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1770 Cards in this Set
- Front
- Back
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What separates the prostate posteriorly from the rectum?
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2 layers of Denonvilliers' fascia
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What is Denonvilliers' fascia remnants of?
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Serosal rudiments of pouch of Douglas
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What is the bloodless plane demarcated by the posterior segment of the renal artery?
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Brodel's line
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What forms the ejaculatory ducts and where do these enter the urethra?
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Seminal vesicles and vas deferens --> veru montanum in the prostatic urethra
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What are the layers of the penis (from outside in)?
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Skin, Colles' Fascia, Buck's Fascia, Tunica albuginea (around the corpora cavernosa)
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Lowsley Classification of prostate anatomy
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5 lobes: anterior, posterior, median, right lateral and left lateral
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McNeal Classification of prostate anatomy
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Peripheral zone, central zone, transitional zone, anterior segment, and preprostatic sphincteric zone
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Which glands lie just beneath the transitional epithelium of prostatic urethra?
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Periurethral glands
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Arterial supply to the prostate
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Inferior vesical arteries, middle rectal arteries, internal pudendal
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What is the main chain of lymph nodes into which the prostate empties?
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Obturator nodes
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What does the spermatic cord contain?
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1. Vas deferens
2. Genital branch of the genitofemoral nerve 3. Pampiniform plexus 4. Artery of the vas 5. Internal and external spermatic arteries 6. Lymph vessels 7. A few fibers of the cremaster muscle |
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What fasical layer separates the testis from the scrotal wall?
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Parietal tunica vaginalis
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2 types of cells in the seminiferous tubules?
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Supporting (Sertoli) cells and spermatogenic cells
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Blood supply to the testes is closely associated with blood supply to what other organ?
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kidneys b/o common embryologic origin
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What structure encloses the urethra in the male?
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Corpus spongiosum
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Each corpus cavernosum is surrounded by ____ which is then enclosed by ____
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1. Tunica albuginea
2. Buck's fascia |
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From where does the suspensory ligament of the penis arise?
Where does it insert? |
1. Arises from Linea alba & Pubic symphysis
2. Inserts into fascial covering of corpora cavernosa |
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What glands are located in the submucosa of the male urethra?
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Glands of Littre
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Arterial supply of penis and urethra?
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Internal pudendal artery (dividing into deep artery of the penis (supplies CC), dorsal artery of penis,and bulbourethral artery)
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Where do the superficial dorsal vein and deep dorsal vein lie in relation to Buck's fascia?
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Superficial lies external; deep lies beneath
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What are the names of the periurethral glands, opening on the floor of the female urethra just inside the meatus?
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Glands of Skene
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Four different phases in kidney CT and timing
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1. Angiographic phase (15-40s after contrast injection)
2. Cortical phase (25-80s) (greatest corticomedullary contrast at this time) 3. Nephrogenic phase- (90-120s) (entire renal parenchyma homogeneous) 4. Excretory or urographic phase (3-5min) |
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Stone protocol consists of...
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Non-contrast spiral CT
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Why no contrast for stone protocol?
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It leads to difficulties in defining bowel diverticula and distinguishing appendix from calculi
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Protocol for evaluating renal masses...
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CT without, then with IV contrast
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If a renal mass is indeed detected after CT, what is the next radiographic study to be ordered?
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Chest CT
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What is the protocol for evaluating renal infection?
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CT without contrast (if questions still remain, use IV contrast next)
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Name the 9 steps in an IV urogram (IVU) - aka IVP or excretory urogram
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1. Scout abdomen & tomogram (KUB to check for excess bowel gas and other benign objects)
2. Inject contrast IV bolus 3. Tomograms at consecutive levels through middle of kidney at 1, 2, and 3 min after injection 4. 5-minute abdominal radiograph 5. Placement of abdominal compression 6. 10-minute coned views of the kidney, AP and both 30 degree posterior obliques 7. Abdominal film after compression device released ("release film") 8. AP and oblique views of the bladder 9. Postvoid AP bladder |
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Why is a compression device used in an IVU?
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It causes partial obstruction of the ureters, to improve visualization of intrarenal collecting system and ureters
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When during an IVU is the best time to visualize the ureters?
