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HBE-9106 | M.S. (Branch-I) General Surgery Paper-III | June 2023

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QUESTION 1 (30 Marks)

Urethral Injuries - Clinical Features, Investigations & Management

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CLASSIFICATION

• Prostatic urethra
• Membranous urethra (most vulnerable - accounts for majority)

• Bulbar urethra (most commonly injured anteriorly - 85% of all urethral injuries)
• Penile urethra

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ETIOLOGY

• Pelvic fractures (most common cause) - occur in 1.5-10% of pelvic fractures
• PFUI is caused by shearing forces at the bulbo-membranous junction - this area is vulnerable as it is anchored proximally by the prostate and distally by the perineal membrane

• Straddle injury (fall astride a hard object - commonest)
• Instrumentation/iatrogenic (catheterization, cystoscopy) - occurs in 3.2-6.7 per 1000 catheterized males
• Penile fracture
• Penetrating trauma (gunshot, stab wounds)

• Urethral stricture disease
• Prior pelvic radiation
• Benign prostatic hyperplasia
• Operator inexperience
• Inflation of Foley balloon in the urethra (false passage)

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CLINICAL FEATURES

1. Blood at the urethral meatus (present in 37-93% of cases)
2. Inability to void / retention of urine
3. Perineal or scrotal hematoma

• "Butterfly hematoma" - in anterior urethral injuries (Buck fascia rupture), hematoma spreads into scrotum and along Scarpa's fascia in a butterfly pattern around the perineum
• High-riding prostate on rectal examination in posterior urethral injuries (due to proximal displacement of the prostate by pelvic hematoma)
• Perineal bruising and swelling
• Distended, palpable bladder
• Inability to pass urine despite desire to void
• Shock in associated pelvic fractures

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INVESTIGATIONS

• Indication: Blood at urethral meatus after pelvic trauma or perineal injury
• Technique: Patient placed obliquely; penis on gentle stretch; contrast fills entire urethra
• Findings:
  • Partial disruption: contrast passes around disruption and opacifies the bladder
  • Complete disruption: contrast does not reach bladder; extravasation seen
• If catheter already in place: pericatheter RUG via 3-Fr catheter at meatus

• For associated pelvic fracture assessment
• Identifies bladder injury (concurrent in 15% of posterior urethral injuries)

• Assessment after catheter removal / before reconstruction

• Diagnostic + therapeutic during endoscopic realignment
• Used with fluoroscopy for primary realignment

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MANAGEMENT

A. IMMEDIATE MANAGEMENT

• Indications: Complete urethral disruption, failed blind catheter placement, hemodynamically unstable patients
• Advantages: Fast, provides long-term drainage, allows delayed reconstruction, can be placed even in patients undergoing ORIF for pelvic fracture
• If bladder is displaced by hematoma - use ultrasound guidance or open placement

• Only for partial disruption
• Success rate ~50%
• Should be done by experienced personnel
• Does NOT convert partial to complete disruption

• For hemodynamically stable patients, within first 7 days
• Performed with two urologists using combined cystoscopy and fluoroscopy
• Catheter maintained 4-6 weeks; pericatheter RUG done at removal
• Reduces stricture complexity but does NOT eliminate stricture risk

B. PRIMARY SURGICAL REPAIR

• NOT recommended for most PFUI (high complication rates)
• 69% still develop strictures requiring further surgery
• Incontinence and erectile dysfunction rates high

1. Concurrent rectal injury (reduces fistula risk)
2. Concurrent bladder neck injury
3. Female PFUI with concurrent vaginal laceration (repair within 7 days)

C. ANTERIOR URETHRAL INJURIES

• Prompt urinary drainage (SPT or catheter)
• Most can be repaired primarily
• If extensive local tissue damage: SPT + delayed repair

• Explore and repair primarily if hemodynamically stable
• Minimal debridement, spatulate urethra, repair over catheter with fine absorbable suture

