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 CLINICAL QUESTIONS

Q. 34 year old male presents to the OPD w ith complaints of abdominal pain and bleeding per rectum. On further evaluation
patient w as found t o have multiple polyps in the intest ine. The patient gives a family history of Gardner's syndrome in his
father. The most common facial abnormality in Gardner's syndrome is:

A .Ect odermal dysplasia

B. Odont ome
C. Mult iple osteomas
D. Dent al cyst s

Answer:C

Solution
Gardner's syndrome
• It is a variant of Familial adenomatous polyposis
• Autosomal dominant condition
• Associated with
o Osteoma (MC bone involved-+Mandible)

The osteomas are characterized by slow, continuous growth, and occur most frequently in the mandible, the outer cortex of
the skull and the paranasal sinuses
• Congenital hypertrophied retinal pigmented epithelium
• Desmoid tumors
• Sebaceous cyst
• Benign lymphoid polyposis of ileum
• Supernumerary teeth (extra teeth)

161
El!] ILEOSTOMY & COLOSTOMY II
• Colostomy: Exteriorization of colon to abdominal skin Types of lleostomies
• lleostomy: Exteriorization of ileum to the abdominal skin 1. End
2. Loop
Most common Indications for Stoma Formation 3. Double Barrel
• Colorectal cancer
• Chronic ulcerative colitis
• Crohn's disease
e
Types of stomas

stoma
• Temporarystoma
o To divert fecal matter
<!:J 00:01:48
• Stoma is of two types- Temporary stoma and Permanent End
stoma

1. End ileostomy
Loop
stoma -/ Two stomas

o Are usually Loop stoma

• Permanent stoma
o Are usually End stomas

Location ofileostomy
• Rightiliacfossa
End Loop
ileostomy ileostomy J-pouch
• • y I I 1

Transverse colostomy f -+ - - 0
{in right upper quadrant)
I • Proximal one end is taken out and the distal end is closed
and placed inside the abdomen
• Usually, Permanent stomas
lleostomy +--+-- -~
{in right iliac fosso) -O I Sigmoid colostomy
(In left Iliac fosso)

2. Loop lleostomy
\ii • Loop of small intestine is brought th~~ld9 Q~,a.~.QP,men
Sites of Stoma Formation
and cut before suturing. -89,n04a soa 39

• Has 2 external stomas joined together

• Usually Temporary stomas (for fecal diversion)
Location of transverse colostomy
• Temporarycolostomy 3. Double barrel ileostomy
• Rightupperquadrant • 2 separate openings with skin bridge in between

Location of Sigmoid colostomy Stomal Complications 0 00:10:11

• Permanentcolostomy
Early complications Late complications
• Left iliac fossa
lleostomy Colostomy • Seen within 1 • S - Seen after 1

• Spouted • Flush month month

• Effluent is liquid and so it is • Effluent is Solid and so • R - Retraction • S - Stenosis

made spouted. it is made flush • A-Abscess • P - Prolapse

• Maximum risk of • P - Poor location • P - Parastomal
Dyselectrolytemia • I - lschemia/ hernia

(because effluent is Liquid) necrosis • G - Gas

162
 • D - Detachment • 0 - Odor • MC complication of both end colostomy and loop
dermatitis • 0 - Obstruction colostomy - Parastomal hernia
• Prolapse is more common in LOOP colostomy (due to
• 0 - Opening w rong
larger opening)
end, Output is high
• Parastomal hernia is more common in END colostomy
(due to extensive dissection)
• MC early complication of ileostomy- lschemia / necrosis
• Overall M/c complication of ileostomy - Skin excoriation/
dermatitis

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nee'4n/11410@gma~ com
9177().1860839

163
Ell INFLAMMATORY BOWEL DISEASE - 1

l11fhunorntory Bowol dlaeosc (18D) c!) 00 00 13 • Infectious agents that are proposed to be causative
• ll '•., 111 lrll<11.rn thlc c:h1 onlc lnflnmmntory di sonso agents arc
• Cl111 1 " ( I P 1lzrrl hy Chronic rPlnpslng course <1 Mycobacterium Paratuberculosis
1v1c 111 rh'v<'lnp<'d c:ollnlrlcs o Measles
• MC' In r rrnnlrs (OCP llSO) • CARD- 15/NOD- 2 mutation (Located on chromosome
• 11,,.-: Rtmorl nl rJlstribullon 16q)
l ntV31d D<'cnde o Aka IBD- 1 Locus
, ~th/7 th D<'cOci<' o Relatively specific for Crohn's disease
• C1o t1 n'-: ci, srnsc is more common in Smokers whereas
Smol..lnA is p1 o tcctlvc in Ulcerative colitis
• r tlology Unknown

Risk foctors
* •
Important Information
Organism rt.sponslblt. for Ulct.rativt. colitis,
• Positive fomlly history (Greatest Risk factor) Clostridium dlf'ficilt. and Campylobactt.r
• Genetic susceptibility - 3 Genes implicated are • 18D-2 Locus (Locatf.d on chromosomt.12q) - MC
, NOD - 2 (Nucleotide Oligomerization Domain - 2) In Ulct.rativt. colitis
,, ATG - 16 L- 1 (Autophagy related 16 Like 1)
,, IRGM (Immunity related GTPase M) Pathology c!) 00:13:35
• Oth crfoctors responsible are • Earliest Gross pathologic lesion - Superficial aphthous
1.~ Alteration in host interaction with intestinal micro- ulcer in Mucosa
organisms • Diseased bowel is separated by areas of grossly normal
l) Altered Gut Micro- Biota bowel - known as Skip lesions
,~ Intestinal epithelial dysfunction • Extensive fat wrapping caused by circumferential growth
o Aberrant Mucosa I immune response of mesenteric fat around the bowel wall - known as
Creeping fat
CROH N'S DISEASE (CD) c!) 00:06:22 • Has Thick, Firm, Rubb611i¥i&aJmgst:in,compressible Bowel
• Chronic Transmural inflammatory disorder of GIT with wall e- 9 1no40so039

unknown etiology • One part of bowel gets attached with the other part of
• Can involve any part - From mouth to anus bowel & form fistula
• MC sites involved • In Crohn's disease there can be
o Ileum o Entero enteric
o lleocecal valve o Entero cutaneous
o Cecum o Entero vesicle fistula
• Upper GI Crohn's disease there is involvement of- Gastric • Mesentery of involved bowel gets thickened
antrum & Duodenum • Linear ulcers collides & forms Transverse ulcers with
• In patients of Colonic disease - Rectal sparing is islands of normal mucosa in between
characteristic in Crohn's
• In Crohn's disease, involvement of Cobblestone appearance
o Small intestine+ Large intestine - seen in 55% cases Colon cross-section

'\
o Only small intestine - 30% cases
o Only Large intestine - 15% cases
• Attacks young adults - 2nd/3rd decade
• MC in Females (OCP use), Smokers & Urban dwellers

Etiology
• Unknown

164
 Normal colon o Perforation - Leads to formation of Internal fistu la
• Fistula occurs in
o Sites of Perforation & Adjacent organs
Creeping fat
o Sites of Previous Laparotomy
• In Long standing CD
o Increased risk of malignancy in - Small intestine &
Large intestine (Colon)
• In Anus & Perianal involvement
o Fissures
o Fistula
Crohn's disease colon o Strictures
o Perianal abscess
• lnCD - MCsiteof
e-
neelesh1410@gma,I com
917704860839
o E/c fistula & E/v fistula }
o Ulcers/Strictures Ileum
o Carcinoma

Investigations
• IOC for Dx of CD - CT Enteroclysis
• Earliest Radiographic finding in CD - Aphthous ulceration
• Other Radiologic findings
o Deep ulcers
o Hose-pipe Appearance (Long stricture extending into
1/C valve with Thickened wall) - Corresponds to String
sign of Kantor
o Fat Halo sign
o Raspberry Thorn / Rose Thorn appearance - Linear
Transmural fissure I ulcer
o Creepingfatsign
o Combsign
o Cobble stone appearance - Deep fissuring ulcers
around inflamed mucosa

On Microscopic examination
• Inflammatory reactions
o Extensive edema -widening of sub mucosa
o Hyperemia
o Lymphangiectasia
o Distortion of mucosa I architecture
o Paneth cell hyperplasia
• Characteristic histologic lesion in Crohn's - Non
Caseating granuloma with Langerhans giant cells
• These Non- Caseating granulomas are located - both in
Bowel wall & Regional Lymph nodes

Clinical features (!J 00:23:28

• MC symptom - )ntermittent colicky lower abdominal pain
> Diarrhea (Intermittent)
• In CD (As compared to UC)
o Fewer bowel movements
o Stool rarely contains mucus, pus, & Blood
• Main intestinal complication of Crohn's disease
o Obstruction

165
Serology Pathology
• ASCA (Anti- Saccharomyces Cerevisiae Antibody) - • lnUC
Relatively Specific for CD o Mucosa+ Submucosa only involved
• P-ANCA (Perinuclear Anti - Neutrophil Cytoplasmic o Muscularis Propria - spared
Antibodies) - RelativelySpecificforUC • Typical Gross appearance in UC - Hyperemic mucosa
o Hyperemic mucosa is responsible for fine mucosal
Extra Intestinal manifestations of CD ('.!) 00·37:07 granularity (Earliest Radiographic finding)
• Rectal involvement / Proctitis - Hall mark of UC (+ in
Refer Table 21.1 100%pts.)
• Disease starts from Rectum - Extends Proximally (It is
continuous)
Previous Year's Questions • Pseudo polyps are MC in UC (UC > CD)

Q. Which state.mt.nt Is not true. re.gar-ding Crohn's

-
dise.ast.? (NEET Jan 2018)
A. Re.ctum Is not lnvolvt.d
8. Continuous lt.slon visuallzt.d in t.ndoscop~
C. Noncast.atlng granulomas
D. Cobble.stone. appt.aranct.

ULCERATIVE COLITIS ('.!) 00:44:00 • Most characteristic lesion of UC - Crypt Abscess (Not
• There is proctocolitis specific for UC)
o Only involvement of rectum: proctitis o Also seen in CD & Infectious colitis
o In l0to 20 %there is backwash ileitis
Normal colon Ulcerative colitis
• Rectum is involved in 100% cases
• MC in developed countries
• Usually occur in Age< 30 years (Young adults)
• MC in Females (OCP's use) Affects
mucosal
• Smoking is protective layer
only
• Appendectomy decreases the risk of UC
• MC in Whites, Jews & Persons of Northern European
Ancestry

Goblet Absence of Crypt

Cells Goblet cells Distortion
and abscess

• Important Characteristic feature of Chronic UC - Crypt

Oolconllng
Branching
cdon
• Patients of UC has
o !Sed No. of Goblet cells
o !Sed Mucus production

Clinical features
Etiology • Includes
• Unknown o Diarrhea
• Infectious agents Implicated are o Rectal bleeding
o Clostridium Difficile o Tenesmus
o Campylobader Jejuni o Passage of mucus
• Riskfactors o Crampy abdominal pain
o Family history: Significant risk • Diarrhea & Bleeding: intermittent
o Smoking: Protective • Rectal involvement: 100% cases
o Appendectomy: !ses risk of UC • Anal involvement: Rare

166
Investigations
• Labfindings
o j CRP, j ESR, jPlatelet count
o !Hb
• Local inflammatory markers
o Fecal lactoferrin - highly Sensitive & Specific marker
for Intestinal inflammation
o Fecal calprotectin
Levels correlate well with histologic inflammation
Predict relapses (l)
Detect Pouchitis U)
o Fecal lactoferrin & Fecal calprotectin - Helps to rule out
Active inflammation Vs Irritable bowel or Bacterial Modified Truelove and Witts severity index 0 01:05:41
overgrowth • Done for Disease severity grading of UC
• Serology
o P - ANCA -+ Specific for UC Extra intestinal manifestations of UC (!) 01:06:48
• Colonoscopy 1. Arthritis
o Done to pts. Not having Acute flare 2. Ankylosing spondylitis
o Used to assess the disease extent & activity 3. Erythema nodosum
o Earliest finding - !sed vascularity with Erythematous & 4.Pyoderma gangrenosum }
Edematous mucosa More common in UC
• Radiological findings
o Earliest change- Fine mucosal granularity . I
fash
neeleshl d 10@gma,I com
911.1od86Cl839I • •
than Crohn's ds.
5. Pnmary sc erosing cno ang1t1s
o Collar button ulcers - Deep ulcers (ulcer has
penetrated the mucosa)
• Radiological findings in End stage/ Burnt out UC
o Shortening of colon
o Loss of normal Redundancy - in Sigmoid region,
Splenic & Hepatic flexure
o Ahaustral colon-also known as
Pipe stem colon
Lead pipe sign
Garden hose appearance
Stove pipe sign
o Featureless mucosa
o Narrow caliber of bowel
• Backwash ileitis - seen in 15 - 20% cases of UC
o On Barium enema
Fixed Patulous 1/C Valve
Dilated granular Terminal ileum

167
 Table 21.1

1. Skin 2. Eyes
• Erythema nodosum • lrit is
• Erythema mult iforme • Uveit is
• Pyoderma gangrenosum • Conjunct ivitis

3. Blood 4. Joints
• A nemia • Peripheral Arthritis
• Thrombocytosis • Ankylosing spondylitis
• Phlebothrombosis
• Arterial thrombosis

5. Liver 6. Kidney
• Non - specific Triaditis • Nephrotic syndrome
• Primary sclerosing cholangitis
• Cholesterol gall stones

7. Urological 8. Pancreas,elesh1410@gma,I com

-0m
917704860839
• Stones (MC type - Oxalate stones) • Pancreatitis
• Ureteral obstruction
• Entero-vesical fistula

9. Amyloidosis

• MC cutaneous manifestations of IBD - Erythema Nodosum

• Erythema Nodosum
o Most Responsive for Rx of Bowel disease
o Persistence of Erythema Nodosum - Indicates inadequate control of 18D

• Manifestations MC in Crohn's disease • Manifestations MC in Ulcerative Colitis

o Erythema Nodosum o Primary sclerosing cholangitis
o Peripheral arthritis o Pyoderma gangrenosum
o Ankylosing spondylitis
o Stones (Cholesterol gall stones/Oxalate stones)
o Ureteral obstruction

168
Ea INFLAMMATORY BOWEL DISEASE - 2

MANAGEMENT OF 18D • Used as Maintenance therapy in both UC & CD

1. 5 - ASAAgents • Used in treating Active perianal disease & Fistula in CD
f- ~,h u " Q""
• Mainstay of th era~ViM1@& CD
• MOA 5. Methotrexate
Inhibition of NF-KB A ct ivation • Effective in inducing Remission & reduci ng steroid doses
..., Inhib ition of PG synthesis • Effective in maintaining remission in Active CD
, Scavenging of Free radicals • Promising role in Maintenance therapy
• Up to 80% of unformulated acquired 5 - ASA is absorbed
at Proximal SI (Does not reach distal SI & Colon) 6. Cyclosporine
• To overcome the Rapid absorption in SI, 5 -ASA is • Used in Severe UC, refractory to IV Glucocorticoids
attached w ith Carriers
0 Sulfasa lazine: 5 -ASA + Sulfapyridine 7. Tacrolimus
• Good efficacy in
o Children with 180
{) Important Information o Adults with extensive involvement of small intestine
• Effective in adults with
• S· ASA - Anti·inflammator!I activit.!I o Steroid dependent or Refractory UC & CD
o Refractoryfistulizing Crohn's disease
• Svl+ap!lriding - Carrigr
o Linlc.gd b!I Azo bond 8. Anti - TNF Therapies
o Rgsponsiblg+or most of thg Sidg gf+gcts • lnfliximab
o Dglivgr S·ASA moigt to thg colon o It is a chimeric lgG 1 antibody against TNF-a
o Olsalazine: 5-ASA + 5-ASA o Usedfor
o Balsalazide: 5-ASA + 4 - Amino benzoyl Beta-Alanine Active CD refractory to Steroids &6- MPOR ASA
Crohn's disease with refractory perianal or E/C
2. Antibiotics Fistula
• Ciprofloxacin, Metronidazole Approved for Rx of Moderate to Severely Active UC
o Mainly used in Crohn's disease • Adalimumab
o No role in Rx of Active or Quiescent Ulcerative Colitis o It is a Humanized Recombinant lgGl Monoclonal
o Used in pts. of Pouchitis (Total Proctocolectomy + lleal antibody against TNF-a
Pouch-Anal Anastomosis) o Approved for Rx of
• Glucocorticoids Moderate to Severe CD
o Used in inducing remission of both UC & CD Moderate to Severely active UC
o No role in Maintenance therapy • Certolizumab Pegol
o It is a Recombinant FAB antibody fragment against
3. Agents used for inducing Remission TNF- a
• Prednisone o Effective for induction of clinical response in patients
• Parenteral agents with Active inflammatory Crohn's disease
o Hydrocortisone • Golimumab
o Methyl Predriisolone o ltisa Human lgGl antibody againstTNF-a
• Budesonide o Approved for Rx of - Moderate to Severely active UC
o It is released entirely in Colon
o Has minimal or no steroid related side effects 9 . Anti- lntegrins
• Natalizumab
4. Azathioprine & 6-Mercaptopurine o It is a Recombinant Human_ized lgG4 antibody against
• Used in management of Steroid dependent 180 a4-lntegrins

169
 , Used for Management of mild to moderate UC
• Induction & Mamtenunce of therapy in CD
• Rx ofrefractory or intolemnt to Anti-TNFtherapies
• Vedoli:wrnab
It is a l\~o.,oclonal ant.body agamst a<1 fl7 lnt~grins
.~ Indicated for pts. w i th inadequat e res po nse t o
Glucocor t ic o i ds o r An t i T N F th era p i es o r
lmmunomodulators

Management of Mild to Moderate Crohn's disease

\!1 00:20.U

Refer Image 22.1

Gluc0C"ort1co1d r111;tol
Ne, lmpro110fl'!Qn\
Management of moderate to severe Crohn's disease
!J ASA oral and/or rental
Mo,nstoy of thorapy

MIid to moderate ulcerative colitis

Moderate to severe UC

Glucocort,co,d I\
For ,nductng rem,ss,on

..
If no improvement

Natall:umab/vedohzumab
Retractor,, or intolerant to
ont1-TNF) herapy

Na improvement
6-Mercaptopunnelazath,opnne/methotrexate +
lnflix,mab, adahmumob/certollzumab pegol 6-Mercoptopurine/
ozothlopnne + 1nll1x1mab
Maintenance therapy
Moderate to severe Crohn's Disease
Glucocortica1d IV
No res onse
Management of Fistulizing Crohn's disease Glucocort1co1d oral
For Inducing remission

Moderate to severe ulcerative colitis

Indication of surgery in 180

• O-Obstruction
• H - Hemorrhage
Natalirumab/vedolizumab • F-Fistula
Intolerance or • A-Abscess
no response to ant,- TNF alpha
• C - Carcinoma
Anti- TNF (infli>1.1mqb/adal1mumab/ .
certolizumab pegolJ + / -6- Mercaptopunne/
azath,oprine/ methotrexate !. Indications of Surgery in Crohn's disease
For active f'E:_rianal disease
Refer Table 22.1
Abscess drainage and antibiotics

Indications of Surgery in Ulcerative Colitis

Fistulizing Crohn's Disease
1. Intractability
2. Dysplasia or Carcinoma
3. Massive Colonic bleeding
4. Toxic Megacolon

170
Surgical options in Ulcerative colitis (!J 00:34·28 • Complications ofTPC + I PAA in Ulcerative colitis
1. TPC + I PAA - Definitive Rx o Pouchitis (7 -33%) - MC
2. TPC + lleostomy o Small bowel obstruction (25%)
3. TPC + Continent ileal reservoir (Kock pouch) o Pelvic sepsis
4. TAC + End ileostomy o Anastomotic & Pouch suture line leak
o Pouch vagina l fistula

*
l.TPC + IPAA
• It is th e Definit ive t reatment r
• Preferred in younger patient w ith no Rectal dysplasia
Importa nt In+ormatio n
• Procedure
o Some part of Ileum, whol e Colon & Rectum are
removed -2h
• MC complication c,;ter TPC • l'MA..inlj f"pdtlents -
" lleal pouch created &Anastomo sed with anus
Small bowel obstruction j
Stomach Surgical option for UC in patients with special situation
• Older patients: TPC + End ileostomy
• Pt. with Fecal incontinence: TPC + End ileostomy
Small • Pt. with confirmed Rectal dysplasia: TPC + Mucosectomy
intest ine
with hand sewn IPAA
• Pt. with Significant Debility (Poor operative candidate) :
TAC with very low Hartman closure with End ileostomy

CROHN'S DISEASE OF ANO-RECTUM

<!, 00:46:14
• Anal manifestations - Most Devastating
o Painful in Nature
Proctocolectomy
Large lnteston<? and o Threat to Patients continence
rectum removed
• Occurs in 20% of Pts. with CD
• Has 3 presentations
o Ulceration (MC)
o Fistula
Pouch
Cyanotic
Chronic
lndurated
Painless
o Stricture

Clinical features
Pouch-anal • Stricture
anastomoses • Fissure, Fistula &Abscess in Perianal region
• Pain, Swelling & Bleeding
• Soil age/ Frank incontinence
• Fever
• Edematous & Purplish tags - Characteristic feature
S pouch J pouch w pouch

Loop of
intestine

Anus ------ ru
Anastomosis - - - -

171
Evaluation related CRC w ith respect to Prognosis
• Inspection • Cumulative risk of cancer increases w ith duration of UC
• Digital Rectal Examination 0 25%Risk - at25years
• Proctoscopy / Proctosigmoidoscopy o 35%Risk - at30years
o 4 5% Risk - at35years
Management o 6 5% Risk - at 40 years
• Most pts. are managed Conservatively • Risk of malignancy in Crohn's Pancolitis
• Surgery - performed for Pain resulting from Undrained or ') 2% after 10 years
Poorly drained abscess o 8% after 20 years
• Fissure in CD o 18% after 30 years
o Multiple
of
• MC cause of death in Crohn's disease'-" <51Matigrnrncy
01 6 10
o Locat ed off the Midline • Other causes include '?o.,~ nH
c Avoid Fissurectomy or Lateral Sphincterotomy o Sepsis
• lnfliximab o Thromboembolic complications
'-' Very successful in t he Rx of Fistul izing CD o Electrolyte d isorders
o Fistula closure rat e is 25 - 6 7%
TOXIC MEGACOLON 0 01:08;20
Staged approach for Perianal disease • It is a serious Life-threatening cond it ion
• 1st Step: Cont rol the Local sepsis • Riskfactors
o 1/D of Abscess+ Antibiotics o Ulcerative colitis (MC)
o Fistula t rack require chronic drainage with Non- cutting o Crohn 's disease
Seton o Infectious colitis (like Pseudomembranous colitis)
• 2nd Step: lnfliximab • Massive dilatation of colon leads t o Necrotic thin-w alled
o Should be given only after control of Local sepsis colon causing Perforation
o After 2-3 infusions of infliximab, Setons are removed
for fistula closure Investigations
• 3rd Step - Surgery • On Radiography - Pneumatosis can be seen in t he bowel
o Performed if Fistula doesn't heal & Local sepsis • Plain X- Ray Abdomen
resolved o Crit ical for diagnosis
o Tofollowupthecourse
COLITIS ASSOCIATED COLON CANCER (CAC) • Radiolog ical findings
<!) 00:57:07
o Transverse colon diameter> 6cm
o Multiple air fluid levels
Refer Table 22.2 o Normal Colonic Haustrations - Absent or severely
disturbed
• Risk forColoniccarcinoma - CD = UC • Organs & their diameter in Megacolon
• Risk for SI Malignancy- CD> UC o Cecum -> > 12 cm
• Risk of Cholangiocarcinoma - UC> CD o Ascending Colon -> > 8 cm
o Transverse colon -> >6 cm
Risk factors for cancer in UC o Rectosigmoid / Descending colon->> 6.5 cm
l. Duration of colitis
2. Extent of colonic involvement
3 . Presence of PSC &family historyofCRC
4. Pancolitis & Disease diagnosed at young age

UC related CRC
• These cancers tend to be
o Multicentric
o Evenly distributed throughout the colon
o Infiltrative
o Highly aggressive
o Poorly differentiated
• Has no significant difference between Sporadic & UC

172
 Management roslstnnt to /\nt il)lotlc t.1 10r,1py
• MC'dicol 111.:irwgcmcnt Pnrti;il ob:.lr uc.lion • I or Slgnlficont Pouchit,-; not rc";pondlno tu Mud ie.ti l<x
Hns high recurrence CD should bo com:idored
, Urgent Lnpnrotomy reciuircd
• Pre- operatively, Stabilization should be done by giving DIFFER[NCE OFTWl l N CROI IN'S DI Sf:/\S• l',
IV Antibiotics UL( FR/\TIVE COLITIS (!J 01 N 11
• TOC - Total Abdominal Colcctomy w ith lloo stomy (With
preservation of Rectum) RC1ft1r 111ble 2l I

POUCHITIS (_T) 0 t.11 E-

• Inflammation of mucosa of lleol pouch
• lncidence = 7- 33%cases

J poud,

Etiology
• Unknown
• Maybedueto
o Bacterial overgrowth
o Mucosa! ischemia
o Local factors

J pouch

Clinical features
• jsed Stool frequency - leading to Dehydration
• Fever
• Bleeding
• Cramps

Treatment
• Rehydration + Oral Antibiotics (Metronidazo le /
Ciprofloxacin)
• Probiotics - Shows dramatic resolution in some cases

173
 Image 22.1

E-

II Q lrnpr,;,, enumt
- • t"' lt.:""'lk'n)
celhemp)

Bu -1(1s00,.:1,, •''t ond 11Qht ,c,>onl

ror Inducing remission

MIid to moderate Crohn's Disease

Table 22.1
Indications in Small intestine Indications in Colon & Anorectum

1. Stricture & Obstruction unresponsive to medical 1. Intractable disease

therapy 2. Fulminant disease
2. Massive hemorrhage 3. Perianal disease unresponsive to medical managemen t
3. Refractory fistula 4. Refractory fistula
4. Abscess 5. Colonic obstruction
6. Cancer prophylaxis
7. Colonic Dysplasia or Cancer