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At the release film
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Current indications for IVU include:
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1. Evaluation of calyces and ureters
2. Detailed eval of calyces, UPJ, and UVJ |
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In Peyronie's disease, where is the most common location of the fibrotic scar?
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Within the tunica albuginea of corpora cavernosa- dorsal aspect
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At what age should DREs begin to be performed?
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40yo (or any male presenting for urologic evaluation)
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What is suggested by the presence of a soft, cystic mass palpable in the midline near the base of the prostate?
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Presence of a mullerian duct cysts or enlarged utricle (remants of the female mullerian system)
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An enlarged utricle is occasionally seen in patients with what other congenital abnormality?
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Proximal hypospadias
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What physical exam maneuvers should be attempted with a varicocele?
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1. Valsalva (should increase the size)
2. Supine (should reduce) |
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On what side is a varicocele usually detected?
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Left
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One French = __ mm
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0.33
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How is rigid cystoscopes better than flexible?
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Rigid provide a greater field of vision and allows more therapeutic options
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Normal pH of urine is between
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5 and 8
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What is the normal value of creatinine clearance?
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90-110 mL/min
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What abnormality may be seen on CBC in patients with renal insufficiency and why?
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Anemia b/o decreased production of EPO
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3 main risks of IV contrast material?
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1. Allergic reaction
2. Renal toxicity 3. Local tissue reaction (if IV needle infiltrates at time of injection) |
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How should a patient be prepared for urography?
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Administer clear liquids beginning the evening before the study and NPO 6h before study
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What drug should NOT be given when a diabetic is given IV contrast?
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Metformin (stop 24h before and wait 24h after to restart)
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5 steps in usual film sequence for urography?
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1. Plain film (KUB)
2. 1 minute (visualizes renal parenchyma) 3. 5 minutes (early visualization of upper collecting system) 4. Tomograms (renal outlines) 5. 15/20 minutes (late visualization for lower ureters and bladder) |
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IVU showing a tear-drop shaped bladder suggests...
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Pelvic lipomatosis
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IVU showing a Christmas-tree shaped bladder suggests...
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Neurogenic bladder
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3 indications for renal venography
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1. Evaluate tumor thrombus (RCC)
2. Definitive eval of renal vein thrombosis 3. Renal vein renin determination in renovascular HTN |
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2 main indications for angiographic renal embolization
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1. RCC (to facilitate operative management of large tumors with venal caval thrombi)
2. Control hemorrhage from perc bx, AVM, or primary/met tumor |
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How does a renal cyst appear on ultrasound?
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Homogeneously hypoechoic with very thin walls
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Who is most often associated with ureteroceles?
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Girls with duplicated collecting systems who present with UTIs
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What does a ureterocele appear as on U/S? What is the name of this?
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A thin but clearlyl defined membrane (called Chawala's membrane)
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How can one use U/S to confirm varicocele?
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Use doppler while patient performs valsalva (and it will demonstrate retrograde flow into the testicle)
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What is the typical TRUS findings for CaP?
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Hypoechoic area within peripheral zone
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What is the PSAD and how is it used?
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It is the PSA density (serum PSA divided by the prostate volume measured by TRUS). A value >= 0.15, suggests CaP
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What is a Hounsfield unit of -1000, 0 and +1000
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-1000 is lung (air)
0 is soft tissue +1000 is bone |
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What are the 3 most important contributions of CT to urology?
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1. Assessment of renal masses
2. Renal trauma evaluation 3. Nephrolithiasis |
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What is T1 MRI best for?
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Defining anatomy
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What is T2 MRI best for?
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Demonstrating pathology (e.g. differentiating renal cysts from solid tumors)
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How will a renal cyst and tumor appear differently on a T2 MRI?
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The cyst will be very bright (tumor only somewhat bright)
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What are the 3 radiopharmaceuticals based on technetium 99 and how are each handled by the kidney?
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1. Tc99-DTPA (80% glomerular filtration, 20% tubular secretion)
2. Tc99- MAG3 (90% tubular secretion)- so high rate of extraction 3. Tc99-glucoheptonate (combo filtration and secretion) |
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On a renogram, what is the normal time delay between peak aortic flow and renal flow?
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<6 seconds
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3 phases of a renogram?