D. DELAYED RECONSTRUCTION (DEFINITIVE)

• Posterior urethroplasty (anastomotic urethroplasty) - gold standard for PFUI
• Performed at 3-6 months after injury
• Complex operation - should be performed by reconstructive experts

E. MANAGEMENT OF COMPLICATIONS

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QUESTION 2 (20 Marks)

Carcinoma of Urinary Bladder - Types, Etiopathology, Clinical Features, Investigations & Management

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TYPES OF BLADDER CARCINOMA

• Most common
• Can be papillary or flat
• Papillary: finger-like projections, usually low grade
• Flat (carcinoma in situ/CIS): high grade, aggressive

• Associated with chronic irritation (Schistosomiasis, stones, chronic catheterization)

• Arises from urachal remnant or metaplastic urothelium

• Non-muscle invasive (NMIBC): pTa (papillary, non-invasive), pTis (CIS), pT1 (invades lamina propria)
• Muscle-invasive (MIBC): pT2 (muscle), pT3 (perivesical fat), pT4 (adjacent organs)
• 75-85% present as superficial (NMIBC); rest are muscle-invasive

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ETIOPATHOLOGY

• Arylamines: 2-naphthylamine, benzidine, 4-aminobiphenyl
• Industries: rubber, dye, textile, leather, printing

• Urinary tract infections
• Calculi
• Long-term indwelling catheter (SCC)

• Two molecular pathways:
  1. Low-grade papillary pathway: FGFR3 mutations, chromosome 9 loss (monosomy 9) - low risk of progression
  2. High-grade/invasive pathway: TP53 and RB1 mutations, chromosome 9 alterations - muscle invasion
• GWAS susceptibility loci: 8q24 (MYC), 3q28 (TP63), 5p15.33 (HTERT)

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CLINICAL FEATURES

1. Painless hematuria (gross or microscopic) - cardinal symptom, present in 80-85%
   • Intermittent, total hematuria (throughout stream)
   • "Clot colic" if clots form
2. Irritative voiding symptoms: frequency, urgency, dysuria - suggest CIS or invasive disease
3. Obstructive symptoms: hesitancy, poor stream, retention - if tumor at bladder neck or ureteric orifice
4. Ureteric obstruction: loin pain, hydronephrosis if tumor obstructs ureter
5. Advanced disease: pelvic pain, edema of lower limbs (lymph node/vascular obstruction), fistula formation (vesicovaginal, vesicorectal)

• Often no signs in early disease
• Palpable suprapubic mass (large tumors)
• Bimanual examination: palpable mass, fixity to pelvis (T3-T4)
• Cachexia, lymphadenopathy in metastatic disease

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INVESTIGATIONS

• Dipstick and microscopy: hematuria
• Urine cytology: malignant urothelial cells; sensitivity 40-60% for all grades, 90%+ for high-grade/CIS
• Urine FISH (Fluorescence In Situ Hybridization): detects chromosomal abnormalities
• NMP22 (Nuclear Matrix Protein): tumor marker

• Ultrasound: First-line; detects masses >0.5 cm; evaluates kidneys for hydronephrosis
• CT Urogram (CTU): Investigation of choice; evaluates entire upper tract; detects filling defects, staging
• MRI: Better soft tissue staging, especially muscle invasion (multiparametric MRI)
• IVU (Intravenous Urogram): Filling defect (rat-bite deformity); largely replaced by CTU
• Chest X-ray/CT chest: For metastasis

• Flexible cystoscopy (outpatient): initial evaluation
• Rigid cystoscopy under GA: for TURBT (transurethral resection of bladder tumor)
• Bimanual examination under anesthesia (EUA): staging - palpable mass before and after TURBT
• Blue Light Cystoscopy (Photodynamic diagnosis): hexaminolevulinate - improves detection of CIS

• Diagnostic and therapeutic for NMIBC
• Must include detrusor muscle in specimen for adequate staging

