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Behind The Knife: The Surgery Podcast
Behind the Knife ABSITE 2025 - Urology
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Welcome to behind the knife Absite Review 2025. Be sure to check out our brand new free study aid which includes all 32 review episodes, brief written summaries, high yield images and flashcards. Simply create an account on our website or app and you will find the entire course in your library. And don't forget our app site review book available on Amazon. Dominate the day and Dominate App site.
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Behind a Knife is proud to partner with Medtronic to support the entire 2025 Absite podcast series. Medtronic has a rich history of supporting surgical education and we couldn't be happier that they chose to partner with behind the Knife. Their sponsorship goes a long way in supporting us as we've developed new exciting content. Medtronic's innovation and Surgical Stapling with Signia Stapler and Tri Staple Technology featuring Adaptive Fire Technology delivers better staple formation with the power of real time feedback. Tristaple provides three staple rows for improved perfusion, reduced tissue stress and consistent results across various tissue thicknesses. Tristaple Technology is also available in both GIA and EEA staplers. This comprehensive stapling portfolio addresses common challenges in bariatric, colorectal, thoracic and HPB specialties supporting open, laparoscopic and robotic approaches.
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Okay, behind the Knife AB Site review Today we're talking about urology. We're going to go over some high yield urology that's going to get you those points on the app site. So here with John so John, let's go into some urologic anatomy. One thing that's frequently tested is the structures in the renal hilum. So anterior posterior, what are we going to encounter in that renal hilum?
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B
So yeah, anterior to posterior. I remember vap. So renal vein, most anterior renal artery and renal pelvis.
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A
Yeah, exactly. So be familiar with those structures, look at some pictures because that's often a question is just the relationship of the structures of the renal hilo. So anterior posterior vein, artery, pelvis. Now with regard to the renal vein, John, so the left renal vein, does it pass anterior or posterior to the aorta?
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B
The left renal vein crosses anterior to the aorta.
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A
Yeah. So left renal vein crosses anterior to the aorta. And you can remember that when you're just think about your approach for a abdominal aortic aneurysm and that proximal dissection you're going to encounter that left renal vein, you need to watch for that. So the left renal vein, what's important as far as like the collateralization. So the left renal vein has some other things that drain into it as collateral. So how is that clinically significant? John?
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B
Yeah. In trauma and in vascular situations, the left renal vein can be ligated from the IVC due to those collaterals. Great.
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A
Perfect. Okay, now let's talk about the renal artery then. So if the left renal vein crosses anterior to the aorta, what's the relationship of the right renal artery and the ivc?
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The right renal artery typically passes posterior to the ivc.
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A
Okay, so your right renal artery, posterior to the ivc. Your left renal vein anterior to the aorta, greater. Okay, let's move on to the ureters. So they're fixed at a couple locations. Where are the fixation points of the ureters?
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B
So they're fixed at the urinary pelvic junction, the urovesicular junction and the pelvic brim.
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A
Okay, and what is the relationship of the ureters to the iliac vessels?
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The ureters cross over or anterior to the iliac vessels and under the uterine artery. So water under the bridge.
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A
Okay, great. So what about the spermatic cord? We covered this in hernia, but let's go over it again. So what are the spermatic cord structures?
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B
Yeah, spermatic cord consists of the testicular artery, that pampiniform plexus, the vas deferens, the cremasteric muscles, the ilioinguinal nerve, and the genital branch of the general femoral nerve.
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A
Okay, great. Now let's move on to some urologic pathology. So. Well, one thing we see very commonly in the surgery world is urinary retention. So acute urinary retention, the etiology is gender specific. So what causes urinary retention? Most commonly in men. And how's that different from women?
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B
Yeah, and men, the most common cause is enlarged prostates. In females, the it's caused by pelvic organ prolapse. Pelvic mass or urethral diverticula.
