haematobium (squamous cell carcinoma - endemic areas) Cyclophosphamide (chemotherapy - acrolein metabolite) Urinary stasis/chronic infection Male sex (M:F = 3:1), age > 60

---

TYPES OF BLADDER CANCER

---

ETIOPATHOLOGY

ETIOPATHOLOGY OF BLADDER CANCER

CARCINOGENS
(Tobacco/aniline dyes/schistosoma)
         │
         ▼
UROTHELIAL EXPOSURE TO CARCINOGENS
(Concentrated in urine, prolonged contact)
         │
         ▼
GENETIC MUTATIONS:
• p53 deletion/mutation (chromosome 17p)
  → High-grade, invasive tumours
• FGFR3 mutation
  → Low-grade, superficial, better prognosis
• Loss of Rb gene (chromosome 13q)
• Deletion 9p, 9q (early events in TCC)
• TERT promoter mutations
         │
         ▼
UROTHELIAL DYSPLASIA
         │
     ┌───┴────────────────────────┐
     ▼                            ▼
NON-INVASIVE (Papillary)    CARCINOMA IN SITU (CIS)
pTa = Lamina propria not      Flat, high-grade
involved                      dysplasia, aggressive
pT1 = Into lamina propria     potential
(NMIBC = Non-muscle invasive  │
bladder cancer = 75-85%)      ▼
                         MIBC (Muscle-invasive)
                         pT2 = Into muscularis propria
                         pT3 = Into perivesical fat
                         pT4 = Into adjacent organs

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STAGING (TNM)

T STAGING:
pTa - Non-invasive papillary (confined to urothelium)
pTis - Carcinoma in situ (flat high-grade)
pT1 - Invades subepithelial connective tissue (lamina propria)
pT2a - Invades superficial muscularis propria (inner half)
pT2b - Invades deep muscularis propria (outer half)
pT3a - Invades perivesical tissue microscopically
pT3b - Invades perivesical tissue grossly
pT4a - Invades prostate/uterus/vagina
pT4b - Invades pelvic wall/abdominal wall

NMIBC = Ta, T1, Tis (75-85% of all bladder Ca)
MIBC = T2-T4 (15-25%)

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CLINICAL FEATURES

SYMPTOMS:
├── PAINLESS HAEMATURIA (90%)
│   ← Hallmark/Cardinal symptom
│   ← FRANK total haematuria at beginning & end of stream
│   ← Clot retention possible
│
├── IRRITATIVE VOIDING SYMPTOMS (25-30%)
│   Frequency, urgency, dysuria
│   (Especially CIS - diffuse disease)
│
├── PAIN: Suprapubic, flank (ureteric obstruction)
│
└── ADVANCED DISEASE:
    ├── Pelvic pain, bilateral leg oedema (nodal mets)
    ├── Renal failure (bilateral ureteric obstruction)
    └── Systemic: Weight loss, anaemia, cachexia

EXAMINATION:
├── Usually normal in early disease
├── Suprapubic mass (large tumour)
├── Bimanual examination (EUA) for staging
│   Palpable mass = T3/T4
└── Hepatomegaly, cervical LN (late mets)

Haematuria rule: "Bladder cancer until proved otherwise in any adult with painless haematuria > 50 years"

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INVESTIGATIONS

INVESTIGATIONS:

URINE:
├── Urine cytology (high-grade tumours/CIS)
│   Sensitivity: Low grade 20%, High grade 70%
├── NMP22 (Nuclear Matrix Protein 22) - newer marker
└── FISH (fluorescence in situ hybridization) - Urovysion

IMAGING:
├── USG: First line - mass in bladder, hydronephrosis
├── CT Urography (CTU): GOLD STANDARD
│   → Tumour in bladder, upper tract TCC, staging
├── MRI: Better soft tissue - T staging
│   Vesico-ureteric junction, local invasion
└── Chest CT/Bone scan: For metastatic workup

DEFINITIVE:
└── CYSTOSCOPY + BIOPSY
    ← GOLD STANDARD for diagnosis
    ← Flexible (OPD) or Rigid (OT)
    ← Papillary growth (most common appearance)
    ← Followed by TURBT (Trans-urethral resection of bladder tumour)

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MANAGEMENT FLOWCHART

MANAGEMENT OF BLADDER CANCER

         BLADDER CANCER
               │
       ┌───────┴─────────────────────┐
       ▼                             ▼
   NMIBC (Ta, T1, Tis)           MIBC (T2-T4)
   (75-85%)                      (15-25%)
       │                             │
       ▼                             ▼
TURBT (Trans-urethral              CT staging (abdomen/pelvis/chest)
Resection Bladder Tumour)              │
+ Histology                     ┌──────┴───────────────────────┐
       │                        ▼                              ▼
  ┌────┴──────────────────┐  RADICAL CYSTECTOMY          Bladder-sparing
  ▼           ▼           │  + Pelvic LN dissection       trimodal therapy:
Low Risk   Int Risk  High Risk  (GOLD STANDARD)           TURBT + Chemo
(Ta, G1,   (T1 G2,  (T1 G3,   + Urinary diversion:      + Radiotherapy
single)    multiple)  CIS)     • Ileal conduit            (Selected patients)
  │           │        │       • Orthotopic neobladder
  ▼           ▼        ▼       • Cutaneous ureterostomy
 Observe   Intravesical  Intravesical
 or single  Mitomycin C   BCG             Neoadjuvant chemo:
 instil of  (6-8 weekly  (Immunotherapy   Cisplatin-based x4
 Mitomycin C sessions)    - GOLD STANDARD  (↑ survival by 5-8%)
 post-TURBT              for CIS + high
                         risk NMIBC)

METASTATIC:
├── Cisplatin-based chemo (GC: Gemcitabine + Cisplatin)
├── Immunotherapy: Pembrolizumab, Atezolizumab (PD-L1 inhibitors)
└── Enfortumab Vedotin + Pembrolizumab (latest approved combo)

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BCG THERAPY (Key Exam Topic)

• BCG = Bacillus Calmette-Guerin
• Mechanism: Local immune activation → cytotoxic T-cell response against tumour cells
• Used for: High-risk NMIBC, CIS
• Schedule: Weekly x 6 weeks (induction) + maintenance x 3 years
• Side effects: Dysuria, haematuria, BCG sepsis (rare but life-threatening)
• BCG failure → Radical cystectomy

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SURVEILLANCE AFTER TURBT

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QUICK SUMMARY TABLE - All 6 Questions

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Sources: Bailey & Love's Short Practice of Surgery 28e; Campbell Walsh Wein Urology; Pye's Surgical Handicraft 22e; Sabiston Textbook of Surgery 21eHere is the complete compiled answer for all 6 questions from your MS General Surgery Answer Book Part 2. Here's a quick guide to what's covered:

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What's Included - Quick Navigation

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Key Memory Tricks Summary