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MANAGEMENT

A. NON-MUSCLE INVASIVE BLADDER CANCER (NMIBC - pTa, pT1, pTis)

• Complete resection of all visible tumors
• Second-look TURBT if: high-grade T1, no muscle in specimen, incomplete initial resection

• Mechanism: local immune activation, T-cell mediated cytotoxicity
• Reduces recurrence by 30-40% and progression by 30-50%
• Contraindicated in active TB, immunocompromised, gross hematuria

• Cystoscopy + urine cytology at 3 months, then every 3-6 months
• Upper tract imaging annually (CTU)

B. MUSCLE-INVASIVE BLADDER CANCER (MIBC - pT2-T4, N0-N3, M0)

• Male: cystoprostatectomy + pelvic lymph node dissection (PLND)
• Female: anterior pelvic exenteration (bladder + uterus + anterior vaginal wall + PLND)

• Ileal conduit (Bricker's): Urine to urostomy bag (most common)
• Orthotopic neobladder (Studer pouch): Ileal reservoir anastomosed to urethra; continence maintained
• Continent urinary diversion (Indiana pouch): Catheterizable stoma

• Cisplatin-based (MVAC or GC) before cystectomy
• Improves 5-year survival by ~5-8%; downstages tumor

• TURBT + radiation + concurrent cisplatin-based chemotherapy
• Selected patients: complete TURBT, single tumor, no CIS, no hydronephrosis
• Alternative to cystectomy in fit patients who refuse surgery

• Adjuvant chemotherapy for pT3/T4 or node-positive disease
• Immunotherapy: Atezolizumab, pembrolizumab (PD-L1 inhibitors) for cisplatin-ineligible metastatic disease

C. METASTATIC BLADDER CANCER

• First-line: Cisplatin + gemcitabine (GC) chemotherapy
• Cisplatin-ineligible: Carboplatin-based or immune checkpoint inhibitors
• Median survival: 13-15 months with chemotherapy

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QUESTION 3 (20 Marks)

Causes of Splenomegaly + Laparoscopic Splenectomy

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PART A: CAUSES OF SPLENOMEGALY

CLASSIFICATION OF CAUSES:

• Acute infections: Typhoid fever (Salmonella typhi), malaria (most common worldwide), infectious mononucleosis (EBV), viral hepatitis, subacute bacterial endocarditis
• Chronic infections: Tuberculosis, brucellosis, leishmaniasis (kala-azar - massive splenomegaly)
• Parasitic: Hydatid disease, schistosomiasis
• Fungal: Histoplasmosis (in immunocompromised)

• Hemolytic anemias:
  • Hereditary spherocytosis
  • Thalassemia (beta-thalassemia major - massive splenomegaly)
  • Sickle cell disease (initially enlarged, later autosplenectomy)
  • G6PD deficiency
  • Autoimmune hemolytic anemia (AIHA)
• Platelet disorders:
  • Immune thrombocytopenic purpura (ITP) - most common indication for elective splenectomy
• Myeloproliferative disorders:
  • Chronic myeloid leukemia (CML) - massive splenomegaly
  • Polycythemia vera
  • Primary myelofibrosis (extramedullary hematopoiesis)
• Lymphoproliferative:
  • Chronic lymphocytic leukemia (CLL)
  • Hodgkin's lymphoma, Non-Hodgkin's lymphoma
  • Hairy cell leukemia

• Portal hypertension (cirrhosis, Budd-Chiari syndrome, portal vein thrombosis)
• Splenic vein thrombosis
• Right heart failure (rare)
• Banti's syndrome (idiopathic portal hypertension + splenomegaly)

• Gaucher's disease (most common - glucocerebrosidase deficiency)
• Niemann-Pick disease
• Amyloidosis
• Sarcoidosis

• Primary splenic lymphoma
• Metastatic tumors (rare)
• Splenic cysts, hemangioma

• Rheumatoid arthritis (Felty's syndrome)
• SLE (systemic lupus erythematosus)

