Absite: Urology – Flashcards
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anatomy and physiology: fascia around kidney
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Gerota's
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anatomy and physiology: anterior to posterior
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renal vein, artery, pelvis (VAP)
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anatomy and physiology: R anterior artery course
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crosses posterior to the IVC
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anatomy and physiology: ureters course
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cross over the iliac vessels
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anatomy and physiology: L vs R renal vein collaterals
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L renal - can be ligated from IVC 2/2 increased collaterals (L adrenal vein, L gonadal vein, L ascending lumbar vein) .... R renal - lacks collaterals
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anatomy and physiology: L renal vein course
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anterior to aorta
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anatomy and physiology: epididymis connects to what?
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vas deferens
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MC cause of acute renal insufficiency after surgery
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hypotension
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kidney stones: sx
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severe colicky pain, restlessness
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kidney stones: UA
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blood or stones
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kidney stones: abd CT findings
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can see stones and associated hydronephrosis
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kidney stones: list types
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Ca oxalate, struvite, uric acid, cysteine
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kidney stones: MC type
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Ca oxalate
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kidney stones: occur with urease producing infections (i.e. proteus mirabilis)
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struvite (cause staghorn calculi that fill renal pelvis)
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kidney stones: inc in pts with ileostomies, gout, myeloproliferative d/o
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uric acid
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kidney stones: assoc with congential d/o
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cysteine stones (congentinal d/o of cysteine reabsorption, i.e. cystinuria)
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kidney stones: radiopaque vs radiolucent
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radiopaque = struvite, 75% of Ca oxalate, .... radiolucent = uric acid, cysteine
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kidney stones: Ca oxalate
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MC type (75%), radiopaque, inc in pts with terminal ileum resection 2/2 inc oxalate absorption in colon
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kidney stones: struvite stones
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magnesium ammonium phosphate, radiopaque, occur with urease-producing infections (i.e. proteus mirabilis), cause stghorn calculi which fill renal pelvis
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kidney stones: uric acid stones
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radiolucent, inc in pts w ileostomies, gout, myeloproliferative disorders
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kidney stones: cysteine stones
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radiolucent, assoc w congenital sdisorders in the reabsorption of cysteine (cystinuria)
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kidney stones: surgical indications
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intractable pain or infection, progressive obstruction, progressive renal damage, solitary kidney
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kidney stones: % opaque
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90%
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kidney stones: size cut off
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>6mm not likely to pass
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kidney stones: tx
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ESWL (extra-corporeal shock wave lithrotripsy), other options - ureteroscopy with stone extraction or placement of stent past obstruction, perc nephrostomy tube, open nephrolithotomy
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#1 cancer killer in M 25-35
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testicular cancer
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testicular cancer: sx
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painless hard mass
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testicular cancer: mgmt. of testicular mass
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pt needs orchiectomy through an inguinal incision (NOT a trans-scrotal incision ---> do NOT want to disrupt lymphatics) ... the testicle and attached mass constitute the bx specimen
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testicular cancer: malignancy
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most testicular masses are malignant
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testicular cancer: dx
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U/S helps
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testicular cancer: imaging
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need CT chest/abd to check for retroperitoneal and chest mets
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testicular cancer: labs
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LDH (correlates with tumor bulk), b-HCG, AFP
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testicular cancer: MC types
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09% are germ cell (seminoma or nonseminoma)
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testicular cancer: inc risk of testicular cancer
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undescended testicles (cryptorchidism), most likely to get seminoma
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testicular cancer: #1 testicular tumor
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seminoma
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testicular cancer: seminoma - b-hcg, AFP elevation
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b-hcg increase seen in 10% of seminomatous tumors .... if AFP increase then it's likely NOT seminoma (treat like non-seminomatous)
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testicular cancer: seminoma - XRT role
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seminoma is very sensitive to XRT
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testicular cancer: seminoma - tx
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all stages get orchiectomy and retroperitoneal XRT ... chemo reserve for metastatic disease or bulky retroperitoneal disease (cisplatin, bleomycin, VP-16) .... surgical resection of residual disease
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testicular cancer: nonseminomatous testicular CA - types
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embryonal, teratoma, choriocarcinoma, yolk sac
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testicular cancer: nonseminomatous testicular CA - AFP and b-HCG
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90% have these markers
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testicular cancer: nonseminomatous testicular CA - mets
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(classical teaching) tumors with inc teratoma components aremore likely to met to the retroperitoneum
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testicular cancer: nonseminomatous testicular CA - tx
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all stages get orchiectomy and retroperitoneal XRT ... stage 2 or greater get chemo (cisplatin, bleomycin, VP-16) ... surgical resection of residual disease
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testicular cancer: seminoma vs nonseminoma - which is more common?
