M.S. (Branch I) General Surgery - Paper III | September 2018

PAN-9106 | Total Marks: 100

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Question 1 (20 Marks)

A 48-year-old male with history of blood in urine - Causes and Management of Hematuria

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Definition and Classification

• Initial stream hematuria - Urethral or prostatic source
• Total (throughout stream) hematuria - Bladder, ureter, or kidney
• Terminal hematuria - Bladder neck or posterior urethra

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Causes of Hematuria in a 48-year-old Male

Surgical / Urological Causes (most important in this age group):

• Transitional cell carcinoma (TCC) of bladder - commonest
• Renal cell carcinoma
• TCC of ureter/renal pelvis
• Prostatic carcinoma

• Stone passing through ureter causes hematuria with colicky pain
• Renal/ureteric stones - often associated with pain

• Common in 48-year-old male; causes obstructive LUTS + hematuria

• Bacterial cystitis, tuberculosis of urinary tract
• Schistosomiasis (endemic areas)

• Renal injury, bladder rupture, urethral injury

• Glomerulonephritis (IgA nephropathy - Berger's disease)
• Polycystic kidney disease
• Renal artery embolism / infarction

• Arteriovenous malformations
• Renal vein thrombosis

• Urethral stricture, urethral caruncle
• Papillary necrosis (analgesic abuse, diabetes, sickle cell)
• Anticoagulant therapy
• Radiation cystitis
• Instrumentation / post-urologic manipulation

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Investigations

1. Urine microscopy - confirm true hematuria (>3 RBCs/HPF); urine dipstick alone not sufficient
2. Urine culture & sensitivity - exclude UTI
3. Urine cytology - screen for malignant cells (TCC)
4. Urine for AFB - if TB suspected

• CBC, BUN, creatinine, PSA (prostate-specific antigen in 48-yr male)
• Coagulation profile (PT, aPTT)
• Serum electrolytes

• Ultrasound abdomen/pelvis - first-line; detects masses, calculi, hydronephrosis
• CT Urogram (CECT) - gold standard; 3-phase CT detects tumors, calculi, vascular lesions
• IVU (Intravenous Urogram) - filling defects, obstruction
• MRI Urogram - if CT contraindicated

• Mandatory in adults with gross hematuria (especially >35 years)
• Direct visualization of bladder and urethra
• Biopsy of suspicious lesions
• Retrograde pyelography if upper tract lesion suspected

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Management

• Treat underlying UTI with appropriate antibiotics
• Hydration and bed rest for stone-passing episodes
• Catheter drainage if clot retention develops

• 3-way Foley catheter irrigation
• Bladder washout with saline
• If persistent - cystoscopy and clot evacuation

Key Point (Campbell-Walsh Urology): "The most common cause of gross hematuria in a patient older than 50 years of age is bladder cancer." Hematuria in this age group demands a full urologic evaluation per AUA guidelines, including upper tract imaging and cystoscopy.

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Question 2 (20 Marks)

12-year-old boy with empty scrotum since birth - Management of Cryptorchidism (Undescended Testis)

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Definition

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Embryology and Pathogenesis

• Testis develops from urogenital ridge in 5th-6th week of embryonic life
• Descends retroperitoneally, through inguinal canal, into scrotum in the 7th-8th month of intrauterine life
• At birth: 95% of infants have testes in scrotum
• Incidence: ~30% in preterm, 1-3% at term
• Testes that remain absent from scrotum after 3 months of age are unlikely to descend spontaneously

1. Abdominal (above internal inguinal ring)
2. Canalicular (in inguinal canal)
3. At external ring / High scrotal
4. Ectopic (superficial inguinal pouch, perineum, femoral triangle, base of penis) - passed external ring but in abnormal position

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Complications of Untreated Cryptorchidism