• CML (Chronic myeloid leukemia)
• Leishmaniasis (kala-azar)
• Autoimmune hemolytic anemia
• IMF (Idiopathic myelofibrosis)
• Malaria (chronic hyperreactive malarial splenomegaly)
• Thalassemia

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PART B: LAPAROSCOPIC SPLENECTOMY

INDICATIONS

1. ITP (Immune Thrombocytopenic Purpura) - most common
2. Hereditary spherocytosis
3. Thrombotic thrombocytopenic purpura (TTP)
4. Autoimmune hemolytic anemia (AIHA) - refractory to steroids

CONTRAINDICATIONS

• Uncorrectable coagulopathy
• Severe cardiopulmonary disease preventing pneumoperitoneum

• Massive splenomegaly (spleen >20 cm / >1 kg) - higher conversion rate
• Portal hypertension with perisplenic varices (now increasingly performed with advanced technique)
• Significant obesity
• Previous abdominal surgery with adhesions
• Sickle cell disease with crisis

PREOPERATIVE PREPARATION

• Vaccinations (at least 2 weeks before surgery):
  • Pneumococcal vaccine (most important - S. pneumoniae)
  • Meningococcal vaccine
  • Haemophilus influenzae type b vaccine
• Platelet transfusion (if count <20,000; ideally after ligation of splenic vessels)
• Bowel preparation
• Identify and plan for accessory spleens (present in 10-30% of patients)

PROCEDURE - LAPAROSCOPIC SPLENECTOMY

• Right lateral decubitus (preferred) OR supine, with 45-60 degree tilt
• Kidney rest raised to maximize space between iliac crest and costal margin
• Reverse Trendelenburg position - viscera fall away from left upper quadrant
• Surgeon stands to patient's right; assistants to patient's left

• Insufflation: 1 cm from costal margin at left midclavicular line (12 mmHg CO2)
• Additional trocars: below xiphoid, posterior axillary line (12-mm port), umbilical
• Total 3-4 trocars

1. Explore abdomen for accessory spleens (gastrosplenic ligament, hilum, tail of pancreas, splenocolic ligament, greater omentum, mesocolon, ovary/testis)
2. Mobilize splenic flexure of colon - divide splenocolic ligament
3. Incise lateral peritoneal attachments of spleen (leave ~1 cm peritoneal cuff for grasping)
4. Separate spleen from kidney and diaphragm
5. Enlarge gap between splenic hilum and tail of pancreas
6. Enter lesser sac along medial border of spleen
7. Identify short gastric vessels; ligate and divide
8. Visualize main splenic vascular pedicle
9. Vascular control: Splenic hilum secured with an endoscopic vascular stapler (2-3 applications may be needed)
10. Elevate spleen after all attachments divided
11. Place spleen in endo-bag (organ retrieval bag) and morcellate / extract through trocar site (or small Pfannenstiel incision for large spleens)
12. Inspect for hemostasis

• Spleen "suspends" from diaphragmatic attachments in lateral position - gravity aids retraction
• Splenic hilum under gentle tension - facilitates dissection
• Tail of pancreas closely related to splenic hilum (risk of injury)

COMPLICATIONS

• Hemorrhage (most common cause of conversion to open surgery)
• Injury to tail of pancreas (pancreatitis, pseudocyst, fistula)
• Injury to stomach/gastric fistula (during short gastric vessel ligation)
• Injury to splenic flexure of colon
• Diaphragmatic injury

• Hemorrhage from slipped ligature
• Left basal atelectasis (common)
• Pleural effusion (left-sided)
• Subphrenic collection/abscess
• Pancreatitis