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seminoma
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testicular cancer: seminoma vs nonseminoma - XRT
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seminoma very sensitive
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testicular cancer: seminoma vs nonseminoma - b-HCG, AFP
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seminoma - 10% with inc b-hcg, should NOT have inc AFP .... non seminoma - 90% have inc in these markers
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testicular cancer: seminoma vs nonseminoma - tx
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BOTH = all stages get orchiectomy and retroperitoneal XRT ... chemo (cisplatin, bleomycin, VP-16): SEM = mets or bulky retroperitoneal disease, NON-SEM = stage 2 or greater ... BOTH = surgical resection of residual disease
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prostate cancer: MC site
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posterior lobe
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prostate cancer: mets - MC site, appearance
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bone ... xray shows hyperdense areas (osteoblastic)
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prostate cancer: complications after resection
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impotence, incontinence, urethral stricutres
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prostate cancer: dx
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transrectal bx, chest/abd/pelvis CT, PSA, alk phos, possible bone scan
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prostate cancer: mgmt. of intracapsular tumors with no mets (T1 and T2)
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XRT .... OR ... radical prostatectomy with l=pelvic lymph node dissection (if life span >10 year) ... OR ... nothing (depending on age and health)
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prostate cancer: mgmt of extracapsular invasion or met disease - tx
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XRT and androgen ablation ( i.e. leuprolide (LH-RH blocker), flutamide (testosterone blocker), or b/l orchiectomy)
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prostate cancer: mgmt. of stage 1a disease found with TURP
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nothing
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prostate cancer: when should PSA decrease after prostatectomy? further workup?
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should go to 0 after 3 weeks ---> if not, get bone scan to check for mets
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prostate cancer: normal PSA
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<4 in pt who has a prostate gland
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prostate cancer: conditions that can inc PSA
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(normal <4 in pts w prostate gland) ... prostatitis, BPH, chronic catheterization
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prostate cancer: inc alk phos in the setting of prostate CA
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concern for bone mets or extracapsular disease
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#1 overall vs primary tumor in kidney
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mets from breast cancer, renal cell carcinoma
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renal cell carcinoma: aka
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RCC, hypernephroma
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renal cell carcinoma / RCC / hypernephroma: risk factor
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smoking
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renal cell carcinoma / RCC / hypernephroma: px
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abd pain, mass, hematuria
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renal cell carcinoma / RCC / hypernephroma: mets rate and mgmt
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1/3 w met disease at the time of dx, can do wedge resection of isolated lung or colon mets
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renal cell carcinoma / RCC / hypernephroma: MC site for mets
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lung
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renal cell carcinoma / RCC / hypernephroma: erythrocytosis
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can be 2/2 inc erythropoietin (HTN)
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renal cell carcinoma / RCC / hypernephroma: tx
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radical nephrectomy with regional nodes, XRT, chemo
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renal cell carcinoma / RCC / hypernephroma: describe radical nephrectomy
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take kidney, adrenal fat, Gerota's fascia, regional nodes
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renal cell carcinoma / RCC / hypernephroma: invasion
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growth into IVC common, can still resect evern if growing up IVC (pull tumor thrombus out of IVC)
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renal cell carcinoma / RCC / hypernephroma: when to consider partial nephrectomy
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patients who would require dialysis after nephrectomy
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renal cell carcinoma / RCC / hypernephroma: paraneoplastic syndromes
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erythropoietin, PTHrp, ACTH, insulin
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tx of transitional cell CA of renal pelvis
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radial nephroureterectomy
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oncocytomas: malignancy
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benign
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describe angiomyolipomas
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hamartomas, can occur with tuberous sclerosis, benign
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VHL syndrome
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multifocal and recurrent RCC, renal custs, CNS tumors, pheochromocytomas
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bladder cancer: MC type
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transitional cell CA
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bladder cancer: px
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painless hematuria
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bladder cancer: MC gender
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M
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bladder cancer: prognosis based on what?
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stage and grade
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bladder cancer: risk factors
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smoking, aniline dyes, cyclophosphamide
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bladder cancer: dx
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cystoscopy
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bladder cancer: tx
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if muscle not involved (T1) ---> intravesical BCG or transuretheral resection ... if muscle wall invaded (T2 or greater) --> cystectomy with ileal conduit, chemo (MVAC = MTX, vinblastine, Adriamycin aka doxorubicin, cisplatin), XRT ... met disease ---> chemo
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bladder cancer: reconstruction
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ileal conduit is standard reconstruction option, avoid stasis b/c predisposes to infection, stones (Ca resorption), and ureteral reflux .... or reservoir or neobladder
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bladder cancer: squamous cell Ca of bladder assoc with what
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schistosomiasis infection
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testicular torsion: peak age
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15yo
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testicular torsion: location
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usually in midline
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testicular torsion: tx
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b/l orchiopexy, if testicle not viable, resection and orchiopexy of contralateral testis
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ureteral trauma: mgmt. consideration
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if going to repair end to end then - apatulate ends, use absorbable suture to avoid stone formation, stent the ureter to avoid stenosis, place drains to ID and potentially help treat leaks ... acoid stripping the soft tissue on the urether b/c is can compromise blood supply
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benign prostatic hypertrophy (BPH): arises from what?