Table 22.2
Colitis associated Colon cancer Sporadic Colon cancer

• Arises from • Arises from: Adenomatous polyps

o Flat dysplasia
o Dysplasia associated lesion or mass
• Has Multiple synchronous colon cancer in • Has Multiple synchronous colon cancer in 3- 5%
12% cases . cases
• Mean age - 30 years • Mean age - 60 years

• Distributed uniformly throughout the colon • Has left sided Predominance

• Mucinous or Anaplastic variety is more common • Mucinous or Anaplastic variety is rare

174
 Tnblc 22.3

Crohn's dlscnsc Ulcerative colitis

M:ir-roscopic footurcs

• (")1st, 1but1on Scgnwnt,11 w ith Skip :1rcus • Distribution - Continuous without Skip areas

• L0c,1tton Ileum (Nor) CC'rnm & A scending colon • Location Rectum, Sigmoid & Extending upwards
cranially

• Ext('nt Entire Thid.ncss of Bowel w nll • Ext ent - Superficial. confined to mucosal layer

• Ulcers Sc, piginous ulcers th<1t may develop into • Ulcers - Superficial mucosal ulcers
Deep ulcers

• Pseudo polyps - Rarely seen • Pseudo polyps - Commonly seen

• Fibrosis - Common • Fibrosis - Rare

• Shor tening - Due to Fibrosis • Shortening - Due to Contraction of Muscularis

Microscopic features

• Depth of inflammation - Transmural (mucosa + • Depth of inflammation - Mucosa! + Submucosal

submucosa + Muscularis propria)

• Type of inflammation • Type of inflammation

o Non-Caseating granuloma o Non- specific Acute & Chronic inflammatory
o Infiltrate of Mononuclear cells cells
• Mucosal changes - Patchy Ulceration • Mucosal changes - Hemorrhagic mucosa with
ulceration
• Submucosa - Widened due to edema & lymphoid • Submucosa - Normal or reduced in width
aggregates

• Muscularis - Infiltrated by inflammatory cells • Muscularis - Spared

• Fibrosis - Present • Fibrosis - Absent

Complications

• Fistula formation - Internal & External fistula in 10% • Fistula formation - Rare
cases

• Malignant changes
o Colon cancer - UC = CD
o SI Malignancy - CD > UC
o Cholangiocarcinoma - UC > CD
• Fibrotic strictures - Common • Fibrotic strictures - Rare

• Toxic Megacolon - Rare • Toxic Megacolon - j sed risk

Ma
n('OI
9177(• I

175
Named features

1. String sign of Ka ntor 1. Garden hose appearance

2. Hose pipe appearance 2. Pipe stem colon
3. Creeping fat sign 3. Lead pipe sign
4. Comb sign 4. Stove pipe appearance
5. Raspberry Thorn / Rose Thorn appearance 5. Collar button ulcers
6. Fat Halo sign

B-
neelesh 1410@gmai com
917704860839

176
fl] VERMIFORM APPENDIX II
NORMAL ANATOMY 1. Tenderness in right iliac fossa
2. Rebound tenderness
Refer Image 23.1 3. Elevated temperature

• Normal length of appendix - 2 to 20 cm Lab investigations

• Intra luminal capacity of appendix: 0.1 ml • Leucocytosis
• Blood Supply: Appendicular artery (Branch of ileocolic • Shift to left
artery)
A lvarado Score aka MANTRELS Score
o Appendicular artery is an end artery.
• Most common location: Retrocecal MANTREL Score
• Least common location: Post ilea I Migratory pain 1
• Most dangerous location - Pelvic
Anorexia 1
ACUTE APPENDICITIS 0 00:02:41 Nausea, Vomiting 1
• MC general surgical emergency worldwide Tenderness 2
• Seen in Young patient usually of 2nd decade Rebound tenderness 1
Elevated Temperature 1
Etiopathogenesis
Leucocytosis 1
• Luminal obstruction can be due to
o Fecalith (MC cause) Shift to Left 2
o Tumors (e.g .. Carcinoid tumor) • Score of 9-10 - Diagnosis is certain
o Worm eggs (e.g., Ascaris eggs) • Score of 7-8 - High likely hood of diagnosis
o Fruit seeds
• Score of 5-6 - Equivocal (most dangerous)
• Luminal obstruction: Increased lntraluminal pressure
o CECT is indicated in cases of Equivocal
!
Impaired Lymphatic drainage MANTREL score findings to confirm
! diagnosis
Impaired Venous drainage & Arterial supply • Score of 1-4 - Negative for acute appendicitis
!
lschemia
! Other named signs
Perforation • DUNPHYS SIGN- Pain on coughing
• Mc site of perforation: Just distal to obstruction on • ARON SIGN - Pain on pressure in epigastrium
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917704860839
• TEN-HORN SIGN - Pain on gentle traction ofrighttestes
• Mc organism Isolated after perforated appendicitis: • ROVSINGS SIGN
Bacteroides fragilis >E. coli o Pain in right iliacfossa on pressing left iliac fossa
o Most characteristic sign of acute appendicitis
Clinical features • ROVSING'S SYNDROME - In horseshoe kidney, hyper
• Pain in peri- umbilical region - Shifting of Pain to right lilac extension of spine causes pain, nausea, Vomiting. [Most
fossa (Migratory Pain) characteristic sign]
• Symptoms • OBTURATOR SIGN
o Most characteristic symptom of A cute appendicitis - o Pain on internal rotation of right thigh over hip joint
Migratory pain o Obturator sign is positive in Pelvic Appendicitis.
o Anorexia o In Pelvic appendicitis, orientation of appendix is
o Nausea, Vomiting towards pelvis and in close relationship to rectum. So,
• Signs abdominal signs are not marked in Pelvic appendicit is.

177
 --4lnitation of rectum - Diarnea • M - Mass size increasing
' Irritat ion of urete r - microscop i c hem aturi a
( > 3RBCs/ HPF) Risk factors for Appendicular perforation
__.. Dela; in Ox - pt. presents with perforation • Fe-calith obstruction
• PSOASSIGN • Diabetes mellitus
• Hyper extens•on at nght htp Joint causes pain in nght • lmmunocompromised state
iliacfossa • Extreme of ages (<5 years.> 65years)
Psoas sign Is Po sitive in Retrocecal appendicitis • Pelvic appendicitis
• ROV SING ' S OPERATION - Deroofing of cys t in • History of Previous surgeries
autosomal dominant poly cystic kidney disease (ADPKD)
CARCINOID TUMOR OF APPENDIX !) oo·Jil.59
Diagnosis • MC t umor of appendix: Carcinoid t umor
• Purely clinical (in adults) • A ka Argentaffinoma
• Supplemented by lab investigation and ult rasound • Small. localized. not associated w ith metastasis
• Leucocytosis is seen on laboratory investigation • Not associated w ith carcinoid syndrome
• IOC • Mc site of appendix - tip of appendix
• In children- ultrasound • Treatment
In Adults - Clinical d iagnosis o Up to 1cm :Appendectomy
• Gold standard for diagnosis of Acute appendicitis- CECT o 2 cm :Right Hemicolectomy
(ever in equivocal cases, CECT can confirm the diagnosis) o 1cm to 2cm :Appendectomy
• Indications of right Hemicolectomy
Treatment o Involvement of mesoappendix
• Emergency appendectomy o Involvement of cecal base
• In patients of acute appendicitis. during emergency o lnvolvementofLN
appendectomies -> abdomen is palpated after spinal
anesthesia to diagnose appendicular lump. Mc Bumey's point 0 00:35:28
• Appendicular lump is a contraindication for surgery. So. • Junction of lateral 113rd from umbilicus & medial 213rd
patients are managed conservatively by Ochsner sherren fromASIS.
regimen • Mc Burney's Point corresponds to base of appendix

Ochsner Sherren Regimen Incisions

• Conservative management of appendicular lump • Mc Burney's incision
• Components of appendicular lump o Incision centered on Mc Bumey's point & perpendicula r
o Appendix,,.,....,,~,, · ol;," gma: """' to umbilical ASIS line.
o Ileum .@-
9 , --o.:S60539 o Aka Grid iron incision
o Cecum o Aka Mc Arthur incision
o Omentum o This is a muscle splitting incision
• Surgery done during appendicular lump formation can • Rutherford- Morrison incision
lead to increased risk of inj ury of cecum. o In retrocecal appendicitis (appendix difficult to be
• To know whether the lump is appendicular lump: CECT visualized) extend the MC Burney incision, upward &
has to be done. laterally by cutting conjoint tendon.
• Start IV antibiotics in all the patients o This incision is Muscle Cutting incision
• If abscess present drain the abscess. o Preferred for retrocecal appendix.
• Monitor pulse rate and temperature every 4 hourly • Lanz incision
• W ithin 24-28 hours - most patients improve o This incision is a muscle splitting inc1s1on placed
• Continue the conservative management transversely 2cm below umbilicus on the line j oining
• Perform Interval appendectomy (Not recommended in all midpoint of clavicle to midpoint of inguinal ligament
patients) o Aka modified Mc Burney's incision
o Only for patients experiencing Recurrent appendicitis o Aka Rocky Davis incision
o Aka Bikini incision
Indications for Exp. Laprotomy o Transverse skin crease incision
• P- Pulse rate rising o Preferred nowadays
• S - Spreading abdominal pain Better exposure

178
 Easier extension 2. Inflamed bone in appendix
• Base is not crushed - fear of spread of infection via
Steps of Appendectomy lymphatics
• Ligated closed to caecal wall
Symptoms Score
3. Gangrenous base
Migratory right iliac fossa p ain 1 • Neither crushing nor ligation is done
• Two stitches are applied through caecal wall
Nausea / Vomiting 1 • Appendix is amputated flush with caecal wall
• Tie the stitches
Anorexia 1
Complication of Appendectomy
Signs • Wound infection (M/C)
• lntraabdominal abscess
Tenderness in right iliac fossa 2
• lieus
• Venous Thrombosis-+ Embolism
Rebound tenderness in right iliac fossa 1
• Portal Pyaemia
• Adhesive intestinal obstruction [M/C late complication]
Elevated t emperature 1
• Fecal fistula in case of appendicular lump
Laboratory findings

Leucocytosis 2

Shift to the left of neutrophils 1

Total 10

1. Skin incision - deepened to external oblique aponeurosis

[EOA]
2. EOA - split along the direction offibres
3. After EOA retraction
4. Internal oblique & transverse abdominalis split along the
direction offibres
5. Fascia transV1eirsalisiq;j1/idedn
-
6 . Peritoneum ~ pPtft~ff!md incision
7. Entery to peritoneal cavity & caecum is identified
• With help ofTaenia coli
• With 1/Cjunction
8. Appendix is indentified- present at base of calcum
9. Hold appendix with babcock'sforceps
10. Ligate mesoappendix & appendicular artery is ligated
11. Pulse string suture around base of appendix
12. Base is crushed with artery forceps & transfixed with
vicryl suture
13. Appendix is cut distal to suture ligature & removed
14. Purse string suture is tightened to bury the stump

Some special situations in which special methods are

adopted are as follows
1. Edematous & inflamed cecal wall
• Purse string suture is not applied
• Stump is not invaginated

179
 Image 23.1

;__ _ lleocolic artery

~ - - -Terminal ileum
_
- - - - Mesoappendix

Appendicular artery

Cecum - ~ -;;;....._4

Appendix

180
m RECTUM AND ANAL CANAL
II
ANATOMY 0 000020 v Superior rectal vessels - branch of inferior mesenteric
artery [main vesseij
..., Middle rectal vessels
o Inferior rectal vessels
• Lymphatic drainage follows vascu lar supply mainly
towards superior rectal vessels - drain into Para-aortic
nodes ,_..,._,. ,O@gma, ex,,,,
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HEMORRHOIDS 0 0 0:05·27
• Are Normal anatomical cushions
• Madeof
o Venules
o Arterioles
• @) length if rectum - 14 cm o Smooth muscle fibers
• @) Ano-rectal angle - 120° o Elastic tissues
• Houstan valves - semi-circular folds present on luminal • Location of hemorrhoids
surface o 3' oclock
• Denonvilliers Fascia / Recto -genital fascia separates o 7'Oclock
prostate & vagina from rectum o ll'0clock
• Recto-sacral fascia / Waldeyer's fascia: Both fascia act as
barrier for rectal met asta sis
• Blood supply of Rectum

Pathophysiology
• On constipation due to Excessive straining
l
• Abnormal descent of anatomical cushions
l
• Injury by hard fecal matter
l
t.al0l£ZONE • Painless Bleeding PR
• Mc cause of bleeding PR --+ Hemorrhoids
• Mc cause of significant lower GI bleed --+ Colonic
diverticula
Inferior rectal vessels
lOWERZONE
and tymphotlcs • Mc cause of occult low er GI bleed --+ Angiodysplasia/
._ to inguinal nodes
--+ Vascular ectasia

181
Clinical Presentation • First dcgrnc: Bleeding only
• Painless bleeding • Second degree: Bleeding + Prol opsc during dofocot,on
• Mucus discharge. prolapse (Spont,mcous resolution)
• Amount of bleeding - 3 to 5 ml to a mox of 10 1111 • Third degree: Bleeding + Prolopso ,,vith monuol roposition
• Fourth degree: Bleeding +- Permonent prolopso
Diagnosis
• Treatment
• They Cannot be palpated. therefore hemorrhoids ca nnot
, First degree hemorrhoids
be diagnosed by DRE
Sitz batch
• Diagnosis of hemorrhoids - by proct oscopy
High fibre diet
) Stool softener
Types of Hemorrhoids

Internal hemorrhoids External hemorrhoids "' First degree, second degree and select ed patients of
third degree
• Location above • Location - below dentate
> Banding: In banding Rubbor bond is applied other
dentate line (Pain line (pain sensitive region)
the hemorrhoid. After 48 hours. hemorrhoids are
insensit ive region) • Painful bleeding
sloughod off because of ischemia and the losion
• Painless bleeding • Aka 5- days painful self-
heals with fibrosis.
curing lesion
4 Sclerothorapy: 5% phenol in almond oil
• Treatment - depends • Recurrent thrombosis in Both banding and sclerotherapy are very cheap and
on the degree external hemorrhoids
effective
leads to semi- ripe black
curra nt Rubber
Internal
• Treatment - Excision

Internal Hemorrhoids classification (!) 00:17:20

Llgator

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91 " 704860839

.. . .
:
:
Band around
hemorrhoid

3 ,, Rest of third - degree pa tients and fourth degree

patients: Hemorrhoidectorny
) Milligan-Morgan open Hemorrhoidectomy
) Ferguson closed hemorrhoidectomy: Not done
nowadays
4
-. Whitefield submucosal hcmorrho1dectorny· Not
done now adays

18 ?
 Longo's Stapler hemorrhoidectomy o Full thickness prolapse mainly in adults
-) Most preferred method - Longo ' s Stapler E.• tornol view

hemorrhoidectomy (Associated with Lesser post-

operative pain)

Complication
• MC complication - Pain> urinary retention • FuHt hlcknest
rectal prolapse

Causes of Rectal prolapse in children

• Common causes: Treat the underline cause
o Protein Energy Malnutrition
o Worm infestation
o Diarrhea
• Rare causes
o Sacral agenesis
o Meningomyelocele

Management
• Depends on cause
• Conservative Management for common causes
• If patient is not responding : Lo khart Mummary
Rectopexy
• For rare causes: Thiersch A nal W iring
• For Adults: Rect opexy via A bdominal approach &
Band around
hemorrhoid Rectopexy via Perinea! approach

Rectopexy via Rectopexy via

Abdominal Approach Perinea! Approach

• Decreased recurrence • Increased recurrence

Rectal prolapsed rate rate
• Associated with high • Associated with low
morbidity morbidity
• Preferred in young • Forold&frai lpatients
patients • Types ofrectopexy

←
1 141 0
• T-ypes of rectopef/A'l ••h Perinea I
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o W-Well's o A - A ltmaier
o A - Abdominal o D - Delorme
o R - Ripstein • Thiersch Anal Wiring
• Rectal Prolapse is of two types • Resection Rectopexy
o Mucosa! prolapse mainly in children o Goldman: Fryberg

183
ANORECTALABSCESS (!) 00·36.27 Treatment
• M/C organism: E coli > Bacteroides • Incision (Cruciate shaped incision) and Drainage +
• Types Antibiotics

a. Perianal (MC)
b. lschiorectal (2nd MC)
c. Submucous
d. Pelvi- rectal

Crypt of
Morgagni
External drainage
close to anal sphincter

Anal gland

1111•111:=----'> Pus
Simple. F ~ - - -, ~ Complex. F

Dentate line

Formation of anorectal abscess FISTULA-IN-ANO

• Opening of anal glands at dentate line - crypt of Morgagni • Chronic abnormal communication between anorectum &
• Via the crypts, infection reaches the anal gland perinea! skin
• There is pus formation & it follows the path of least • History of Anorectal Abscess/ Ano rectal sepsis
resistance • Forms a tract outside known as Fistula in Ano
• Pus is collected in the perianal area causing perianal • Theory responsible for Fistula in Ano - Cryptoglandular
abscess.
Theory
• It is tract behind, U- shaped tract in the ischiorectal fossa
• Simple fistula: Has ingle straight track
forming ischiorectal abscess.
• Complex fistula: Has multiple branched tracts
• Theory responsible for formation of Anorectal Abscess -
CryptoglandularTheory Components of ANO RECTAL RING
• Puborectalis (like sling around rectum junction)
Clinical features • Internal Anal Sphincter (Formed by inner circular layer)
• Severe pain • External Anal Sphincter (Formed by outer longitudinal
• Throbbing swelling layer)
• Swinging pyrexia
Types
• Low lying: If internal opening of fistula is below anorectal
ring

=
• High lying: If inter11~~ ! ~ ~f 'nstula is above anorectal
ring

Causes
• Ano rectal Abscess (MC)
• Crohn's disease
• Lymphogranulom a venereum

184
 • Actinomycosis • First investigation: Fistulogram
• Foreign body in rectum
• IOC: MRI
• Malignancy
• HIV
GOOD SALL'S RULE
• To indicate the likely position of internal opening on the
PARK'S CLASSIFICATION
basis of external opening
Type 1 • Inter- sphincteric (MC) • Anteriorly located external openings are joined by short
straight track. (Example - l l'o clock position of external
Type 2 • Trans- sphincteric
opening is same as l l'o clock portion of interna l opening)
Type 3 • Supra- sphincteric • Posteriorly located external openings are joined by Long
curved track & opens in posterior midline (in posteriorly
Type 4 • Extra- sphincteric
located external openings, whatever position of external
opening, internal opening is at 6'oclock posit ion)

00
'"

Typel
EAS

~'t Type2
Exception of Goodsall's rule
• External opening> 3cm from anal verge
• Multiple external openings

~'~"
11 O'clock 1O'clock

5% 10 O'clock 12 /

Anterior
- - - - - - - - - - 9- - - - 3 - - - - - - - -
Posterior
00
6
Type 3 Type4

Clinical Features Treatment

• More common in Males • Fistulotomy- Incision over fistula tract }
• Usually seen in 3rd - 5th decade High morbidity
• Intermittent purulent discharge+ Pain • Fistulectomy - Excision of fistula tract
• If patient passes Feces & flatus from external opening - • SETON
likely position of internal opening is in Rectum • VAAFT (Video Assisted Anal Fistula Treatment)
• Glue
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neelesh1410@gma,I com
917704860839
Key points to be assessed in fistula
• Location of Internal opening SETON
• Thread made of silk, linen, nylon, silastic
• Location of External opening
• Types of seton
• Course of tract
a. Cutting seton
• Secondary extensions- present/not
b. Non-Cutting seton (aka Draining seton)
• Complicating disease/ condition that can affect healing of
c. Marking seton
fistula
d. Staging seton
• Cutting seton
Investigations
o Cutting Seton is inserted over the fistula and tied and
• ON DRE, induration around internal opening can be
knot is applied.
localized.
• On proctoscopy also, internal opening can be localized if o Every w eek, knot is made tight and hence it starts
the internal opening is within 10cm of anal verge. cutting the tissues.

185
 0 Uses - Cutting seton converts High lying fistula to Low Pathophysiology
lying fi stula
• Spasm of Internal Anal sphincter
(Treatment of high lying fistula is associated w ith high
• Patients have constipation
risk of fecal incontinence)
• During excessive straining at the time of defecation, the
fecal matter passing through internal anal sphincter
• Draining seton
injures the pain sensitive mucosa of anal canal.
o Crohn's disease and HIV +ve patients
Tear/ split in the anoderm
!
Indications of Seton Decreased vascularity
• Treatment of Complex Ano rectal fistula !
Healing of Tear decreases (due to ischemia)
• Treatment of fistula in Crohn's disease &HIV patients:
Draining seton is used to control infections as they have
• Principle of treatment is based on relaxing the spasm
multiple, infectious fistula
• Fissure in Ano is similar to Achalasia cardia
• Anterior fistulas: More common in females
• Fistulas associated with Chronic diarrheal state. Clinical features
• Serve pain during defecation
FISSURE-IN-ANO 0 0 1:06:35 • Streaking of blood over stool
• In fissure in Ano - Digital rectal exam ination is
contraindicated.
• Examine the gluteal region, find the longitudinal spilt in
posterior midline

Management
• Initially conservative management
o Sitz bath
o High fibre diet
o Stool softener
Dentate line
• MedicalTreatment
o CCB - 2% Diltiazem Gel - (Local application)
o Nitrates - 0.2% nitroglycerine
o Botox injection into sphincters

-0C o Lord's procedure - manual dilatation of sphincter (not

performed usually).
• Location of dentate line - usually 2cm below the anal o TOC - NOTARA'S late ra l sphincterotomy (divide
verge. internal anal sphincter laterally)
• Longitudinal split in the anoderm from anal verge to the o Anal advancement flap
dentate line
• Location - In posterior mid line at 6 10 clock position PILONIDAL SINUS (!) 0 1:16:56
• Fissureisoftwotypes • Acquired condition
o Acute fissures • Seen in hairy males
o Chronicfissures • Usually among 20 -29 years
• Chronic fissures - Characterized by Triad • Common in military personnel
o Canoe- Shaped Ulcer • Aka JEEP'S DISEASE (common in Jeep d rivers of Army)
o Sentinel Pile (aka skin tag) • Collection of dead hair in the nat al cleft overlying the
coccyx.
o Hypertrophied papilla

186
 o F - 5-FV (5-Flurouracil)
o Ox- Oxaliplatin

Clinical features
Hair
• MC symptom - Bleeding PR

I
• Early morn ing bloody diarrhea
Pilonidal cyst • Passage of bloody slime (no fecal matter)
• Spurious diarrhea (every 2 to 3 hours, rectum is full with
Fat I:_..a
• discharge from tumor, so patient passes like stool every 3
hours)
Pilonidal sinus • Tenesmus - Painfu l def ecation with sensation of
incomplete evacuation seen in lower part of CA rectum
A
• Back ache/ sci atica (sacral pl exus involvement
B
posteriorly)
• Weight loss & Anorexia

Ellipt;f° r,
excision
Investigations
• Length of proctoscope - 10 cm
• Rigid sigmoidoscope -25 cm

_ • Flexible sigmoidoscope- 60cm

Pilonidal sinus excision and repair by rhomboid flap • Colonoscope - 160 cm

• Investigation of choice - Rigid sigmoidoscopy + biopsy
• Colonoscopy is mandatory for adequate evaluation of
Clinical features
whole colon and to rule out any synchronous polyp or
• Discomfort in post- natal cleft region with intermittent synchronous malignancy
serous discharge o Synchronous- simultaneously
• Infection - Abscess formation o Metachronous- later after surgery
• Location • Virtual colonoscopy (3D reconstruction colonoscopy
o lnterdigital pilonidal sinus (common in barbers) using CT)
o Umbilicus o Advantage: can visualize outside of lumen also
o Axilla o Disadvantage: Biopsy of colon cannot be done
• In head & neck malignancies & pelvic malignancies,
Management overcrowding of nerves, blood vessels & soft tissues. So,
• For Abscess: Incision & Drainage+ Antibiotics IOC for staging of most of head and neck malignancy -
• If no abscess: Excision of sinus tract + Closure of defect MRI
using flap • ForT- staging, invest igation of choice- TRUS (Transrectal
• Flaps Used for closure ultrasound)
o Limberg's Flap/Rhomboid Flap
• Distantly lying nerve, lymph node, vessel cannot be
o Karydakis flap
differentiated as Sensitivity of ultrasound decrease if
• Procedure performed for the treatment of Pilonidal sinus:
distance between probe & organ increase.
BASCOM procedure
• For lymph node staging, investigation of choice is -
Endorectal MRI
CA RECTUM <!) 01:22:59
• Overall Best investigation for staging- MRI
• MC site of large bowel malignancy
• Usually seen in 5th - 6 decades
Treatment
• MC site of metastasis - Liver
• Principle of treatment in CA Rectum
• Chemotherapy regimen- FOL FOX-IV
o Stage I: Surgical resection
o FOL - Folinic acid/ leucovorin

187
 State 11 & 111: Neoadjuvant chemoradiation followed by Risk Factors
surgical resection (down st age the tumo r & then • Smoking
surgery) • HPV infection (16, 18. 3 1.33)
Stage IV: NcondJuvant chemoradiation followed by • HIV +ve/lmmunocompromised state
• Anal receptive intercourse
pall1at1on ± surgical exc1s1on
• Multiple partners
• TOC- TOTAL MESORECTAL EXCISION
• History of CA Cervix /VulvaI cancer
Given by Bill Heald • Initially, growth in anus is inside lumen.
,.,, Significant length of bowel removal around the tumor • Later, growth is seen outside lumen.
' Removal of Surrounding tissues up to the plane • In advanced malignancies in anus. they can infiltrate into
between Mesorectum & Presacral Fascia known as bladder/ vagina leading to fistula and if sphincters are
involved, incontinence can happen.
HEALD'S HOLYPLANE
• If CA rectum is located > 5 cm above Anal verge - Low
Clinical features
Anterior Resection (LAR) • MC symptom- Bleeding PR
• If CA rectum is located at or below 5 cm from anal verge - • Foul smelling discharge
APR (Adomino Perinea! resection) aka Mile's Procedure • Involvement of
o Bladder
o Vagina Ominous symptoms

o Sphincters: Incontinence of advanced cases

Important ln.foPM-aiw'OA1com -
-
q1770486083q • Alteration of bowel habit
• MC site of metastasis is Lungs
LAR- i+ Tumour> Scm+rom Anal Vtrgt