• Postsplenectomy sepsis (OPSI - Overwhelming Post-Splenectomy Infection):
  • Causative organisms: S. pneumoniae (most common), Neisseria meningitidis, H. influenzae, E. coli
  • Risk: 3x increased risk of pneumonia, meningitis, major sepsis
  • Risk is greatest in young patients, those with thalassemia or lymphoma, and those receiving chemoradiotherapy
  • Prevention: Pneumococcal, meningococcal, and Hib vaccines; long-term prophylactic penicillin (especially in children)
• Thrombocytosis: If platelet count >1 x 10^6/mL, prophylactic aspirin recommended
• DVT/PE: increased risk (surveillance)
• Missed accessory spleen (recurrence of hematological disease)

• Reduced hospital stay and cost
• Decreased morbidity and mortality
• Less postoperative pain
• Faster recovery
• Better cosmesis

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QUESTION 4 - Short Notes (30 Marks, 10 each)

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Q4 (1): Impotence - Causes, Management & Recent Trends (10 Marks)

CAUSES / ETIOLOGY

• Performance anxiety, depression, relationship problems
• Stress, psychiatric illness

• Arteriogenic: arteriosclerosis (commonest), hypertension, diabetes, smoking, hyperlipidemia
• Venogenic: failure to occlude venous outflow (venous leak)

• Diabetic autonomic neuropathy
• Multiple sclerosis, Parkinson's disease
• Spinal cord injury
• Radical prostatectomy, abdominoperineal resection (injury to cavernous nerves)
• Pelvic radiation

• Hypogonadism (low testosterone)
• Hyperprolactinemia
• Hypothyroidism, Cushing's syndrome
• Diabetes mellitus (mixed - vascular + neurogenic)

• Peyronie's disease (fibrous plaque)
• Post-priapism
• Penile fracture

• Antihypertensives (beta-blockers, thiazides, methyldopa)
• Antidepressants (SSRIs, TCAs)
• Antipsychotics
• Antiandrogens, GnRH agonists
• Alcohol, tobacco

• Pelvic fracture urethral injury (ED in ~50%, usually severe)
• Perineal trauma

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INVESTIGATIONS

• Detailed history + psychosocial assessment
• Hormone panel: testosterone (early morning), LH, FSH, prolactin, TSH
• Blood glucose, HbA1c, lipids
• NPT (Nocturnal Penile Tumescence) - differentiates psychogenic from organic
• Duplex penile ultrasound (after intracavernous injection) - assesses arterial and venous function
• Selective pudendal arteriography - for young patients considering arterial reconstruction
• SHIM/IIEF questionnaire

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MANAGEMENT

• Weight loss, exercise, smoking cessation, alcohol reduction
• Treat underlying conditions (hypertension, diabetes, dyslipidemia)
• Review and adjust medications

• For psychogenic ED or combined psychogenic component
• Cognitive behavioral therapy, sex therapy, couples therapy

• PDE5 inhibitors (Phosphodiesterase-5 inhibitors):
  • Sildenafil (Viagra) 25-100 mg - 1 hour before
  • Tadalafil (Cialis) 5-20 mg - daily dose or on-demand; longest duration (36 hrs)
  • Vardenafil, Avanafil
  • Mechanism: inhibit PDE5 - NO mediated cGMP accumulation - smooth muscle relaxation - increased blood flow
  • Contraindicated with nitrates (severe hypotension)
  • Efficacy: ~70-80%

• Vacuum Erection Device (VED): External penile pump creates negative pressure; constriction ring maintains erection
• Intracavernosal injection (ICI): Alprostadil (PGE1), Papaverine, Phentolamine ("Trimix")
• Intraurethral prostaglandin: MUSE (Medicated Urethral System for Erection) - alprostadil pellet
• Testosterone replacement (if hypogonadism confirmed)

• Penile prosthesis (implant): Gold standard for refractory ED
  • Inflatable (3-piece: AMS 700) - most natural
  • Semi-rigid (malleable) prosthesis
  • Satisfaction rates >90%
• Vascular surgery: Penile arterial revascularization (young, non-diabetic, arterial ED after perineal trauma)
• Venous ligation (for venous leak) - less successful, largely abandoned

