Behind the Knife ABSITE 2026 - Urology

[Music] Welcome to Behind the Knife, AppSight Review 2026. Be sure to check out our 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, you will find the entire course in your library. And don't forget our AppSight Review book, Available on Amazon. Dominate the day and dominate the AppSight. Hi, all your BTFK fans. It's Scott here. And Behind the Knife is proud to partner with Metronik to support the entire 2026 AppSight podcast series. Metronik has a rich history of supporting surgical education, and we couldn't be happier here at BTK that they chose the partner with us. Their sponsorship goes a long way in supporting as we develop exciting new content. Metronik's innovation and surgical stapling with the Sigma linear stapler with Tri-Stable Technology featuring adaptive firing technology, delivers better staple formation with the power of real-time feedback. Tri-Stable Technology provides three rows of staples designed to promote better perfusion, reduce tissue stress, and deliver constant and consistent performance across a broad range of tissue thickness. Tri-Stable Technology is also available in both the GIA and EEA staples. This comprehensive stapling portfolio addresses common challenges in bariatric, colorectal, thoracic, and HPP specialties, supporting open laparoscopic and even robotic approaches. Dominate the day. Behind the Knife AppSight 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 AppSight. So, you know John, so John, let's go into some urologic anatomy. One thing that's frequently tested is the structures in the renal high-lum. So, anterior posture, what are we going to encounter in that renal high-lum? So yeah, anterior to posterior, I remember VAP. So, real vein, most anterior, renal artery, and renal pelvis. 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 high-lum. So, anterior posture, your vein artery pelvis. Now, with regard to the real vein, John, so, the left renal vein, does it pass anterior or posterior to the aorta? The left renal vein crosses anterior to the aorta. Yeah, so left renal vein crosses anterior to the aorta. And you can remember that when you're just thinking about your approach for abdominal aorta, aneurysm, and that proximal dissection, you're going to encounter that left renal vein, and you need to watch for that. So, the left renal vein, what's important as far as the collateralization? So, the left renal vein has some other things that drain into it as collateral. So, how is that clinically significant, John? Yeah, and trauma in an invascular situation, the left renal vein can be ligated from the IVC, do those collateral. Great, 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? The right renal artery typically passes posterior to the IVC. Okay, so, your right renal artery postures to the IVC, your left renal vein, anterior to the aorta. Great. Okay, let's move on to the ureters. So, they're fixed at a couple of locations. Where are the fixation points of the ureters? So, they're fixed at the ureter pelvic junction, the ureobesicular junction, and the pelvic brub. Okay. And what is the relationship of the ureters to the iliac vessels? The ureters cross over or anterior to the iliac vessels and under the ureter artery, so water under the bridge. Okay, great. So, what about the spermatic cord? We cover this in hernia, but let's go over it again. So, what are the spermatic cord structures? Yeah, spermatic cord consists of the testicular artery that pimpiniform plexus, the vas deferens, the cremestareg muffles, the ilio-ingol nerve, and the genital branch of the general femoral nerve. Okay, great. Now, let's move on to some urologic pathology. So, one thing we see very commonly in the surgery world is urinary retention. So, acute urinary retention. The ureology is gender specific, so what causes urinary retention most commonly in men in the house that differ from women? Yeah, in men, the most common causes and large prostate. In females, it's caused by pelvic organ prolapse, pelvic mass, or urethral diverticula. Yes, so much more common in men, again, do that prostate, especially older gentlemen. You know, other ideologies, you have urethral strictures, trauma, neurogenic bladders, you can have blood clots within the bladder, urethra, infection, some medications can induce a urinary retention as well as constipation. What are some risk factors then for acute urinary retention? So, being male, being a voter age, history of VPH or prior urinary retention, pelvic or perennial surgery, spinal surgery, or any of your ingloral procedures as you ingloral herniar repair. Yes, so, typical, you know, first line treatment for this is decompression of the bladder, usually trans urethral with just a basic fully catheter, but what if that's unsuccessful? What are other interventions for