Surgery - Urology Topics: Short Notes

KIDNEY

1. Ureteric / Ureteral Calculi (Urolithiasis)

• Definition: Stones forming in the kidney and passing into the ureter.
• Types: Calcium oxalate (most common, ~80%), uric acid, struvite (infection stones), cystine.
• Presentation: Severe colicky flank pain radiating to the groin, hematuria, nausea/vomiting.
• Diagnosis: Non-contrast CT (gold standard), KUB X-ray, ultrasound.
• Treatment: Conservative (hydration, analgesics) for small stones (<5 mm); ESWL (shock wave lithotripsy) for moderate stones; ureteroscopy + laser for larger stones; PCNL for very large renal stones.
• (Campbell Walsh Wein Urology)

2. Wilms' Tumor (Nephroblastoma)

• Definition: Most common solid renal tumor of childhood; ~5% of all childhood cancers.
• Peak age: 3rd year of life; no sex predilection; 5% bilateral.
• Genetics: WT1 gene mutation on chromosome 11p13; associated with WAGR syndrome (Wilms, Aniridia, Genitourinary malformation, mental Retardation), Beckwith-Wiedemann syndrome, hemihypertrophy.
• Histology: Triphasic - blastemal, epithelial, and stromal elements.
• Presentation: Asymptomatic abdominal mass, hematuria, hypertension.
• Treatment: Nephrectomy + chemotherapy (vincristine, actinomycin D) ± radiotherapy. Excellent prognosis (~90% survival).
• (Smith and Tanagho's General Urology, 19th Ed.; Campbell Walsh Wein Urology)

3. Renal Cell Carcinoma (RCC)

• Definition: Most common renal malignancy in adults (arising from tubular epithelium); in children, translocation-associated RCC is most common (~50%).
• Types: Clear cell (most common, ~75%), papillary, chromophobe, collecting duct.
• Risk factors: Smoking, obesity, hypertension, von Hippel-Lindau disease.
• Classic triad: Hematuria + flank pain + palpable mass (only ~10% present with all three).
• Paraneoplastic syndromes: Polycythemia, hypercalcemia, hypertension, Stauffer syndrome (liver dysfunction).
• Staging: CT chest/abdomen/pelvis; MRI for IVC thrombus.
• Treatment: Radical or partial nephrectomy; targeted therapy (sunitinib, pazopanib) for metastatic disease; immunotherapy (nivolumab).
• (Campbell Walsh Wein Urology; Grainger & Allison's Diagnostic Radiology)

BLADDER

4. Cystitis

• Definition: Inflammation/infection of the urinary bladder.
• Causes: Mostly bacterial (E. coli ~80%); also fungal, viral, chemical, radiation.
• Presentation: Dysuria, frequency, urgency, suprapubic pain, cloudy/foul-smelling urine.
• Treatment: Short-course antibiotics (trimethoprim, nitrofurantoin); complicated cystitis needs culture-guided therapy.

5. Bladder Stone

• Definition: Urinary calculi forming in or migrating to the bladder.
• Causes: BOO (BPH), urinary stasis, recurrent UTI, foreign body.
• Presentation: Hematuria, lower urinary symptoms, interrupted stream, pain at end of micturition.
• Treatment: Cystolitholapaxy (endoscopic fragmentation); open cystolithotomy for large stones; treat underlying cause.

6. Carcinoma of Bladder (Ca. Bladder)

• Definition: Most commonly transitional cell carcinoma (TCC/urothelial carcinoma).
• Risk factors: Smoking (#1), aniline dyes, cyclophosphamide, chronic schistosomiasis (squamous cell carcinoma).
• Presentation: Painless hematuria (most common), frequency, dysuria.
• Diagnosis: Cystoscopy + biopsy (gold standard); CT urogram; urine cytology.
• Treatment:
  • Non-muscle invasive (Ta, T1, CIS): TURBT ± intravesical BCG or mitomycin C.
  • Muscle invasive (T2+): Radical cystectomy + neobladder/ileal conduit + chemotherapy.

7. Bladder Outflow Obstruction (BOO)

• Definition: Obstruction to urine flow from the bladder, most commonly from BPH.
• Consequences: Trabeculation, diverticula, hydronephrosis, renal failure, UTI.
• Symptoms: LUTS - weak stream, hesitancy, nocturia, incomplete emptying.

8. Vesicoureteric Reflux (VUR)

• Definition: Retrograde flow of urine from bladder into the ureter/kidney.
• Grading: I-V (I = reflux into ureter only; V = gross reflux with ureteral dilatation and renal damage).
• Complications: Recurrent UTIs, reflux nephropathy, scarring, hypertension, CKD.
• Treatment: Antibiotics prophylaxis (low grades); endoscopic subureteric injection (STING); ureteric reimplantation for high grades.

