37.3 Specialty II: Thoracic and Cardiovascular Surgery (Pleural Effusion and Empyema, Lung Cancer, Mediastinal Masses, Surgical Heart Disease, Aortic Aneurysm and Dissection, Peripheral Arterial and Venous Disease), Urology (Stones, Infections, Torsion, BPH, Urologic Tumors) and Gynecologic Surgery

Why this area matters

Pleural TB and parapneumonic empyema, rheumatic heart disease, diabetic peripheral arterial disease and urinary stones are common in the Philippines. The TOS asks for operative indications and emergencies: when to place a chest tube, when an aneurysm or dissection needs surgery, how to save an ischemic limb or a twisted testis, and how to evaluate hematuria.

Pleural effusion and empyema

• Light criteria: an effusion is an exudate if any one is met:
  • pleural fluid protein divided by serum protein is more than 0.5;
  • pleural LDH divided by serum LDH is more than 0.6;
  • pleural LDH is more than two-thirds of the upper normal serum LDH.
• Transudates: heart failure, cirrhosis, nephrotic syndrome.
• Exudates: pneumonia, tuberculosis (lymphocytic, high adenosine deaminase), cancer, pulmonary embolism.
• Parapneumonic effusion and empyema:
  • chest tube drainage is needed if the fluid is frank pus, Gram stain or culture is positive, pH is below 7.2, glucose is low, or the effusion is large or loculated;
  • intrapleural fibrinolytic and DNase therapy helps loculated collections;
  • VATS or open decortication for organized empyema or a trapped lung.
• Malignant effusion: drainage with pleurodesis (talc) or an indwelling pleural catheter.
• Hemothorax: a chest tube; thoracotomy for an initial drainage of 1500 mL or ongoing 200 mL per hour for 2 to 4 hours.
• Spontaneous pneumothorax:
  • primary: tall thin young smokers (apical blebs);
  • secondary: COPD and TB;
  • treated by observation, aspiration or chest drain;
  • surgery (VATS bullectomy and pleurodesis) for recurrence or persistent air leak.

Lung cancer and mediastinal masses

• Solitary pulmonary nodule:
  • managed by size and risk (Fleischner criteria);
  • calcified patterns (central, laminated, popcorn) and stability over 2 years suggest benign disease;
  • TB granulomas are common benign causes in the Philippines.
• Lung cancer surgery:
  • non-small cell lung cancer stages I to II (and selected IIIA) are treated by lobectomy with mediastinal lymph node sampling;
  • operability requires adequate lung function (FEV1 and DLCO) and the absence of N3 or M1 disease;
  • mediastinal staging uses PET-CT and EBUS or mediastinoscopy;
  • small cell lung cancer is treated with chemotherapy and radiotherapy, rarely surgery;
  • a Pancoast tumor causes Horner syndrome and shoulder and arm pain.
• Mediastinal masses by compartment:
  • anterior: the 4 Ts: thymoma (associated with myasthenia gravis), teratoma and other germ cell tumors (check AFP and beta-hCG), retrosternal thyroid goiter and "terrible" lymphoma;
  • middle: lymphadenopathy, bronchogenic and pericardial cysts;
  • posterior: neurogenic tumors (schwannoma, neuroblastoma in children).
  • Large anterior masses can cause airway collapse during general anesthesia.

Surgical heart disease

• Congenital heart disease:
  • PDA is closed with indomethacin or ibuprofen in preterm infants, or by device or ligation;
  • ASD and VSD are closed by device or patch when they cause significant shunting;
  • coarctation is repaired by resection or balloon or stent;
  • tetralogy of Fallot gets complete repair in infancy (a Blalock-Taussig shunt is a palliative bridge);
  • transposition of the great arteries needs the arterial switch in the first weeks, with prostaglandin E1 and balloon septostomy first;
  • Eisenmenger syndrome (reversed shunt) makes defect closure contraindicated.
• Acquired heart disease:
  • coronary artery bypass grafting for left main disease, three-vessel disease (especially with diabetes or reduced ejection fraction);
  • valve surgery: rheumatic mitral stenosis is treated by balloon mitral valvotomy when the valve is suitable, otherwise valve replacement; valve replacement or repair for severe symptomatic aortic stenosis (surgical or TAVI), severe regurgitation and endocarditis complications;
  • mechanical valves need lifelong warfarin; bioprosthetic valves degenerate over 10 to 20 years.
• Pericardial tamponade: Beck triad (hypotension, distended neck veins, muffled heart sounds) with pulsus paradoxus. Treat by pericardiocentesis, or a pericardial window or surgery after trauma.