acute urinary retention? Yeah, I'd say you want to try fully placement multiple times before you move on, and also use the console 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 virus that accessible through the urethra, you can consider a super-pubic catheter. Also known as a cystostomy. Yeah, and a lot of times, like you say, urologist can be able to help with this, and they can form cystoscopy in order to get a catheter trans urethral into the bladder. And of course, you want to address those underlying, you know, their own medications or any other underlying ideologies that's leading to the keve here here retention, but yeah, you may need a super-pubic catheter replacement if all other things fail. So let's say we have a super-pubic catheter. What are some principles to management of that super-pubic catheter? So one of the major side effects of the catheter bladder spasms, and these can be treated with anticolynergics. 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. 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? Yeah, so we have the most common type, 75% of all kidney stones, is calcium oxalate. These are radiopeque on imaging, and it's increased risk in patients with terminally in resection and acrozozies due to the increased oxalate absorption in the colon. Next, we have streuviestones. These are also radiopeque, and these form the stag core and calculia 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 radio loosent on imaging. You have increased occurrence in patients with iliosomies, gout, and myoperiferative disorders. And finally, you have cysteine stones. Once again, are radio loosent, and you have increased risk with congenital disorders of the cysteine ray absorption. Yeah, so the way you'll see that show up is sometimes the last one, 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 crone patient and say what kind of kidney stones are this patient? Prone too, and again, that's calcium oxalate. A big one is that iliosomy. So patients with iliosomies are an increased uric acid stones, or they may show you a picture. They show you a picture of that stag corn calculia that stag corn calculia, then know that that's the streuviestone. 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? 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 all-engoing chronic infections, progressive obstruction or renal damage, so you think of like hydrinofersis related to a stone. Stones that are quite large, greater than 6 millimeters, and these are likely to spontaneously pass. And then obviously patient with an solitary kidney, or you're worried about damage to that kidney, you'd want to take care of this earlier than later. But what are our surgical intervention options? So the most common, acute surgical intervention would be youroscopy 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 and open nephrolithotomy, and more of a nod urgent setting, you can consider extra corporeal shockwave lithotrypsy. The contraindications to this, and I don't think this would probably come up on the absolute, our pregnancy, patients who bleed easy or have hematologic disorders, our stones that are multiple centimeters in size. Okay, good. Okay, so let's move on from stones and let's talk about some additional neurologic pathologies. So let's start with a patient who has an large scrotum, and we can distinguish this in between pain lists. and painful and large scrotal. So patient presents with a pain list in large scrotal. What's other differential diagnosis? Yeah, and this is clinically, you should better list these out as well. So hydricio, spermatocel or epidemial cyst, varicoseal, which is the well-known bag of worms, ingorinor hernia, obviously, should be on there for any general surgeon and always want to consider to stick it to her. Now talk to me about that varicoseal. Yeah, that's great. When we see these patients typically top of our differential is that ingorinor hernia, but certainly we have to be aware of these other things. That varicoseal you're talking about, the bag of worms. Sometimes 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? On the left side, the left gonadol vein drains into the left real vein. And that's why you typically find varicoseals on the left side. On the right side, the right gonadol vein drains directly into the IVC. However, if you have isolated, right-sided varicoseals, they're concerning for a retroperitoneal process. Okay, great. So let's move on to the painful and large scrotum. So painful scrotum swelling should be evaluated immediately as it's a emergent condition. So what's on your differential for a painful and large scrotum? Yeah, so if you truly add a painful and large scrotum, the things that would be in the highest differential would be desicular rupture, txticular torsion, potentially incarcerating