9. Diverticulum of Bladder

• Definition: Herniation of bladder mucosa through detrusor muscle, forming a sac.
• Types: Congenital (usually single, near ureteral orifice) and acquired (due to BOO).
• Complications: Urinary stasis, UTI, stone formation, carcinoma within the diverticulum.
• Treatment: Treat underlying BOO; diverticulectomy if symptomatic.

PROSTATE

10. BPH (Benign Prostatic Hyperplasia)

• Definition: Non-malignant nodular enlargement of the prostate gland affecting the transitional zone.
• Epidemiology: 50% of men >60 years have histological BPH; most common cause of BOO in men >70 years.
• Pathology: Hyperplasia of glandular epithelium and stroma → lateral and middle lobe enlargement → compresses peripheral zone → "false capsule."
• Symptoms: LUTS (frequency, nocturia, hesitancy, poor stream, dribbling), acute urinary retention.
• Investigations: PSA, flow rate (<10 mL/s significant), post-void residual, USS.
• Treatment:
  • Medical: Alpha-blockers (tamsulosin), 5-alpha reductase inhibitors (finasteride).
  • Surgical: TURP (gold standard), laser prostatectomy, open prostatectomy for very large glands.
• (Bailey & Love's Surgery, 28th Ed.)

11. Prostatitis

• Definition: Inflammation of the prostate; classified into 4 types (NIH classification).
• Types:
  • Type I: Acute bacterial (E. coli, Klebsiella) - fever, perineal pain, dysuria, tender prostate.
  • Type II: Chronic bacterial - recurrent UTIs, pelvic pain.
  • Type III: Chronic pelvic pain syndrome (most common) - pelvic/perineal pain without identifiable infection.
  • Type IV: Asymptomatic inflammatory prostatitis.
• Treatment: Fluoroquinolones (ciprofloxacin) for bacterial types; NSAIDs, alpha-blockers for CPPS.

12. Carcinoma of Prostate (Ca. Prostate)

• Definition: Most common malignancy in men >65 years; arises predominantly in the peripheral zone.
• Pathology: Almost all are adenocarcinomas; graded by Gleason score (1-10).
• Risk factors: Age, family history, African ethnicity, high-fat diet.
• Screening: PSA (controversial); >4 ng/mL suspicious; free:total PSA ratio <15% suspicious for malignancy.
• Metastases: Osteoblastic bone secondaries (lumbar spine, pelvis, femur); lymph nodes.
• Diagnosis: mpMRI, TRUS-guided biopsy, or transperineal biopsy.
• Treatment:
  • Localized (T1/T2): Active surveillance, radical prostatectomy, or radiotherapy.
  • Locally advanced (T3/T4): Hormonal therapy (LHRH agonists/antagonists) + radiotherapy.
  • Metastatic: Androgen deprivation therapy (ADT), docetaxel, abiraterone.
• (Bailey & Love's Surgery, 28th Ed.; Robbins & Kumar Basic Pathology)

URETHRA

13. Urethral Stricture

• Definition: Narrowing of the urethra due to fibrosis following inflammation/injury.
• Causes: Traumatic (straddle injury, pelvic fracture), iatrogenic (catheter, TURP, instrumentation), inflammatory (gonorrhea - bulbar urethra most common site).
• Presentation: Poor stream, straining, split stream, hematuria, recurrent UTI, retention.
• Diagnosis: Urethrogram (ascending/MCU), urethroscopy, uroflowmetry.
• Treatment:
  • Dilatation (bougies/sounds) - temporary.
  • Optical urethrotomy (OIU/DVU) - for short, thin strictures.
  • Urethroplasty (anastomotic or substitution using buccal mucosa graft) - definitive.
• (Bailey & Love's Surgery, 28th Ed.; Campbell Walsh Wein Urology)

14. Hypospadias

• Definition: Congenital anomaly where the urethral meatus opens on the ventral (underside) surface of the penis, proximal to the normal position.
• Classification: Glandular (most common, ~70%), coronal, penile shaft, penoscrotal, perineal.
• Associated anomalies: Chordee (ventral penile curvature), cryptorchidism, inguinal hernia.
• Treatment: Surgical repair (urethroplasty) - usually between 6-18 months of age. Tubularized incised plate (TIP/Snodgrass) repair is most common. Avoid circumcision (foreskin used for repair).

15. Urethritis

• Definition: Inflammation of the urethra.
• Types: Gonococcal (Neisseria gonorrhoeae) and Non-gonococcal (Chlamydia trachomatis most common; also Mycoplasma, Ureaplasma).
• Presentation: Urethral discharge (purulent in GC, mucopurulent/clear in NGU), dysuria.
• Treatment: Ceftriaxone for GC; doxycycline or azithromycin for NGU; treat partner.