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transitional zone
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benign prostatic hypertrophy (BPH): sx
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nocturia, frequency, dysuria, weak stream, urinary retention
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benign prostatic hypertrophy (BPH): initial therapy
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alpha blockers (terazosin, doxazosin) relax smooth muscle ... 5-alpha reductase inhibitors (finasteride) inhibits the conversion of testosterone to dihydrotestosterone ---> inhibits prostate hypertrophy
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benign prostatic hypertrophy (BPH): surgery - approach and indications
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TURP = trans-urethral resection of prostate ... recurrent UTIs, gross hematuria, stones, renal insufficiency, failure of medical therapy
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benign prostatic hypertrophy (BPH): post-TURP syndrome
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hypoNa 2/2 irrigation with water, can precipitate seizures from cerebral edema ---> tx w careful correction of Na with diuresis
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benign prostatic hypertrophy (BPH): TURP complication
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most pts have retrograde ejaculation, post-TURP syndrome = hypoNa
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cause of neurogenic bladder vs neurogenic obstructive uropathy
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above vs below T-12
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neurogenic bladder: pathophys, MC cause, px, tx
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nerve injury above T-12, MC 2/2 spinal compression, pt urinates all the time, tx = surgery to improve bladder resistance
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neurogenic obstructive uropathy: pathophys, cause, px, tx
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nerve injury below T-12, can occur w APR, p/w incomplete emptying, tx w intermittent catheterization
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incontinence: types
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stress (i.e. cough, sneeze), overflow
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incontinence: stress - pathophys, MC pts, tx
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hypermobile urethra or loss of sphincter mechanism, F, tx = Kegels, alpha-adrenergic agents, surgery for urethral suspension or pubovaginal sling
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incontinence: overflow - pathophys, MC pts, tx
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incompete emptying of an enlarged bladder, obstruction (BPH) leads to the distention and leakage, tx w TURP
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tx ureteropelvic obstruction
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pyeloplasty
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tx vesicoureteral reflux
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reimplantation with long bladder portion
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MC urinary tract abnormality
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ureteral duplication
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ureteral duplication
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MC urinary tract abnormality, tx w reimplantation if obstruction occurs
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ureterocele tx
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resect and reimplant if symptomatic
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hypospadias vs epispadias - describe, tx
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hypo = ventral urethral opening, tx - repair at 6mo w penile skin .... epi = dorsal opening, tx - surgery
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horseshoe kidney - describe, complications, tx
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usually joined at lower poles .... complications = UTI, urolithiasis, hydronephrosis ... tx - may need pyeloplasty
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mgmt. of polycystic kidney disease
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resect only if sx
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failure of closure of urachus - describe, tx
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connection between umbilicus and bladder, occurs in pts w bladder outlet obstructive disease (wet umbilicus), tx - resection of sinus/cyst and closure of bladder, relieve bladder outlet obstruction
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epididymitis
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sterile epididymitis can occur from increase abd straining
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varicocele
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worrisome for renal cell CA (L gonadal vein inserts into L renal vein, obstruction by renal tumor causes varicocele), can also be 2/2 another retroperitoneal malignancy
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spermatocele
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fluid-filled cystic structure separate from and superior to the testis along the epididymis, tx = surgical removal if sx
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hydrocele in adults
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translucent ... if acute, suspect tumor elsewhere (i.e. pelvic, abd)
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pneumaturia - MC cause, dx
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MC cause is diverticulitis w subsequent formation of colovesical fistula ... dx w cystoscopy
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WBC casts vs RBC casts
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WBC casts 2/2 pyelonephritis, glomerulonephritis ... RBC casts 2/2 glomerulonephritis
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interstitial nephritis - px
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fever, rash, arthralgias, eosinophils
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pregnancy rate after repair of vasectomy
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50%
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priapism: tx
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aspiration of the corpus covernosum with dilute epi or phenylephrine ... may need to create a communication through the glans with a scalpel
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priapism: risk factors
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sickle-cell anemia, hypercoagulable states, trauma, intracorporeal injections for impotence
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mgmt. of SCC of penis
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penectomy with 2cm margin
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how to check for urine leak
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use indigo carmine or methylene blue
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tx of phimosis found at time of laparotomy
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dorsal slit .... phimosis = the foreskin of the penis cannot be pulled back past the glans. A balloon-like swelling under the foreskin may occur with urination. In teenagers and adults, it may result in pain during an erection, but is otherwise not painful. Those affected are at greater risk of inflammation of the glans, known as balanitis, and other complications. In young children, it is normal to not be able to pull back the foreskin. In more than 90% of cases, this inability resolves by the age of seven, and in 99% of cases by age 16. Occasionally, phimosis may be caused by an underlying condition such as scarring due to balanitis or balanitis xerotica obliterans. This can typically be diagnosed by seeing scarring of the opening of the foreskin. Typically, it resolves without treatment by the age of three. Efforts to pull back the foreskin during the early years of a boy's life should not be attempted. For those in whom the condition does not improve further time can be given or a steroid cream may be used to attempt to loosen the tight skin. If this method, combined with stretching exercises, is not effective then other treatments such as circumcision may be recommended. A potential complication of phimosis is paraphimosis, where the tight foreskin becomes trapped behind the glans. The word is from the Greek phimos, meaning "muzzle
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erythropoietin production in renal failure pts
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decreased