guajernia. Other things you may consider, and definitely a cause of this, is forneogang greens or an eti. Trial it to the eschrotum, could also do this. You could also have referred pain from some type of uralococulus, and obviously cancer can also do this. Okay, great. So let's talk a little bit more about hydrosiles, very common. So what is a hydrosile? So it's swelling in the scrotum caused by an imbalance of secreted, in-emptorum fluid. Okay, so yeah, this can form in response to adjacent inflammation, and it reports between the pridele and visceral layers of the tunic of aginallus. There's two types, that's right. So there's communicating and not communicating. So what's a communicating hydrosile? So that's characterized by fluctuation in size versus non-communicating, which does not fluctuate in size. So yeah, like communicating, that's characterized by the fluctuating size. The reason for that is because its etiology is due to an underlying and beaten process of vaginalis and it's typically seen in pediatric patients. So in addition to an enlarged scrotum job, what other findings are typically associated with a hydrosile? These are usually unilateral. They typically have a gradual onset. They're painless, and if you do the flashlight test, these will transoliminate. So John, a physical example, how do you differentiate between a spermada seal and a hydrosile? Yeah, if the testes cannot be palpated due to the fluid, it is a hydrosile. If both the testes and fluid collection can be felt, it is a spermada seal. Okay, good to know. I doubt that's going to show up on the test, but good to know. But let's talk more about operative management of hydrosiles. So how do you approach these? So there's two approaches, anglinal or scrotal. Anglinal is indicated in pediatric patients with a communicating hydrosile, or when there's a concern from a pregnancy. Scrotal, you approach these to the mediarafe or a transverse to viral incision, and this is used for repair of most adult hydrosiles. Okay, great. Okay. And what are your types of repair? So the two types of repairs are the Jabale bottleneck repair and the Lord Placation repair. 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 in general, especially for adults, non-communicating hydrosiles, you're going to open the hydrosile, drain the fluid, excise, excess stack, and then you can plikeate or you can invert that hydrosile 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 postoperative complications. So John, what are some potential postoperative complications after a surgery for a hydrosile? Yeah, the most common are squirtle hematoma and obviously hydrosile recurrence. Ispermia can also occur with damage to the epididimus or vas deferens. But this is more common with the excision of a spermatisile. Okay. Great. So let's move on to some malignancies. Some high yield, a 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 group that you're at risk for a testicular neoplasm? So there's three age groups, infants, men in their 20s, the 30s, and then those in their 60s. 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 out? So the imaging is the first thing you want to do. And that's typically a squirtle ultrasound. And then you need CT staging. So your chest out in an pelvis to look for any metastatic disease. Yeah. No, never forget the stadiums. The squirtle ultrasound is the first thing you kind of go to and then followed by your CT chest out in pelvis. There are some biomarkers that understand that are associated with some of these testicular neoplasms. Yeah, your beta-ACG, your AFP, and your LDH are the three you need to know for this. Perfect. Okay. So let's talk about some different types. So what's the most common type? Neoplasm is the most common type. It's the number one testicular tumor. Biomarkers for this, you don't have any elevation and specifically AFP is not elevated if you see that on a test. Okay. Yeah, great. So a lot of the questions on the test are going to be distinguishing between some of Neoplas and now some of Neoplas. So just remember that some of Neoplasm number one and it does not have AFP elevation. And now what is treatment for a Neoplasm? So the treatment for a Seminoma is Orchiac to Me, I had retroperitinial radiation for all stations. There are some caveats to this, but the most likely answer you're going to see on a test is the Orchiac to Me in the radiation. Yeah. So these are very sensitive to XRT. So almost all of them, if not all of them, will be getting XRT. Of course, you know, the treatment is individualized to the patient. What about chemotherapy? Chemotherbaries reserved for bulky retroperitinial or metastatic disease. That's usually followed by a surgical resection. There is a Zorges after a course of chemo. Okay. Again, so just briefly, number one, no AFP elevation treatments