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1. Renal blood flow
2. Parenchymal function 3. Excretion |
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On a renogram, what is the normal time that peak uptake should occur in renal parenchyma?
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Within 5 minutes after injection
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A normal DTPA renogram will demonstrate 50% emptying of nuclide from the kidney within how much time?
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20 minutes
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How may scintigraphy be used to diagnose AIN?
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Gallium 67 is useful and will show uptake persisting greater than the normal 72 hours
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Name 3 agents used to image infectious or inflammatory processes within the kidney.
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1. WBC labeled with In111
2. Gallium 67 3. Tc99-DMSA |
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What is a lasix renal scan used for?
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Differentiating between obstructive and nonobstructive hydronephrosis
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What is a "normal" lasix scan?
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50% emptying of the kidney and pelvis within 20 minutes after injection
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How is radionuclide cystography helpful for VUR?
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A VCUG should be the initial test but subsequent tests should be used with RNC b/c it has 1/1000 of the radiation exposure as VCUG
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What nerves innervate the penis and are responsible for tumescence and detumescence?
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Cavernous nerves
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What structures do the cavernous nerves innervate that are most responsible for erections?
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1. Helicine arteries
2. Trabecular smooth muscle |
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What are the 3 main types of erections?
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1. Genital-stimulated (contact or reflexogenic)
2. Central-stimulated (noncontact or psychogenic) 3. Central-originated (nocturnal) |
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At what stage of sleep do nocturnal erections occur?
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REM
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Why do nocturnal erections occur during REM?
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Cholinergic neurons in lateral pontine tegmentum are activated while the serotonergic neurons in the midbrain raphe are silent.
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What is the main arterial supply to the penis- and what are its 3 branches?
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Internal pudendal arteries:
1. Cavernous artery 2. Dorsal artery 3. Bulbourethral artery |
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What does the cavernous artery supply?
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Corpora cavernosa
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What does the dorsal artery of the penis supply?
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The skin, subcutaneous tissue and glans penis
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What does the bulbourethral artery supply?
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Corpus spongiosum
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Describe the mechanics of an erection.
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1. Activated autonomic nerves produce a full erection via filling and trapping of blood into the cavernous bodies
2. Ischiocavernous muscle then contracts to compress the proximal corpora and raise corpora pressure well above systolic pressure |
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Where do the emissary veins lie in the penis and why is this imortant?
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Directly underneath the tunica albuginea (so that increased arterial pressure will increase blood in the sinusoids and therefore compress the emissary veins between the sinusoids against the tunica)
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Is androgen absolutely necessary for erection?
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No-- it enhances it a lot though
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Do hypogonadal men show a decrease in nocturnal erections?
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YES
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What is the principal neurotransmitter for penile erection and from what nerve terminals does it come from?
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NO from parasympathetic NANC nerve terminals
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Describe the signal transduction which occurs in penile erection.
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1. During sexual stimulation, NO is released from nerve ending
2. NO diffuses into arterial smooth muscle cells and activates cGMP 3. cGMP activates protein kinase G which phosphorylates K and Ca channels resulting in hyperpolarization and SM relaxation 4. cAMP also does a similar thing 5. Phosphodiesterase (mainly type V) then breaks down cGMP and cAMP to GMP and AMP. |
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Name 3 conditions in which peripheral neuropathy may result in ED.
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1. DM
2. Alcohol abuse (chronic) 3. Vitamin deficiency (B12) |
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Name 5 endocrine disorders which may result in decreased libido and ED.
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1. Hyogonadism
2. Hyperthyroidism 3. Hypothyroidism 4. Addison's Disease 5. Cushing syndrome |
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What are the 2 classifications of arterial disease leading to ED?
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1. Extrapenile (amenable to surgical repair)
2. Intrapenile |
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Name 3 causes of intrapenile arterial disease.
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1. Aging
2. Arteriosclerosis 3. DM |
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Name 5 types of cavernous (venous) impotence.
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1. Type 1: large veins exiting cc (congenital)
2. Type 2: venous channels enlarged due to distortion of tunica albuginea (Peyronie's) 3. Type 3: cavernous SM unable to relax b/o fibrosis, degeneration, or dysfunction of gap junctions 4. Type 4: inadequate neurotransmitter release 5. Type 5: abnormal communication b/w cc and spongiosum or glans (trauma, congenital or consequent to shunt procedure for priapism) |
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What are 3 main classes of drugs listed as causes of ED?