16. Urethral Calculi

• Definition: Stones in the urethra, usually migrating from the bladder/kidney.
• Presentation: Sudden onset complete urinary retention, perineal/penile pain, palpable stone.
• Treatment: Push back into bladder + cystolitholapaxy; or external meatotomy/urethrotomy for distal stones.

17. Retention of Urine

• Definition: Inability to void despite a full bladder.
• Types: Acute (painful, sudden) and Chronic (painless, large residual).
• Causes: BPH, urethral stricture, clot retention, calculi, drugs (anticholinergics, opioids), spinal cord lesions.
• Management: Urethral catheterization; suprapubic catheter if urethral route fails; treat underlying cause.

Other Urethral Topics

Urethral Catheterization

• Indicated for urinary retention, monitoring output, post-op, bladder irrigation.
• Foley catheter most common; strict aseptic technique; avoid in urethral trauma.

Urinary Incontinence

• Types: Stress, urge, overflow, mixed. Management: pelvic floor exercises, anticholinergics, surgery (TVT/TOT for stress incontinence).

Urinary Fistula

• Types: VVF (vesicovaginal - most common, often post-obstetric in developing countries), urethrovaginal, ureterovaginal.
• Management: Surgical repair.

UTI (Urinary Tract Infection)

• Uncomplicated (female, community): Trimethoprim / nitrofurantoin 3-7 days.
• Complicated (male, catheter, structural abnormality): Urine C&S; fluoroquinolones.
• Recurrent UTI: Look for underlying structural cause; long-term prophylaxis.

PENIS

18. Phimosis

• Definition: Inability to retract the prepuce (foreskin) over the glans.
• Types: Physiological (normal up to age 3-4) and Pathological (BXO/lichen sclerosus).
• Complications: Paraphimosis (can't reduce foreskin - emergency), balanitis, urinary obstruction.
• Treatment: Topical steroid cream (mild cases); circumcision (definitive).

19. Circumcision

• Indications: Phimosis, paraphimosis, recurrent balanitis, BXO, religious/cultural, reduced HIV risk.
• Complications: Bleeding, infection, urethral meatus injury, poor cosmetic result.

20. Carcinoma of Penis

• Definition: Rare squamous cell carcinoma; associated with HPV (types 16 & 18), phimosis, poor hygiene, smoking.
• Presentation: Ulcerative or proliferative lesion on glans or prepuce; inguinal lymphadenopathy (metastases).
• Staging: Jackson staging / TNM.
• Treatment: Glansectomy / partial penectomy for localized; radical penectomy + bilateral inguinal lymph node dissection for advanced; chemoradiation.

21. Balanoposthitis

• Definition: Inflammation of the glans (balanitis) and foreskin (posthitis).
• Causes: Candida (most common, esp. diabetics), bacterial, contact dermatitis.
• Treatment: Topical antifungals (clotrimazole), topical antibiotics; treat diabetes; circumcision for recurrent cases.

22. Peyronie's Disease

• Definition: Formation of fibrous plaque in the tunica albuginea of the penis, causing painful erection and penile curvature.
• Presentation: Dorsal penile curvature during erection, painful erections, palpable plaque, erectile dysfunction.
• Treatment: Conservative (colchicine, verapamil injection); surgery (Nesbit procedure, plaque excision + grafting) for severe deformity.

23. Priapism

• Definition: Prolonged, painful penile erection unrelated to sexual stimulation (>4 hours - emergency).
• Types: Ischemic (low-flow, most common, painful, emergency) and Non-ischemic (high-flow, usually painless).
• Causes: Sickle cell disease (most common in children/young adults), drugs (trazodone, antipsychotics, PDE5 inhibitors), leukemia, idiopathic.
• Management: Ischemic: aspiration of blood from corpora cavernosa + phenylephrine injection (intracorporeal); if fails, surgical shunt.

SCROTUM / TESTES

24. Undescended Testis (Cryptorchidism)

• Definition: Failure of testis to descend into the scrotum; found in inguinal canal or abdomen.
• Incidence: ~3% of full-term males; ~30% of premature infants.
• Complications: Infertility, malignancy (10x increased risk - seminoma most common), torsion, hernia, psychological.
• Treatment: Orchidopexy - performed between 6-18 months of age (before 2 years is essential to preserve fertility). Hormonal therapy (hCG) rarely used.

25. Retractile Testis

• Definition: Testis that can be manipulated into the scrotum but retracts due to an active cremasteric reflex; normal variant (not truly undescended).
• Management: Reassurance and annual review until puberty; rarely needs orchidopexy.