L APR· if Tumour at or btlow Scm+rom Anal Vtrgt

Total Muortctum ucision is dont in Ca Rtctum.
• MC involved group of lymph nodes: Inguinal Lymph
nodes

Investigations
• IOC: Proctoscopy with biopsy

8th AJCC TNM CLASSIFICATION

Rectum- 14cm Refer Table 24.1

LAR Treatment
• NIGRO regimen - Chemotherapy followed by radiation
~ - - - - 4APR
o 5- fluorouracil + Mitomycin-C followed by radiation
Anal canal • No response then Abdomino-perineal resection

<~
0
Previous Year's Questions

Q. Trtatmtnt of stagt II carcinoma anal canal?

(JIPMER Nov 2018)
A.APR
CARCINOMA ANAL CANAL <!:) 01:42:42 B. APR +ollowtd by chtmoradiation
• MC histological type - sec> BCC >MM
C. Concurrtnt chtmoradiation
D. Ntoacljuvant che.mothtrapy followtd by Surgtry
• MC site of metastasis - lungs
• In perinea! malignancies like CA Penis, CA Scrotum, CA
Anus - Inguinal lymph nodes are involved

188
 Table 24.1

ns • Carcinoma-in-situ
• Aka BOWEN'S DISEASE
• Anal intraepithelial neoplasia type I - Ill

Tl • Size of t umor up to 2 cm

TI • Siz:e of tumor> 2-5 cm

TI • Size of tumor> 5 cm

T4 • Involvement of adj acent structures i.e. Vagina, Urethra, Bladder

Nla • Metastasis to inguinal. meso rectal and/or internal iliac lymph node
Nlb • Metastasis to external iliac lymph nodes
Nlc • Metastasis to external iliac lymph nodes+ inguinal lymph nodes + mesorectal and/or
internal iliac lymph nodes
MO • No Metastasis
Ml • Distant Metastasis

E- neelesh1410@9ma
91 TT04860839
a,m

18 9
m HERNIA AND ABDOMINAL WALL - 1
II
HERNIA • Factors that can cause increased intrabdominal pressure
• Protrusion of viscus or part of viscus through the wall of o Chronic cough
its containing cavity '.) COPD/Bronchitis
o Chronic constipation
NYHUS classification <!) 00:01:06 o Obstructive uropathy (BPH, stricture urethra)
o Heavyweightlifting
Type 1 • Indirect hernia (normal internal ring) o Ascites
o Pseudomyxoma peritonei
Type 2 • Indirect hernia (enlarged internal ring)
o Pregnancy
Type 3A • Direct hernia
o Chronic ambulatory peritoneal dialysis (CAPO)
Type 38 • Indirect hernial enlarge enough to
encroach upon posterior inguinal wall Typesofhemia <!) 00:15:12
• Indirect sliding / Scrotal hernial • MC type of hernia in both male & females - Indirect
inguinal hernia
• Pantaloon hernia
• Femoral hernia - more common in females.
Type 3C • Femoral hernia • Deep ring - defect in Fascia transversal is
Type 4 • Recurrent hernia • Superficial ring - defect in External oblique aponeurosis.
o 4A - direct hernia
1. Indirect Inguinal Hernia
o 48 - indirect hernia Sac enters via deep ring
o 4C - femoral hernia !
o 40 - combine hernia Traverse inguinal canal
!
GILBERT classification 0 00:05:36 Goes out via superficial ring
• Type ! - indirect, small
• Type 2 - indirect, medium Herniated loop of small Intestine

• Type 3-indirect, large \ ,/

• Type 4 - direct, involves entire floor Deep Inguinal
Ring
• Type 5 - direct, diverticular
U--===-- lnferor
• Type 6 - combined (pantaloon/saddle back/ dual hernia/ Epigastrlc
Artery
ROM BERG'S hernia)
• Type 7 - femoral hernia " ",____. Peritoneal sac
Extraperitoneal tissue
Internal spermotlc fascia
Riskfactors 0 00:08:18
Indirect Cremoster fascia
• Factors that can cause weakness of abdominal wall Hernia R-,#/P..1--+ External spermotlc fascia
muscles
o Patent Processus vaginalis
o Patent canal ofnuck

syndrome)
. →
o Connective tissues disO'fm1fsO@lsE'f'l1i't!'l'' s Danlos
9 1770486083,/
2. Direct Inguinal Hernia
• Sac protruding directly from posterior abdominal wall via
triangle of Hesselbach and enters the inguinal canal
o Prune - Belly syndrome
• Triangle of HESSELBACH
o Ectopia vesicae
• Boundaries
o Lower abdominal incision
o Laterally- lnferiorepigastric artery
o Defective collagen synthesis
o Medially - Lateral border of Rectus abdominus
o Smoking
o Inferiorly- Inguinal ligament
o Steroid intake

190
 Relation of neck of sac
• In Inguinal hernia - above and medial of pubic tubercle
• In femoral hernia - below and lateral to pubic tubercle

Types of Indirect Inguinal hernia 0 00:22:33

• BUBONOCELE: Hernia content is limited to inguinal canal
• FUNICULAR
o Processus vaginalis is closed above epididymis
.......
We<ncl
l'lac: o Content of hernia is felt separately from the testis.
• COMPLETE/ SCROTAL: Testes appears to lie in the lower

--
lotoral part of hernia
femoral
cutaneout

llolngulrlo4

!locus mutc:le
o.nitolomorottlCMI
P1oo1 muscte

Hostofboch'•
triangle"

Bubonocele Funicular complete

B Clinical features
• Swelling in lnguino scrotal region (more prominent on
lr'orlo
[pig t .c Hemiated loop ol amoll lnt"tlne coughing/ straining)
Attor-
• Reduce spontaneously on lying position
• Progressive increase in t he size of swelling over a period.
1'9nt-lOC
Exlloper1toneal tlaue
!llo.\.t" _ ,W" F o a c l a - Definitions

~=I
Conjolnt tendon

apem,otlc
Refer Table 25.1
Direct
. Hernia

Relation of sac w ith the spermatic cord

r~
• Sac is posterior t o spermatic cord in Direct inguinal hernia
0
Previous Year's Questions
• Sac is ant erolateral t o spermatic cord in Indirect inguinal
hernia Q. While doing emergency laparotomy +or an
Internal
tnguinol intestinal obstruction. which organ should you +irst

-·
ring
lnfllnOf
epigoatric visualize to say whether it is small bowel or large
111ocus <---
bowed obstruction? (AIIMS Nov 2018)
A. Ileum
Nerve Extemol
B. Cecum
Femoral Artery
~ I C. Sigmoid colon

G-
{
Vein Pubic
D. Rectum
neelesh ~.i 10~g""a
~· 7704860839

Diagnosis
• Made by clinical examination.
SOC of Indirect
Inguinal hernia • Exception - Spigelian hernia/Internal hernia
o They are not palpable
soc of femoral
hernia

191
 o Diagnosed with help of CT/ ultrasound l) TEP
• Preferred by experienced surgeon
Treatment
• Advantage - decreased nsk of bowel injury & adhesions

→
1. Treatment of Sac n~clt:sh , 1 QrlJ 1,-
• Disadvantage - small working space (surgru;y;l~~iwcult)
• Herniotomy: steps of hemiotomy
a. Inguinal skin crease incision 2)TAPP
b. Division of Subcutaneous fat • Preferred by beginners
c. Division of Camper's fascia, Scarpa's fascia • Advantage-huge working space (surgery is easy)
d. Incision along direction of fibres n ext erna l oblique • Disadvantage - increased risk of bowel injury & adhesion
aponeurosis formation
e. Isolate the Sac from cord • Government setup - LIECHTENST EIN REPAIR
f. Open the Sac atfundus • Private setup - LAPROSCOPIC REPAIR
g. Invert the contents back • Early repair
h. Apply PURSE- STRING suture over the sac • NoScarvisible
1. Excise the Redundant Sac

• Hern i orrhaphy : Hernioto my + Ingu ina l floor LANDMARKS IN LAPAROSCOPIC REPAIR

Reconstruction with sutures a. TRIANGLE of DOOM
• Hernioplasty: Herniotomy + Inguinal floor Reconstruction • Boundaries
with MESH o Medially- Vas Deferens
o Laterally - Gonadal vessels
2. Inguinal floor Reconstruction o Base - fold of peritoneum
o Apex - deep ring
Primary tissue Anterior tension Laparoscopic / • Content - lliacvessels
repair free repair Preperitoneal • Sharp dissection in this area can lead to injury of ILIAC
repair vessels

• BASSINl'S • LICHENSTEIN • TEP (Totally extra TRIANGLE OF DOOM TRIANGLE OF PAIN

• SHOULDICE peritoneal)
• TEP (Trans
abdominal

Refer Table 25.2 .. _..

.....
F.-norCII twancn

c. Laparoscopic preperitoneal repair <!) 00:49:55

• TEP - Totally extra peritoneal
• TAPP - Transabdominal pre peritoneal
Endolcope with balloon In
CORONA MORTIS
~-- Endolc:ope

b. Triangle of Pain
• Boundaries
o Medially- gonadal vessels
o Laterally- Fold of peritoneum
o Superiorly - lliopubic tract
• Contents
o Femoral nerve
o Femoral branch of Genito- Femoral nerve
o Anterior cutaneous nerve of thigh
o Lateral cutaneous nerve of thigh
• Electro cautery should not be used in this are as it is
Electric Hazard Zone & nerves can be injured
• MC Nerve injured - lateral cutaneous Nerve of thigh

192
 'P
SPACE OF RETZIUS SPACE OF BOGROS
,1
Pre.viovs Ye.ar's Que.stions
• Aka Retropubic space • Aka Retro ir,ig.ui~l~i;i!;eo,,
• E-
9 17701860839
Q. Which of the f ollowil'lg is correct regardil'lg the • Extrape rito neal space • Extra-pentonea1 space
boul'ldarles of trial'lgle of Doom? (AIIMS May 2018)
located between pubis & located deep to inguinal

A Medially vas deferel'ls. Iott.rally gol'ladal ve.ssel. urinary bladder ligament.

Inferiorly perltol'lt.Vm • Situated laterally &
B. Laterally vas defer-ens. medially gol'ladal vessel.
cranially to the space of
inferiorly perltol'levm
C. Lott.rally medial umbilical ligamel'lt. mt.dially Retzius.
gol'ladal vesst.1. latt.ral ll'lft.rlorly peritol'levm
D. Latt.rally gol'ladal vt.sse.ls al'ld mt.dially lahral Complications of Groin hernia repair
umbilical ligamt.l'lt. inferlorly pt.ritol'lt.Um 1. Recurrence
2. Hematoma formation
3. Seroma formation
Nerves injured 4. lschemic orchitis
• Laparoscopic Hernia Repair - Lateral Cutaneous N. of 5. Testicular atrophy (if testicular artery is injured)
thigh> Genito-femoral N. 6. Osteitis pubis (due to damage to periosteum of pubic
• Open Hernia Repair - llio inguinal > lliohypogastric, tubercle)
Genital branch of Genitofemoral N. 7. Bladderinjury
8. Wound infection
c. Crown Of Death/ Corona Mortis (!) 01:02:30 9. Mesh related complications like Contraction of mesh,
• Inferior epigastric artery- Branch of external iliac artery Erosion due to mesh and Infection
• Obturator artery - Branch of internal iliac artery
• Usually no communication between IEA and obturator STRANGULATED HERNIA (!J 01:08:34
artery. • Characterized by Intestinal obstruction + impaired
• Aberrant obturator artery arises from - IEA vascular supply of the bowl
L • MC Constricting agent- Neck of sac
Attaches to obturator artery
L Clinical features
Forms a vascular loop • Irreducible hernia
L • Intestinal obstruction signs and Symptoms like colicky
Injured during dissection/ mesh fixation pain, bilious vomiting, non-passage offeces and flatus.
L • History of sudden pain over hernia followed by
Bleeding & death Generalized pain
• On examination
o Tense and extremely tender hernia
o Discoloration of skin (Reddish/ Bluish tinge) of skin
overlying hernia.
o No cough impulse
• Diagnosis of Strangulation - Based on clinical
examination

193
Treatment • Incision given on most prominent part of hernia
J
• Resuscitation
e-
·r~1C" ?J ' J l
l~•
, IVfluids Dissection till reaching the Sac and open the sac fundus
--. IV antibiotics
l
• Nasogastric aspiration Collected fluids is aspirated
• Foley's Catheterization
!
Examine bowl

Bowel viable Gangrenous bowel

l l
Reduce bowel to Excise gangrenous Bowel
Peritoneal cavity l
If omentum also non-viable
l
Secure Ligature and excise the
non-viable part of omentum
• Use of synthetic mesh is contraindicated in strangulated
hernia (because there is increased risk of infection)
• If mesh needed --+ Use bioprosthetic/ absorbable mesh.

Table 25.1
1. Irreducible Hernia
• Cannot be reduced due to formation of adhesions between
sac & content
Sac

Irreducible hernia
2. Incarcerated Hernia
• Contents cannot be reduced due to presence of fecal matter
in the content

Incarcerate d hernia

194
3. Obstructed Hernia
B-
r1cc•11~._•.: • l'l,-zQf"" c ·
• Intestinal obstruction with preserved blood supply tBf Jclt",
'1'r

Obstructed hernia
4. Strangulated Hernia
• Intestinal obstruction with impaired blood supply

5. Enterocele
• Content- Small intestine
• First part is difficult to reduce
• Last part is easy to reduce (reduces with Gurgling sound)

6. Omentocele
• First part is easy to reduce
• Last part is difficult to reduce
• Content- Doughy (omentum)

7. Littre's Hernia
• Content is Meckel's diverticulum

Littre hernia
8. Amyand's Hernia
• Content is Appendix

Appendix
Amyand's Hernia

10<:
 Table 25.2

a. Primary tension free repair

1) BASSI NI'S
BASSINI REPAIR
• Internal oblique + transverses abdominus +
fascia transversalis
•

•
These are suture to inferior edge/ shelving
edge of inguinal ligament
Aka TRIPPLE LAYER REPAIR
-
·-
• Increased tension in tissues -increased
recurrence rate
B
A

2) Shouldice
Shouldice Repair
• Double breasting of Fascia transversalis
• Multilayer repair of the posterior wall of the inguinal canal
• Aka FOUR LAYERED REPAIR
• Double bresting of transversal is fascia
• Relatively low tension in tissues - low • Transverse abdominis aponeurotic arch to the iliopubic
recurrence rate tract and conjoined tendon to the inguinal ligament

3) Modified Shouldice
• Double breasting of Internal oblique, Transverses Abdominis, Fascia transversalis
• Gold standard for Inguinal hernia repair - Lichtenstein repair
1) Lichtenstein Repair
f-
neelesh1410@gma1I com
917704860839 o Fix the mesh to the anterior rectus sheath just above pubic tubercle
!
Fix mesh (inferior aspect) to inguinal ligament
!
Create artificial deep ring (by overlapping the cut edges of mesh)
!
Superior aspect of mesh can be fixed to conjoint tendon

1 01-
 m HERNIA AND ABDOMINAL WALL - 2
II
FEMORAL HERNIA (!} 00:00:25 • Sub inguinal incision - LOCKWOOD
• Ing uinal incision - LOTH IESSEN
lliacus
• Supra inguinal incision - Mc EVE DY

TOC
• HENRY'S procedure
• Midline abdominal ext raperitoneal f emoral hernioplasty

Variants of femoral hernia

Locunor ligament

• MC type of Hernia in Females - Indirect inguinal hernia /

• Femoral hernia is more common in fema les
~ ollnl's hem[o
• MC in Right side (retrovosculor) ~ - --
Pubic tubercle
• Bilateral in 20% cases Fermoral hernia + - - - - -- - t"t"C--t- Lougiefs hernia
• MC in Multipara females
• TRUSS - Notto be used in femoral hernia Cloquer s hernia

_,__ _ Pectineus

Femoral Canal and Femoral Ring

• Femoral canal i s rigid & narrow: Increased ris k of
strangulation
• Surgery should be performed as early as possible to 1. LAUGIER'S: Hernia through gap in Lacunar ligament
prevent strangulation 2. CLOQUET: Hernia located behind pectineus fascia
• Diameter of femoral ring - 1.25 cm 3. NARATH HERNIA
• Length offemoral canal - 1.25 cm • Seen in congenital dislocation of Hip
• Cloquet group of nodes present in femoral canal • Lat eral displacement of Sac
• Sac is located behind f emoral vessels
Clinical presentation
neeleshw1oS,wel!mg located below and lateral to pubic tubercle SPIGELIAN HERNIA (!} 00:09:36
-0
917704860839

Approaches of repair depends on incision

Splgelian
0 fascia -+- +h"-'fil

Sem,lunar line
(ofsplegel)
Umbollcal
plane
Sp,gelian
' Me'Evody, tugh 19P'ooch }- Hernia belt

Monro Inferior
fine 1'-6l~ -+- Ppogastroc
~ ------::,,.4 LolholNefl••ngulnal vessels
app,ooch Hesselbach ,,....,..-
triangle

197
 • Hernia through Spigelian fascia
• Located at Infra umbilical region (below arcuate line)
• Most of hernias are usually seen in infra- umbilical region
due to absence of posterior rectus sheath
• Spigelian fascia - thin aponeurosis located between
Rectus abdominus muscle medially and semilunar line
laterally
• Aka Inter parietal hernia (located between internal
oblique and external oblique & penetrates spigelian fascia
and internal oblique)
• Located behind external oblique - hence not palpable/ not • Herniation in the lumbar region of posterior abdominal
visible wall
• MC - left side
Clinical presentation • Can be Congenital/ acquired
• Swelling is neither visible nor palpable leading to delayed • Congenital in 20 % cases
presentation • Acquired in BO% of cases
• Abdominal pain • Most of lumbar hernias are occurring through Superior
• Delay in presentation -+ Delay in diagnosis -+ Increased triangle of Grynf elt
risk of strangulation • Some of lumbar hernias are occurring through Inferior
triangle of Petit.
Investigations
• USG/CT Boundaries of Superior triangle of Grynfelt
• Posteriorly - Para spinal muscle
Management • Superiorly - 12th Rib
• Reduce the herniated content back & close the defect • Anteriorly - Internal oblique muscle

SLIDING HERNIA (HERNIA - EN- (!J 00:16:14

GLISSADE)
• Posterior wall of sac is formed by viscera. Ut1Hmut
dof,1 muse'•
• Increased risk of bow el surgery during ligation of Sac.
• More common in Left side. MC content - sigmoid colon
htfl!m1tl
• More common in males ob Que m,-
• On Right side MC content - Cecum

max
m<>
f ,cto, sptnal
;cle (covered
L opor,ou,oms)

•
neelesh141 , . q
917704860839

Boundaries of Inferior triangle of Petit

• Posteriorly - Latissimus Darsi
• Anteriorly - External oblique muscle
• Inferiorly - Iliac crest

Clinical Features
Management • Defect is very large. so. patient is not aware mostly.
• Sac along with content is reduced back • Presence of unilateral bulge in the lumbar region
• Close/repair the defect • Strangulation is very rare (large defect)

LUMBAR HERNIA 0 00:20:09 Management

• Dowd's Operation

198
OBTURATOR HERN IA (!J 00:25:55 o Congenital
• Aka Skinny old lady hernia o More common in Africans
• Aka French hernia o Closes spontaneously in majority of cases by 2 years
• Due to loss of fatty tissue in obturat or canal • In adults
o Acquired
Risk factors o Mic in females
• Lean thin patients (chronic malnutrition) o tlAP
• Elderlyfemales o Seen in pregnancy
• Multipara patients o Ascites , cirrhosis , obesity
• Chronic constipation • Complications- rare
• Other factors which increases intra-abdominal pressure
Indications of surgery
Clinical Presentations • If it persists beyond Syrs age
• Howshi p - Romberg Sign: Compre ssion of obturator • Sympto matic patients
nerve -+ Pain along medial aspect of thigh radiatin g to • Strangulation
ipsilateral knee j oint • Size> 2cm
• Hanning ton - Kiff- Sign: Absence of obturat or reflex • Progressive enlarge ment of hernia after 1- 2 years
• Maximu m time to wait- 5 years
Treatm ent
• Repair by posterior approach Treatm ent
• Small defects - Closed primarily
EPIGASTRIC HERN IA (!J 00:32:21 • Size of defect >3cm- Prosthetic mesh
• Any hernia from xiphoid process till 2 cm of umbilicus • Mayo's Repair
• Aka Epigastric Lipoma o Aka vests-o ver- pants repair
• Aka Fatty hernia of Linea Alba o Not usually perform ed because of increased tension
• Just off the midline in 80% cases associated with increased Recurrence
• Multiple in 20% cases

Clinical feature Epigast ric

• Pain referred to epigastric region - It mimics peptic l'.jll"~t hernia1
-9 1410@gma,I com
911ro4e6oe39

. cision1I
heml1

Inguinal
I
hernia
Treatm ent
• Excision of pre- peritoneal fat+ Repair
• If size of defect > 4cm- MESH is t o be used

UMBIL ICAL HERN IA (!J 00:36:30

• Hernia occurring directly through umbilicus
• Paraumbilical hernia- Hernia within 2cm of umbilicus but
not through umbilicu s. ABDO MINAL WALL DEFECTS (!J 00:43:20
• In infants 1. Ompha locele

199
 • Associated with Intesti nal atresia

Risk factors
• If mothe r has histor y of intake of
o Alcohol
o Smoking
o Aspirin during first trimester
o Ibuprofen
o Pseudoephedrine
• Age of mothe r - < 20 years age
• Not associated with congenital anomalies - so good
prognosis

INCIS IONA L HERN IA (!) 00:52:5 0

• Intestine fa ils return to the intra-abdominal cavity
• Covered by 2 layers VENTRAL HERNIA
o Amnion: Outer layer
o Peritoneum: inner layer
• For Small defect - Protrusion of small amounts of bowel Intes tine
• For Large defect - Protrusion of small bowel along with Protrusion
liver of tissue
• Associated with Trisomy 13, 18, 21 through
• Associated with conge nital malfor mation s - CVS defect
>
Musculoskeletal system > Gast roint esti nal system >
Genito urinar y system Hernia
• MC cause of death - congenit al malformation s defec t
• Associated w ith Beckw ith - Weidman Syndr ome (varian
(hole )
t
of Wilms tumour)
o Hemi hyper trophy
o Macroglossia
o Visceromegaly -8
ncelesh 1410~gma 1I co
91770486 0839 Abdominal
o Omphalocele wall
o Hepatoblastoma
• Poor progn o sis (asso ciate d with cong
enita l
malfor mations)
• Aka Post-operative ventral wall hernia
• Caused by failure of fusion offasc ial tissues
2. Gastroschisis (!J 00:49:3 2 • During laparotomy
o With the help of Prolene suture (non- absorbable)
o Subcutaneou s fat is usually closed with V icryl/ catgu t
o Skin is closed with silk (non- absorbable)
o After laparotomy, rectus sheath is closed
• If failure of fusion offascial tissues - Herniation of bowel
• Increased riskof incisional hernia
o In Long, vertical, midline, lower abdominal incision

Risk factors

Refer Table 26.1

• Splittin g of abdom inal w all from right side w ith herniation

EHS classification
of bowel.
• Bowel is expos ed , becomes thickened, matted and
Refer Table 26.2
edematous

200
 Midline Distribution
• In 60% cases: Extra abdominal
• In 25% cases: arises from abdominal wall
Subxiphoidal • In 50% cases: Intra -abdominal
,1 M1
! 3cm

I, J \_ Location
Epigastric M2 • Abdominal wall desmoid

l !
I
3cm
o Arises from Musculoapo neurot ic st ruct ures in t he
infra -umbilical region
Umbilical M3 \
! 3cm o Unencapsul ated- cracks whenever it is being cut.
lnfraumbilical M4
Risk factors
Suprapubic
Ms\ • History of surgical incision/Trauma
• Estrogen stimulates growth (Mc in female)
• Variant of FAP - Gardner's syndrome (t risk of desmoid
Lateral
tumor)
• No sarcomatou s changes
• No d istant metastasis
• Increased risk of recurrence despite of excision

Clinical features
L1 Subcostal • Mic presentation : Lumps/ mass

Lumbar L4 Investigations
L2 Flank
• Investigation of choice
o For diagnosis - Biopsy
o For extent - MRI

Treatment
• Wide local excision w ith 2cm margin
Treatment • For recurrent desmoids: Surgery + Radiotherapy
• Gold standard Treatment- lPOM
o A - Onlay /overlay: placing mesh above the facial
sheath
o B - Inlay / lnt erlay: suturing the edges of mesh through Previous Year's Questions
the sheath without closure & is the least commonly
Q. Most common prt.St.ntation of abdominal dt.smoids
performed.
tumor is? (AIIMS Nov 2017)
o CID - Sublay / underlay: placing mesh below the
A. Abdominal pain
sheath & then closure B. Abdominal mass
o E- IPOM: Intra peritoneal Onlay mesh repair C. Ft.vt.r
Decrease Recurrence rate by > 50% D. Urinary rt.tention

rp
nc
A B 91

<))
(I
0
Previous Year's Question s
Q. Dt.smoid tumor is associatt.d with?
(JIPMER May 201,)
A. Colonic polyps
B. Pancrt.atic cancer
C. Ovarian cancer
D. Gastric cancer
DESMOID TUMOR 0 01:07:09

201
Ot her Named Hernias

1. GIBBONS HERNIA - Hernia + Hydrocele ,.,,oo,=~ f Hernias

2. BERGER'S HERNIA - Hernia into pouch of Douglas
..~ '{j~ -v·{QJ-
3. BECLAR'S HERNIA - Hernia t hrough saphenous
Rkhtff's hernia Pantaloon hernia
opening