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1. Antipsychotics
2. Antidepressants 3. Centrally acting anti-hypertensives |
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With regard to ED, what do alpha-adrenergic antagonists do?
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May cause retrograde ejaculation due to relaxation of the bladder neck
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How do beta-blockers cause ED?
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They potentiate alpha1 adrenergic activity
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What diuretics cause ED?
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Spironolactone and thiazides (mechanism unknown)
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How does alcohol affect ED?
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In small amounts, it improves it and increases libido (b/o vasodilatory effects). In large amounts, it causes central sedation, decreased libido and transient ED
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ED severity is classified into how many categories? What's the name of the self-reporting measure?
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5 (severe, moderate, mild to moderate, mild and no ED)
International Index of Erection Function (IIEF) |
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The average man has how many episodes of NPT per night and how long should each last?
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3-5 per night, each lasting 30-60 minutes
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Name 5 neurologic tests for ED.
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1. Biothesiometry
2. Bulbocavernosus reflex latency 3. Genitocerebral evoked potential 4. Smooth muscle EMG 5. Tests for penile vascular function |
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What is CIS and what does it detect?
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Combined intracavernous injection and stimulation test- it detects vascular status of penis
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What is a normal CIS result?
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A rigid erection lasting for more than 20 minutes (indicates normal venous function)
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What is used to inject in the CIS test?
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1. Alprostadil
2. Phentolamine and papaverine |
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Name 5 methods of evaluating penile vascular function.
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1. CIS
2. Duplex US 3. Cavernous arterial occlusion pressure 4. Cavernosometry and cavernosography 5. Arteriography |
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What are two lifestyle changes that may be attempted with ED?
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1. Better diet & exercise
2. No long-term bicycling or sitting |
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What antidepressants are preferred for those with ED?
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Trazodone & buproprion
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What is the most common laboratory abnormality in men being treated with testosterone?
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Erythrocytosis
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What surveillance labs should be ordered for a patient on testosterone therapy?
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1. LFTs
2. H&H 3. Cholesterol & lipid profile |
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How does papaverine injection therapy work?
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It inhibits PDE leading to increased cAMP and cGMP
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2 major disadvantages of papaverine injections are...
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1. Corporal fibrosis (1-33%) due to low acidity
2. Occasional LFTs |
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What is the mechanism of phentolamine injection therapy?
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Competitive alpha-adrenergic antagonist (= affinity for alpha 1 and alpha 2)
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3 types of intracavernous injection therapy?
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1. Papaverine
2. Phentolamine 3. Alprostadil (PGE1) |
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What is the best regimen for treating priapism due to injection therapy?
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Intracavernous injection of diluted phenylephrine 250-500ug q3-5 minutes until detumescence
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In what 3 patients is intracavernous injection contraindicated?
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1. Sickle cell
2. Schizophrenia or severe psychiatric disorder 3. Severe venous incompetence |
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What is the most commonly used technique for penile revascularization?
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Bypass from inferior epigastric artery to dorsal artery or deep dorsal vein of penis
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What are 3 types of penile prostheses?
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1. Malleable (semirigid)
2. Mechanical 3. Inflatable (2 and 3 piece) |
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Which penile prostheses last longer than others?
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Malleable last longer than inflatable
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What are potential complications of IPP?
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1. Mechanical failures
2. Cylinder leaks 3. Tubing leaks 4. Infection 5. Perforation 6. Persistent pain 7. Autoinflation |
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What is the 5-year failure rate of IPP?
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5-15%
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How long do penile prostheses generally last?
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10-15 years (and then will need a replacement)
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What is the mechanism of retrograde ejaculation?
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Dysfunction of the internal sphincter or the bladder neck
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In what 3 states/conditions does retrograde ejaculation occur?
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1. After prostatectomy
2. Alpha-blocker therapy 3. Autonomic neuropathy (DM) |
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What is used to treat retrograde ejaculation?
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Alpha sympathomimetics (or eliminate the alpha blocker therapy)
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What are 4 things which can be used to treat premature ejaculation?