1. Infertility - Most significant complication
   • Histological changes begin from 1 year of age (reduced spermatogonia)
   • Bilateral cases: very high risk of infertility
   • Even after orchidopexy, fertility may not be normal
   • Higher temperature outside scrotum impairs spermatogenesis
2. Malignant degeneration (Testicular cancer)
   • 10-40x increased risk vs general population
   • Seminoma is most common
   • Risk NOT eliminated by orchidopexy but detection facilitated (scrotal position allows self-examination)
3. Inguinal hernia - Patent processus vaginalis present in ~90%
4. Testicular torsion - Higher risk due to abnormal attachment
5. Psychological impact - Empty scrotum in developing male

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Evaluation

• Bilateral or unilateral? Duration?
• Previous surgery/hormonal therapy?
• Associated hypospadias, micropenis (suggests disorder of sex development)

• Examine in warm room, child relaxed, supine then sitting cross-legged (reduces cremasteric reflex)
• Palpable testis (>70%): Can often be felt in inguinal canal
• Non-palpable testis (~30%): Challenges diagnosis

• Retractile testis - Mobile due to cremasteric reflex; can be milked to bottom of scrotum; normal scrotal development; requires yearly follow-up as 2-50% may become acquired undescended testis
• True undescended testis - Scrotum underdeveloped; cannot be milked to bottom; requires orchidopexy
• Absent testis (monorchism/anorchism) - Vanishing testis syndrome

• Ultrasound - High PPV for inguinal testes; only 45% sensitivity for non-palpable testes
• MRI - Greater sensitivity/specificity for non-palpable testes; may need anesthesia in children
• CT scan - Avoided due to radiation in children
• Diagnostic laparoscopy - Gold standard for non-palpable testis (can also be therapeutic)
• Hormonal tests: FSH, LH, testosterone, AMH (anti-Mullerian hormone to confirm testicular tissue); HCG stimulation test
• Chromosomal karyotype - If bilateral non-palpable testes (rule out 46,XX DSD or Turner variants)

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Management

A. Hormonal Treatment (Limited role)

• hCG (Human Chorionic Gonadotropin): 500-1000 IU IM twice weekly for 5 weeks
• GnRH analogue (Buserelin): Intranasal
• Success rate only 15-20%; more effective for bilateral cases or retractile testes
• If no descent after 1 month of therapy - proceed to surgery

B. Surgical Treatment - Orchidopexy (DEFINITIVE)

• Stage 1: Division of testicular vessels (laparoscopic); allows collateral blood supply (deferential artery) to develop
• Stage 2: (6 months later) Bring testis to scrotum using deferential vessels

• Groin + scrotal incision
• Identify testis in inguinal canal
• Mobilize vas deferens and testicular vessels
• Repair associated hernia (patent processus vaginalis)
• Create dartos pouch between dartos muscle and skin of scrotum
• Fix testis in dartos pouch (orchidopexy)

• Diagnostic laparoscopy first
• If viable testis found: laparoscopic orchidopexy or Fowler-Stephens procedure
• If testicular nubbin/absent: remove remnant (risk of malignant transformation in dysgenetic gonadal tissue)

• Both testes should be secured
• Semen analysis and hormone levels should be obtained at appropriate time
• Psychological counseling
• Long-term follow-up for regular testicular self-examination (even after orchidopexy, malignancy risk persists)

(Bailey & Love's Short Practice of Surgery, 28th Ed.; Schwartz's Principles of Surgery, 11th Ed.)

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Question 3 (20 Marks)

Pathophysiology of Head Injuries

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Classification of Head Injuries

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PRIMARY BRAIN INJURY MECHANISMS

1. Direct Focal Injury (Contact Forces)

2. Coup-Contrecoup Injury (Inertial Forces / Acceleration-Deceleration)

• Initial blow accelerates skull against the floating brain (in CSF)
• Brain accelerates to match skull speed
• When skull stops abruptly - brain continues onward and strikes the inner table of skull opposite the original blow site
• Named after Courville (first described) and documented by Gurdjian (high-speed films in monkeys)
• If occipital blow: frontal and temporal lobe damage is worse because skull has narrow angles at frontal/temporal poles
• Even without parenchymal injury: movement shears olfactory nerve fibers through the cribriform plate causing anosmia