4. OGILVIE'S HERNIA - Hernia through defect in conjoint

tendon
5. STAMMER'S HERNIA - Hernia through transverse
m esocolon after retrocolic Gastro-jejunostomy

6 . PETERSON HERNIA - Hernia behind Roux limb after Llttre hernia

Sliding hernia
Roux-e n-Y Gastric bypass (MC Bariatric surgery
performed worldwide)

7. VELPAEU'S HERNIA
• Aka pre vascular hernia
• Sac is in front of femoral vessels

8. SERAFINl'S HERNIA Amyand hemla Maydl hernia

• Aka Retro vascular hernia
• Sac is located behind femoral vessels t)
0
Previous Year's Questions
9. HOLTHOSUE H ERNIA
• Type of inguinal herni a Q. He.rnla not re.late.d to abdominal wall?(J IPMER Ma!J
201,)
• Extension of bowel along inguinal ligament
A. Am!Jand's he.rnia
8. Richte.r's he.rnia
C. Littre.'s he.rnia
RICHTER'S HERNIA <!) 0 1:21:12 D. Pe.te.rson he.rnia

• Herniation of P<!rt of circumference of bowel

Clinical Feat ures

• Colicky pain
• Diarrhoea
• Mimics acute Gastroenteritis -+ Delay in Diagnosis -+

jRisk of strangulation

202 →
 Table 26.1

Surgery related Surgeon related Patient related

• En,ergency Surgeries • Poor technique • Factors that contribut e to
• Post Op. Complications • Closure under tension Impaired wound healing
, Wound Infection s • Use of absorbab le sutures Diabetes mellitus
Burst Abdomen Steroid intake
, HIV positive/
immunocompromised
o Jaundice & Cirrhosis

Table 26.2

Midline (Ml - MS) Ml: Sub xiphoidal (3cm from xiphoid process)
M2: Epigastric (3 cm below xiphoid to 3cm above umbilicus )
M3: Umbilical (3cm above and below umbilicus)
M4: Infra umbilical (3cm below umbilicus and till 3cm above pubis)
MS: Suprapubic (3cm cranial to the pubis)

Lateral (Ll- L4) Ll: Subcoastal

L2: Flank
L3: Iliac
L4: Lumbar

203
-3
 CLINICAL QUESTIONS

Q. 45 year old male ca me to the OPD with complaints of swelling in the abdominal wall which reduces
on lying down.
Examinati on revealed a positive cough impulse. CT scan findings w ere consistent with Spigelian
hernia. True st atement
regard ing Spigelian hernia:

A . It occurs exclusively in males

B. It involves p art of the circumf erence of t he bowel wall
C. It is best repaired by the classical Bassini technique of inguinal ligament repair
D. lt occu rs at the lateral edge of the linea semilunari s

Answer:D

Solution
Spigelian hernia occurs at the linea semilunaris, which extends along the lateral border of each
rectus abdominis muscle. The
posterior rectus sheath is deficient at the level of the arcuate line (semicircular line) about one-third
of the distance between
the umbilicus and the pubic symphysis; this is the most common site for spigelian hernia to occur
through the linea semilunaris

They affect men and women equally and can occur at any age, but most common in elderly
people

Patient often presents with localised pain in the area without a bulge because the hernia lies
beneath the intact external
oblique aponeurosis

Ultrasoun d or CT of the abdomen can be useful to establish the diagnosis

Spigelian hernias are repaired because of the risk for incarceration associated with its relatively
narrow neck

The Bassini technique is used for the repairofin guinal hernias only

In Richter hernia, a small portion or circumference of the anti mesenteric wall of the intestine
is trapped within the hernia
and strangulat ion can occur without the presence of intestinal obstruction

-8g
ree-lesh 1410:@qma•I
91 "7048608Jq

204
m SPLEEN

• Largest lymphatic organ Epistaxis

• Blood bank of body o Gum bleeding
• Stores 2% of blood o Size of spleen is characteristically norma l (not
• Average weight 75- 100 grams. enlarged)
• Usually, spleen is not palpable
• If enlarged> 2.5 times, it becomes palpable Management
• Relations of spleen • Steroids - When used in long duration causes steroid
o Spleen is in relation to 9'". 10'". 11"', ribs. related complications(like Hypertrichosis and Hyper
o Long axis of spleen is along the lO'h rib pigm entation which makes patient to discontinue
• Develops from Cephalic part of Dorsal mesogastri um treatment)
• Azathioprine
SPLENECTOMY (!) 00:02:54 • Cyclophosphamide
• MC Indication - Trauma • Gold standa rd treatment for ITP - Lapa roscopic
• MC indication of Elective splenectomy- lTP Splenectomy (open splenectomy not preferred because
• Splenectomy always indicated in of normal size of spleen)
o Primary splenictumor • In normal patient. for elective surgery minimum platelet
3
o Hereditary spherocytosis count- I00000/mm
• Splenectomy usually indicated in • In ITP patient, for elective surgery minimum plat elet count
3
o Primary hypersplenism - 50, 000/mm
o Chronic ITP • Best time for platelet transfusion in ITP - after ligation of
o Splenic vein thrombosis leading to gastricvarices splenic artery (So, that platelets will not reach spleen &
o Splenic Abscess does not gest destroyed)

ITP (IDIOPATHIC THROMBOCYT OPENIC Complications

PURPURA) (!) oo:os:s6 • Lung related complications
• Aka Immune Thrombocytopenic purpura. o MC complication responsible for fever after surgery up
• Formation of Auto ant ibodies against platelets to 48 hours is Atelectasis
• Autoantibody coated platelets are selectively destroyed o (Noninfectious fever and is not associated w it h chills
in spleen, Platelet Destruction in spleen decreased and rigors)
Platelet count causing ITP leading to Petechiae & purpura o Consolidation - (fever + chills and rigors)
• Size of spleen is typically normal o Pleural effusion
• MC in children
• Seen in both boys & girls • Diaphragm related complications -8 nePlesh ..$ 1O~gma I Jm
Gl 1704860839

• Resolve sponta~eously in boys o Sub diaphragmatic hematom a

• Chron ic ITP usually seen in g irls o Sub diaphragmatic abscess

• ITP persists in girls

• Pancreas related complications
o Acute pancreatitis
• Clinical f eatures
o Injury to tail of pancreas
o Pet echiae
o Pancreatic fistula
o Purpura

205
 Thro mboc ytosi s 1
• Thro mbo embolic comp licat ions

Increased risk of DVT -+ Increased

SP LEN IC ABSCESS
• Rare cond it ion
• Heal thy patie nt havin g unilocular absc ess
<!) 00:27 ·10

- mort ality rate

risk of Pulm onar y Embolism
is 15 - 20%
" Immobilization
• lmmunocompromised, multi locular - mort
ality rate is
80%
OPS I (Ove rwhe lmin g post splenectomy infec
tion) • Pred isposing facto rs
• MC late fatal complication of splenectom y
o Malignancy
• Usually seen after 2- 5 years of spl enectomy
o Polycythemia vera
• Increased risk of OPSI in malignancy and
hematological o IV drug abuse
disorders
o HIV positive
• Leas t risk in Trauma
o Hem oglob inopa thy
• 40 -50% mortality rate
o UTI
• Normal function of Spleen - Phagocytosis
F-
neelr sh 141 O@,grra11corn
of capsulated • MC organismcre~~filSI0le - staph aureus
organ isms
• Fungal abscess is typic ally seen in HIV
• In absence of spleen due to splenectomy - posit ive and
increased risk immunocompromised caused by candida
of capsulated organism infec tions
• Other organisms responsible
• Organisms responsibleforOPSI
o Streptococcus
o MC - Strep pneumoniae (Pneumococcus)
o Salmonella
" Neisseria meni ngitid is (Meningococcus)
o Gram negative enteric bacilli
o H. influenza type 8
• Healthy person -+ strep. Pneumoniae -+
usually cleared • Clinical features
by 5 to 7 days .
o Abdominal pain
• Prevention: By vaccination.
o Tenderness
• Best time forva ccina tion
o Peritonitis
o 2 weeks before elective splenectomy
o Pruri ticch estpa in
o As early as possible after emergency splen
ectom y
• Investigation
SPLENIC CYST
o Investigation of choice - CECT
• MC true cyst of sple en- Hyda tid cyst
• MC non- para sitic cyst - Pseu docy st
(cyst lines by • Trea tmen t
granulation tissue) (70- 80% )
o Unilocular abscess: drainage+ antibiotics
• MC congenital splenic cyst - Epidermoid cyst
o Multilocular abscess: splenectomy + drain
• Overall, most common splenic cyst - Pseudocy age of left
st upper quadrant + antibiotics
• Incidence of hyda tid cyst - 10%
• Incidence of pseudocyst - 70 to 80 %

SPLENIC TUMORS 0 00:25:18

• MC neoplasm of spleen - NHL
• MC primary benign tumo r of spleen - Hem
angioma
• MC primary malignant tumo r of spleen - Angi
osarcoma
• MC primary for splenic metastasis - Malignant
melanoma
• MC primary for isolated secondaries to splee
n - CA ovary

L 206
 • LEARNING OBJECTIVES
-5 r,r-,, M,t t 410 i ~rn~
, 11 .... 10.1ci,r1r 930

UNIT 4 : UROLOGY
. - Kidney and Ureter Part- 1
o Introdu ction of Renal Stones and its Types, Calcium Oxalate Renal
Stone, Uric Acid Stone, Struvite Stone, Cystine
Stone, Xanthine Stone, Triamterene Stone, Silicate Stone
') Investigation for Renal Stone
o Indications for Conservative Management and Surgical Interve
ntions
1 ESWL (Extrac orporeal Shock Wave Lithotr ipsy)
""' PCNL (Percutaneous Nephrolithotomy, Ureteroscopy, lntracorporea
l Lithotr ipsy
o Management of Renal Stones and ureteric stones
o Infectious Disord ers of Kidney, EmphysematousPyelonephr
itis(EPN),Xanthogranulomat ous Pyelonephritis(XGP),
Difference betwee n Pyonephrosis and Perinephric Abscess
o Hydronephrosis (HON), Unilateral and bilateral HON
o Genitourinary Tuberculosis
o Changes seen in Kidney , Ureter.Bladder and Prostate.
. - Kidney and Ureter Part-2
o Renal Tumors, Angiomyolipoma, Renal Oncocytoma,
o Renal Cell Carcinoma: Pathological and surgical aspect.classif
ication and treatm ent
o Pediatric Tumors,wilms tumour, CA Renal Pelvis
. - Kidney and Ureter Part-3
o Polycystic Kidney Disease, autosomal domina nt and infantile PKO
o Renal Agenesis, Renal Vascular Abnormality, Medullary Sponge
Kidney
o PelviuretericJunction Obstruction, Retrocaval Ureter, Horse-
Shoe Kidney
o Ureterocele, Duplication of Ureter, Vesicoureteric Reflex
. - Urinar y Bladde r
o Ectopia Vesicae
o Bladder stone.p rimary and secondary
o Schistosomiasis, Similarity b/w Schistosomiasis and Genito Urinary
TB
o Malakoplakia
o Interstitial Cystitis
o Bladde r Rupture
o Carcinoma Bladder, Malignant Cystitis/Carcinoma -In-Situ, classifi
cation and manag ement
. - Prosta te and Seminal Vesicles
o McNeal Zone and basic principles
o BPH, IPS scoring system, investigation and treatment
o Indications of Surgical Interve ntion, Transurethral Incision of the
Prosta te, Open Prostatectom y
o Acute Bacterial Prostatitis, Prostatic Calculi,
o Carcinoma Prosta te, tumor marker, PSA density, classification,
gleason grade
. - Urethr a and Penis
o Anatom y of urethra.penis
o Hypospadia and epispadias
o Posteri or urethral valve
o Phimosis and paraph imosis
o Priapism, Urethral Injuries, Urethral Strictu re,

207
 o Peyronie's Disease,
o Carcinoma Penis and urethra
.,. Testis Scrotum Part-1
c Normal Descen tofTest is
n Position of Testis in Int rauterin e Life
o Unde,~r~~Q~tr~~1~~~~"'
_
o Ecto~crmrC!lcR'etractile Testis
o Acute Epididymo-orchitis
o Testiculartorsion
o hydrocele
. - Testis Scrotum Part-2
o Varicocele,spermatocele
o Fournier's Gangrene
o Testicular Tumors: Risk Factors & WHO Classification
o One line Questions regarding Testicular Tumors
o Seminoma- MC Testicular Tumor
o Tumor Markers in TT
o ITGCN
o Carcinoma Scrotum
o Perinephric Abscess
o Bilateral HDN

208
m KIDNEY AND URETER PART-1

RENAL STONES (!) 0000:21 NH4+, Phosphate)

• Mandatory factors for stone formation
o Super saturation
_
• MC in females because of shorturethra,(«ml
• Short urethra-Increased risk ofur1.'.:..Proteus ....... produces
0 Crystallization urease.
• Randall Plaques • Urease converts urea into ammonia - Ammonia gets
") Soft tissue calcification found in deep renal medulla precipitated
:-- Act as nucleating agent for renal stones • 3- 5 minor calyces join major calyx and later forms pelvis,
pelvic uretericjunc tion and then ureter.
TYPES OF RENAL STONES (!) 00:02:00 • Struvite stone is very large & fills pelvic calyceal system
Ca OXALATE STONES. and looks like staghorn (due to branching in stone) _.
• Most common type of renal stones very large silent destruction of kidney
• Radiopaque
• Risk factors Managemen t
o Hypercalcemia • Sandwich Technique-PCNL (percutaneous
o Hypercalciuria nephrolithotomy)+ ESWL (Extra corporeal shock wave
o Hyperoxalur ia lithotripsy)
• To prevent recurrence of stone formation - Irreversible
URIC ACID STONES (!) 00:03:55 inhibitor of urease (Acetoxy Hydroxamic acid)
• Most common type of radiolucent renal stone

Risk factors
• Gout
• Lesch- Nyhan syndrome
• Myeloprol iferative disorders (due to increased
breakdown of cells)
• (Hypoxanth ine- Xanthine ---+Uric Acid)

Manageme nt Principles
• If acidic stone - do alkalinisation of urine
• If basic stone - do acidification of urine.
• Acid combines with base & forms salt which is soluble &
is excreted in urine.
• Plenty offluids
• Low purine diet
• Acetazolamideis used for Alkalinisatio n of urine
• Allopu rinol-To block conversion of Hypoxanthi ne t o
xanthine & hence block formation of uric acid.

STRUVITE STONES (!) 00:08:18

• Aka staghorn calculi / Triple phosphate stone (Ca, Mg,

209
 0
excessive use of K+ sparing diuretic leads to formation
'j Previous Year's Questions of radiolucent stone
ll

• lndinavir
Q. Strwitf. stonf. IS causf.d by which mf.tal?
(NEET J an 2018)
0 Protease inhibitor used in HIV leads to formation of
A. Magnf.sium radiolucent stone
B. Calcium • Silicate stone
C. Sodium and potassium 11
D. BothA and B Excessive consumption of antacids containing silica

e-
• Radiolucent stones l",<"O fl t--' .1 1 .iQ'l11il NI,
Q1 77()48608JO
o T - T riamterene
CYSTINE STONES (!J 00:12:50 o I - lndinavir
• Seen in cyst inuria o X - Xanthine
• Radio Opaque (double sulphide bond) o U - Uric acid
• Very Hard (not easily broken by ESWL) • Acidic stone
• Crystal- Benzene shaped Crystal (Hexagonal Crystal o Calcium oxalate
• 0 - Penicillamine o Cysteine
• a -MPG (Alpha- mercaptopropionyl glycine) o Uricacid
o (Alpha MPG> D- penicillamine)

i
o Alpha - MPG - Better tolerated
How to remember
• CCU

o Renal Stones-more common in males

o Infectious renal stones -more common in females

CLINICAL FEATURES <!J 00:22:41

• Abdominal pain - MC presentation
• Causes of pain in the renal stone
XANTHINE STONES 0 00:15:47 o Obstruction is going to cause stretching in the renal
• Seen in xanthinuria capsule which can lead to non- colicky abdominal pain.
• Hypoxanthine-xanthine (Allopurinol can be used to block o Stone fragment reaches ureter, ureter starts
conversion of Hypoxanthineto xanthine) hyperperistalsis which can lead to colicky pain.
• Radiolucent o Radiation of pain depends on the location of stone
• Brick- red in color • If stone in Upper 113rd of ureter, pain radiates to
• Lamination on cross section o Testes (Males)
o Labia majora (Females)
• If stone in Middle 1/3rd of ureter, pain radiates to (via
iliohypogastric nerve)
o lliacfossa
o Hypogastrium
o Groin
• On right side-it mimics Acute Appendicit is
• On left side - it mimics Diverticulitis
• If stone in Lower 113rd of ureter, pain radiates to (Via

DRUG INDUCED STONES 0 00:17:34 ilioinguinal nerve)

• Triamterene
o Scrotum

210
 o Perineum.
o Inner aspect of thigh
• If stone i n intramu ral ureter-s trangury (PAI NFUL
FREQUENT URIN ATION OF <;MALL QUANTl1Y).
~ ~ ->
•,..,
~ \.
.J
:;..;..-
,
.:~,
.,.

. (~,;-1~
J
• I
,,, ,
·· -"' •
.
I
,~ ...
,..,
,,.
... ....... ~ ')
-
--
- '"
>. \ (,"'

Pre.vious Ye.ar's Que.st ions o 0

-\. ~ .. -
0 "
.

, ·i~ /1 .
, ._,
p .>
Q. Re.+e.rre.d pain +rom vre.te.rlc colic Is +dl in the. ,.
groin due. lo the. involve.me.nl o+ l he. +ollowing , fl
ne.rve.· (NEET PG 20") •
A. svbcost al "
B iliohypogastrlc
X- RAYKUB
C. ilioingvinal 0 00:3330
D. ge.nit.o+e.moral • 90% of Renal Stone- Radio opaque
• 90% of gall stones- Radiolucent
• 80% salivary gland stone - Radiopaque
• Investiga tion of choice - Non contrast spiral CT • Ultrasou nd-Screening investigation for Hydronephrosis

Management IVP (!} 00:35:24

• Analgesics [ DOC- Diclofena c (Voveran)] • (access site of obstructi on)- Int ravenous dye injected
usually antecubital fossa
• Used t o access
INVESTI GATION S PERFORMED 0 00:28:22 o Proximal part of obstruction
• Urine Routine &Microscopy o Hydronephrosis
o Color o Renal function
o pH
o Specific Gravity RGP (!} 00:37:52
o Presence of Sugar/ Albumin • Retrogra de pyelogram
o RBCs/ WBCs/P uscells • Used to assess t he distal part of obstruction
o Cast/ crystals
• Urine Culture & Sensitiv ity Radionucleotide scans (!} 00:38:56
o Confirma tion of infection is done DMSA
o To diagnose UTI +l- • Dimercaprol succinic acid scan
o To identify organism • Used to assess M- Morpholo gy
o To identify antibiotic sensitivit y • S- Scar
• SA- Surface A natomy
• Calcium oxalate monohyd rate st one- Dumbbell shaped • Can evaluate presence of scar in kidney
• Calcium oxalate dihydrat e stone o Eg: Chronic pyelonephritis
• Envelope shaped
• Aka Bipyram idal shaped DTPA
• Uric Acid Crystals • Diethylene triaminePenta acetic acid scan
o Rosette shaped • Perfusion and Function
o Multi-facet ed • IOC- for renal perfusion and function - DTPA
• Calcium Phosphate-Amorp hous crystals
• Struvite stone - coffin lid crystals MAG-3
• Brushite stone- Needle shaped • Mercapto Acetyl glycine
• Cystine- Hexagonal or benzene shaped • Gold st andard for Renal perfusion

211
INDICATIONS OF CONSERVATIVE MANAGEMENT

<!) 00:42.13
• Stone size up to 5mm Shock waves
• Non dilate d urete r break up
• Stone located in lowe r t hird of ureter kidne y stones
• Progressiv e down ward mom ent on repea ted
scan.
Principle
• Preve nt super satur ation & crystallization by
dilution of
urine .
Small pieces
Management pass through
urinary tract
• -+Ple nty amou nt of fluids (4-6 liters / day)
• -+For 4mm stone -> Take 4 liters of wate
r- > stone is
excreted within 4 week s Complications
• -+Alk alinis ation /Acid ificati on of urine for 4 week • If there is dista l obstr uctio n of urete r, all
s the stone
fragm ents are collected in the Proximal part of urete
Interventions r
(!) 00:45:11
• ESW L (Extra corporeal shock wave lithot ripsy)
: 85% of Aka Steinstrasse / Street Of Stone/ Colummation Of
cases Gravel
• Hema toma in kidne y (Bleeding due to shock
off
nce·e~ti 1 .i 1 -
• PCNL (Percutaneous neph rolith otom y) } wave s) 9177Q.laGOBJCI
• Increase risk of UTI
• URS (Ureteroscopy): 15% of cases
• LSS (Lapa rosco pic stone surge ry) : Not • Increased risk of Extra systo les
comm only
prefe rred • For stones of size up to 2cm - ESW L is used
• OSS (Open stone surgery)
Hard stones that cannot be broken down by ESW
L
055 indications • B - Bru
• Stone with non- funct ion kidne y = Neph recto • shite
my has to
be perfo rmed -+ open appro ach • H - Hydro xyapa tite
• Stone with anato mical disor der of kidne • C - Cysti ne
y e.g. (PUJ
Obst ructio n) pyelo lithot omy& pyelo plast y has • C - Calcium oxalate Mono hydra te
to be
performed -+ so, open approach

7? Previous Year's Questions

j How to re.member
0

Q. Management of 'i cm size. renal stag horn • BHC2

calculus? (AIIMS Nov 2017)
A. ESWL
CONTRAINDICATIONS OF ESWL
B. PCNL
C. Intra renal re.pair surge.r!J
D. Open p!Je.lolit.hotom!J Absolute Relative Contraindications
Contraindications
ESWL <!) 00:47:52 • Pregnancy (shock • Pacemaker
• Gold stand ard litho tripte r used in ESW wave s dama ge fetus)
L-Do rnier • UTI
unmodified HM~3 • Bleeding disor ders. • Unco ntroll ed HTN
• Shoc k wave induc ed tensil e cracking • (Increased risk of • Obesity
i hema toma & bleed ing • Ortho pedic abno rmali ties
Erosion & shatt ering so not be given in (Scoli osis/ kypho scoliosis)
patients diagnosed • Dist al Obst ructio n
i
with bleed ing • Renal failure
Stone fragm ent excreted in urine via uret er
disor ders) • Aneu rysm

212
PCNL (PERCUTANEOUS NEPHROLITHOTOMY) • MC Complication of URS-Ureteric perforation of URS
(!) 00:56:08 (Internal diameter of ureter - 4mm)
• A tract is created in kidney via abdominal skin & then
nephrolitho tomy is performed. Indications
• Renal artery has two branches • For insertion of DJ stent
o Anterior branch of renal artery • For removal of stone
o Posterior branch of renal artery • For removal of foreign body
• For PCLN - posterior approach is used. There are two • Taking biopsy from urothelial tumor
posterior approaches followed.
o Posterior pelvic approach
o Posterior calyceal approach
• In posterior pelvic approach, the posterior branch of renal
artery is injured. So, posterior calyceal approach is preferred Basket ---,~-fl

in percutaneous nephrolithot omy to prevent injury of

posterior branch of renal artery Ureteral stone---1- -- ~

A-
neetA-.ti 1d 1tJ'cl'~
Ureteroscope
91770486083Q

Bladder
yepiece

1a-- - Urethra
Ureteroscope

Irrigation drain

li"i9
~ /

- - - -...-- Ureter
Indications
rl-----+- Bladder
• Size of stone> 2cm
--..c---- t- Ure~ra
• Distal obstruction
• UTI ___..,__ Ureteroscope
• Hard Stone (BHC- 2)
• Lower calycea I stone
o Staghom calculi (PCNL + ESWL) - Sandwich technique
o Most common complications of PCNL -Bleeding
Most commonly injured organ - Pleura> colon> Spleen
INTRACORPOREAL LITHOTRIPSY (!) 1:os:04
0
4 lithotripters are used

(!) a. Electro- hydraulic lithotripter (mainly used)

URS(URE TEROSCO PY) 1:02:13
b. Ult rasonic Lithotripter
• Performed under spinal anesthesia

213
 c. Ballistic Lithotripter
Important points:
d. Laser Lithotripter
Emphysematous Cholecystitis
• MC organism involved - Cl. Perfringens (Cl. Welchii)
EHL
• MC aerobic organism responsible - E.coli
• Cheap
• Very effective
Emphysematous pyelonephritis
• Narrow safety margin
• MC organism involved - E. coli
• Mainly used for bladder stone

Xanthogranulomatous Pyelonephritis
laser lithotripter • MC organi sm involved - Proteus (Staghorn calculi)
• Uses "Holmium YAG" laser
" Best source of laser for intracorpore al lithot ri psy. Xanthogranulomatouscholecystitis
' MC used laser for renal stones and Benign prostatic • Non-infectio us condit ion
hyperplasia. • Caused by - Rupture of RokitanskyA schoff Sinuses
o Causes stone vaporization by photothermal mechanism
!
If laser lit hotripter used for Uric acid stones - Bile leak
ca uses prod uction of Cyanide
!
No Significa nt Toxicity from the cyanide produced. Xanthogranu lomat ouscholecys titis
Hight cost, butveryeffe ctive
EMPHYSEMATOUS PYELONEPHRITIS <!J 01:17:30
MANAGENMENTOFRENALSTONE (!J 01:09:47 • Characterised by: Presence of ring of air around kidney
• For Stone size up to 2cm - ESWL (perinephric region) or within the kidney
• For Stone size> 2cm - PCNL • MC organism responsible: E.coli >klebsiella
• For Hard stone (BHC- 2) - PCNL • MC in Diabetic (due to low immunity) & Females
• For Staghom calculi-Sand wich technique (PCNL + ESWL)
Clinical features
MANAGEM ENT OF URETERIC STONE <!J 01:11:41 • Flank pain, Fever & Vomiting
Depends on location of stone • Mortality rate is 19- 43%
E-
neelesh 141
q1770455na
• Stone in upper and middle 113rd of ureter
• Size of stone up to 1cm - ESW L > URS Investigation
• Size of stone > 1cm - URS • On X- ray- Presence of air in relation to kidney
• Stone in lower 113rd of ureter- URS(No use of shockwaves • IOC-CTsca n
in this area)
Treatment
• IV antibiotics
"/) Previous Year's Questions • Resuscitation
0