orchiac to Me and retroperitinial XRT as it is very sensitive to XRT. And then chemotherapy for bulky retroperitinial or metastatic disease. Yeah. So what do you use for chemotherapy for seminomas or cisplatin, bleomysin and antipacite? Okay. Perfect. Great. So let's move on to non-seminoma. So embryonal, teratoma, choral carcinoma and yolk sac at tumors. These are all non-seminomas. What are the biomarkers that we see in non-seminoma testicular cancer? So you can have increased AFP for most of these. And you would see increased beta-HCG, Enquiry of carcinoma and teratoma. Okay. So this is where you start seeing the elevation of bodywarkers again, and non-seminoma. It's a seminoma. There's no AFP elevation. Okay. Treatment for non-seminoma. So like I said, the general treatment is orchiac to Me and retroperitinial lymph node as section for all stages. Okay. So stage two plus, it's gone beyond the testes, received chemotherapy. And again, that's cisplatin, bleomysin, and toposide prior to resection. But yes, orchiac to Me, retroperitinial lymph node dissection. At least have a tendency to spread via lymphatics except for choral carcinoma subtype, which has an imogenous spread. So, especially to the lungs. So remember that. Lymphatic spread except for choral, which has hemogenous spread to the lungs. So in resection, we say orchiac to Me for these two. What type of is this a scrotal incision or what type of incision are you using? Yeah. We approach these through an ingloral incision to avoid disrupting a lymphatics. Okay. Perfect. Okay. So let's move on to prostate cancer now. So what are some risk factors for prostate cancer? So this is age greater than 40 years old African American race, first degree relative diagnosed before the age of 65 and the Brake commutation. Yeah. Sometimes we forget about that Brake associational prostate cancer. Okay. So how do we screen patients? So screening is controversial and they seem to be always changing it. 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 seven. We typically start a screening patients between the age of 40 and 45 and 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 we can get tested that on the app site, but just so you know. Yeah. We 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 work up then? So if you add a PSA greater than seven is center urology and you need to further work these patients up, the most common is a trans rectal ultrasound, got a biopsy. We then will also work these patients up with further imaging to include CT, chest, abdomen, pelvis, plus from myus of both scan if prostate cancer is diagnosed. And once again, biochemical markers, we can follow the PSA. It can also follow out fast, but if you have body met. 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, a terrain, a turp. What do you do in that situation? There's nothing further you need to do during that. Right, and how about intercapsular tumors without metastasis? So you consider radiation or perform a radical processectomy, which is recection of the prostate, seminal vesicles and ampilla, the vas deferens. And you can also consider a pelvic lymph node dissection or nothing, which is really kind of straight. - Yeah, I mean, the age of hell. - Yeah, 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 gonna get you before this prostate cancer. So that is an option. But in general, treatment, XRT or radical prostateectomy depending on the individual patient. Okay, so what about extra capsular or there's metastatic disease? - So in this case, you wanna do radiation and angi-germlation. So angi-germlation is lupelied. That's a GNRH agonist. He also wanna do flutamide, which is just testosterone receptor blocker or perform bilateral or geochemacy. So in some form of antigenerplation and lupelied, flutamide, bilateral orchectomy, most likely is gonna be one of those medical options. So when should you check a PSA, be rechecked after a prostateectomy? - Three weeks. If it's the PSA should go to zero, if it does not, we wanna check a bone scan to look for metastasis. - Okay, great, okay, moving on. So let's talk about bladder cancer. So what are red flags of those that should prompt an evaluation for bladder cancer? - Yeah, this is where you'd see on the test, painless hematuria. - Okay, and what are risk factors for bladder cancer? - So smoking, prior history of use of psychophosphamide, anal endides, occupational toxins, such as arsenic, and also any radiation to the pelvis. - And it will work up. - Yeah, the first workup is this isoscopy. - Okay, so how do we treat bladder cancer? - So T1 tumors, whether there's no muscle involvement, you can do antivacicl BCG or transurethororosection, T2 tumors, where there is a muscle involvement, Ienus must do a sysectomy with the helioconduit, I also do a leukemotherapy and radiation. - Great, so