Aortic and peripheral vascular disease

• Abdominal aortic aneurysm:
  • risk factors are smoking, male sex, age and family history;
  • screened with a one-time ultrasound in men aged 65 to 75 who ever smoked;
  • elective repair (open or endovascular, EVAR) at 5.5 cm or more in men (5.0 cm in women), growth over 1 cm a year, or symptoms;
  • rupture: sudden abdominal or back pain, hypotension and a pulsatile mass. Unstable patients go directly to the operating room with permissive hypotension; imaging is only for stable patients.
• Aortic dissection:
  • tearing chest pain radiating to the back, a pulse or BP difference between arms, and a widened mediastinum;
  • linked to hypertension, Marfan syndrome and bicuspid aortic valve;
  • diagnosed by CT angiography (or TEE if unstable);
  • Stanford type A (ascending aorta) needs emergency surgery;
  • Stanford type B (descending only) is treated with IV beta-blockers (heart rate below 60 and systolic BP about 100 to 120), with endovascular repair if complicated (rupture, malperfusion);
  • thrombolysis is contraindicated.
• Peripheral arterial disease:
  • intermittent claudication is managed with smoking cessation, supervised exercise, antiplatelet therapy and statins;
  • chronic limb-threatening ischemia (rest pain, ulcers, gangrene) needs revascularization;
  • the ankle-brachial index is below 0.9 in PAD, and falsely high in diabetic calcified vessels.
• Acute limb ischemia:
  • the 6 Ps: pain, pallor, pulselessness, poikilothermia, paresthesia, paralysis;
  • causes are embolism (atrial fibrillation) and thrombosis on existing disease;
  • give IV heparin immediately, then embolectomy, bypass or catheter-directed thrombolysis;
  • paralysis and sensory loss mean a threatened limb needing urgent revascularization;
  • after reperfusion, watch for compartment syndrome and hyperkalemia.
• Diabetic foot: wet gangrene and abscesses need urgent debridement or amputation; dry gangrene with ischemia needs revascularization assessment.
• Venous disease:
  • varicose veins (saphenous reflux) are treated by compression, endovenous ablation or surgery;
  • venous ulcers occur at the medial malleolus (gaiter area), treated with compression after checking the ABI;
  • deep vein thrombosis prophylaxis and treatment are covered in the perioperative section.

Urological Surgery: Stones, Torsion & Prostatic Disease

Nephrolithiasis (Renal Calculi)

Renal colic presents as sudden, excruciating flank pain radiating around the flank to the groin, scrotum, or labia, accompanied by microscopic or gross hematuria.

• Diagnostic Modality of Choice: Non-contrast helical CT scan of the abdomen and pelvis (identifies $> 99\%$ of stones, size, and exact location).
• Stone Types:
  • Calcium Oxalate ($70-80\%$): Radiopaque on X-ray; envelope- or dumbbell-shaped crystals. Associated with hypercalciuria, hyperoxaluria, and ethylene glycol ingestion.
  • Calcium Phosphate ($5-10\%$): Radiopaque; wedge-shaped crystals; associated with renal tubular acidosis (RTA Type 1) and alkaline urine.
  • Struvite ($10-15\%$): Radiopaque "Staghorn Calculi" filling the renal pelvis and calyces. Composed of magnesium ammonium phosphate; caused by urease-producing organisms (Proteus mirabilis, Klebsiella) which hydrolyze urea into ammonia, creating alkaline urine ($\text{pH} > 7.5$).
  • Uric Acid ($5-10\%$): Radiolucent on plain KUB radiographs (invisible), visible on non-contrast CT; rhomboid or needle-shaped crystals in acidic urine ($\text{pH} < 5.5$). Treatment: Urinary alkalinization with oral potassium citrate (target $\text{pH} \ge 6.5$).
  • Cystine ($1\%$): Faintly radiopaque; hexagonal crystals; inborn error of dibasic amino acid transporter.
• Management Guidelines: Stones $< 5\text{ mm}$ pass spontaneously in $> 80\%$ with hydration, analgesia, and alpha-1 blockers (Tamsulosin). Stones $5-10\text{ mm}$ can undergo medical expulsive therapy or Shock Wave Lithotripsy (SWL). Stones $> 20\text{ mm}$ or staghorn calculi require Percutaneous Nephrolithotomy (PCNL).
• Urologic Emergency: An infected, obstructing ureteral calculus (hydronephrosis with concurrent fever, sepsis, or pyuria) requires emergent decompression via retrograde ureteral double-J stent placement or percutaneous nephrostomy. Lithotripsy is strictly contraindicated in active infection.