A. calcium oxalatf. stonf.: M/C typ'- o+ kidnf.y stonf. • Control blood glucose

B. uric acid stonf.S:MIC radiolucf.nt rf.nal stonf. • If pus/ evidence of infection is present- Drainage should

C, xanthinf. stonf.S: Brick rf.d colourf.d, round and show be done

• Neph recto my to save the lif e of patient
lamination on cross Sf.ction
D, cystinf.:Extrf.mely hard radiolvcent stones
XANTHOGR ANULOMAT OUS PYELONEPHRITIS
Ans,D
<!) 1:20:10
• Chronic bacterial infection
INFECTIO US DISORDE RS OF KIDNEY • MC organism - Proteus
(!} 1:13:22 • Associated wit h St ruvite stone causing Obstructed and

214
 hydro nephr otic kid ney
Mana geme nt
• IV antibi otics + Drain age
Pathology
• Percu taneous nephrost omy (Olde r, diabetic etc)
• Presence of Xanth oma cells in renal paren chym a
(Foamy • For Non-F unctio ning Kidne y- Neph rectom y
lipid laden histoc ytes)
l PERINEPHRIC ABSCESS (:) 01:29:2 1
Mimics - Clear cell varian t of RCC
• Collec tion of Pus aroun d kidne y
• Spread by 2 routes
Clinical features
o Cortical exten sion
• Flank pain
o Hema togenous spread
• Fever with chills and rigor
Urine culture positive in 1/ 3rd cases
• Flank Mass
Blood cultur e positi ve in 50% cases
• Bacteriuria
Most Comm on organ ism - E. coli > Proteus

Investigation
Clinical features
• IOC - CECT
• Pain
• Tenderness
Treatment
• Fever
• Init ially, Partial Neph rectom y - if not possible
l Diagnosis
Total Neph rectom y
• USG/ CT

Pyonephrosis and pernephric abscess

Mana geme nt
Basic difference
• IV antibiotics + percu taneo us draina ge
! not respo nding
Perinephric abscess Pyonephrosis
Open drain age/ Neph rectom y
• Collection of Pus aroun d • Pus is collected inside
the
kidne y kidne y (Bag of Pus) HYDRONEPHROSIS (:) 0 1:32:33 ,eelesh14H
• Asept ic dilatio n of kidney E- 917704860

• Caused by Outflo w obstru ction of Urine

PYON EPHR OSIS <!) 0 1:25:01 • Can be Unilat eral/B ilatera l
• Kidne y is a bag of Pus
• Seen in chron ic obstru ction: Hydro nephr osis
Causes of Unilateral Hydronephrosis <!) 01:35: 25
l
Destr uction of renal parenchyma
Extramural Intramural lntraluminal
l
• Advan ced • PUJ • Stone
Pus collec tion
Malignancies Obstr uction • OM
• Most Comm on cause of obstru ction - Renal stone
s o Colorectal cancer
o Carcinoma cervix
Clinical features o Carcinoma
• Fever o Prost at e
• Anem ia
• Retro perit oneal • Uret erocele • Papill ary Sloug h
• Mass in loin fibrosis • Due to
o Analg esic
Diagnosis
nephropath y
• USG o Sickle cell
anaemia

215
• Retrocaval Ureter • Ureteric • Ureteric Primarily involved organs by Hematogenous spread
Stricture st ricture. • Kidney
• Prostate
• Urothelia l
tumor
Secondarily involved organs by Hematogenous spread
• By ascent of infection: form Prostate to vas deferens
CAUSES OF BILATERAL HYDRONEPHROSIS 0 013a;20 (moving upwards)
• By Descent of infection: from kidney to uret er & bladder
Congenital Acquired (moving dow n)

Post erior Urethral Valve • Testes is spared

Bladder neck stenosis
Pathophysiology
Ureth ral atresia BPH Bacteria (From hematogenous spread)

CA Prostate !
Lodged into peri- glomerular capillaries
Urethral strictures !
If good immunity - Infection cleared
If bad immunity - Activation of bacteria
CLINICAL FEATURES <!) 01:40:24 !
U/L Hydronephrosis Form at ion of cortical granuloma
• Mild pain / Dull aching pain
!
• Acute Ureteric Colic Format ion of t ubercular abscess
• Int ermittent hydronephrosis (DIETL'S Crisis)
!
! Ruptures into pelvicalyceal system
Patient present w ith severe pain in flank and palpable !
swelling Sterile Pyuria
! (On urine routine & microscopy - Pus cells)
Disappears after passage of large volume of Urine (On culture & sensit ivity - No growt h w ithin 48 hours)
• MC earliest symptom of GU T B - Increased frequency of
B/L Hydronephrosis urination
• Symptoms of Bladder Outlet Obstruction
• Signs and symptoms of renal failure. In Kidney and ureter
Calyceal Stenosis / stenosis at PUJ
G-
ne81esfi U"·1O'@gmat1 com
Investigation ! 917704860839

• Screening investigation - USG Hydronep hrosis / Pyonep hrosis

• IOC for Dx - DTPA !
Perinephric abscess
Management !
• < 10% kidney function - Indication for nephrectomy Caseous necrosis
• Treatment of underlying cause !
Kidney filled w it h cheesy mat erial (Aka Putty kidney)
GENITOURINARYTB C) 01:45:27 !
• MC organism involved - Mycobacterium t uberculosis Calcification
• MC inmales, 20to40years (Calcified kidney Aka cement kidney)
• MC route of spread - Hematogenous !
• Primary organ involved -Lungs Becomes Non-functioning calcified kidney
(Auto nephrectomy)

216
 *
\ :
lmportal"\t Inform ation
ne.phre.ctomy
Investigation
• Urine Routine and microscopy- Pus
• Urine culture & Sensitivity - no growth within 48 hours

L:::: sple.ne.ctomy isissun

se.e.n GUTSIn
in sickle. ce.11 dlse.ase.
(sterile Pyuria)
• Earliest sign of renal TB on IVP - Moth Eaten calyx
• IOC for diagnosis of earliest changes of renal TB - IVP
• Other changes seen in IVP
o Calectasis (calyx become swollen and dilated)
o Space occupyin g lesion
o Hydronephrosis
• IOC for diagnosis of Renal TB - CECT
o On RGP-Pipe-Stem Ureter (Medial deviation of ureter)
Treatme nt

• ATT + Management of complications

Complications
1. For Ureteric st ricture - Dilation
2. For Sma ll co ntracted bladder -Augme ntati on
Enterocystoplasty
In bladder (!J 01:53:50 3. For non -function ing kidney - Nephrectomy
• Infection moves from ureter into bladder - Pallor around 4. For Non-dilatable stricture of lower 3rd of ureter -
ureteric orifice in the bladder BOAR l'S OPERAT ION (Excise the Non dilatable
• Initial sign visualized during cystoscopy in TB - Pallor stricture and part of ureter & then rise a flap from
around ureteric orifice. bladder and suture the defect)
• hronic inflamma tion in bladder forms tubercles
i
Fibrosis
i
Bladder becomes small, contracted bladder with highly
reduced capacity - Thimble bladder
• In advanced cases of TB, when there is contracted
bladder - it gives Golf hole ureteric orifice.

Is

Boari's operation

'~
0
Previous Year's Questiol"\S
In prostat e (!J 01:57:00 Q. The. most sensitive. imaging modality to detect
• Becomes Calcified - hard & nodular early renal tvbe.rcvlosis is: (NEET PG 2015)
• Testis is spared in genitourinary TB A, intravenous urograp hy
• Characteristic feature of TB - Beaded appearance of vas
8: computed tomography
C, ultrasound
deferens with multiple discharging sinuses via scrotum D, Magnetic resonance. imaging.

217
m KIDNEY AND URETER p~~;:,:
F-
BENIGN RENAL TUMORS
'??
0
Previous Year's Questions
ANGIOMYOLIPOMA (!) 00:00:24
• Benign tumor
Q. All of the following stahments an cor-r-ect abovt
• Composition - Blood vessel+ Muscle+ fat anglom!Jolioma except, (JIPMER Jul!J 2018)
• MC in Females among 5- 6 th decade A. associated with tuberous sclerosis
• Associated with tuberous sclerosis (young patient with B. positive lmmunor-eactivit!Jfor- HMB-~5
multiple & bilateral Angiolipoma) C. presence of fat and calcification on CT
• On lmmunohistochemistry D. wunder-lich' s S!Jndr-ome Is seen in IOt of patients.

o Marker-HMB-45 is positive in both Angiomyolipoma&

Malignant melanoma
• Presence of Macro aneurysm : Increased ri sk of RENAL ONCOCYTOMA (!} 00:09:04
Retroperitoneal Hemorrhage in 10% cases and is called as • Responsible for 3-7% of solid renal tumor
WUNDERLICH Syndrome • Arise from oncocytes. having rich mitochondria
• Renal oncocytoma looks like eosinophilic variant of
i chromophobe RCC
I
- I
}~ I

. -~ ,,·j
.; ,i~~
' .. ~:r. . .· .
Clinical Features Investigation
• Asymptomatic- so diagnosed incidentally • IOC for D. - CECT (shows Central stellate scar)
• On Angiography - spoke wheel pattern
Investigations
• IOC for most renal tumors: CECT (except Wilms tumor - Treatment
MRI) • Nephron sparing surgery
o Presence of fat
0 Absence of calcification (These features differentiate

RCC from angiomyolipoma)

Treatment
*
•
Important ln+ormation
Central stellate scar-
• Also Seen in
• For Asymptomatic, tumor up to 4cm: Observation • FNH (focal nodular- h!Jpe.r-plasia)
• For Symptomatic,> 4cm - Nephron sparing surgery • Fibr-olame.llar- variant in HCC
partial nephrectomy. • Se.r-ous C!JStade.noma pancreas
• Bleeding: Angioembolization • Re.nal oncoc!jtoma

218
RENAL CELL CARCINOMA 0 00:12:59
Pathological aspect '~
Clear cell variant of RCC (1
Previous Year's Questions
• MC variant of RCC Q. Which of the. .following combination is incorrect?
• Arise from PCT (NEE T PG 201~,>
• Cells contain glycogen & lipids -.washed away during
=
A· M/C t ype. ~Wi1~~'-,-J
l"'r,)1-,µ0~ a I ,.om
3i.,1e.ar cell carcinoma
B. MIC type. se.e.n with dialysis associated cystic
staining - Cell appears clear disease., Papillary carcinoma
• Mutation ofVHL gene located on chromosome 3. C. Exclusively associated with sickle. ce.11 trait ,
o Deletion
Me.dvllary ce.11 carcinoma
D. be.st pr ognosis, Clear ce.11 carcinoma.
o Translocation t (3:6 , 3:8, 3:11)

Papillary cell variant of RCC RENAL CELL CARCINOMA <!) 00:23:04

• Papillary projection Surgical aspect
• MC type of RCC Seen in patients of cystic disease requiring • Aka Hyper Nephroma / Gravitz Tumor/ Radiologist tumor
hemodialysis / Internist tumor
• Mutation of MET gene located on Chromosome 7 (trisomy) • MC malignancy of kidney
• ln trisomy, chromosome 7, 16, 17 are also involved • MC in Males among 6- 7th decade
• It arises from PCT • Sporadic [scattered in the population]
• This variant of RCC is Hemorrhagic + cystic Tumor
• Associated with Dystrophic Calcification- Psammoma Risk factors
Bodies • Smoking/Tobacco
• Psammoma bodies are seen in • Analgesic Nephropathy
o P - Papillary variant of RCC and PCT • Cadmium+ Asbestos exposure
o S - serous cyst adenoma ovary
o M - meningioma UNIQUE FEATURES OF RCC <!) 00:27:00
• Has pseudo capsule
Chromophobe variant of RCC • Refractory to cytotoxic agents
• Best prognosis • Shows response to biological response modifiers
• Arise from - Intercalated cells of collecting duct (IL-2&1NF-a)
• Plant cell appearance • Prolonged period of stable disease
o Relatively clear eosinophilic cytoplasm • Spontaneous Regression is seen in 5 malignancies
o Nucleus with fine chromatin o N-Neuroblastoma
o Thickened cell membrane o C-Choriocarcinoma
o Perinuclear halo. o R- Renal Cell Carcinoma
• Chromosomes lostare- 1, 2. 6, 10, 13, 17, 21, Y o M - Malignant Melanoma
• Multiple chromosome Loss - Extreme Hypodiploidy o R- Retinoblastoma

BELLINI DUCT CARCINOMA VARIANT OF RCC

(!) 00:20:49 How to re.member
• Rare
• Arises from collecting duct • NCRMR
• Has HOBNAIL Pattern
• Associated with - Desmoplastic Reaction Clinical Features <!) 00:30:00
• Poor prognosis • "TOO - LATE"TRIAD: Mass+ Pain+ Hematuria
Medullary variant of RCC • Triad is seen in 10% patient s with advanced disease
• Exclusively seen in children having Sickle cell trait • MC presentation: Hematuria
• Rare

219
• In Advan ced cases, Non -Reducing Varicocele: suspicious
Investigation
varicocele. 0 00:42:20
• IOC: CECT
Due to thromb us from left RCC.
• IOC for det ecting tumor thromb us - MRI (to differe ntiate
PARAN EOPLA STIC MANIF ESTAT IONS OF RCC
t umor thromb osis from bland thrombosis)
0 00:34:17 • GOLD STANDARD INVEST IGATION for ivc invasio n-
1. Raised ESR - MC(> 55% of patients)
lnferior vena cava gram
2 . Anemi a- decreased erythro poietin due to nonfun ctional
mass replaci ng functio nal kidney
8TH AJCC TNM CLASSIFICATION OF RCC (!) 00:44:20
3. Polycy themia - due t o functio nal mass which increas e
erythropoietin produc tion
T1o Size up to 4cm confined to kidney
4. Hypertension-Increase Renin by production from mass I by
compression of flood vessels by activation of RAAS system T1b Size > 4-7 cm confined to kidney

5. Hypercalcemia - due to release of PTH- rp Medically T 2, Size > 7- 10 cm confined to kidney

manag ed with Bisphosphonates, (ZolendroNate) . When
T2b Size > 10 cm confined to kidney
consuming Bisphosphonates, plenty of water should be
taken and standin g erect for half an hour to preven t T3, • Tumor grossly extend s into renal veins or its
esophagitis segmental branches.
• Tumor invades perirenal and/or renal sinus fat
6. St auffer's Syndrome (Non metastatic hepatic dysfunction)
withou t involvement of Gerota 's fascia
RCC patient with jaundice - Raised bilirubin, ALP
• On USG & CT abdomen - No evidence of metastasis. T 3b Tumor extends grossly into IVC below diaphragm
• These changes are due to IL-6 and this is known as
T 3c Tumor extends into IVC above diaphragm or
non-metastatic hepatic dysfun ction and improves after tumor invades the wall of IVC.
tumor resection
€4
neetosh141 0~
T, Tumor invades beyond Gerota's Fascia 91770~860839

Route of spread 0 00:39:05

• MC route of spread : Hemat ogenou s N Classification
• MC site of metast asis: lungs
• Canno n Bal l Secon da ries are seen in RC C an d
N. No metastasis to regional lymph nodes
Chorioca rcinom a (varian t of testicu lar tumor)
... Metastasis to regional LN

rI ,,
. ;t
• I B

Stages

....' I
Stage I

Stage II
T1

\ T2
l

__,,,,~
A /' Stage Ill T1. 3
T)
N 1

Stage IV T, N0 M0
• MC malign ancy respon sible for Osteoblastic second aries
Tany N any M 1
in Males - Carcino ma prost ate
• MC malign an~ respon sible for Osteol yticsecondaries Treatment (!) 00:50:06
(Hyper vascula r) in Males: RCC
• Pulsatile second aries are seen in Localized RCC Locally advanced /
Metastatic RCC
o RCC
o Follicular Carcino ma Thyroid • Radical nephrectomy • Radical Nephrectomy
• Indicati ons of Nephron sparing • 1st line agent:
surgery:RCC size up to 4cm, SUNITINIB

220
• RCC in solitary kidney, • 2nd line agent - IL-2 + o 8-Blastema
o Bilateral RCC, IFN-a o E- Epithelium
o RCC with diseased
o ST - STroma
contralateral kidn ey like Renal
artery stenosis.

({J_ How to re.member

Previous Year's Questions • BEST

Q. Manage.me.nt o+ RCC le.ss than 'i cm in size.?

(NEET Jan 2020) Variants of Wilm's tumor
A. Radical ne.phre.ctomy
• WAGR Syndrome
B Partial ne.phre.ctomy
C. Che.mothe.rapy o Wilms Tumor
D. Svrge.ry +ollowe.d by che.mothe.rapy o Aniridia
o Genital anomalies
o Retardation (mental)
NAMED STAGING &GRADING (:) 00:53:26 • DENYS DRASCH Syndrome
o Gonadal Dysgenesis (associated with male pseudo
• Robson staging RCC hermaphroditism)
• FuhrmanGrading o Renal failure
• Jackson staging CA Penis • BECKWITH WEIDMAN Syndrome
o Hemihypertrophy
• Gleason Grading CA Prostate
o Visceromegaly
o Macroglossia
no
neelesh14101i}•

PEDIATRIC TUMORS 0 00:54:26 o Omphalocele

917704860839

• MC malignancy of infancy, extra cranial malignancy: o Hepatoblastoma

Neuroblastoma
• MC malignancy of childhood - Leukemia CLINICAL PRESENTATION (!) 1:02:31
• MC solid malignancy of childhood - Brain tumor • TRIAD
• MC intra-abdominal malignancy in children - Neuroblastoma o Intra-abdominal mass (MC presentation)
• MC extracranial solid malignancy-Neuroblastoma o Fever (disappears after tumor resection)
• MC second Intra-abdominal Malignancy in children - W ilms' o Microscopic Hematuria
t umor • Pain (But pain is not part ofTriad)
• MC primary Renal Malignancy-Wilm's Tumors
• MC Renal Tumor of infancy-Congenital Mesoblastic Route of spread
Nephroma • Route of spread: Hematogenou s
• MC Soft tissue tumor in children - Rhabdomyosarcoma • MC site of metastasis: Lungs
• MC malignancy of childhood - Leukemia (ALL)
• MC solid malignancy of childhood - Brain tumor Investigations
• Investigation of choice: MRI > CECT (better soft tissue
WILM'S TUMOR (!, 00:sa:11 details)
• A ka Nephroblastoma • In Wilm'stumor
• MC primary renal Malignancy of childhood 0 CRESCENT shaped discrete and peripheralcalcification

• 2nd MC intraabdominal malignancy of childhood o Cannot cross midline

• Usually seen among children of 2-5 years of age • In Neuroblastoma
o Finely stippled calcification
• Usually Unilateral
• Genes involved - WTl & WT2 locat ed on chromosome II o Can cross midline

• Components of Wilms tumor

22 1
Treat ment
• In CA of renal pelvis, due to poo r cohesion betw
• Radical Neph rectom y een cells,
these cells w ill pass via urete r and any obstru ction
• Most impor tant Progn ostic Facto r - Histo logy> Stage in the
ureter w ill cause dilatation of proxim al as well as
• If Adver se hist ological factor s Start chem other apy dist al
within part from obstru ction.
5 days & start Radiothera py within 10 days
• GOBLET sign - dilatio n of parts of uret er d istal to
• Chem othera py Regim en
obstru ction seen on Ret rograd e pyelo graph y.
V - Vincrist ine
• Bergm an sign - coiling of cathe ter distal t o obstru
::: C - Cyclo phosp hamid e ction
• IOC for Diagn osis - CT Urogr aphy
_ D - Doxo rubicin/ Dactin omyci n

Staging

Pre chemotherapy Post chemotherapy staging

staging

• Preferred by NWTS G • Preferred by intern ationa l

stagin g syst em socie ty of Pedia tric
• Stagi ng & surge ry is Onco logy (SIOP stagin g
done before syst em)
chem otherapy • Stagin g & Surge ry is done
after chem othera py

CAR CINO MA RENAL PELVIS (:) 01:11:3 0

• MC histol ogical type - Trans itional Cell Carcinoma

Risk Factors
• Smoking
Treat ment
• A nalgesics like phenacet in
• Neph rouret erecto my + Removal of cuff of bladd er
• Indust rial Dye/ Solve nt
• Balkan's Neph ropat hy
Previous Yea r's Questions
Clinical Features
Q. A 55 yr old male with 35 pack years prese nted
• MC symptom: Painless gross hema turia
with painl ess mass in le+t scrot al sac and
• Flank pain micro scopic haem atvria. On lab inves tigations.
• Irritative voidin g symp toms alpa- +etop rotein and lacta te dehyd rogenase was
negat ive. What is the diagnosis?
Investigations (AIIMSNOV2018)
A. Epidydmit.is
• Urete roscopic brush cytolo gy: can diagnose
tumor at B. Seminoma
renal pelvis. C. renal cell carcinoma
D. carcinoma lung.
• On IVP- Filling defec t can be seen.

222
I!] KIDNEY AND URETER PART-3
CONGENITAL ABNORMALITIES OF KIDNEY • Other Presentations
AND URETER 0 00:00:24 • Polyuria
Polycystic kidney disease • Nocturia
2Types • Hematuria
• ADPKD: Autosomal Dominant • Nephrolithiasis
• Infantile PKD: Autosomal Recessive • MC cause of death-Cardiovascular Disorders( like berry
aneurysm
• CRF
• Usually in 5th to 6th decade
• Management - Hemodialysis/ Renal transplantat ion

Extra- renal manifestations of ADPKD 0 00:07:56

• Polycystic Liver Disease (MC)
o Cyst in Ovary, Pancreas, Spleen
o Mitral Valve prolapses
o Berry Aneurysm
o Colonic diverticulosis
o Arachnoid cyst
o Cyst in seminal vesicle
ADPKD [Autosomal Dominant Polycystic Kidney Disease) o In ADPKD, Cyst is not seen in Lungs
• Involvemen t of chromosome 16, 4. o In 8% of cases-+ Arachnoid cyst is seen involving brain
• Abnormal protein - Polycyst in
• In ADPKD - both kidneys are replaced by multiple cysts Investigations
! • IOC - CECT
Kidney loses its function of concentration of urine • On IVP
! o Spider leg/ Bell- Shaped appearance
Pt. passes large amount of diluted urine (polyuria) o Bubble Appearance
Decreased specific gravity of urine. o Swiss- Cheese Appearance

• Due t o cysts in kidney - Compression of blood vessels

!
Activation of RAAS
!
Hypertension
Any compression in pelvicalyceal system will lead to HIS
(Hydronephrosis; Infection; Stone)-+Haematuria

Clinical Features
• Usually presented on 3rd to 4th decade
• MC - Hypertensio n (75% Adults & 25% Children)

223
Managem ent
MEDULL ARY SPONGE KIDNEY (AUTOS OMAL
• TOC-Ren al Transplan tation
RECESSIVE) c!, 00:21.27
• ROVSING'S Operat,on- Deroofing of Cyst in ADPKD
• Collecting duct is dilated and associated with multiple cyst
• ROVSING 'S Syndrome - Hy perext ension of spine in
• On cut section - sponge or honey comb appearance
treatment of horseshoe kidney produces abdominal Pain,
• Usually bilateral
Nausea, Vomiting.
• Stones and infection are responsible for most of the
• ROVSING Sign-pain in right iliac fossa on pressing left
symptoms
iliacfossa
• Associated w ith:
o Hypert rophy
o Hypercalcemia
Previous Year's Questions
o Nephrolithiasis (presence of stone)
Q. Which is the. most common infection in a transplan t o Nephroca lcinosis (depositio n of ca lcium in renal
patient after 3-'i months? In renal transplan t parenchyma)
re.cipie.nts. which is the. likely organism causing Clinical features
re.activat ion disease. within 3'i months after
• Renal colic > UTI > Gross hematuria
surgery? (NEET Jan 2020)
Investigation
A. HSV
B. CMV • IOC - IVP
C. EBV • Findings
D VZV o Bristles of brush appearance
o Bouquet of flowers appearance

INFANTILE POLYCYSTIC KIDNEY DISEASE (AR) Treatmen t

• Bilateral and most severe form of polycystic kidney disease
• Nocure
• Most patient die within 2 months of birth because of uremia • Palliative treatment depends on complication
and pulmonary hypoplasia
• Also associated with hepatic fibrosis and pulmonary
fibrosis PUJ OBSTRU CTION (PELVIC URETERIC
JUNCTIO N OBSTRU CTION) <!:J 00:27:03
Diagnosis • Unilateral
• IVP (sunburst pattern) • Left side (MC)
• MCinboys
Treatmen t
• Nocure Cause
• Only palliative treatment is done
-
neelesh1410@gma1I com
Congenital causes 9m04s¢,.~u ired Causes

• Atresia/ Stenosis of • MC Cause- St one

RENAL AGENES IS <!:J oo:1a:16
ureter at PUJ • Infection
• Unilateral renal agenesis 1:1000 live birth
• Aberrant left renal • Instrumentation can lead to
• More common in males in left side
artery Stricture and then leading to
• Associat ed w ith:
obstruction
0 Oligohydr arrlnios
0 Pulmonar y hypoplasi a
0 Amnion nodosum In PUJ obstru ction, patient w ill be having unilateral
o Potterfac ies (usually seen in bilateral agenesis) hydronephrosis. This condition can be diagnosed even
• MC renal vascula r abnormal ity-supernumerary renal before birth by the presentation of oligohydramnios by the
artery (supernum erary renal vein is less common) mother.