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A
Yes, so much more common in men. Again, do that prostate, especially older gentlemen, you know, other etiologies, you can have urethral strictures, trauma, neurogenic bladders. You can have blood clots within the bladder and the urethra infection. Some medications can induce a urinary retention as well as constipation. What are some risk factors then for acute urinary retention?
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B
So, being male, being of older age, history of BPH or prior urinary retention, pelvic or perineal surgery, spinal surgery, or any of your angular procedures such as Anguilla Hernia repair.
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A
Yeah. So our typical first line treatment for this is decompression of the bladder, usually transurethral with just a basic Foley catheter. But what if that's John, what if that's unsuccessful? What are our other interventions for acute urinary retention?
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B
Yeah, I'd say you want to try Foley placement multiple times before you move on and also usually consult a urologist. But additional options, specifically in people with pelvic trauma causing urethral disruption, or if they have a complex urinary tract reconstruction, such as a bladder is not accessible through the urethra, you can consider a suprapubic catheter, also known as a cystostomy.
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A
Yeah, and a lot of times, like you say, you know, urology is going to be able to help with this. And they can form cystoscopy in order to get a catheter transurethral into the bladder. And of course you want to address those underlying, you know, if they're on medications or any other underlying etiology that's leading to the acute urinary retention. But yeah, you may need a suprapubic catheter replacement if all, if other things fail. So let's say we have a suprapubic catheter. What are some principles to management of that suprapubic catheter?
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B
So one of the major side effects of that catheter, bladder spasms. And these can be treated with anticholinergics. The tract between the bladder and the abdominal wall takes about four to six weeks to fully mature and be established. If you have chronic indwelling catheters, these need to be changed every four to six weeks and the urine will be always be colonized. It's communicating with the outside. So you only treat with the UTI if you have symptoms. And they do, unfortunately do get a lot of UTIs.
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Okay, let's move on to something a little bit more high yield. And that's the types of kidney stones. So what are some different types of kidney stones?
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Yeah, so we have the most common type. 75% of all kidney stones is calcium oxalate. These are radiopaque on imaging, and it's increased risk in patients with termoilium resection or crohn's disease due to the increased oxalate absorption in the colon. Next we have struvite stones. These are also radiopaque and these form the stagcorn calculi that you might see in questions. These are associated with urease producing infections such as proteus. The next type is uric acid stones. These are radiolucent. On imaging, you have increased occurrence in patients with ileostomies, gout and myeloperiferative disorders. And finally, you have cysteine stones, once again, are radiolucent. And you have increased risk with congenital disorders of the cysteine reabsorption.
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Yeah. So the way you'll see that show up is sometimes they'll ask what's the most common type? And that's again, like you say calcium oxalate. Or they may give you a specific patient, like a Crohn's patient, and say, what kind of kidney stones is this patient prone to? And again, that's calcium oxalate, a big one. Is that ileostomy? So patients with ileostomies are increased uric acid stones. Or they may show you a picture. They show you a picture of that staghorn calculi. The staghorn calculi, then know that that's the struvite stone. So that's the way that that will typically show up. So be familiar with those. So, John, what are some indications for surgical intervention while managing kidney stones?
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I think the most common scenario you're going to see on the test is a patient who has an acute infection or infected stone. But other indications are intractable pain, multiple ongoing chronic infections, progressive obstruction or renal damage. So you think of like hydronephrosis related to stone stones that are quite large, greater than 6 millimeters. And these are likely to spontaneously pass. And then obviously a patient with a solitary kidney where you're worried about damage to that kidney, you'd want to take care of this earlier than later.
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What are our surgical intervention options?
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So the most, most common acute surgical intervention would be ureteroscopy with stone extraction and then usually a stent placement placed to pass the obstruction or to decompress the kidney. Other things that you can also consider are percutaneous nephrostomy tubes, an open nephrolithotomy, and in more of a non urgent setting, you can consider extracorporeal shockwave lithotripsy. The contraindications to this, and I don't think this would probably come up on the app site, are pregnancy patients who bleed easy or have hematologic disorders or stones that are multiple centimeters in size.