3. Diffuse Axonal Injury (DAI) - Shear Forces

• Rotational acceleration causes shearing forces on long axonal tracts
• Long axis of brainstem is at ~80° angle to forebrain - vulnerable to shear
• Axonal retraction balls and microglial clusters in white matter
• Hemorrhagic injury to corpus callosum and dorsal mesopontine junction (hammered against free edge of falx and tentorium)
• Responsible for prolonged unconsciousness
• Gennarelli et al. experiments: lateral rotational acceleration caused most severe and prolonged coma
• Detectable by: Diffusion Tensor Imaging (DTI-MRI) - reduced fractional anisotropy; MRS - reduced N-acetylaspartate, elevated choline/creatinine

4. Concussion

• Brief LOC: Shearing forces transiently applied to the ascending arousal system at the mesodiencephalic junction
• Neurochemical cascade: Abrupt neuronal depolarization → massive glutamate release → K⁺ efflux from cells + Ca²⁺ influx → spreading cortical depression
• Alterations in cerebral blood flow and glucose metabolism
• Impaired neuronal and axonal function

• Retrograde amnesia (events before injury)
• Post-traumatic (anterograde) amnesia (events after injury)

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SECONDARY BRAIN INJURY MECHANISMS

1. Cerebral Edema

• Edema increases Intracranial Pressure (ICP)
• Monroe-Kellie doctrine: Volume of brain + blood + CSF = constant; any increase in one → decrease in others or ↑ ICP

2. Raised Intracranial Pressure (ICP)

• Normal ICP: 0-15 mmHg
• ICP >20 mmHg = raised; requires treatment
• Cerebral Perfusion Pressure (CPP) = MAP - ICP
• CPP <70 mmHg → cerebral ischemia
• Cushing's reflex (triad of raised ICP): Hypertension + bradycardia + irregular respiration (ominous sign)

3. Brain Herniation Syndromes

4. Post-traumatic Hemorrhage

5. Excitotoxicity and Calcium Influx

• Massive glutamate release → NMDA receptor activation
• Excessive Ca²⁺ influx → mitochondrial dysfunction, caspase activation → apoptosis
• Free radical production → lipid peroxidation of cell membranes

6. Post-concussion Syndrome

• Headache, dizziness, irritability, memory and attention difficulties
• Follows mild/repeated concussions
• May involve psychological factors
• Particularly after repeated concussions (Chronic Traumatic Encephalopathy - CTE)

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Management Principles (Brief)

1. ATLS protocol - Airway, Breathing, Circulation first
2. CT head - initial investigation of choice
3. ICP monitoring - if GCS ≤8
4. Maintain CPP >60-70 mmHg
5. Head elevation 30°, avoid hypoxia/hypotension
6. Osmotherapy - Mannitol 20%, hypertonic saline
7. Surgical evacuation of EDH/SDH when indicated
8. Decompressive craniectomy for refractory raised ICP

(Plum and Posner's Diagnosis and Treatment of Stupor and Coma)

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Question 4 (30 Marks) - Write in Brief

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Q4(1) - Various Treatment Modalities for Urinary Bladder Stone (10 Marks)

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Presentation

• Intermittent hematuria, dysuria, suprapubic pain
• Interruption of urinary stream (ball-valve effect) - relieved by change of position
• Strangury, recurrent UTI

Investigation

• Plain X-ray KUB (80% radiopaque - oxalate, phosphate, cystine stones)
• Urine R/M, culture
• USG bladder
• CT KUB - most sensitive
• Cystoscopy - diagnostic and therapeutic

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Treatment Modalities

• Increased fluid intake
• Treat underlying cause (UTI, BPH)
• Small stones (<5mm) may pass spontaneously with alpha-blockers (tamsulosin)
• Urinary alkalinization for uric acid stones (sodium bicarbonate, allopurinol)