26. Torsion of Testis

• Definition: Twisting of the spermatic cord cutting off blood supply to the testis - surgical emergency.
• Risk factors: Bell-clapper deformity (most common predisposing anomaly), cryptorchidism.
• Peak age: Bimodal - neonates and puberty (12-18 years).
• Presentation: Sudden severe scrotal pain, tender elevated testis ("high-riding"), absent cremasteric reflex, nausea/vomiting.
• Diagnosis: Clinical (don't delay for imaging); Doppler USS can confirm.
• Treatment: Emergency scrotal exploration within 6 hours (>90% testicular salvage); bilateral orchidopexy (bell-clapper is usually bilateral).

27. Varicocele

• Definition: Abnormal dilatation of the pampiniform venous plexus, most common on the left side (due to 90-degree angle of left testicular vein draining into left renal vein).
• Grading: Grade I (palpable only on Valsalva), II (palpable at rest), III (visible "bag of worms").
• Clinical significance: Most common correctable cause of male infertility; testicular atrophy.
• Sudden right-sided varicocele: Consider retroperitoneal mass/renal tumor compressing IVC.
• Treatment: Surgical ligation (Palomo/inguinal approach) or percutaneous embolization; indicated if infertility or pain.
• (ROSEN's Emergency Medicine)

28. Hydrocele

• Definition: Collection of fluid in the tunica vaginalis around the testis.
• Types:
  • Primary (idiopathic - most common, middle-aged men).
  • Secondary (due to infection, tumor, trauma, torsion).
  • Congenital (patent processus vaginalis - communicating).
• Presentation: Smooth, non-tender scrotal swelling; transilluminates; testis cannot be felt separately.
• Treatment: Aspiration + sclerotherapy (temporary); surgical - eversion of sac (Jaboulay's procedure) or excision (Lord's procedure). Congenital: usually resolves by age 2; surgery if persists.

29. Fournier's Gangrene

• Definition: Rapidly progressive, life-threatening necrotizing fasciitis of the perineum, genitalia, and perianal region.
• Causes: Mixed aerobic-anaerobic infection (E. coli, Klebsiella, Bacteroides, Clostridia).
• Risk factors: Diabetes, alcohol, immunosuppression, obesity; but can affect healthy individuals.
• Presentation: Severe perineal pain, swelling, crepitus (gas in tissues), purple/black necrotic skin patches, signs of systemic sepsis.
• Diagnosis: Clinical + CT (gas in soft tissues). LRINEC score >6 = high risk for necrotizing infection.
• Treatment: Surgical emergency - aggressive wide debridement, IV broad-spectrum antibiotics (carbapenem + metronidazole), ITU support, hyperbaric oxygen as adjunct. High mortality (20-40%).
• (Sabiston Textbook of Surgery; Fitzpatrick's Dermatology)

30. Epididymo-orchitis

• Definition: Inflammation/infection of the epididymis (epididymitis) ± testis (orchitis).
• Causes:
  • Young men (<35 years): STI - Chlamydia trachomatis, N. gonorrhoeae.
  • Older men (>35 years): Urinary organisms - E. coli, Klebsiella.
  • Viral: Mumps orchitis (without epididymitis; post-pubertal males; can cause infertility).
• Presentation: Gradual onset scrotal pain and swelling, fever, urethral discharge; positive cremasteric reflex (differentiates from torsion).
• Treatment: Antibiotics (doxycycline for STI organisms; ciprofloxacin for urinary organisms), scrotal support, NSAIDs. Exclude torsion first.

31. Testicular Tumors

• Definition: Most common solid malignancy in males aged 15-35 years.
• Types:
  • Germ Cell Tumors (95%):
    • Seminoma (most common, ~50%) - radiosensitive, good prognosis.
    • Non-seminomatous GCT (NSGCT) - teratoma, embryonal carcinoma, choriocarcinoma, yolk sac tumor.
  • Non-germ cell (<5%): Leydig cell, Sertoli cell tumors.
• Risk factors: Cryptorchidism (#1 risk factor), family history, Klinefelter syndrome.
• Presentation: Painless testicular lump; backache (retroperitoneal LN mets); gynecomastia.
• Tumor markers: AFP (not raised in seminoma), β-hCG (raised in choriocarcinoma), LDH.
• Diagnosis: USS scrotum; CT chest/abdomen/pelvis for staging.
• Treatment: Radical orchidectomy (through inguinal incision) first; then:
  • Seminoma: Radiotherapy (stage I/II) or carboplatin (adjuvant); BEP chemotherapy for advanced.
  • NSGCT: BEP chemotherapy (bleomycin, etoposide, cisplatin); retroperitoneal lymph node dissection (RPLND).

Sources: Bailey & Love's Short Practice of Surgery (28th Ed.), Campbell Walsh Wein Urology, Smith & Tanagho's General Urology (19th Ed.), Robbins & Kumar Basic Pathology, Sabiston Textbook of Surgery, ROSEN's Emergency Medicine.