224
Clinical features
• In Anderson Hynes Dismembered Pyeloplasty - Removal
• Asymptomatic
of obstruction site and end to end anastomosis is done.
• Palpable intra- abdominal mass (unilateralhydronephrosis)

A B C
Hydronephrosis

Renal pelvis

Obstructed
ureteropelvic
junction

Ureter

Investigations
• IOC- DTPA Scan

(To diagnose the obstruction & renal function of each

Kidney can be identified)
t
If equivocal Anderson Hynes Dismembered Pyeloplasty
t
Pressure - Flow study (Whittaker's test) RETROCAVAL URETER / CIRCUMCAVAL
• Whittaker's test URETER oo:37:47
o Kidney is punctured percutaneously and contrast is • Embryologically normal ureter is entrapped behind IVC
injected into pelvis, simultaneously intrapelvic pressure is • Caused by Abnormal persistence of right posterior
measured Abnormal Rise lntrapelvic Pressure subcardinal vein
t suggestive of
-8
neelr,;h 14 10@gma1I com
PUJ Obstruction Clinical features q1POJ860839

• Signs and symptoms of Ureteric obstruction

Treatment
Investigation
Open Treatment Endoscopic treatment • IOCforDx- MRI
• On !VP-Reverse J/fish hook/ shepherd crook appearance
• Gold Standard - • Done for small/ Intra- renal
A nderson- Hynes pelvis
Management
Dismembered o Endopyelotomy
• Treatment of choice - Relocation Uretero-ureterostomy
Pyeloplasty o Balloon dilatation
• Foley V-Y Pyeloplasty
HORSESHOE KIDNEY 0 00:42:57
• Flap (Spiral/ Vertical)
• Fusion of kidneys at lower pole

225
• Incid ence - 1: 400 live births (0 .25%)
Flow er vase like curve of Urel er
• MC inMales

Flower vase like curve of Ureter

)~ Important Information! Management
• Management of Complications Stag horn calculi -.PCNL
• Both Testis & kidney change their permanent • Isthmus should not be divided
position att,u- development • In pregnant patients, HSK Leads to Dystocia
• Testis
Develops +rom posterior abdominal wall
, Descends to scrotum +or effective
'~ Previous Year's Questions
sperrnatogenesis (has 2°C below the 0

bodyternperature) Q. Which o+ the following statement is correct

• Kidney about horseshoe kidney? (NEETPG 201(.)
"' Develops in pelvis Ascends up and rotates from A. Incidence o+ 1:'100 live births
vertical axis to obliqueaxis 8. IMA prevents full agent
C. hand joining sign& +lower vase like curves ot
ureters is seen
• If kidney fuses at lower pole - inferior Mesenteric artery
D allot the above
←
;~t t m ~mhe ascend of isthmus of kidney
o Level of isthmus of horseshoekidney- L3 to L4
o Kidney axis remains vertical as kidney is not able to URETEROCELE (!) 00:54:52
rotate. • Cystic dilatation of terminal ureter
o Medial calyx is seen • MC in Females
• Types
Clinical features o Intra- Vesical (20%)
• Asymptomatic (Diagnosed incidentally on radiologic o Ectopic (80%) - NW duplication of ureter
examination) • In lntravesicalureterocele-Terminal part of ureter is cystic
• MC symptom - Vague Dull A ching pain & dilated and is inside the bladder
• On hyperextension of spine • In ectopic ureterocele- Duplication of ureter and the
o Abdominal Pain } upper pole of ureter is having ectopic ureteric orifice.
o Nausea ROVSING'S syndrome • • ••
o Vomiting
Investigations
• IOC for Dx- CT Angio [CECTI (to diagnose HSK & localize
the position & abnormal vascularity)
• OnlVP
Med ial Orientation of Calyx- Hand Joining Sign
c High Insertion of Ureter with Anterior Tra nsposition -
Ureterocele

226
 c, Incomple te Duplicati on (bifid ureter)
o Complete Duplicati on (Weigert Meyers Rule)
• Weigert Meyers Rule
Upper pole ureter is caudal and medial compare d to
lower pole ureter complete duplicatio n
• Yo -Yo reflux
o Reflux of contrast in both limbs of ureter on retrog rade
pyelogra m in incomple te duplicatio n

~c,,
(T

I •
. :r-

•,t
. ' f
I •

,- L •ij
Adder Head appearan ce

Clinical presentation
• Recurren t attacks of UTI/ Uroseps is Duplicati on of ureter W iegert Meyers rule
• Unilatera l Hydro- ureteron ephrosis
• Palpable mass COMPLETE DOU
• Upper pole ureter-H as Ureterocele
Investigations • Lower pole ureter-Ha s VUR (due to short intravesical
• On USG-Hy drourete ronephro sis with cyst in the bladder length)
• On IVP-Add er Head/ Cobra- head ap pearance • MC location of Ectopic ureteric orifice
-
• ;~ f ~i'a'~5sis- lVP o In males-or ifice is in Prostatic urethra & is proximal to
• On MCU - Filling defect in bladder external urinary sphincte r
• On Cystoscopy-Enlarging and collapsing cyst in the bladder o In females- orifice of upper pole is in Anterior urethra &
is distal to external urinary sphincte r
Treatme nt
• Depends on type of ureterocele Clinical features
o In intravesi calureter ocele- Incision over the cyst wall • In Males
(Free flow of urine into bladder) o Continen t
o In ectopic ureteroc ele- Excision and reimplan tation o Increased risk of UTI
into bladder • In Females
o MC Congeni tal abnorma lity of upper urinary tract - o Continuo us incontine nce with normal voiding pattern
Du plication of ureter (AD)
o MC Congeni tal abnorma lity of urogenita l tract-VU R Investigations
(AD) • IOC for Dx is IVP-Add er head/ Cobra head appearance
• IOC for VUR - MCU (micturat ingcysto urethrog ram)

DUPLIC ATION OF URETER (:) 01:03:48 Treatme nt

• Autosom al dominan t • For upper pole uret er
• MCinfem ales o Excision
• Usually bilateral
+
• It is of two types
Reimplan tation int o bladder

227
• For low er pole ureter
Grade Ill Mild to moder ate dilatat ion of uret er w ith
Urcter ovesic opla ty (stren gtheni ng of urcter o- vesical
reflux into pelvica lycea l system
junctio n)
• If there is upper pole hyd roneph rosis with no functio n Grade IV Blunti ng of forn ix w ith reflux into
Upper pole nephr ectom y should be performed p elvical yceal system
On IVP - Show s Droop ing Lilly sign Grade V Dilate d and tortuo u s uret er with reflux into
pelvica lyceal system

• Chances of sponta neous resolu tion of VUR

c Grade I & II: 80%
o Grade Ill: 50%
o Grade IV: 20%
o Grade V: 0 - 5%

Manag ement
• Prophylactic antibiotics to all patient irrespective of Grade
of
VUR-To prevent UTI
• For children upto 6 weeks
o Ampic illin
o Amoxi cillin
VESICOURETERIC REFLUX (VUR) <!) 01:16:27 • Children age > 6week s
• A utosom al domin ant
o TMP- SMX
• MC conge nital abnor mality of urogen ital tract • Medical Manag ement Sufficient for
• MC in childre n o Grade I- Grade Ill VUR
• Asymp tomat ic o Unilateral Grade IV - VUR
• Mostly resolves Spont aneously - because • Indica tions of surgical interve ntion
o Bilateral Grade IV - VUR
o At the time of birth, Trigon e & bladde r system
is not o Grade V - VUR
matur e - High risk ofVUR.
o Recurrent UTI despit e of antibio tics
o By 5-6 years of age, matur ation occurs - low o Older Children
grade
VUR disappears o Presence of Perma nent scar
Causes o Presence of Bladde r Diverticula
• Various surgical interve ntions perfor med
Prima ry causes Secondary causes 1. Ureterove sicopla st y- Streng thenin g of ureter ovesic
al
junctio n
• Short in intrave sical • In children - Posterior 2. STING Operation
length of ureter urethral valves (Sub ureteric trans- urethral injecti on ofTeflon paste)
• Deficie ncy of • In adults - Neurogenic 3. Uret eric reimplantation
longitu dinal muscl e over bladde r o Lich - Grego irtechn ique
the surfac e of ureter
(preferred for ureteric reimpl antatio n)
o LeadbetterPolitano techni que
Investigations
• IOC for Dx- MCU
• MCU is IOC for VUR, poster ior urethral valve, poster
ior
urethr al strictu re ti
0
Previous Year 's Questions
INTE RNA TION AL CLASSIFICATION OF VUR Q. All of the +ollowing statem ents are corre ct about
VUR excep t? (AIIMS Nov 20")
(BASED ON MCU)
A. Avtosomal dominant
B. Majori t~ of cases are as~mp tomat ic
Grade I Reflux into non- dilated uret er C. MCU is IOC for diagnosis
D Pre+erred method of vrete ric impla ntation is Lich
Grade II Reflux into pelvicalyceal system Gregor techn iq ve.
_
~eo lP oJ9

??R
DI URINARY BLADDER
ECTOPIAVESICAE 0 00:0024 BLADDER STONE (!; 00:08:51
• Aka Exstrophy bladder
• Characterised by Complete ventral defect of urogenital Primary bladder stone Secondary bladder stone
sinus with overlying defect in muscular system.
• Abnorma l over maturation of urogenital sinus Formed in bladder in Formed in bladder due to
absence of • Anatomical factors
i • Anatomical factors • Functional factors
Ventral defect (rupture of ventral wall)
• Functional factors • Infections factors
• Infections factors • Obstructive factors
• Obstructive factors

Migrant bladder calculi

• Stones that are formed in the kidney & retained in the
bladder due to distal obstruction

Primary bladder stone (!; 00:12:24

• Aka Endemic bladder calculi
• Endemic in undeveloped countries (Burma, Indonesia,
Thailand, Africa)
• Associated w ith
• Usually seen in children < 10 years and commonly seen in
o Absent anterior wall of bladder
2-4 years and MC in males
o Absent infra- umbilical abdominal wall • In lndia-Andhra Pradesh, Rajasthan have been reported.
o Exposed posterior wall of bladder and urine dribbling • MC type of primary bladder stone - Ammonium urate
from trigone Other stones- Calcium oxalate
o Widely separated public rami Predisposing factors
o Umbilical hernia l. Chronic dehydration
o Rectal prolapse 2. Exclusive milk
• In Males
3. High carbohydrate diet
4. Low phosphate intake
o Epispadias
• In chronic laxative abuses most common type of stone is -
o Undescended testis
Ammonium urate> CA oxalate
o Shallow scrotum • Primary bladder stones-rarely associated with recurrence
• In Females once aftertreatment.
o Epispadias

'?)
o Bifid clitoris
o Widely separated labia Previous Year's Questions
0

• the risk of Adenocarcinoma.

Q. Chronic laxative abuse can result in the format ion
of which of the following renal stones?
Management- complex (NEET Jan 201&)
• Augmentation Enterocystoplast y A. Uric acid
• Abdominal wall closure after posterior iliac ~-o ne B. Ammonium urate
osteotomy+ Repair/ correction of associated abnormalities C. Struvite
D. Calcium oxalate

-87
riice :S:gmalcon
q 1 7.., ,.18b 839
229
Seco ndary bladd er stone
<!) 00:17:58 o S. Haem atobi um -Inva des bladd er
• MC in elderly males due to BPH /Bladder outle
t obstruction o S. Japonicum -inva des liver and small intestine
• MC type of secondary bladd er stone - Uric acid
>Strw ite o S. Mans oni -invades largeAntesti ~
• Overall MC bladd er stone-Seco ndary bladd
er stone (Uric _
q, 770~860
• Defin itive host- Man (Sexual phase839
occur)
com

acid)
• Interm ediat e host - Snail (Asexual phase occur
• Henc e, most of the bladd er stone are Radio )
lucen t (As uric
acid stone is radio lucen t)
Life cycle

Predisposing factors
• Bladd er outle t obstr uctio n/BP H
• Forei gn body
• Bladd er diver ticula
{~ Ir-I\~~~-;:,
• Prolo nged cathe teriza tion
"7 , ~
Clinical Features ( 1° & 2° bladd er stones) <!) 00:21:05 Li J fn )
Jack stones
• Comp ositio n of Jack stone - Ca Oxala te di hydra
Cercaria
(about 300 µm)
Ax .
140 µm)

te
• Havin g proje ction s.
Snail
~ ~ _/ Q= Miracidia
• Inter mitte nt painful voidi ng with sever e pain (about 180 µm)
at the end of Intermediate host
mictu rition with termi nal hema turia

1. Swimmer's itch-occurs at the site of penetration

of cercaria
within < 24 hours
2. Katayama fever-Within 3 weeks-4 months, larva
converts
to adult worm
!
Egg laying occurs
(Submucosal venous plexus)
Inves tigati on (1° & 2° bladd er stones) !
• IOCf orDx - Ultra soun d Eggs are highly antig enic
• On USG -Cha racte ristic shad owin g which
chang es the !
posit ion w ith chan ge of postu re Forms a stron g inflam mato ry response

• Fever
Trea tmen t (1° & 2° bladd er stones) • Chills & rigor

• For small stones • Hepa tosple nome galy

Cysto lithol apex y • Lymp hade nopa thy

0

• For Larg e stones Clinical features

• Earliest MC symp tom - Increased urine frequ ency
0 Elect rohyd raulic lithot ripsy
• Schis tosom iasis- MC cause of bladd er
Supr a pubic cysto lithot omy cal cifica tion
0
world wide
of sec &
• Due to chronic inflam matio n- Increased risk
SCHISTOSOM~ASIS <!J 00:26:26
Transitional cell Carcinoma
• Aka Bilha rziasi s
• Caus ative agen t - S. haem atobi um Investigations
• On cysto scopy -Sand y patch es
• Ende mic in Midd le east, Egyp t, Africa
• On Urine examination - prese nce of eggs
0 MC in Male s
• On X-ray - Fet al head -in-pe lvis appea rance.
• Spec ies of Schistosom a

230
 Treat ment
• Antibiotics
o Fluoroquin olones nt~<"<'cl11 : 1 1qm 11 con

TMP- SMX f-
"•tno 1RM'l.{'I

• In case of Uppe r urinary tract involvement-Ant

ibiotics +
Surgery (max. cure rate)
• Involvemen t of bilateral kidney-Associated
with poor
prognosis

Interstitial cystitis (Hunner's ulcer)

{!) 00:43:53
• Characterized by Chronic Pancystitis
• Infiltration of lymphocytes and macrophages
• MC in females
• Etiology is unkn own
• Prese nce of linear bleeding ulcer in the fundu
s (involving
mucosa)
Treat ment
• Drug of choice - Praziquantel
Clinical features
Alternative drugs
• Initial symp tom - Increased frequ ency
o Metrifonat e
• Pain increased by distention of bladd er &
o Oxamniquine relieved by
micturition
• Bladd er capacity is reduced to 30 - 50ml
MAL AKO PLA KIA (!) 00:36:05
• Inflam mato ry disorder of bladd er
Diagnosis
• Also involve ureter and kidney
• On Cystoscopy-presence of linear bleeding ulcer
• Form ation of nodu les/p laque s , comp osed in fund us
of large • To rule out malignancy:
histiocytes (Von Hanseman n cells)
o Urinary cytology
• Associated with laminar inclusion bodies -
o Biopsy
Michaelis-Guttman bodies

Treat ment
Patho phys iolog y
• Diffic ult and unsatisfactory
• Defe ctive phag o-lysosomal activ ity - Inadequate
killing • Bladder distention under anesthesia
of bacteria by monocytes/macrophage
• Instillation of dime thyl-s ulphoxide into the bladd
er
Predisposing factors
Bladder rupture
• lmmu nosu ppressed (!) 00:49:47
• 2type s
• Diabetes mellitus
o Extra- perito neal (responsible for 80% cases)
• Rheumatoid arthritis
o Intra- peritoneal (responsible for 20% cases )
• lymp homa

Extraperitoneal bladder rupture

Clinical featu res
• Caused by - Road traffic accident
• MC in females having UTI - Causes Irritative symp
toms RTA causes Pelvic fracture
! ! leads to
Frequency Extra-peritoneal rupture of bladder and
Urgency Posterior Urethral injury
Investigation
Clinical features
• On USG/CT- Mass in the bladder
• Suprapubic pain
• If there is involv emen t of ureter-Evidence of
obstruction • Difficulty in passing urine
is seen
• Hematuria
• On Urine culture sens itivity - E. coli

231
 Clinical features
• Suprapubic pain
• Difficu lty in passing urine
• Hematuria
• Peritonitis
Investigation
• IOC for Dx -Cystography
• On Cystog raphy- Sunburst appearance
• On Ultrasound - Bladder in bladder appearance
Manag ement
• Exploratory Laparotomy + Peritoneal lavage + Repair of
defect + Suprapubic cathete r/ Foley's catheterization

CA Bladder
Investigations 0 01:01:06
• TCC > SCC > Adenocarcinoma
• IOC - CT cystog raphy/ Cystog ram
• Findings
Risk factors
o Flames ign
o Pearsi gn Transitional cell carcinoma Squamous cell carcinoma
c- Teardr op bladde r
1. Smoking 1. Schistosomiasis
2. Drugs 2. Chronic Inflamm ation
• Phenacetin • Bladder stone
• Chlornaphazine • Bladder diverticulum
• Cyclophosphamide • Prolonged catheterization
3. Exposure of
• Benzidine
• Hydrocarbon
• Aniline
Manag ement • Acrolein
• Foley's catheterization • Beta- naphthylamine
• Spontaneous healing within 7- 10 days 4. Printing, Dyeing, Rubber,
Indications of surgical intervention Leather, Automobile &
• Repeated occlusion on catheter due to ongoing hematuria Petroleum industries
• Projecting bone fragment, impinging over the bladder wall. 5. Schistosomiasis (SSC >
TCC)
• Tear near neck of bladde r
6. Pelvic irradiation
Intra peritoneal bladde r ruptur e 0 00:57:56
• External blow/ kick to full bladde r may lead to
intrape ritonea l bladde r rupture Squamous cell Adenocarcinoma
• MCinM ales carcinoma
• Nodular & Risk factors
Dye m the pentoneum
invasive • Ectopic vesicae
• Patent urachus
• Treatment: • Intestinal pouch/ condui t
Radical • Augmentation Enterocystoplasty
cystectomy Treatment: Radical cystectomy +
Pelvic lymphadenectomy (due to
9f
involve ment of pelvic gr£MP.h1 -.~'T, "
-00
0
lymph nodes) gmoJsr,-,s ·•

232
• MC benign mesenchymal t umor of bladder - Leiomyo ma
Gross
• MC malign ant mesen chym al tum or of bladde r -
Intermit tent hematu r@
Leiomyosarcom a
• Irritative symptoms
• MC maligna nt mesenc hymal tumor of bladder in children Frequency
- Embryo nal Rhabdomyosarcoma Urgency
Dysuria
Route of spread
Pre.viovs Ye.or's Qve.stions • MC route of spread - Hematogenous
Q. A f,7 ye.ars old chronic heavy smoker presen ts with • MC site of metastasis - Liver
2 we.e.lc.s history o+ frank hae.matvrla. Ultrasound • Non-GI malignancies w ith liver as MC site of metasta sis
pelv is shows a +illlng de.+e.ct . Most probable. o CA bladder
diagnosis? o+ which ot the following renal stones? o Malignant melanoma
(NEET May 2018) o Medullary carcinoma thyroid
A. Bladder dive.rtlc vla
B. Ade.nocarcinoma o+ bladder • MC group pf LN involved - Pelvic LN (obturator nodes)
C. Sqvamovs cell carcinoma o+ bladder
D Transltlonal cell carcinoma o+ bladder Investigations
• IOC for Ox- Cystoscopy + Biopsy
• Urinary cytology
CA BLADDER 0 01:11:12 o To confirm the diagnosis
• MC in high socio-economic status
o But location of tumor cannot be identified.
• MC among whites, males and smokers
• IOCfors taging- MRI
• MC in 6th / 7th decade
• Urinary tumor markers
• MC type histological type - Transitional cell carcinoma
o BTA (Bladder tumor antigen)
• MC site of CA bladder - Posterolateral wall ofTrigone
• Precursor lesions of CA bladder o NMP - 22 (Nuclea r Matrix Protein)
o Papillar ytumor o Lewis- X- antigen
o Maligna nt cystitis o Hyaluronidase
o Helpful in diagnos is and for follow up to assist the
Papillar y tumor (Benign) response of therapy and to detect recurrence
• Aka kiss ulcer
• Exophy tic tumor when touches(kisses) surroun ding 8th AJCC TNM Classification 0 01:21:40
bladder mucosa , implantation of daughter tumor arises
• Characterized by Painless, profuse paroxysmal hematuria Ta Noninvasive papillary carcinoma

Carcino ma in Situ Tis Carcinoma insitu

• Aka Maligna nt cystitis Tl Tumor invades subepithelial connective tissue
• High grade tumor
T2a Superficial muscularispropria invasion of inner
• Present w ith Irritative symptoms
o F- Frequency half
o U-Urge ncy T2b Deep muscularispropria invasion of outer half
o D-Dysu ria
T3a Microscopic extension into perivesical fat
Investigations
• Diagnosis is made by - Urinary cytology (Transitional T3b Macroscopic extension into perivesical fat
epithel ium has multipl e layers and poor cohesi on T 4a Cancer invading pelvic viscera
between cells - causes shedding of these cells in urine) • Prostatic stroma
Treatm ent • Vaginal wall
• lntravesical BCG • Rectum
• Uterus
Clinical Features T4b Extension to pelvic side walls, abdomin al W?,IIS 1 •
• MC sympto m - Hematuria -2h "
or bony pelvis
o Painless
Nl Single regional LN in true pelvis
tumo r (TURBT)
N2 Multiple regional LN in true pelvis o Traumatic catheteri zation
o Hyp~- iji~\ \;tc;; 1 "' 0 Total urinary incon tinenc
o Obtu rato r 0 Order
, External iliac o Histo ry of BCG sepsis
o Pres acral • Urin ary dive rsion
0 1.38:00
N3 LN meta stasis to com mon iliac lymph node o Stricture at the site of anastomosis
s
o Refl uxof urine
MO No metastasis o High risk of Dyselectrolytemia
Ml Metastasis o Best or gold standard conduit for urina
ry diversion is
ileum
Treatment Easy to perform
<!> 1:28:2 8
• For Tis (malignant cystitis) - lntravesical Minimal intraoperative and
BCG
• For Ta (single, low to moderate grade, Immediate postoperative complication
non- recurrent) -
Complete TUR • Dyselectrolytemia in ilea I/colonic conduit
• For Ta (mul tiple, high grade, recurrent) o Hyperchloremic
- Complete TUR +
lntravesical chem othe rapy o Hypokalemic
• For Tl - Complete TUR + lntravesical chem o Metabolic acidosis
otherapy
• ForT 2-T4
o Radical cystectomy • Dyselectrolytemia in Jejuna! conduit
o Neo Adju vant chem othe rapy follo wed o Hypochloremic
by radical
cystectomy o Hyponatremic
o Radical cystectomy followed by adjuvant o Hyperkalemic
chemotherapy
± Radiotherapy o Metabolic acidosis
• Systemic Che moth erap y agents
• MVA C
o Meth otrex ate
o Vinc ristin e
o Adri amy cin
o Cisplatin
• lntravesical chemotherapy agents
o Mito myc in-C
o Epirubicin
o Thio tepa
Stoma
o BCG (mos t effective)
(out side
• Any T, N+, M+- +Ne oadj uvan t chemothe
rapy follo wed by bod y)
Surgery/Palliation
• BCG Con duit
o Atte nuat ed strain, of M. bovis (ins ide rem ove
o Mos t effec tive body)
0 MOA- imm unol ogic ally mediated (exact mech
anism
not known)
0 MC side effec ts -Frequen cy, urge ncy, dysu
ria
0 lmm unoc omp romi sed patie nts may develop
Severe
BCG sepsis - treat ed by ATT
• Absolute Contraindications for intravesic • Oyselectrolytemia in Stomach conduit (sam
al BCG e like IHPS)
o lmm unoc omp romised patients o Hypochloremic
o Gross hematuria o Hypokalemic
0 Imm edia tely after Tran s urethral resection of o Metabolic alkalosis
bladder

234
m PR'QSTATE AND SEMINAL VESICLE

ANATOMY OF PROSTATE ,.,.