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RECENT TRENDS

1. Low Intensity Shockwave Therapy (LiESWT): Non-invasive; promotes angiogenesis and neovascularization in cavernous tissue; promising for vasculogenic ED; may restore natural erection without drugs
2. Platelet-Rich Plasma (PRP) / "P-shot": Intracavernous PRP injection; growth factors promote tissue regeneration; investigational
3. Stem cell therapy: Intracavernous injection of adipose-derived or bone marrow stem cells; early phase trials showing promise
4. Gene therapy: AAV-vector based delivery of eNOS gene; pre-clinical stage
5. Melanocortin receptor agonists (Bremelanotide/PT-141): Central acting; approved for HSDD in women; being studied in men
6. Topical PDE5 inhibitors: Topical cream formulations under investigation
7. Robotic nerve-sparing prostatectomy: Improved preservation of cavernous nerves, reducing post-prostatectomy ED rates

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Q4 (2): Modalities Available for Breast Reconstruction (10 Marks)

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CLASSIFICATION OF BREAST RECONSTRUCTION

• Implant placed at time of mastectomy (skin-sparing or nipple-sparing mastectomy)
• Suitable for smaller-breasted, non-ptotic patients

• Most common method
• Stage 1: Tissue expander placed at mastectomy; expanded gradually over weeks-months with saline
• Stage 2: Exchange expander for permanent silicone/saline implant
• Implant types: Saline, silicone gel (more natural feel), form-stable "gummy bear" cohesive gel
• Acellular Dermal Matrix (ADM): e.g. AlloDerm - used to reinforce implant pocket, improve definition

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1. TRAM Flap (Transverse Rectus Abdominis Myocutaneous):
   • Uses skin, fat and rectus abdominis muscle from lower abdomen
   • Pedicled on superior epigastric vessels
   • Disadvantages: abdominal wall weakness, hernia, bulge
2. Latissimus Dorsi (LD) Flap:
   • Skin, fat + latissimus dorsi muscle from back
   • Pedicled on thoracodorsal vessels
   • Often combined with implant (insufficient volume alone)
   • Reliable, low failure rate
   • Particularly useful post-radiotherapy

1. DIEP Flap (Deep Inferior Epigastric Perforator):
   • Skin and fat from lower abdomen, perforator vessels only (no rectus muscle)
   • Most popular free flap; better abdominal wall preservation than TRAM
   • Superior aesthetic outcome; natural-looking, warm reconstruction
2. Free TRAM Flap:
   • Similar to pedicled TRAM but anastomosed to internal mammary vessels
   • Better blood supply than pedicled TRAM
3. SIEA Flap (Superficial Inferior Epigastric Artery):
   • Same territory as DIEP but uses SIEA vessels
   • No abdominal fasciotomy required; only suitable when SIEA large enough
4. GAP Flap (Gluteal Artery Perforator):
   • SGAP (Superior Gluteal) or IGAP (Inferior Gluteal)
   • Used when abdominal donor site not available
   • Disadvantage: difficult positioning, shorter pedicle
5. TUG Flap (Transverse Upper Gracilis):
   • Inner thigh tissue
   • Smaller volume; suitable for smaller reconstructions
6. PAP Flap (Profunda Artery Perforator):
   • Posterior thigh tissue; less visible scar than TUG

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• Final stage of reconstruction (3-6 months after main reconstruction)
• Nipple reconstruction: Local skin flaps (CV flap, skate flap, C-V flap technique)
• Areola reconstruction: Tattooing (3D medical tattooing most common today) OR skin graft from inner thigh/opposite areola

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• Autologous fat injected to correct contour irregularities
• Adjunct to all reconstruction types
• May allow implant downsizing or improve capsular contracture
• Increasing role as primary reconstruction for small-breasted patients

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• Combines oncological resection with immediate volume replacement
• For partial mastectomy / breast-conserving surgery
• Volume replacement with local glandular rearrangement or LD mini-flap