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A
Okay, good. Okay, so let's move on from stones and let's talk about some additional urologic pathologies. So let's start with a patient who has an enlarged scrotum, and we can distinguish this in between painless and painful enlarged scrotum. So a patient Presents with a painless enlarged scrotum. What's under differential diagnosis?
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B
Yeah, and this is, you know, clinically you should be able to list these out as well. So hydrocele spermatocele or epididymal cyst varicocele, which is that the well known bag of worms. Inguinal hernia obviously should be on there for any general surgeon and always want to consider testicular tumors.
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A
Now talk to me about that varicocele. Yeah, that's great. You know, as us as general surgeons, when we see these patients, typically top of our differential is that inguinal hernia. But certainly we have to be aware of these other things. That varicocele, you're talking about the bag of worms, sometimes if they present on the left, sometimes they present on the right. And that can clue us into potential underlying pathology or etiologies. So what's the difference between the left and the right?
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On the left side, the left gonadal vein drains into the left renal vein, and that's why you typically find varicoceles on the left side. On the right side, the right gonadal vein drains directly into the ivc. However, if you have isolated right sided varicoceles, they're concerning for a retroperitoneal process.
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Okay, great. So let's move on to the painful enlarged scrotum. So painful scrotum swelling, it should be evaluated immediately as it's an emergent condition. So what's on your differential for a painful enlarged scrotum?
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Yeah, so if you truly had a painful enlarged scrotum, the things that would be in the highest differential would be testicular rupture, testicular torsion, and a potentially incarcerated inguinal hernia. Other things you may consider, and definitely a cause of this is fournier gangrenes or an nsti. Trauma to the scrotum could also do this. You can also have referred pain from some type of urethral coculus. And obviously cancer can also do this.
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Okay, great. So let's talk a little bit more about hydroceles. Very common. So what is a hydrocele?
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So it's swelling in the scrotum caused by an imbalance of secreted and absorbed fluid.
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Okay, so yeah, this can form in response to adjacent inflammation and it forms between the parietal and visceral layers of the tunica vaginalis. There's two types. That's right. So there's communicating and non communicating. So what's a communicating hydrocele?
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So that's characterized by fluctuation in size versus non communicating, which does not fluctuate in size.
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So yeah, like communicating, that's characterizing, like I say, by the fluctuating size. The reason for that is because its etiology is due to an underlying patent processes vaginalis and it's typically seen in pediatric patients. So in addition to an enlarged sclerotum job, what other findings are typically associated with a hydrocele?
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These are usually unilateral. They typically have a gradual onset, they're painless. And if you do the flashlight test, these will trans eliminate.
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So John, on physical exam, how do you differentiate between a spermatocele and a hydrocele?
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Yeah, if the testes cannot be palpated due to the fluid, it is a hydrocele. If both the testes and fluid collection can be felt, it is a spermatocele.
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Okay, good to know. I doubt that's gonna show up on the test, but good to know. But let's talk more about operative management of hydroceles. So how do you approach these?
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So there's two approaches. Inguinal or scrotal. Inguinal is indicated in pediatric patients with a communicating hydrocele, or when there's a concern for malignancy, scrotal approaches to the median raphe or a transverse unilateral incision. And this is used for repair of most adult hydroceles.
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Okay, great. Okay, and what are your types of repair?
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So the two types of repairs are the job, a bottleneck repair and the lord Plication repair.
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Yeah, I don't think it's important to know the distinction between those different types of repairs. You're definitely not going to be asked that. But you know, in general, especially for adults, non communicating hydro seals, you know, you're going to open the hydro seal, drain the fluid, excise the excess stack, and then, you know, you can plycate or you can invert that hydrocele edges to prevent recurrence. But again, for the upside, you don't really need to know that. But what you may need to know is some potential post operative complications. So John, what are some potential post operative complications after a surgery for a hydrocele?