Testicular Torsion versus Acute Epididymitis

Prostatic Pathology: BPH versus Adenocarcinoma

• Benign Prostatic Hyperplasia (BPH): Hyperplasia of stromal and epithelial cells localized to the transition zone (periurethral). Produces Lower Urinary Tract Symptoms (LUTS: urinary frequency, nocturia, hesitancy, weak stream, post-void dribbling). Digital Rectal Examination (DRE) reveals a smooth, symmetrically enlarged, elastic, non-tender prostate. Treatment: $\alpha_1$-adrenergic antagonists (Tamsulosin; rapid symptom relief by relaxing prostatic smooth muscle) and $5\alpha$-reductase inhibitors (Finasteride, Dutasteride; reduces prostate volume over 6 months by blocking conversion of testosterone to dihydrotestosterone). Transurethral Resection of the Prostate (TURP) is indicated for refractory urinary retention or recurrent UTIs.
• Prostate Adenocarcinoma: Malignant proliferation arising predominantly in the peripheral zone (posterior lobe). Asymptomatic early; DRE reveals a hard, nodular, asymmetrical, irregular gland. Evaluated via serum Prostate-Specific Antigen (PSA) and transrectal ultrasound (TRUS) or MRI-guided needle biopsy; graded using the Gleason scoring system.

More urology

• Urologic infections:
  • acute pyelonephritis with obstruction is drained (see stones above);
  • emphysematous pyelonephritis in diabetics needs drainage or nephrectomy;
  • acute bacterial prostatitis causes fever, perineal pain and a tender boggy prostate (avoid vigorous massage);
  • Fournier gangrene needs emergency debridement.
• Acute urinary retention (often BPH, anticholinergics or alpha-agonist cold remedies): urethral catheterization (suprapubic if urethral passage fails or is contraindicated), then an alpha-blocker and a trial without catheter.
• Hematuria:
  • painless gross hematuria in an adult is bladder cancer until proven otherwise, especially in smokers;
  • evaluate with cystoscopy and CT urography.
• Urologic tumors:
  • renal cell carcinoma: often incidental, with the classic triad of hematuria, flank pain and mass, and paraneoplastic polycythemia, hypercalcemia and hypertension; treated by partial or radical nephrectomy;
  • bladder urothelial carcinoma: transurethral resection (TURBT) and intravesical BCG for non-muscle-invasive tumors, and radical cystectomy or chemoradiation for muscle-invasive tumors;
  • prostate cancer: active surveillance for low risk, radical prostatectomy or radiotherapy for localized disease, and androgen deprivation for advanced disease (bone metastases are osteoblastic);
  • testicular cancer: a painless firm testicular mass in a young man; ultrasound and AFP, beta-hCG and LDH; treated by radical inguinal orchiectomy (never a scrotal biopsy or incision). Seminomas are radiosensitive with normal AFP. Cryptorchidism increases the risk.
• Other scrotal conditions: hydrocele (transilluminates; check for an underlying tumor in adults), varicocele (left-sided, "bag of worms"; a new right-sided or non-reducing one suggests a retroperitoneal mass), and undescended testis (orchiopexy by about 6 to 18 months).
• Phimosis and paraphimosis: paraphimosis is an emergency, managed by manual reduction or a dorsal slit.
• Urethral injury: blood at the meatus after pelvic fracture means no urethral catheter until a retrograde urethrogram is done.

Gynecologic surgery

• Abnormal uterine bleeding:
  • use the PALM-COEIN classification;
  • always exclude pregnancy;
  • endometrial sampling for women aged 45 or more, or younger women with risk factors (obesity, PCOS, unopposed estrogen) or failed treatment;
  • postmenopausal bleeding needs transvaginal ultrasound and/or endometrial biopsy to exclude endometrial cancer;
  • acute heavy bleeding: stabilize, then IV estrogen, tranexamic acid or tamponade, with dilation and curettage or hysterectomy for failure.
• Uterine fibroids (leiomyoma): treated medically, by myomectomy (to preserve fertility), uterine artery embolization or hysterectomy.
• Endometrial cancer:
  • risk factors are unopposed estrogen, obesity, diabetes, nulliparity, PCOS, tamoxifen and Lynch syndrome;
  • presents with postmenopausal bleeding;
  • treated by total hysterectomy with bilateral salpingo-oophorectomy and surgical staging.
• Ovarian cancer:
  • often diagnosed late with bloating, early satiety and ascites;
  • suspected from complex adnexal masses, CA-125 in postmenopausal women and RMI scoring;
  • epithelial cancer is treated by surgical staging and maximal cytoreductive (debulking) surgery with platinum-taxane chemotherapy;
  • germ cell tumors (dysgerminoma, yolk sac tumor) affect young women and can be managed by fertility-sparing surgery.
• Adnexal emergencies: ovarian torsion needs urgent laparoscopy with detorsion, preserving the ovary. A ruptured ectopic pregnancy with shock needs immediate surgery.
• Cervical cancer screening and staging are covered in the gynecology chapter.