T1 disease, antivethicl BCG, I've seen that show up before, T2, sysectomy, helioconduit, chemo, and XRT. So the chemotherapy regimen is methyltricsate, been blasting, adrymysin, isisplatin, unlikely you need to know that for bladder cancer, but just so you're aware. And then of course, for metastatic disease, it's a definitive chemotherapy. Okay, moving on, how about renal cell cancer? What are some red flag symptoms for renal cell cancer? - So you have a patient with a flank pain in hematuria. - Okay, and what's your workup? - You do a CT-yorogram, plus or minus, this isoscopy, and treatment. - Treatment for this is radical nephrectomy. What do you mean when you say radical nephrectomy? - So that is removing the kidney, the fats around the kidney, gerotus fascia, and all the regional notes. - Yeah, and possibly the adrenomal end, if it's involved by the tumor, or if it's immediately adjacent to it. So a third of these patients will have metastectancies at the time of diagnosis, often isolated lung or colon metastasis that can be resected as part of your RZR resection. So what about, we were sometimes about perineal plastic syndromes associated due to renal cell cancer, what are those? - Yeah, there's a few of these, so you can have perineal plastic syndromes with renal, erythopoeidin, which you get erythocytosis, and remember the PTH related protein, which can cause hypercalcemia, ACTH, and insulin. - Okay, great, okay, so let's finish it out with some quikets. Okay, so John, what is the most common cause of acute renal insufficiency after surgery? So hypertension, great, okay. What childhood condition leads to an increased risk of testicular cancer? - So undistended testicles, and I would most likely result in a seminoma. - Excellent, okay. - Sudden onset of severe testicular pain in a teenage boy, what are you concerned about? - I have to be concerned about testicular torsion. - And how does that present? - Present with high-riding testes that is tender and swollen, and you'd have absent to comisteric reflex on that side. - Perfect, okay, and what do we do for these? - So you do emergent detourion and bilateral orchipectae? - Yeah, that's important, don't forget that bilateral orchipectae with that emergent detourion for testicular torsion. That's very commonly tested. But the testicles are viable, of course, you need to resact and then perform an orchipectae of the contralateral testes, but bilateral orchipectae. How do you distinguish torsion from acute epidid amytus? - So these patients with acute epidid amytus will present with fever, pyaria, and attendered cord. You can use ultrasound, be the best to determine the difference between the two. - Yeah, ultrasound is very useful and be able to establish or the flow to that testicle. So how about testicular rupture? How does that appear in ultrasound? - So you have heterogeneous echo patterns of the testes and disruption of the tunicabinibuginia. - Oh, yeah, perfect. - What's the most common tumor of the kidney? - It's metastasis from breast cancer, actually. - Yeah, that's really interesting. Metastasis from breast cancer is the most common tumor of the kidney. Well, how about, where is it most likely for renal cell cancer? Where does that normally metastasize too? - These usually go to the lung and like we said before, renal cell cancers often fall late. So you'd find, a lot of people find lung meds prior to finding the renal cell. - Okay, and like we mentioned before, those isolated meds can be resected as part of a zero-bar, zero-resection. What's the syndrome associated with multiple and recurrent renal cell cancer in addition to renal cysts, CNS tumors, and field chromosome isotomas? - That's your Von hippolindal syndrome. - Okay, Von hippolindal. So renal cell cancer is renal cysts, CNS tumors, field chromosome tone, okay. So with regard to prostate cancer, what's the most common site within the prostate? - It's the posterior lobe in the prostate, okay. Post-earlobe, okay. Most common site for metastasis, a prostate cancer. - That'll be the bone. - Great. So see, have a patient who went to a TURP and now has altered mental status or seizures. What is the concern there? - That's your post-TURP syndrome. It's caused by hyponatremia secondary to irrigation with water during the procedure. - And how do you treat it? Just treat it with sodium correction with diaries. - Okay, perfect. - Okay, so that's it for our Eurality section. Thank you so much for listening. - Thanks for listening and thank you to metronic for supporting surgical residents preparing for the 2026 app site. Since 1949, metronic cancer letnally pursued therapies that changed lives. Today, we thank metronic for supporting surgical residents as they relentlessly pursued their dreams. from all of us behind the knife and metronik dominate the app site.