• Limited role for bladder stones
• Less effective (stone mobility in bladder reduces targeting)
• Used occasionally for small stones in poor surgical candidates

• Suprapubic cystostomy approach (Pfannenstiel or midline incision)
• Indications:
  • Very large stones (>4 cm)
  • Multiple large stones
  • Failed endoscopy
  • Concurrent BPH requiring open prostatectomy (Freyer's / Millin's)
  • Pediatric patients with narrow urethra
  • Associated bladder pathology requiring repair

• Percutaneous suprapubic approach
• Reserved for cases where urethral approach not possible (urethral stricture, children)

• BPH: Alpha-blockers, 5-ARI; TURP/open prostatectomy
• Urethral stricture: Urethral dilatation, optical urethrotomy, urethroplasty
• Removal of foreign body if present
• Dietary modification: low oxalate/calcium diet, increased fluid intake

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Q4(2) - Bilateral Hydronephrosis (10 Marks)

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Causes of Bilateral Hydronephrosis (Obstruction below ureterovesical junction)

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Pathogenesis

1. Obstruction → continued glomerular filtration → rising pressure in collecting system
2. Pressure transmitted retrograde → compresses renal vasculature → arterial insufficiency + venous stasis
3. Papillae affected first (most pressure) → initial tubular dysfunction (impaired concentration)
4. Later → glomerular filtration decreases
5. Obstruction may trigger interstitial inflammatory reaction → progressive interstitial fibrosis
6. With subtotal obstruction: massive dilatation (kidney up to 20 cm); parenchyma compressed
7. With complete sudden obstruction: early GFR compromise; less dilatation

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Clinical Features

• Symptoms often due to the underlying cause (bilateral cases)
• Dull loin ache or sense of weight
• Dietl's crisis: Intermittent severe pain + large urine output + reduction in swelling (intermittent obstruction)
• Progressive renal failure (azotemia, uremia)
• Bilateral palpable renal masses (cystic, ballottable, bimanually palpable)
• Features of BPH: nocturia, hesitancy, dribbling, weak stream
• Hypertension

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Investigations

• Ultrasound - Least invasive; first-line; detects dilated pelvicalyceal system
• IVU / CT Urogram - Delineates level and cause of obstruction; delayed films (6-hour films) needed
• CT KUB - Stone detection
• Retrograde pyelography - If pelvis/calyces not seen on IVU
• Isotope renography (MAG3/DTPA) - Quantifies obstruction; measures split renal function
• Whitaker test - Intrapelvic pressure measurement; specialized units
• Cystoscopy - To evaluate bladder and ureteric orifices
• Serum creatinine, BUN - Assess renal function

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Management

• Bilateral ureteric JJ stents (antegrade or retrograde)
• Or percutaneous nephrostomy (PCN) bilaterally
• Dialysis if severe renal failure

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Q4(3) - Haemothorax (10 Marks)

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Causes

• Blunt chest trauma (rib fractures, lung laceration)
• Penetrating trauma (stab wounds, gunshot wounds)
• Iatrogenic (subclavian line insertion, thoracocentesis, biopsy)

• Ruptured aortic aneurysm
• Thoracic tumors (primary lung cancer, metastatic, pleural mesothelioma)
• Coagulopathy / anticoagulant therapy
• Pulmonary embolism with infarction
• Ruptured arteriovenous malformation
• Haemophilia / bleeding disorders

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Pathophysiology

• Blood enters pleural space → lung compressed → atelectasis → hypoxia
• Mediastinal shift to opposite side → impairs venous return → obstructive shock
• Blood in pleural cavity stimulates fibrinolysis initially, but in large volumes → fibrothorax (organized clot → fibrous peel over lung → trapped lung → restrictive defect)
• Empyema thoracis may develop if blood becomes infected

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Clinical Features

• Chest pain (pleuritic or constant)
• Dyspnoea, tachypnoea
• History of trauma
• Haemoptysis (if lung laceration)
• Shock (in massive haemothorax)