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B
Yeah, the most common are scrotal hematoma and obviously hydrocele recurrence. Ispermia can also occur with damage to the epididymis or vas deferens. But this is more common with excision of a spermatocele.
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A
Okay, great. So let's move on to some malignancies, some high yield urologic malignancies that you may need to know. So the first one would be testicular neoplasm. So these have age group distribution. So what are the peaks in age groups that you're at risk for a testicular neoplasm?
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So there's three age groups. Infants, men in their 20s to 30s, and then those in their 60s.
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Yeah. Interestingly, like for men age 25 to 35, this is the number one cause of a cancer related mortality as a testicular neoplasm. So pretty common. So how do you work these up?
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So the imaging is the first thing you want to do, and that's typically a scrotal ultrasound. And then you need CT staging. So your chest, abdomen and pelvis to look for any metastatic disease.
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Yeah. Yep. Don't ever forget the staging. It's a scrotal ultrasound is the first thing you kind of go to and then followed by your ct, chest, abdomen, pelvis. There. There are some biomarkers that I understand that are associated with some of these testicular neoplasms.
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Yeah, your beta acg, your AFP, and your LDH are the three you need to know for this perf.
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Okay, so let's talk about some different types. So what's the most common type?
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Seminoma is the most common type. It's the number one testicular tumor. The biomarkers for this, you don't have any elevation. And specifically AFP is not elevated. If you see that on a test.
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Okay, yeah, Great. So a lot of the questions on the test are going to be distinguishing between seminoma and non seminoma. So just remember that seminoma is number one and it does not have AFP elevation. Now, what is treatment for a seminoma?
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So the treatment for a seminoma is orchiectomy and retroperitoneal radiation for all stages. There are some caveats to this, but the most likely answer you're going to see on a test is the orchiectomy and the radiation.
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Yeah. So these are very sensitive to xrt. So almost all of them, if not all of them, will be getting xrt. Of course, the treatment is individualized to the patient. What about chemotherapy?
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Chemotherapy is reserved for bulky retroperitoneal or metastatic disease. That's usually followed by a surgical resection, the residual disease after a course of chemo.
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Okay, again, so just briefly, seminoma number one, no AFP elevation treatments, orchiectomy and retroperitoneal XRT as it is very sensitive to xrt, and then chemotherapy for bulky retroperitoneal or metastatic disease.
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Yeah, and the drugs we use for chemotherapy for seminomas are cisplatin, bleomycin and antoposide.
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A
Okay, perfect. Great. So let's move on to non seminoma. So embryonal teratoma, choriocarcinoma and yolk sac tumors. These are all non seminomas. What are the biomarkers that we see in non seminoma? Testicular cancer.
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So you can have increased AFP for most of these, and you would see increased beta HCG in choriocarcinoma and teratoma.
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Okay, so this is where you start seeing the elevation of biomarkers. Again, in non seminoma. It's a seminoma. There's no AFP elevation. Okay, treatment for non seminoma.
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So like I said, the. The general treatment is orchiectomy and retroperitoneal lymph node dissection for all stages.
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A
Okay, so stage two plus that's, you know, when it's gone beyond the testes, receive chemotherapy. And again, that's cisplatin, bleomycin and toposide prior to resection. But yes. Orchiectomy, retroperitoneal lymph node dissection. These have a tendency to spread via lymphatics, except for choriocarcinoma subtype, which has a hemogenous spread, so especially to the lungs. So remember that lymphatic spread except for chorio, which has hemogenous spread to the lungs. So in resection we say orchiectomy for these tumors. What type of. Is this a scrotal incision or what type of incision are you using?
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B
Yeah, we approach these through an inguinal incision to avoid disrupting any lymphatics.
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A
Okay, perfect. Okay, so let's move on to prostate cancer. Now, so what are some risk factors for prostate cancer?