\!, 00.0013 • Age related
• MC site of BPH - Median lobe /Transit ional zone
o Incidence of age 41-50 years - 20%
• MC site of CA Prostate - Posterio r lobe / Peripher al zone
o Incidence of age 5 1- 60 years - 50%
• On DRE- Posterio r lobe is felt and medial lobe is felt when
o Incidence of age >80 y - 90%
enlarged .
• Endocrin e controlled - Under control of testoster one
• lncutsec tionofBP H

A'"ltenor ob o Epitheliu m
Lateral lobes o Stroma-c omposed of collagen and smooth muscles
and has rich adrenerg ic nerve endings.
Med an IObl" o Testoste rone converte d into

Urel"lra
5-aredu ctase 5 DHT ( acts on epithelium )
(inhibite d by 5-aredu ctaseinh ibitor)
Posterior lobe
• If stromal compone nt is predomin ant-a blockers are
given for relaxation of smooth muscles.
Mc Neal zones classification • If epithelia l compone nt is predomin ant-Sa Reductase
• Prostate has been divided into three zones: inhibitors are given
• Transitio nal zone • a blockers are instantaneously active.
• Central zone • Minimum t ime required for 5a Reductase inhibitors to act -
• Peripher al zone 1 month
• Maximum effect of 5a Reductas e inhibitors is seen after 6
Importa nt principles months
• Severity of symptom s depends on Nodules and its
relation of being close to urethra Secondary changes in bladder
o Nodule close to urethra even small will be symptomatic • Due to increased force of contraction
• Nodule far from urethra even large will be asympto matic o Collagen deposition
o No correlation between size of prostate & severity of o Detrusor muscle hyperplasia
symptom s o Detrusor muscle hypertro phy
o Most patients of CA prostate - Asympto matic (initially) Clinical features
o Screening of CA prostate-Digital rectal examination + • Obstructive Symptom s
Prostate specific antigen o Poorflow/stream
o In patients of BPH-TURP is done but it is not protective o Hesitanc y
for CA prostate. So, DRE+ PSA is to be continued for o lntermitte ncy
screening of CA prostate. o Incomple te evacuation of bladder
o Dribbling of urine
BENIGN PROSTATIC HYPERPLASIA <!> 00:oa:26 o Post residual volume
• Age related • Irritative symptom s
• Endocrin e controlle d o F - Frequency
• Multifact orial process o U-Urgency
• MC site - Transitio n zone o N - Nocturia

235
 c High PSA level
How to re.membe r • Indications of Surgical intervention
o No improvement after medical management
• FUN
o Recurrent UTI
o HON/ Renal failure
o Bladder stone
IPSS Score-International Prostatic Symptom Score
Gross hematuria
(:"'\ 00:19 08
• Score varies from Oto 3 5
o Refractory urinary retention
• Surgical t reatment
o Mild - 0to7
o Gold standard -TURP (Trans Urethral Resection of
Moderate - 8 to 19
Prostate)
o Severe - 20 to 35
• OnDRE
TURP
0 00:30. 1
BPH • Techniques used for TU RP
CA Prostate
o Nesbit technique (preferred)
• Smooth elastic • Enlarged & hard prostate o Mauer- Meyer technique
enlargement of with obliteration of median • For irrigation - 1.5% Glycine is used
prostate sulcus Bladder

Investigations 0 00:22:23
• Uroflowmetry- to document the obstruction
o Normal- if Qmax> 15 mVs
o Equivocal- if Qmax 10-15 mVs
o Suggestive of obstruction but not confirmatory-if
Qmax<l0mVs
• Cystometry- to confirm the diaanosis
→
neel~ h-14 f 0@gma 1! com
o Voiding pressure > 80 cm~notffl39
o Diagnostic criteria for BPH -Qmax< 10 ml/s & Bladder
pressure> 80 cm of H20

... ...
Urethr
..
Management 0 00:25:16 Resectosco .. .
Medical management • In Monopolarcautery
• a blockers (preferred) • Electrolyte like Normal saline should not be used (Ion
o Prazosin dissipates current locally)
o Terazosin • In BipolarCautery
o Doxazosin • Normal saline can be used.
o Alfuzosin o This is aka TURIS (TURP in Saline)
o Silodosin • Most important distal landmark in TURP-Verumontanum
• MC used-Tamsulosin (alA selective blocker) (Located proximal to external urinary sphincter)
• 2nd line agents'..5- a Reductase inhibitors • No landmark proximally - High risk of injury to internal
o Finast eride urinary sphinct er by TURP
o Dutasteride
o Triptorelinpam oate Complications of TU RP 0 00:36:44
• Combination treatment (a blockers + Sa RI) preferred in • MC - Retrograde ejaculation (75% of cases)
patients w ith • lmpotence(10% ofcases)
0 Larg e prostate

236
• Incont inence (< 1% of cases)
Open prosta tectom y 0
• Retrog rade ejacul ation 00:47:32
Indications
Erecti on is due to paras ympa thetic system and
• Size of prosta te> 75g
Ej aculation is due to sympa thetic system .
• Bladd er stone
' Intern al urinar y sphinc ter is under t he contro l of Ll
• Bladd er diverti cula
sympa thet ic gangli on
0 Norma lly, at the time of ejaculation, Internal urinar y
Name d Prostatectomy
sphinc ter is closed .
1. Fraye r's supra p ubic proste ctomy -Prefe rred for
• Retrog rade ejacula tion is seen after
patien ts having b ladder stone. bladde r diverticulum
0 TURP (Injury of Internal urinar y sphinc ter)
2. Millin's retropu bicprostecto my
Bilater al Lumba r sympa thecto my
3. Young's Perinea! Prostectomy - obsolete
o a Blockers (Relaxation of Smoo th muscles of interna l • Ho -YAG laser is used for BPH, Renal Stones
u rinary sphincter)
• Late compl ication s ACUTE BACTERIAL PROSTATITIS
c- MC- Bladd er neck stenosis (4%) > Urethr al Strictu
0 00·54:0 1
re • Acute inflam mation of prostate associated with UTI
(3.6%) • MC organism responsible - E.coli

TUR syndrome (!) 00:42:2 2 Clinical Features

• Aka Water intoxic ation/ Dilutio nal hypon atrem ia
• Fever
• Predis posing factor s
• Chills and rigor
o Size of prosta te> 7 5 g
• Irritativ e sympt oms
o Durati on ofSur gery> 90 min
f-neelesh1410@gma1I com
91770486 0839
• On DRE- Prostate is enlarged, tende r boggy
• Catheterization & massage of prosta te is contra indicated
Clinical featur es
• Dizziness Treatm ent
• Confu sion • Antibi otics
• Fluid overload
0
TMP-SMX } Treatment should be done 4-6 weeks to
• Visual abnor malitie s
prevent Chronic bacterial Prostatitis
• Brady cardia o Ciprofloxacin
• Hyper tensio n
Treatm ent Chronic bacterial prostatitis (!) 00:56:2 4
• Drug ofchoi ce- Furosemide • Persistent infection of prostate
• If no response to Furosemide -3% saline (hypertonic • Recurrent attacks of UTI
saline)
Investigations
Trans Ureth ral Incision of prostate (TUIP) (!) 00:45:3 9 • Microscopic examination}prostatic expresate& urine taken
• Culture before& afterprostatic massage
Procedure
• Collin' s Knife is used Treatm ent
• Two incisions at S'o clock & 7'o clock • Antibio tics for 3-4 month s

Advan tage Prostatic abscess (!) 00:59:1 6

• Prosta te up to 20g can be opera ted witho ut any • Most cases - Complication of Acute bacterial prosta titis
compl ication s as of TU RP like retrog rade ejaculation and • Fluctuation - late sign in cases of prosta tic abscess
Impote nce. Predisposing Factors
• DM

?'H
• Renal insuffic iency
• MC genetic alteration seen in CA prostate-
• lmmun ocomp romi sed st at e
Hypermethylati on of GSTP 1 (Glutathione Transferase
• Chroni c cathete ri zation
promotor region 1) located on chromosome 11
• H istolog ical appearance of Malign ant Glands
Diagno sis
o Small
• TRU S (Transrectal Ultrasound) / Pelvic CT
o Crowd ed
o Absen ce of basal layer (unlike benign)
Treatm ent
o Lack Branching
• Trans urethra l drainag e w ith antibio tics

Clinical feature s
Prosta tic calculi <!) 01:01:39 • Asympt omatic in initial stages
• Calcified corpora amylacea
• Sympto ms in advanced state/ metastasis
• Compo sed of Calcium phosph ate
o Backache (MC site of metastasis is lumbar vertebrae)
• Locat ion - Periph eral region of t ransitio n zone
• Lymph node Metastasis - pelvic LN - obturat or Ln
• Occurs in clusters
• A sympto matic (periph eral location)
Route of spread
• Doesn 't predisp ose t o infection
• MC route of spread- hemat ogenous
• MC site of metastasis - lumbar vertebrae
o Osteoblastic secondaries
o V ia batson plexus
Trans1t 1on zone • MC malignancy responsible for osteoblast ic secondaries
Urcthru ---:=:=:: Urethral muscle in males - CA prostate
• MC malign ancy responsible for osteoly tic second aries in
males - RCC
FJaculato Central zone
duct • MC malignancy responsible for osteoblastic &
osteolyticsecondaries in females- CA Breast
, , , Peripheral zone
• MC site of visceral metastasis- Lungs

Investigations
CA PROS TATE <!) 01:03:01 • On DRE - prostate is hard and nodula r w ith oblit eration of
• MC histolo gical type-A denoca rcinom a > TCC
median sulcus
• Seen in high socio-e conom ic status
• IOC for Dx-TRUS guided Biopsy
• MC among Afro- Americ ans
• IOC for staging - Endo rectal MRI (TRUS can be used)
• Usually seen in 7th to 8th decade
• Prostascint
• Other malign ancies seen during 7th to 8t h decade
o Antibo dy imaging for CA prostat e
o CA Prosta te
o Radiolabeled monoclonal antibod y agains t prostat e
o Anapla stic Carcinoma of thyroid
specific membrane antigen
o Advant age-In Biopsy proven CA prosta te---+So ft t issue
Risk factors
and lymph node metastasis can be detected
• Advan cing age
• Tumormarkers
a-
nee1esh141 0@gmall com
• Highfa tdiet
o PSA 9 17704860839

o Prostatic acid phosphatase

Protec tive factors
o ALP
• L - Lycopene
o Alpha Methyl CoA racemase
• E- Vitami n E
o Hepsin
• S - Selenium
o D03
• A - VitaminA
Pathol ogy
• MC site of CA prostate-Peripheral zone (75%) > Transitional PSA (Prostate Specific Antige n)

zone (15%) > Central zone (10 %) • Can be raised in benign conditi ons of prostat e also

238
• Not cancer specific
• Normal level - < 4ng/ml NO No regional Lymph node metastasis
• diagnostic of Ca prostate: > 20ng/dl N1 Meta stasis to regional LN (obturator, internal iliac,
External iliac, presacral)
PSAdensity
• PSA / Prostate volume
MO No metastasis
• PSA density 2: 0.15 - Biopsy is recommended
Mla Distant metasta sis in non- regional LN
PSA velocity
Mlb Distant metastasis to bone
• Rate of change of PSA
• PSA velocity2:0 .75ng/ml/year is diagnostic of CA Mlc Distant metastasis to other sites
prostate
Management of CA prostate (!) 0127 .45
FreePSA(%) • Tla - observation + Follow up (DRE+ PSA)
• If 4- 10 ng/ml • Tlb, Tlc&T2
o > 70years - Observation +followup
Conditions that leads to Conditions that leads to o < 70 years - Radical prostatectomy Or Radiotherapy
increased PSA decreased PSA • T3&T4
o Androgen ablation> Palliative radiotherapy
• CA prostate • Castration o Bilateral Orchidectomy + Flutamide
• BPH • Radical prostatectomy o LHRH Agonist (Goserelin, Leuprolide) + Flutamide
• ASP, CSP, prostatic Abscess • Chemotherapy/
• Goserelin-Recently FDA approved for advanced and
• DRE. prostatic massage radiotherapy metastatic CA prostate
• Catheterization
• New drugs for castration res istant metastatic CA
• Sexual intercourse
Prostate
• Prostatic Biopsy
o Cabazitaxel
o Sipuleucel. T: it is a vaccine
8th AJCC TNM Classification for Ca Prostate <!) 01:20:31 Gleason Grade:

Tis Carcinoma in Situ

Tla up to 5% of tissue in resection for benign disease

~-----------...-------
1" MChistological
Gleason Grade

2nd Mc occurring histological

type type
has cancer, DRE normal (1 °) grade (2°) grade
Tlb >5% of tissue in resection for benign disease has
cancer, DRE normal Gleason Score
• 1° + 2° grade
Tlc Tumor is identified by needle biopsy • 1-5+ 1-5
• Minimum score is 2
T2a Tumor involves one half of lobe
• Maximum score is 10
T2b Tumor involves more than one half of lobe • Grade 1-well differentiated

*
• Grade 5- Poorly differentiated
T2c Tumor involves both lobes
T3a Extra capsular extension on one or both sides I Important Information
including bladder Neck
1• Gleason score 7 (3•'t) has better prognosis than ('t• 3)
T3b Seminal vesjcle involvement

T4
-8
neelesh1410@9ma1I com

Tumor is9#'l~~rmtades adjacent structures other than

seminal vesicle like Important ln+ormation
• External sphincter
• Rectum Robson Staging, RCC
• Levator muscles and or pelvic wall Jackson Staging, CA Penis
Gleason Grading=CA Prostate.

239
m I]
UR ETH RA AN D PENIS

B \Sir "N "COt>-'Y (!) 000025 CONGENITAL ABNO RMAL ITY OF URETH RA
Anatom y of penis
c!) oo OJ .is
• Length of male urethra - 20 cm
Hypospadias
• Length of female urethra - 4 cm
• MC congen ital abnorm ality of urethra
• Incidence
Parts of urethra
0 Hyposp adias 1:250 live births.
• Posterior urethra o Horsesh oe kidney 1:400 live births.
prostati c urethra o Unilateral renal agenesis 1· 1000 live births.
Membra nous urethra • Caused by failure of fusion of urethral folds - Meatus 1s
• Anterio r urethra presents over ventral aspect.
0 Bulbar urethra • Ureth ral fold usually closes in posterio r t o anterior
o Penile urethra direct ion.
'-' urethra meatus
Retrac ted EPISPADIAS
Penis foresk in DORSA L

Foreskin

u
Prepuce 4 PREPU CE

COROM AL SULCU S
HYPOS PADIAS

• Prostatic urethra - w idest & most dilatabl e part of urethra

• Membr anous urethra - shortes t. narrow est & least
dilatabl e part of urethra
_ _ ,__ Gianular
• Penile urethra - longest urethra _ _,___ Subcoronal
• Meatus>membranous urethra -Narrowest part of urethra
+--~ -- Distal penile

Bladder
...
01'0
----- - Midshaft
-~£ Prostatic urethra
t;~ - -- - - - Proximal penile
&::i Membranous urethra

Bulbous urethra ~ ...t-- - - - Penoscrotal

...
11)

...,
Penile urethra +-----''- -- - - Scrotal
...0
::,

·c
.2l
C
<!
- - - - - - - Perinea!
Fossa navicularis

?-1 0
Types of Hypospadias
<:.) 0007·01 • In proximal penile hypospad ias. at the time of intercourse,
• Glandular Hypospadias
semen is deposited outside vagina. making t han infertile.
• Coronal Hypospad ias
• Abnormal Stream
• Distal penile hypospad ias
• Painful erection.
• Mid shafthypo spadias
• Infertility
• Proximal penile hypospad ias
• Penoscrot al hypospad ias
Treatmen t
• scrotal hypospadias
• Best age for repair is 6 - 12 Months
• Perinea! Hypospadias
• Principle
• MC are Anterior types (glandular, coronal and distal penile)
o 1st Principle - Meatal advancem ent
• Galandula r,Coronal hypospad ias and di sta l penile
o 2nd Principle - reconstruction of Glans Penis
hypospadias contribute to 70% of cases of hypospadias.
• Both Surgeries are performed together known as MAGPI

Associations
Various Treatmen t procedures
• Hooded prepuce over dorsal aspect
• MAGPI (Meatal advancem ent & glanulopla sty integrated)
• Ventral Chordee.
• DENNIS BROWN
• Flattened Glans penis.
• THIERSCH - DUPLAY
• Microphallus [ short length of penis]
• BRACKA'S
• Ectopic Meatus
• MATHIEW'S
• Meatal Stenosis
• ASOPA&D UCKET

Complications
• After reconstruction of urethra, infant feeding tube has to
be inserted. If not inserted, patient may experience
complication like Urethral Fistula in 10% of cases (most
common complication of hypospad ias repair)

Epispadias <:} 00:17:50

Uncommon
• Characterized by urethral opening over dorsal aspect of
penis
• In females-fissure or cleft in anterior wall of urethra which
opens above the clitoris.
• Associated with
• Anterior type of hypospadias-Circumcision is contraindicated o EctopiaVesicae
because prepuce is used for urethral reconstruction o Dorsal chordee
o VUR(40% ofcases)
Clinical features
Depends on type Clinical features
Ese
neelesh 14 l O@gmail com
917704860839

Especially glandular hypospad ias • In Females

• Anterior type especia lly glandular hypospad ia s - o Maldevelo pment of urinary sphincters
Abnormal stream of urine o Bifid clitoris
• Posterior Type (e.g. Midshaft/ proximal penile) at the time o Widely separated labia with incontinence
of erection, there is downward curvature of penis causi ng • In Males
chordee and painful erection. o Undescended testis and shallow scrotum

241
Treatme nt
Manage ment
• 1" - correction of incontinence
• 1" step - Infant feeding tube insertion
• 2"d - Removal of Chordee
rd
• 2'1d step -After tube insertion
• 3 - Extension of urethral opening till glans

If Creatinine is normal If Creatinine is raised

Posterio r Urethral Valve
0 00 21.58 (means there is no effective drainage
• Symmet ric folds of Urotheliu m that starts from prostatic
Endoscopic Fulguration !
urethra & extends to external urinary sphincte r Of valve Suprapubic cystostomy by
• Male urethra is affected exclusively
Blockson Technique.
• MC type - Type 1
o Located justdista l/atverum ontanum Phimosis 0 00:33:59
• Posterio r urethral value - seconda ry cause of VUR • Contracted foreskin or prepuce cannot be retracted over
glans penis.
Clinical features • MC cause of phi mos is chronic infection is because of poor
• Associat ed with Vesicoureteric reflex - 50% cases. hygiene
• Other associations • Others causes:
o Oligohyd ramnios o Congenital
o Pulmonary hypoplasia (most common cause of death in o Acquired
PUV and also in CDH ie congenital diaphragmatic Trauma
hernia). CA Penis
o Renal parenchymal dysplasia
o Bladder dysfunct ion. (Balanitis Xerotica Obliterans)
• Most patients present with
o Symptom atic after birth
o Bilateral hydro-ur eteronep hrosis
o Bilateral palpable abdomin al mass
o Distende d bladder.
o Ascites (urinary ascites)
o infants increased UTI/Sepsis

Investigation
• IOC -MCU (Mictura ting { PUV
cysto urethrogram) Posterior Urethral Stricture
Vesicourethral Reflex
• On Prenatal Ultrasou nd - At28wee ks,keyho lesign

f-
nce!eshl410@ gma1I com
Clinical features 917704860839 <!) 00:34:05
• MC symptom - Difficulty in micturition
• In children - Ballooning of Prepuce
• In adults - Difficulty in intercourse
Complications
• Infection of glans/ prepuce- Increased risk of Balanoposthitis
• Secretion become solidified - Preputial calculi
• Chronic inflammation - CA penis

242
Treatme nt
Treatme nt
• In Children -Conservative managem ent (Steroidal cream
• Ice bag application
applicati on for 4 - 6 W eeks)
• Manual compression
• Circumcision
• Hyaluronidase injection
Not pref erred for young patent s because t hey are not
• For non - responding patients - Circumci sion
co-opera tive for local anesthesia.
, Performed for younger age only w hen there is an
indicat ion for circumcision
SUIIOOldll dorlllC eMe,y Deep dorlll ""n ol per,o
olperq o.t,p <101aal 0'1""f of pon,o
Indications of Circumcision OorUl,_.,,,di >entt

• No improvem ent after steroidal cream applicat ion Corpu, cavernosum Deep 14101 (llod< & fllCJl\l cl p<'nll

• Recurren t infection 0.ftl) Mery of pe<"OI

Skin - TunlC8 1•bug1nee
• Age 16- lSyears Superl\clal fascia
/Vt""f of bulb of pen,1
Urethra
Paraphimosis 0 00:40:24 CorPYt apongloSum

• A cquired condition
• Caused by formatio n of ring of Prepuce around glans Priapism 0 00:47 55
because once prepuce is retracted it cannot be brought to • Persistent painful erection i n abse nce of sexual
its Normal position. exciteme nt/ desire or it persist after sexual exciteme nt /
Formatio n of ring around Glans penis desire
! • Min duration of painful erection - 24 hours
Impaired Lymphat ic Drainage • It is an emergen cy & delay in treatm ent lead s to
! Cavernosal fibrosis & impotence
Edema of Glans • It should be treated w ithin 6 hours to prevent other
! complications
Impaired venous Drainage
! Priapism is of 2 types
Further edema
High Flow Low Flow (MC)
!
Impaired Arterial Supply • Non- lschemic • lschemic
! Causes Causes
Gangren e formatio n [ in severe cases] • Penile Trauma • Sickle cell anemia
• Perinea! trauma • Leukemia
• Leading to • Fat emboli
formatio n of • Spinal cord lesion
arterial sinusoidal • Malignan t Penile inflamma tion
shunts. • Trazadone Injection

f-
neolesh 141 0~gma,I com
Clinical Presentation 9111048608J 9
• In children (4- 10 years) with sickle cell disease - Painful
erection during nights
• In Adults- iatrogenic

Diagnosis
• Mainly cli nical
• Urine flow not obstruct ed • Doppler is helpful in diagnosis

243
Treatm ent
Clinical featur es
• If patien t comes within 4-6 hrs.
• Urinar y retent ion+ Blood at meatu s + pelvic hemat
• ketam ine injecti on given( > 50% cases improv e) oma
• If injury at Prosta tomem branou s junctio n - H igh
lying
! No improv ement prosta te
Aspira tion & saline irrigati on
! No improv ement !
On IVP - Pie in sky appea rance
Hyalur onidas e injecti on
• For High flow priapi sm -Selec tive intern al Puden
da! Instru menta tion
Angio graph yf/b embol ization of feedin g vessel .
• Cathe terizat ion Should n't be done [ if blood is found
• Anoth er surgical option - Shunt s [Blood is shunte d at
from meatu s] - Partia l tear may get conve rted to compl ete t
ear
corpor a cavern osa]
• Retrog rade urethr ogram (RGU} only can be perfor
med to
o Corpo ro - glanul ar shunt - w inter shunt
rule out Urethr al injurie s
o Corpor o-spon giosal Shunt- QUAC KEL or SACHER shunt
o Corpo ro- saphe nou s shunt - GRAY HACK shunt
Manag ement
o Corpo ro - dorsal vein shunt- BARR Y shunt
• Gold standa rd Treatm ent - SPC (Supra pubic cystos
tomy}
• Emerg ency repair should not be attemp ted - Can
URET HRAL INJURIES lead to
(!) 01:01:2 9 increa sed risk of
• 2type s
o Impote nce
o Poster ior Urethr al Injuries
o in Contin ence
o Anteri or Urethr al injurie s
o Strictu reform ation
• Delaye d repair within 3 month s is prefor med
Poste rior Urethr al injuries
• MCtyp e
Anteri or Urethr al Injuries
• Cause d by road traffic accide nt
• MC injured anterio r urethr al part - bulbar part of urethr
• Leadin g to pelvic fractur e which furthe r leads to a

o Extra periton eal bladde r ruptur e

Causes
o Poster ior Urethr al injurie s (20%)
• Extern al blow/ kick
• MC site of injury- Memb ranous Urethr a (Bulbo memb
ranous • Stradd le/ manho le injury
junctio n>Pro statom embra nous junctio n}

Pubic
Symph ysis

244
 Pubic
Symphysis ,

• Urinary retention Investigation

• Blood atmeatu s • IOC for diagnosis of post Urethral Stricture - MCU
• Perinea! Hemato ma - involves shaft & Bilateral scrotum • IOC for diagnosis of ant Urethral Stricture - RGU
(butterf ly shaped) • Perform both RGU + MCU in an emergency patient for
adequate evaluation of stricture
Treatm ent Manage ment of patients of stricture
• Suprap ubic cystoto my perform ed followe d by delayed 1. Dilatation
repair 2. Optical internal urethro tomy at 12"0 clock Position - only
• Usually Asymp tomatic even after develop ment of perform ed for short bu Ibar stricture
strictures 3. If length of stricture up to 2cm - Excisions with end to end
• Antibiot ics Anastomoses
4. If length of stricture > 2cm - Excision with tissue transfer
for reconstruction

Membranou s urethra
i
Tissues used are
• Buccal mucosa (MC used)
• Bladdermucosa
• Penile skin

'?)
Urinary stricture <!) 1:14:29
Most commo n cause is trauma 0
Previous Year' s Questions
Q. A man is brough t to the. emerge ncy a+te.r he. fell
into a man hole. and injured his perineu m. He. feels
the. urge. to mictura te. but is unable. to pass urine.
and the.re. is blood at the. tip of tht. me.atus with
extensive. swelling of the. penis and scrotum . What
is the. location of the. injury?
CNEET Jan 2020)
A. Bulbar urethr a
8. Prostat ic urt.thra
C. Bladder
D. Membra nous urethra

245
PEYRONIE1S DISEASE <!) 01:23:24 Treatment
• Aka Penilefibromatosis • >50% cases spontaneous resolution-observation+
• Chronic vasculitis involving tunica albuginea emotional support
• Characterized by • If doesn't reduce we go for-NESBIT Operation by placement
fibrous plaque over dorsolateral aspect of penis of Non-absorbable suture opposite to the plaque

l
Contraction causes Characteristic curvature of penis
CARCINOMA PENIS 0 01·29:17
• MC histological type - sec
• Associated with GALEZIA'S triad
• Common in Low socio-economic status
o DUPUYTREN'S contracture (+)
• Poor hygiene, 6th decade
o PEYRONIE'S disease (+)
• 40 % of patients< 40 years of age
o RPF- Retroperitoneal fibrosis
• >SO% cases associated with phimosis only
Peyronie's Disease o Neonatal circumcision is protective for CA Penis, HIV/
STDs
• Viral infection is cause i.e. HPV infection - (16,18,31,33)

Important points about CA Penis

Fibrous plaque • In CA penis - Skin and Colle's fascia is involved
• MC route of spread in CA penis - Hematogenous
• MC cause of death in CA penis - Bleeding caused by
enlarged inguinal lymph nodes leading to erosion of
Corpus cavernosum Femoral blood vessels
• In Ca Penis - Incidence of Pulmonary metastasis is rare
Urethra
L (even in advanced cases)
Tunica Albuginea & Buck's fascia (Strong barriers)
Clinical features
l
• Painful erection
Prevents invasion vessels
• Poor erection (Distal to plaque)
• Upward curvature on erection Premalignant lesion in CA penis
• Impotency &infertility • BUSHKEE LOWENSTEIN TUMOR - locally malignant
• Dorsolateral plaque over the penis also known as verrucous carcinoma.
CrO! s, ct of • BXO (balanitis xerotica obliterans)
'.'lrM j)f"'ll',

• Cutaneous Horns

..
--
• Genital Warts
• Leukoplakia

I
Crr; ,. ecl1Jn d

I . ! ~•·· l'l!)•w

I BushkeelowesteinTumor

J
Carcinoma in situ forms in CA Penis (!) 01:34:28
• If it involves penis known as BOWEN'S disease
\, , ... • Erythroplasia of Queyrat - Glans Penis Malignancy in this
Case I.e. MC site. Glans> Prepuce> Sulcus (G>P>S)

246
 Nl Palpab le, mobile, unilateral inguinal lymph node

N2 Palpable, mobile, multiple or bilateral inguinal lymph

node.
N3 Fixed inguinal nodal masses or pelvic
lymph adeno pathy which is unilateral or bilateral.