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1. Desensitization
2. The Squeeze technique 3. Application of local anesthetic or condom 4. SSRIs |
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What is the treatment of choice for renal AV fistulas?
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Transcatheter embolization
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Optimal time delay between embolization and nephrectomy for RCC is...
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1 day
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What is post-embolization syndrome?
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Pain, n/v, fever, leukocytosis following tumor embolization (very common & should not delay surgery!)
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What material is used for renal tumor embolization?
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Ethanol
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What approach is preferred for embolization of varicocele?
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IJV to the L gonadal vein
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Recurrence rate for embolization of varicocele?
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4%
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What are 7 indications for treatment of renal artery aneurysms?
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1. Interval enlargement
2. Diameter >2.5cm 3. Lesions in women of child-bearing age 4. Pain 5. Hematuria 6. Renovascular HTN 7. Intrarenal thromboemboli |
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What is the usual anatomic relationship between the renal artery and vein?
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Artery is posterior to the vein
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With a R-sided nephrectomy, what plane is crossed to direct one from the IVC to the R renal vein?
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Plane of Leriche
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Where is the most likely location of a urethral stricture after straddle injury?
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Bulbar urethral injury
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Patients with what disorder should you be wary of latex allergy?
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Myelomeningocele
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What is a good alternative for a urethral catheter in those with latex allergy?
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Silicone
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What element forms the basis of MRI?
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Hydrogen
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How do blood vessels appear on MRI?
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Dark
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How does calcium appear on MRI?
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Dark
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What is Technetium 99c's half life?
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6 hours
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What radionuclide agent is best used for renal vascular imaging?
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DTPA
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What radionuclide agents may be used in patients with renal failure?
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123-I and 131-I hippurate (b/c renal concentration may occur with as little as 3% of normal renal function)
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What is a "superscan"?
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When the kidneys can't be imaged b/c the bone (from prostatic boney mets) has intensely uptaken the radionuclide
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How many Hounsfield units would be typical of a renal cyst on noncontrast CT?
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<20
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What is a renal pseudotumor?
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An area of normal renal parenchyma that gives the appearance of a solid renal mass
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What % of RCCs are avascular?
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20-25%
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Is routine biopsy of solid renal masses recommended? Why or why not?
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NO- because of the high incidence of false negative findings in patients with RCC
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In a newborn, what is the #1 and #2 most common causes of an abdominal mass?
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1. Hydronephrosis (usually secondary to UPJ obstruction)
2. Multicystic kidney |
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What is the most common malignancy of the newborn?
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Neuroblastoma (50% of all neonatal malignant tumors)
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In a neonate, what is the most common cause of hydronephrosis?
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UPJ obstruction
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If US shows hydronephrosis in a child, what is the next study that should be ordered?
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VCUG
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At what age is neuroblastoma and Wilms's tumors most common?
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Neuroblastoma: <2yo
Wilms' Tumor: >2yo |
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What is aniridia and what is it associated with?
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Developmental absence of most of the iris-- associated with Wilms tumor
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What urologic abnormality is microcephaly associated with?
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PUVs and Beckwith-Wiedemann syndrome
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Macroglossia should make you think of......
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Beckwith-Wiedemann
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Hemihypertrophy should make you think of...
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Beckwith-Wiedemann
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Webbing of the neck should make you think of what syndrome (and what associated renal abnormality)?
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Turner's Syndrome & horseshoe kidney
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What is the significance of bright pink or bluish subcutaneous nodules in the newborn?
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May indicate the presence of disseminated neuroblastoma
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What is the significance of HTN in a child with an abdominal mass?
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It may suggest the presence of neuroblastoma, congenital mesoblastic nephroma, and less commonly Wilms tumor, hydronephrosis or multicystic kidney
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What is the significance of hematuria in a newborn with an abdominal mass?
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Renal vein thrombosis
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Offspring of which mothers are at increased risk for renal vein thrombosis?
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Diabetic moms
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What is the most likely diagnosis of an abdominal mass in a female neonate with a bulging interlabial mass?
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Hydrocolpos secondary to imperforate hymen
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What is the significance of stippled calcification in a retroperitoneal solid mass?
|
50% of patients with neuroblastoma have stippled calcification
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Which tumor is more likely to be fixed rather than mobile- neuroblastoma or Wilms?