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So this is age greater than 40 years old, African American race, first degree relative, diagnosed before the age of 65. And the BRCA mutation?
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A
Yeah, sometimes we forget about that BRCA association with prostate cancer. Okay, so how do we screen patients?
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B
So screening is controversial and they seem to be always changing. At the test we use for screening is a prostate specific antigen or a psa. And we want to refer patients to urology. If that PSA is greater than 7, we typically start screening patients between the age of 40 and 45 in high risk individuals. So that's African American men and men with family history of prostate cancer. But of average risk patients, we start screening them at 50 years old. I don't think you can get tested out on the app site. But just so you know.
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A
Yeah. And as you say, it changes year by year. So those are in general, and they're not going to ask you that specific of a question on the. On the app site. So what's the workup then?
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So if you had a PSA greater than 7 in central urology, and you need to further work these patients up, the most common is a transrectal ultrasound guided biopsy. We then will also work these patients up with further imaging to include ct, chest, abdomen, pelvis, plus or minus a bone scan if prostate cancer is diagnosed. And once again, biochemical markers, we can follow the psa. We can also follow alk fall, especially if you have bony mets.
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A
Okay, so let's move on to treatment then. So let's say, you know, early stage, you know, like stage one, A incidental finding during a turp. What do you do in that situation?
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So there's nothing further you need to do during that.
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A
Okay. All right, how about intracapsular tumors without metastasis?
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So you can consider radiation or perform a radical prostatectomy, which is resection of the prostate, seminal vesicles, and ampulla, the vas deferens. And you can also consider a pelvic lymph node dissection or nothing, which is really kind of strange. Yeah, I mean, the age of health.
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A
Yeah. You know, I think the reason for that is these tend to be indolent and slow growing. So if you're an older individual, it's likely something else is going to get you before this prostate cancer. So that is an option. But in general treatment, XRT or radical prostatectomy, depending on the individual patient. Okay, so what about extra capsular? Or there's metastatic disease.
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B
So in this case, you want to do radiation and androgen ablation. So angiogener ablation is leuprolide. That's a GNRH agonist. You also want to do flutamide, which is a testosterone receptor blocker, or perform bilateral orchiectomies.
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A
Yeah. So some form of androgen ablation and leuprolide, flutamide. Bilateral orchiectomy most likely is going to be one of those medical options. So when should you recheck a PSA be rechecked? After a prostatectomy, three weeks.
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If it's the PSA should go to zero. If it does not, we want to check a bone scan to look for metastases.
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A
Okay, great. Okay, moving on. So let's talk about bladder cancer. So what are red flag symptoms? That should prompt an evaluation for bladder cancer.
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Yeah, this is where you'd see on the test painless hematuria.
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A
And what are risk factors for bladder cancer?
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So smoking, prior history of use of cyclophosphamide, aniline dyes, and occupational toxins such as arsenic. And also any radiation to the pelvis.
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Okay, and we'll have workup.
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Yeah, the first workup is a cystoscopy.
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A
Okay, so how do we treat bladder cancer?
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So, T1 tumors where there's no muscle involvement, you can do intravesical BCG or transurethral resection. T2 tumors where there is a muscle involvement, you must do a cystectomy with the ileal conduit. You also don't want to do chemotherapy and radiation.
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Great, so T1 disease, intravesical BCG. I've seen that show up before. T2 cystectomy with ileal conduit, chemo and XRT. So the chemotherapy regimen is methotrexate, benblastine, adriamycin and cisplatin. Unlikely. You need to know that for bladder cancer. But just so you're aware. And then, of course, for metastatic disease, definitive chemotherapy. Okay, moving on. How about renal cell cancer? What are some red flag symptoms for renal cell cancer?
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So you find you have a patient who had flank pain and hematuria.
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A
Okay, and what's your workup?
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You do a CT urogram, plus or minus a cystoscopy.
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A
Okay. And treatment?