• Tachycardia, hypotension (shock in massive)
• Tracheal deviation to opposite side (tension haemothorax)
• Reduced chest expansion on affected side
• Stony dull percussion note (contrast with hyper-resonance in pneumothorax)
• Absent/reduced breath sounds on affected side
• Shifting dullness

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Investigations

1. CXR - Opacification of hemithorax; blunting of costophrenic angle (needs >200 mL); fluid level
2. Ultrasound chest (FAST/EFAST) - Detects as little as 20 mL; immediate bedside diagnosis in trauma
3. CT chest - Gold standard; delineates extent, associated injuries, retained haemothorax
4. Diagnostic thoracocentesis - Aspirated blood to confirm; haematocrit >50% of peripheral blood confirms haemothorax
5. CBC, coagulation profile, cross-match blood

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Management

• ATLS protocol: Airway, Breathing, Circulation
• High-flow oxygen (15 L/min), IV access (2 large-bore), IV fluids / blood products
• Cross-match 4-6 units packed RBCs

• Indication: All cases of haemothorax requiring drainage
• Site: 5th intercostal space, anterior axillary line (safe triangle: bordered by anterior border of latissimus dorsi, lateral border of pectoralis major, a horizontal line at level of nipple)
• Large-bore drain (28-32 Fr) - to prevent clotting
• Drain to underwater seal / suction
• Monitoring: Immediate drainage >1500 mL, or continued bleeding >200 mL/hour for 4 hours → consider thoracotomy

• For clotted haemothorax / organized clot not cleared by ICD (within 7-10 days)
• For empyema following haemothorax
• Less morbid than open thoracotomy

• Indications:
  • Initial drainage >1500 mL
  • Continued blood loss >200 mL/hour for 4 hours
  • Haemodynamic instability despite drainage
  • Cardiac tamponade not relieved by pericardiocentesis
  • Massive air leak
  • Retained haemothorax unresponsive to VATS
• Approach: Posterolateral thoracotomy or anterolateral (emergency room thoracotomy for arrest)
• Control bleeding source (intercostal vessels, lung laceration, hilar vessels, heart)

• Intrapleural streptokinase / urokinase via chest drain
• For late-presenting clotted haemothorax (alternative to VATS)
• Limited evidence; associated with risk of re-bleeding

• Coagulopathy: FFP, platelets, Vitamin K
• Tumors: Chemotherapy / radiotherapy / pleurodesis
• Aortic aneurysm: Vascular surgery / TEVAR

• Chest physiotherapy (prevent fibrothorax)
• Repeat CXR to confirm resolution
• Spirometry at 6 weeks if significant haemothorax

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Sources: Campbell-Walsh-Wein Urology (10th/12th Ed.); Bailey & Love's Short Practice of Surgery (28th Ed.); Schwartz's Principles of Surgery (11th Ed.); Plum & Posner's Diagnosis and Treatment of Stupor and Coma; Robbins & Kumar Basic Pathology; S. Das Manual on Clinical Surgery (13th Ed.)

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Paper Summary

• Q1: Always mention AUA guidelines mandate cystoscopy + upper tract imaging in adults; the phrase "most common cause of gross hematuria in >50 year = bladder cancer" is a high-yield examiner favorite
• Q2: Emphasize that histological damage begins at 1 year of age - orchidopexy should be done by 12-18 months; the 12-year-old has significant delay with implications for fertility
• Q3: The primary vs. secondary injury distinction, DAI mechanism, coup-contrecoup, and the "talk and die" phenomenon (lucid interval) carry maximum marks; include the Monroe-Kellie doctrine and herniation syndromes
• Q4(1): Always mention treatment of the underlying cause (BPH/stricture) alongside stone removal or recurrence is guaranteed
• Q4(2): "Bilateral hydronephrosis = obstruction BELOW ureters" is a classical examiner test point
• Q4(3): Initial drain >1500 mL or continued >200 mL/hour for 4 hours are the standard thoracotomy thresholds - must mention these numbers