MO No metastasis

Clinical featur es Ml Distan t metastasis

• MC Presentation is lesion itself associated with foul smellin
g
discharge & is associated with minimal or no pain
Other staging
• More than 50% cases are having enlarg ed inguinal lymph
• Jackson stagin g - CA Penis

~--------".._---...,
nodes out of which half are because of
• Robson Staging - RCC
Metastasis • Gleason Grading - CA Prostate
Sepsis
• And in all cases prophylactic antibiotics are again 4
-6
Weeks . Treatm ent
• So, MC cause of death is bleeding caused by erosion • Circumcision for CA Penis involving prepuce
of
femoral vessels. • CA involving distal part
• 2nd MC causes of death are sepsis o Partial penec tomyw ith 2cm margin
• Earliest & MC symptom of metastasis or CA Penis - priapis • CA Penis involving proximal Part
m
• MC route of spread - Hematogenous
o Total penec tomy+ perinea! urethr ostom y

Diagnosis
Chem othera py agents
• IOC - Biopsy
• Bleomycin + cisplatin
• IOCfo rstagi ng - MRI
• SLN Biopsy
o CABre ast CA MALE URETHRA (!} 01:54:0 1
o Malign ant melanoma • Chronic irritati on
o CAPe nis • Infection (HPV - 16%)
o H& N malignancy • Stricture (24 - 76 %)
o Vulva lCA
o 1st SLN Biops y was perfor med by CABANA & Clinical featur es
Procedure was known as CABA NA Procedure. • Palpable mass+ obstructive sympt om
• M.C site of CA male Urethra - Bulbomembranous> Penile
8th AJCC. TNM Classification for CA Penis
(!} 01:45:2 0 urethr a> Prostatic urethra
• MC histological type - SCC > TCC > Adenocarcinoma
Tis Carcinoma in-situ • Penile Urethra - SCC > TCC
• Pro static - TCC > SCC
Ta Non- invasive Verrucous Carcinoma

Tla Invades sub epithelial connective tissue witho ut Investigations

Lymphovascular invasion & it's not poorly differentiated • MRI+ Gadolinium contra st
T1b Invades sub epithelial connective tissue with
Lymphovascular invasion or poorly differentiated Treatm ent
• Surgery ± radioth erapy
T2 Invades corpus spongiosum with or withou t invasion
• If lymph node involvement, then ilioinguinal lymph node
T3 Invades corpus cavernosum with or withou t invasion dissection
T4 Invades other adjacent structure

247
m TESTIS & SCROTUM PART-1

DESCENT OF TESTIS 0 00 0023 ABO . 2nd morcis CT weela)

• Lumbar Region
T111u.- .o : PeMa (IBIIC foeso ) . 3rd mon:h (12 week&)
• Pelvis -+ Scrotum (- 2° Clower than body) Deep lngUlnal nng End d e morths (2,4 W99ks)
7 rnorntw (25-28 weelal)

Factors responsible for Descent of Testis

f-
" " " ' , •1· .i,~.tcl<.D
• Most important: - Disproportionate growth of upper ~,n tllou,naJ ting
18 s j ir ~n u;1a1

abdominal region away from the pelvic region.

o Pull of Gubernaculum
c Hormonal factors.
Normal

UNDESCENDED TESTIS (UDT) 0 00:07:09

• lncidence ofUDTatBirth - 3%
• lncidenceofUDTatl Yearofage - 1%
• Spontaneous descent occurs in 70-77% patients by 3
months of age
• Location
Tunica vaginali o Inguinal/Palpable UDT - 80%
• Peritoneum invaginates along with gubernaculum and o Abdominal/Non-Palpable UDT - 20%
forms:
r

Processusvaginalis
!obl iterates
Tunica vaginalis (remnant )

POSITION OF TESTIS IN INTRAUTERINE LIFE

0 00:04:13
• Abdomen-> 2nd Month/7TH Week

o Pelvis (ILIAC FOSSA)-> 3rd month (12th week)

o Deep inguinal ring-> at the end of 6th month (24th Risk factors
week) Two independent factors
o Pass inguinal canal-> During 7th Month (25th - 28th • Prematurity
week) • Low birth weight

LEYDIG CELLS- are less sensitive to temperatu re

• Superficial ingu!nal Ring -> 8th month (29-32 w eek)
!
Testosterone
Enters Scrotum -> Beginning of 9th Month (33 w eek)
o At the base of scrotum-> Before birth end of 9th !
Secondary Sexual Characters
Month/ 36 Week

By 5-6 Ye ars of age there is complet e absence of

spermatogenesis

248
H1stop atholo gy- Abnormal germ cell histol ogy
Diagnostic Laparoscopy
• 1-2 Years:
) Earlie st chang e - Hypo plasia of Leydig cells (1 month
Find the Deep Ri ng and trace Vas Defer ens
of age)
• If Vas Deferens-> is blind-> Testis +/- -+sta rt
• Degeneration of Serto li Cells tracing
Testic ular artery -> if testic ular artery also blind
• Delayed disappearance of gonocytes ->
Testicular agenesis
• Delay ed appearance of adult dark spermatogonia

Complication
• S- Sterili ty
• A- Atrop hy _ Nicp..t'«Trflid

• T -Trauma, tumor, torsion

o Most common tumo r- Seminoma
o Maximum risk of tumo r- Abdominal > Inguinal Testes
- _ PlbcT. -.,.

Femotll R,ng
• H - Herni a (>90% cases PPV- Paten t Processes vagin
alis)
• I- Inflammation
MNEMONIC: SATHI E.demllli ocMe<y

'??
0
Pre.vious Year's Questions
• If testis is present need to bring it int o scrotu
Orchidopexy
m:

• Best age of orchidopexy -> 6 MONTHS Should

Q. All of thf. following arf. truf. about undf.Stf.ndf. not be
d delayed by 12 months (6- 12 month s)
tutis e.xcf.pt? nut pg 2015 • Named orchidopexy are
A. Palapablt. In 807. casf.s o Ombridannes
o Keetley- Torek
B. Hypoplasla of thf. lf.ydlg tf.llS Is thf. f.arliest o St ephen- Fowlers
postnatal histologlc abnormality o Ladd & Gross
o Placing test is in Dart os Pouch
C. IOC for diagnosis is diagnostic laparo scopy o Best resu lts - M icrov asc u la r Test ic ular Aut
o
Transplantation
D. Best t ime for orchidopexy is, months.
ECTOPIC TESTIS 0 00:26:1 6

ORC HIDO PEX Y 0 00:18:1 1 • Normal desce nt t ill inguinal canal

• Due to abnormality of Gubernaculum
• Doesn 't decrease t he risk of test icular t umor
• Only Facilitates- >Early diagnosis !
Abnormal locat ion in the groin
• MC location: Superficial Inguinal Pouch
INVE STIG ATIO N OF CHOI CE FOR UDT- Ingui • Least Common locat ion: Contra lateral Scrotum
nal
exploration • Normal developed testis & palpable
INVESTIGATION OF CH OICE FOR "NON - PALP
ABLE"
UDT- Diagnostic laparo scopy

Superficial Inguin al
Suprap ubic ..,__ _........,.._..
r.----- -1r+ pouch (MC)

~ - - . Femoral canal
Contra lateral - - - -~
scrotum (LC)
wt-- - ---t-. Perinea!

Ecot opic Testis Location

249
Rx
toward the inguinal canal. (pos1t1ve Cremastenc sign)
• Surgical treatmen t orch1dope.X)~ 6 months
• Thickened Cord
• 1\/ot be de la\ ed b, 2 years
• lOC- Ultrasound
Thickened/ enlarged cord
Secondar y hydrocele - min1mal amou nt or fluid
Pre.viou s Ye.or' s Que.stio ns collected

0 All of lht. following slatunt.n ls art. corrt.cl abovt. NOTE. MCC of Secondary hydrocele: A cute Ep1d1dymo -
t.clop,c t.e.st.,s uupt.? FMGE 2020 orchitis.
A an t.clop1c lt.slis ,s usually fully dt.vt.lopt.d Lrine routine microscopic examination WBCc;
B MC location is supt.rficia l inguinal pouch Urine culture and sensit1v1ty· UT _
C most t.ctop c t es t clt.s are. non-palablt.
D surgical trf.atmt. nt should bt. dont. aftt.r {. months Treatml!nt ,,.,
of agt. e-
- '1' 'S3'1.
• A nf1b1otics
or
• Scrotal support
• NSAIDS
RETRAC TILE TESTIS 00:30:12
TESTICU LAR TORSIO N (TT) ~.. 00 39·0 \
• Testis has completed process of normal descent but
Normal Bell-clapper deformity Torsion
found in Groin
, Becauseo f
Overactive cremasteric reflex
Increased tone of cremasteric muscle.
.:: No treatment required

ACUTE EPIDIDY MO- ORCHm s (EDO) 0 00:32-06

Tunica vaginalis
• Inflamma tion of testis &epididym is
• Associate d w ith Ascending bacterial infection from lower
EXTRAVAGINAL INTRA VAGINAL
urinary tract (via UTI or STI)
• Most common organism - Acute EDO
!
• Extra Vaginal Torsion • Torsion occurs within
occurs outside the the tunica vaginalis
Sexua lly act ive male (<35 years)- Ch lamydia (Tx:
DOXYCYCLINE)
tunica vaginalis • Most common
• Most common organism -> Acute EDO ->
o Children } Normal testicle Testicular torsion
o Elderly Nonna! Testicular torsion
E. coli
o Homosexu als

Clinical features
• Fever
• Pain in inguino- scrotal region
• Burning micturition
I TISllde
Epct,dyn'ls Ep,diclyn"d
On Examinat ion
• Prehn's Sign - +VE INTRAV AGINAL TESTICULAR TORSIO N
0 The affecteq hemiscrot um is elevated. This action
0 00:41:11
relieves the pain of epididymi tis but exacerbates the • 10-25 Years (Pre-Pubertal males)
pain of torsion (positive Prehn sign) . • Spiral attachmen t of Cremasteric fibers over the cord
• Cremaste ricreflex- +VE !
In males is elicited when the inner part of the thigh is Brisk cremasteric reflex
0
stroked. Stroking of the skin causes the cremaster !
m uscle to contract and pull up the ipsilateral testicle Testicular t orsion

250
Predisposing factor
Bilateral Orchidopexy- Performed.
• MC- Inversion of Testes
• In case of ischemic testis->Orchidectomy ± Prosthesis
• Bell clapper's deformity
• Separation of testis from body of epididymis
EXTRAVAGINAL TESTICULAR TORSIONoos 106
• Blue Dot sign: Torsion of appendage of testis • Perinatal Period
• No anatomical defect
• No testicular fixation in perinatal period is primary cause
(Spermatic cord + Tunica Vaginalis)
Twisted
testicular !
appendage Rotates as a single unit

Refer Table 34.1

e- nee·e.., 11
o . 7704860~39
im:, , com

HYDROCELE 0 00:54:06

Bluedot Sign • Collection offluid within the layers oftunica Vaginalis

Clinical features
• Severe agonizing pain
• Nausea & Vomiting
• On examination affected testis->
High Riding in upper part of scrotum
! 1. Congenital Hydrocele
Deming Sign
2. Funicular Hydrocele
Contralateral testis is normally lying, placed transversely
3. Infantile Hydrocele
! 4. Encysted Hydrocele
Due to mesorchium-> Angel Sign
• PREHNS SIGN - -ve
5. Vaginal Hydrocele
• Cremasteric reflex - Absent
6. Bilocular Hydrocele
7. Hydrocele of Hernia sac
• Treatment- Emergency Orchidopexy w ithin 4 Hours

Diagnosis Vaginal hydrocele

• USG-Anatomy Most common type
• Doppler - forflow • Large/tense
• Combined - Duplex scan • Clearfluid
• Trans illumination test is +ve
IOC- Doppler
• Anywhere flow needs to be assessed: Doppler is IOC like: Congenital hydrocele
o Portal Hypertension Patent Processus vaginalis
o DVT • Size varies with the activity level and posture
o W • Spontaneous Obliteration - 2 Years
o TT • Treatment - Herniotomy (if spontaneous obliteration
o Varicocele does not occur)

Duplex - lOC -+W, DVT Funicular Hydrocele

• Processus Vaginalis patent up to top of testis where it
• Tc Pertechnate scan-> decrease uptake of radionuclide shuts off from tunica vaginalis

Treatment- Orchidopexy Infantile hydrocele

• Contra lateral hemiscrotum should be explored. • Processus vaginalis is pat ent up to deep ring
• Doesn't communicate with peritoneal cavity
• In case of bell- clappers deformity
!

25 1
Hydrocele of cord/ of canal of neck
Vaginal Hydrocele
• Obliteration of upper & lower part of PV
• When testis pulled-cystic swelling goes down and when
Refer Table 34.2
testis is released cystic swelling goes up.
Treatment
Bilocular hydrocele / Hydrocele en-bisac
• Small hydrocele - LORD s PLICATION OF SAC
• Two sacs communica ting with each other near neck of • Medium hydrocele - laboulay's evers1on of sac
scrotum
• large hydrocele - Exc,s,on of Sac

Hydrocele of Hernial sac

• Neck of hernial Sac is closed by adhesion/ plugged by
oment um
• Retention of fluid secreted by peritoneum of hernial sac.

Table 34.1

PRENATAL POSTNATAL

Testis is hard and fixed to the skin. • Tender scrotum

non viable, located in inguinal • Testis is not fixed to skin
canal • Treatment- Orchidopexy.
! • 20% - Bell- clapper's deformity
Orchidectom y

Table 34.2

Primary Hydrocele Secondary Hydrocele

• Collection of fluid in Tunica • Causes

Vaginalis 0 Trauma
• Large 0 Tumor
• Dense 0 Epididymo - orchit is (MC)
• MIC • can be felt separately
• Testis can't be felt separately • Small
• Lax
• Diagnosis- Ultrasound

-07
neeiesh 1-! t0@gma1I com
917704860839

252
m TESTIS AND SCROTUM PART-2

VARICOCELE r, oo oo 1s Suspiciousvaricocele - RCC

SUSPICIOUS VARICOCOELE:
• Dilated Pampinif orm plexus of veins, locat ed posterior • Elderly males
and above testis • Short history
• Tortuous • Does not decompress on lying down position
• MC surgically correctable cause of male subfertil ity (i.e. • Due to large veins aro und scrotum ---increase in
borderlin e fertility) t emperat ure of testes:
• MC cause reversible atrophy of t estis in adolesce nt males
• 90% left side
l
Lsperm motility }
~ - SMA
Semen analysis
Lsperm number

Investigations
• IOC for diagnosis - Doppler
• Gold standard - Venography
TestlCUal Yeln

Varicocele classification
Predisposing factors
• LGV drains at right angle into left RV • Subclinic al varicocele
If left gonadal vein has incompe tent or defective valves - o neither visible nor palpable at rest or during Valsalva
increase t ransmission of pressure . maneuver
• Nutcracker's phenome non: LRV compressed between o Demonstrable after special test.
aorta and renal vein • Grade 1 - palpable during Valsalva maneuver
• Sigmoid colon - loaded fecal matter-+ compresses LGV • Grade 2 - palpable at rest
• Grade3 - visible and palpable
Clinical features
• Seen in tall, thin adults Indication of treatmen t
• Discomf ort in scrotal region • Significant discomfo rt
• Swelling in scrotal region-> more promine nt in standing • Infertility
position • Poor Testicular growth in adolesce nts
• Decompress in lying down position • Lmotility/s perm count
• On palpation - • Recruitment in army and police services
'Bag of worm' sensation
Treatment
• High inguinal ligation (near deep ring) of pampiniform
Left Spem1111e
Renal a,nj
plexus of veins
Vein
• Microvascular sub inguinal ligation of pampinif orm plexus
of veins (best results)
E- • Palomo's operation: ligation of Left Gonadal Vein in
retroperitoneum
• Alternative venous drainage via cremast ric veins.

vanax:e6e seen on EpiddymuS Tesbs

surlac:e ol lhe scrOC1.m

253
SPERM ATO CELE c!) 00.18:40

• Unilocu lar retention cyst

• Derived from some port ion of sperm cond uct ing
mechanism ofepidid ymis
• Location: Epididy mal head: above and behind upper pole
of testis
• Presence of sperma tozoa
l
(Barley - water appearance)
• Softer, laxer
• Transillu mination is positive
Predisposing factors
• OM
Spefmat
Spermalic • Local Trauma
E <X>r'd • Para phimos is
• Anal infections
• H/0 recent instrumentation .
• lmmuno suppression

Clinical features
H/0 perinea! trauma/ infection /instrum entation
Normal Spennatocole
!
Cellulitis
Treatm ent
!
• Small sperma tocele- observation (ONLY) Swollen , tender, erythem atous skin
• Large spermatocele - aspiration or excision !
• Chinese lantern pattern - seen in epididymal cyst • Purplish to Blackish discolor ation
• Dish water like discharge
FOUR NIER'S GANG RENE 0 00:22:18 • Fetid odour
!
• Also known as idiopath ic scrotal gangren e Necrosi s of skin
• Type of necrot izing fasciitis of scrotal region • Pain, high grade fever, marked systemic toxicity
• Abrupt onset
• Idiopath ic Polymicrobial infections(aerobes + anaerobes)
!
Oblitera tive end arthritis of arterioles of scrotal region
!
Gangrene
• Involved structures
Skin
Superfi cial Fascia
Deep Fascia Manage ment
• IV fluids+ IV antibiotics
• Spared structures • Extensive surgical debride ment
Corpora Cavemosa • After extensive debride ment skin grafting is done over
Corpora Spongiosa testes.

f-
nee!es"i 1.: 10@gma,I com
Urethra 91;-()-1860S 39 • Mortalit y rate - 7-75% (avg-20 %)
Testis
Cord Structures TESTICULAR TUMO URS 0 00:30:40

Risk factors for testicular tumors

• Cryptorchidism
• Test icular feminization syndrome(androgen insensitivity

254
 syndrome)
Granulosa cell t umor
• Klinefelter's syndrome
Thecoma
• H/0 testicular tumor in siblings Fibroma
• Personal H/0 Test icu la r Tumor- increases ris k of Gonadoblastoma
contralateral testicular t umor
• ln-utero exposu re of DES (Diethylst ilbestrol)
NON - HODGKIN LYMPHOMA(NHL) 0 004042

WHO classification of testicular tumor • Extra nodal lymphoma

• MC type - DLBL(Diffuse large B cell lymphoma)
Germ cell t umors • DLBL is MC type of lymphoma in
-----~A____ Primary CNS Lymphoma
/ \ Orbital Lymphoma
Seminoma Non-Seminomatous GCT Thyroid Lymphoma
o Yolk sac tumor Breast lymphoma
1.. Teratoma Gastric lymphoma - DLBL (52%) case followed by
o Embryonal carcinoma MALToma (35%)
o Choriocarcinoma Small intestine lymphoma
o Appendicular lymphoma
Sex cord / gonadal stromal tumors Colonic lymphoma
• Leydig cell tumor Rectal lymphoma
• Sertoli cell tumor Testicular Lymphoma
• Granulosa cell tumor
• Thecoma / fibroma Testicular tumors:
• MC TT - seminoma (3rd and 4th decades)
M ixed (germ cell & gonadal stromal tumors) • MC TT in elderly - lymphoma (6th decade)
• Gonadoblastoma
Clinical features of Seminoma
Lymphoid/ hematopoietic: • Painless swelling or mass in relation to testis
• Lymphoma • 10% cases have secondary hydrocele
• Leukemia • 5% cases - Gynecomastia
• Plasmacytoma o MC in Leydig cell tumors
o Sertoli cell tumors
One liners for Testicular tumor (TT): o Granulosa cell tumor
• MC TT - seminoma (mixed if given in option) o Gonadoblastoma
• MC primary 8/L TT - Seminoma • Seminoma -2/3rd - localized tumor
• MC Radiosensitive TT - Seminoma • NSGCT - widespread metastasis
• MC TT in children (1 -3 years) - Yolk sac tumor • MC route of spread - Lymphatics
• TT w ith bestprognosis - Yolksactumor
• MC TT in pre-pubertal children (11- 13 years)- Teratoma • Choriocarcinoma
o Early hematogenous spread

• MC TT in elderly o Early metastasis to lungs

• MCTT (B/L) Lymphoma (diffuse large B cell o Cannon Ball 20 (RCC>Choriocarcinoma)

} lymphoma variant of NHL)
• MC secondary TT Diagnosis
• TT with early hematogenous spread • Ultrasound:
With early pulmonary metastasis Choriocarcinoma o Enlarged and hard affected testis
. L o Secondaryhydrocele (10%)

F-
neelesh1 4 10@gma1I com
Worst prognosis VammtofMurricane tumor) o Hypoechoic mass in relation to t estis

• Tumors w it h increased risk of gynecomastia - any tumor FNAC / trans scrotal biopsy - contraindicated
with gonadal stromal component - L (Seeding of tu mor cells in tract)
lead to inguinal lymph node metastasis
Leydig cell tumor
Sertoli cell t umor

255
Treatment
invasion
• High inguinal orchidectomy(even on suspicion of TT-
Because most TT are malignant)
Lymph node staging
• Chevassu maneuver - Isolate testis from cord and
• N 1 - LN mass :s 2cm or multiple LN mass. none;;,: 2cm
placement of soft clamp over the cord
• N2 - LN mass > 2cm but <Scm or multiple LN mass
l anyone one mass is >2cm but <Scm
Take f rozen section biopsy • N3- LN mass > 5cm
l
If Malignant tumor Metastasis
l
High inguinal orchidectomy • MO - no distant metastasis
• CECT - for retroperitoneal LN involvement • M 1 - metastasis to non - regional LN or pulmonary
• Primary landing site from right testicular tumor metastasis
mter - aortocaval LN • M2- Non- pulmonary visceral metastasis
• Primary landing site from left testicular tumor- Para-
aortic LN Management 0 01:03·44
• Cross over metastasis from right to left but NOT left to
right Refer Table 35.1

J
• MC group LN involved in TT- Para aortic LN
Chemotherapy regimens
Tumor markers
B- Bleomycin
AFP E- Etoposide x 6 cycles
• Y-YolkSacTumor P- cisplatin
• E-Embryonal Carcinoma
• T-Teratoma Intra tubular germ cell neoplasm (ITGCN) (!> 01:06:20
8 - HCG • A/K testicular CA-in-situ
• C - Choriocarcinoma • Pre invasive precursor of all testicular germ cell tumor
• E - embryonal carcinoma except
• S-Seminoma (10% which have Syncytiotrophoblast) o Spermatocyte seminoma
o Yolk sac tumor

• LDH
• PLAP
• GGT
J
Markers based on bulk of disease

Seminoma
o Teratoma

Risk factors
• H/0 germ cell tumor
• Cryptorchidism
8th AJCC TNMS classification • Infertility
• Extra gonadal germ cell tumor
Serum markers • Atrophic- contra lateral testis
• AFB • Somatosexual ambiguity
• HCG
• LDH Clinical features
• Affected Testis is normal or atrophic
PATHOLOGICAL STAGING (P) (!) 0 1:01:10 • No established tumor maker
• P Tis - lTGCN (carcinoma-in-situ) • USG testis- not reliable for diagnosis
• P Tl - limited to testis without Lymphovascular invasion • Gold standard investigation for ITGCN: testicular
Tumor may invade tunica albuginea but not the tunica biopsy
vaginal is .
see
neelesh1410@gma,I com
86
• PT 2 - Limited to t e9~7t7Ps ~tfd epididymis w ith Treatment
Lymphovascular invasion or extending to tun ica • Observation
albuginea with involvement oftunica vaginalis • Radiotherapy
• PT3 - invades the spermatic cord with or w ithout • Orchidectomy
Lymphovascular invasion
• PT 4 - invades scrotum w ith or without Lymphovascular

256
CA SCROTUM 0 01.10:33 • Primar y landing site from right testicu lar tumor- inter-
aortocaval LN
• A/K Chimn ey sweep s cancer • Primar y landing site from left testicular tumor- Para-
• MC histological type - SCC aortic LN (Overall MC)
• 5th/ 6th decades
Composition of stone in various organs
Risk Factors • MC gall stone - cholest erol
• TAR • MC pancreatic stone- calcium carbonate
• SOOT • MC salivary stone- calcium carbon ate
• Hydroc arbon • MC renal stone - calcium oxalate
• MC radiolucent renal stone - uric acid
Clinical feature s-ulcer with everted edges and indurated • MC 10 Bladde r stone: Ammo nium Urate
base (MC LN involved: Inguinal) • MC 20 Bladde r stone: Uric Acid >Struv ite
• MC Prostatic Stone: Calcium Phosph ate
IOC for diagnosis- Biopsy

Treatm ent - wide local excision with 2cm margin

IMPO RTAN T POIN TS ASKED IN UROL OGY

0 0 1:13:17

MC group of LN involve d

• CApen is }
Inguinal LN
• CAscro tum

• CA Bladde r }
Obtura tor LN
• CA prostat e

Table 35.1

Seminoma Non-Seminomatous GCT

IAIB
• Radioth erapy • RPLND
IIAIIB

lie Ill
• Chemotherapy • Chemotherapy± RPLND
Is

-00
neclesh141 Q@gma1 com
, 17704 860839

257
PREP NUGGETS
II
Prep Nuggets

Axillary LN Levels in relation with Pectoralis minor

level Relation with Pectoralis minor Axillary LNs Included

Below or lateral

II

Ill Apical

Prep Nuggets

TSH T4 T3

Graves disease High

Hashimot o's Elevated

thyroiditis

Pituitary failure Low

Hypothala mic Low

failure ·

e-
neelesh1410@gma,I com
917704860839
Pre.p Nuggets

Indic ation s of Liver Transplant ation (LT)

Most common indications of LT

HCV Induced Cirrhosis

Most common indication of pediatric LT

Most common metabolic disorder requiring LT in

paediatric
patients

Most common indication for LT follow ing acute

liver failure

fog