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• Patient factors: BMI, smoking, comorbidities, abdominal scars, body habitus
• Cancer factors: stage, need for adjuvant radiotherapy (radiation damages implants - autologous preferred)
• Surgeon expertise
• Patient preference
• Timing: immediate vs. delayed

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Q4 (3): Psoas Abscess - Etiopathology, Investigations & Management (10 Marks)

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CLASSIFICATION

• No identifiable source
• Due to hematogenous spread from occult infection
• Seen in immunocompromised patients, IV drug users
• Organisms: S. aureus (most common), Streptococcus

• Extension from adjacent infection (more common)
• Seen in advanced Crohn's disease (most common in developed countries)

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ETIOPATHOLOGY

• At the start of the 20th century, psoas abscess was mainly caused by Pott's disease (TB of the spine, L1-L4)
• With decline of tuberculosis in developed countries, secondary spread from bowel (Crohn's disease) became predominant
• In developing countries (including India), Pott's disease remains the most common cause

• TB: Mycobacterium tuberculosis (cold abscess - no signs of acute inflammation)
• Pyogenic: Staphylococcus aureus, E. coli, Bacteroides, mixed flora
• Crohn's: enteric gram-negative organisms

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PATHOPHYSIOLOGY

• The iliopsoas muscle is contained within the iliopsoas compartment bounded by psoas fascia
• Pus collects within this fascial sheath
• The abscess tracks distally along the psoas muscle, under the inguinal ligament, and points in the femoral triangle (below and lateral to the inguinal ligament, medial to ASIS)
• It may present as a fluctuant groin swelling

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CLINICAL FEATURES

• Back pain / loin pain (often severe, poorly localized)
• Fever and malaise (lassitude)
• Groin swelling (as abscess tracks distally)
• Hip pain

• Swelling in iliac fossa or groin (fluctuant in pyogenic; may be non-fluctuant "cold" in TB)
• Fixed flexion deformity of hip / antalgic gait (psoas spasm)
• Pain on passive extension of hip (positive psoas sign)
• Fever, tachycardia (in pyogenic)
• In Pott's disease: gibbus deformity (kyphosis), paraplegia, no acute inflammation

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INVESTIGATIONS

• FBC: leukocytosis (pyogenic); lymphocytosis (TB)
• ESR, CRP: elevated
• Blood cultures
• Mantoux test / IGRA (for TB)
• HIV testing
• Pus culture and sensitivity (on drainage)
• AFB smear and culture, PCR for TB

1. CT Scan (Investigation of choice):
   • Defines abscess size, location, and tracking
   • Identifies source (vertebral destruction in Pott's, bowel pathology in Crohn's)
   • Guides percutaneous drainage
   • CT-guided drainage is standard of care
2. MRI:
   • Superior for spinal TB evaluation (cord compression, disc involvement)
   • Better soft tissue detail without radiation
3. Ultrasound:
   • Detects large abscesses; guides drainage
   • Limited by bowel gas
4. Plain X-ray (spine, pelvis):
   • Loss of psoas shadow
   • Vertebral destruction / disc space loss (Pott's disease)
   • Paravertebral soft tissue shadow
5. Barium enema / colonoscopy:
   • Identifies Crohn's disease as underlying cause

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MANAGEMENT

• Pyogenic: broad-spectrum antibiotics (IV piperacillin-tazobactam or carbapenem initially; narrow based on culture)
• TB psoas abscess: Anti-tubercular therapy (ATT) - HRZE for 2 months, then HR for 4-10 months (total 6-18 months depending on spinal involvement)
• Continue antibiotics for 4-6 weeks minimum (pyogenic)

• Minimally invasive, effective
• Large-bore catheter placement under CT guidance
• Suitable for most cases
• May need serial drainage or tube left in situ for complete resolution
• Pus sent for C&S, AFB, histology