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Treatment for this is radical nephrectomy.
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A
What do you mean when you say radical nephrectomy?
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B
So that is removing the kidney, the fat surrounding the kidney, Giroda's fascia and all the regional notes.
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A
Yeah, and possibly the adrenal gland if the. If. If it's involved by the tumor or if it's immediately adjacent to it. So a third of these patients will have metastatic disease at the time of diagnosis, Often isolated lung or colon metastases that can be resected as part of your R0 resection. So what about we hear sometimes about paraneoplastic syndromes associated due to renal cell cancer. What are those?
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B
Yeah, there's a few of these. So you can have perineoplastic syndromes with renin, erythropoietin, which you get erythrocytosis, remember the PTH related protein, which can cause hypercalcemia, ACTH and insulin.
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A
Okay, great. Okay, so let's finish it out with some quick hits. Okay, so, John, what is the most common cause of acute renal insufficiency after surgery.
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B
So hypotension.
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A
Great. Okay, what childhood condition leads to an increased risk of testicular cancer?
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B
So, undistended testicles and would most likely result in a seminoma.
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A
Excellent. Okay, sudden onset of severe testicular pain in a teenage boy. What are you concerned about?
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B
You have to be concerned about testicular torsion. And how does that present with high riding testes that is tender and swollen. And you'd have absent chemisteric reflex on that side.
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A
Perfect. Okay, and what do we do for these?
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B
So you do emergent detergent and bilateral orchopexy.
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A
Yeah, that's important. Don't forget that. Bilateral orchopexy with that emergent detergent for testicular torsion. That's very commonly tested, but the testicle's not viable. Of course. You need to resect and then perform an orchopexy of the contralateral testes. But bilateral orchopexy. How do you distinguish torsion from acute epididymitis?
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B
So these patients with acute epididymitis will present with fever, pyuria and a tender cord. You can use ultrasound would be the best to determine the difference between the two.
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A
Yeah, ultrasound is very useful in being able to establish the flow to that testicle. So how about testicular rupture? How does that appear on ultrasound?
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B
So you have heterogeneous echo patterns of the testes and disruption of the tunica albuginea.
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A
Okay, perfect. What's the most common tumor of the kidney?
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B
It's metastases from breast cancer. Actually.
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A
Yeah, that's really interesting. Metastases from breast cancer is the most common tumor of the kidney. How about where is it most likely for renal cell cancer? Where does that normally metastasize to?
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B
These usually go to the lung. And like we said before, renal cell cancer is often found late. So you'd find a lot of people find lung mets prior to finding the renal cell.
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A
Okay, and like we mentioned before, those isolated mets can be resected as part of a Bar 0 resection. What's the syndrome associated with multifocal and recurrent renal cell cancer? In addition to renal cyst, CNS tumors and pheochromocytomas?
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B
That's your Von Hippel Lindau syndrome.
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A
Okay, Von Hippel Lindau. So renal cell cancers, renal cysts, CNS tumors, pheochromocytoma. Okay, so with regard to prostate cancer, what's the most common site within the prostate?
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B
It's the posterior lobe of the crest.
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A
Okay. Posterior lobe. Okay. Most common site for metastasis of prostate cancer.
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B
That would be the bone.
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A
Great. So say you have a patient who underwent a turp and now has altered mental status or seizures. What is the concern there?
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B
That's your post chirp syndrome. It's caused by hyponatremia secondary to irrigation with water during the procedure.
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A
And how do you treat it?
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B
Just treat it with sodium correction and with diuresis.
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A
Okay, perfect. Okay, so that's it for our urology section. Thank you so much for listening.
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Thank you for listening. And a big thank you to Medtronic for supporting surgical residents preparing for the 2025 AB site. Since 1949, Medtronic has been a leader in pioneering therapies that change lives, including innovations in surgical stapling that empower surgeons to deliver optimal outcomes from all of us. At Behind a Knife and Medtronic dominate the app site.