• For easily accessible abscesses

• Indicated when:
  • CT-guided drainage fails or is incomplete
  • Multi-loculated abscess not amenable to drainage
  • Need to address underlying cause (e.g., resection for Crohn's disease, debridement for spinal TB)
  • Concurrent source requiring surgery (perforated appendix, perforated colon cancer)
• Approach: retroperitoneal (extraperitoneal) or transperitoneal

• Pott's disease: ATT; posterior spinal stabilization/decompression if cord compromise
• Crohn's disease: Resection of involved bowel segment + abscess drainage; ileostomy may be needed
• Appendicitis/diverticulitis: Appropriate surgical treatment

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• Primary psoas abscess: good with drainage + antibiotics
• Secondary psoas abscess: depends on underlying cause
• TB: excellent with complete ATT
• Crohn's: recurrence possible if bowel disease not controlled

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Summary of Answers

Q1 - Urethral Injuries (30 marks) ✅

• Classification: Posterior (PFUI with pelvic fracture) vs. Anterior (straddle/bulbar); Goldman grading
• Etiology: Pelvic fractures, straddle injury, iatrogenic catheterization
• Clinical features: Classic triad (blood at meatus, retention, butterfly hematoma), high-riding prostate
• Investigations: RUG (gold standard), CT pelvis, cystoscopy
• Management: SPT (AUA preferred), single blind catheter attempt, endoscopic realignment, delayed urethroplasty (3-6 months); complications - stricture (45-100%), ED (~50%)

Q2 - Carcinoma Bladder (20 marks) ✅

• Types: TCC (90-95%), SCC, Adenocarcinoma; NMIBC vs. MIBC staging
• Etiopathology: Tobacco (most important), aromatic amines, schistosomiasis (SCC), cyclophosphamide, radiation; molecular pathways (FGFR3 vs. TP53/RB1)
• Clinical features: Painless hematuria (cardinal), irritative symptoms, ureteric obstruction
• Investigations: Urine cytology, CTU, Cystoscopy + TURBT (gold standard)
• Management: TURBT + intravesical BCG/mitomycin for NMIBC; radical cystectomy + neoadjuvant chemo for MIBC; immunotherapy (pembrolizumab) for metastatic disease

Q3 - Splenomegaly + Laparoscopic Splenectomy (20 marks) ✅

• Causes: Infective (malaria, kala-azar), hematological (ITP, spherocytosis, thalassemia, CML), congestive (portal hypertension), storage disorders (Gaucher's)
• Laparoscopic splenectomy: Indications, contraindications, pre-op vaccinations, step-by-step technique (lateral decubitus, vascular stapler at hilum, endo-bag extraction), complications (OPSI, hemorrhage, pancreatic injury, thrombocytosis)

Q4(1) - Impotence (10 marks) ✅

• Causes: Psychogenic, vasculogenic (most common organic), neurogenic, endocrine, drug-induced
• Management: Lifestyle → psychotherapy → PDE5 inhibitors (sildenafil/tadalafil) → VED/ICI → penile prosthesis
• Recent trends: LiESWT, PRP, stem cell therapy, gene therapy, robotic nerve-sparing surgery

Q4(2) - Breast Reconstruction (10 marks) ✅

• Implant-based: tissue expander + implant (most common), direct implant
• Autologous flaps: LD flap (pedicled), TRAM (pedicled), DIEP (gold standard free flap), SIEA, GAP, TUG, PAP
• Adjuncts: fat grafting, nipple-areola tattooing, oncoplastic techniques

Q4(3) - Psoas Abscess (10 marks) ✅

• Etiopathology: Primary (hematogenous - S. aureus) vs. Secondary (Pott's disease in developing countries; Crohn's disease in developed world)
• Tracking along psoas to femoral triangle; "cold abscess" in TB
• Investigations: CT scan (gold standard), MRI for spinal TB, AFB/IGRA
• Management: ATT/antibiotics + CT-guided percutaneous drainage (first-line) → surgical drainage if failed; treat underlying cause