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Neuroblastoma
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What are the 2 primary causes of masses arising from the female genital system?
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1. Hydrocolpos
2. Ovarian cysts |
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How often are the kidneys palpable in the neonate
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Very often
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What is the usual age for urinary TB?
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Young adults (60% between 20-40)
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What are the primary sites of TB infection in the GU system?
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Kidneys & possibly the prostate
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What is the route of infection for GU TB?
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Descending from the kidney
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Chronic draining scrotal sinus should make you think of...
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TB of the GU tract
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How is GU TB diagnosed?
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Demonstration of tubercle bacilli in urine by culture
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What are the usual earliest symptoms of renal TB?
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Vesicular sx including burning, frequency and urgency
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A thickened and beaded vas deferens suggests...
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GU TB
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What is the "great mimicer" of GU TB?
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Schistosomiasis (b/c both present with sx of cystitis and some hematuria)
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Is surgery necessary for GU TB?
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Not usually... medical treatment with 3-drug protocol is appropriate
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Who does abacterial cystitis usually affect?
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Usually adult men
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What is the suspected etiology of abacterial cystitis?
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Mycoplasmas and chlamydiae. Possibly adenovirus
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How are the initial presentations of renal TB and abacterial cystitis different?
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Renal TB comes on gradually while abacterial cystitis is sudden onset. Also, renal TB will reveal deep chronic ulcers while the ulcers of abacterial cystitis are superficial.
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Name 4 drugs used to treat abacterial cystitis.
|
1. Tetracyclines
2. Chloramphenicol 3. Streptomycin 4. Neoarsphenamine (it's an arsenical- drug of choice but hard to find) |
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How is vesical candidiasis treated?
|
Alkalinize urine with sodium bicarb for urine pH of 7.5. If this fails, amphotericin B instilled into bladder.
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Yellow bodies called "sulfur granules" are pathognomonic for what infection?
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Actinomyces israelii
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|
|
What is the drug of choice for infection with actinomyces?
|
Penicillin G for 4-6 weeks followed by Penicillin V for prolonged period
|
|
|
Name 3 drugs to be used for treatment of actinomyces
|
1. Penicillin G (choice drug)
2. Sulfonamide 3. Streptomycin |
|
|
Name 3 types of schistosomiasis... and corresponding locations.
|
1. Schistosoma mansoni (central America, Pakistan, India)
2. Schistosoma japonicum (middle east) 3. Schistosoma haematobium (Africa, Saudi Arabia, Israel, jordan, Lebanon, Syria) |
|
|
Which schistosoma type primarily affects the bladder? What do the other schistosoma types affect?
|
Haematobium affects the bladder. Mansoni and japonicum primarily affect the colon.
|
|
|
Where does the adult S. haematobium worm live?
|
In the prostatovesical plexus of veins
|
|
|
Main symptom of schistosomiasis?
|
Hematuria
|
|
|
What are the 3 drugs of choice for treating schistosomiasis?
|
1. Praziquantel (for any schisto) x 1 day
2. Metrifonate (only for haematobium) 3 total doses (1 dose q2wk) 3. Oxamniquine (only for mansoni) |
|
|
What nematode is responsible for filariasis?
|
Wuchereria bancrofti
|
|
|
What is the usual host to deliver filariasis?
|
Mosquito
|
|
|
Most common symptoms associated with filariasis?
|
1. Lymphadenitis and lymphangitis
2. Inflammation of epididymis, testis, scrotum, and spermatic cord |
|
|
What are the 2 key lab findings in filariasis?
|
1. Chylous urine (top layer fatty, middle layer pinkish, bottom layer clear)
2. Eosinophilia |
|
|
What is the treatment of choice for filariasis?
|
Diethylcarbamazine (hertrazan) but it is very toxic and only kills microfilariae (and not adult worms)
|
|
|
How does GU echinococcus usually occur?
|
After rupture of an echinococcal liver cyst
|
|
|
What cystic findings would suggest an echinococcal cause?
|
Calcifications along the rim
|
|
|
What is the treatment of choice for renal hydatid (echinococcus) disease?
|
Nephrectomy
|
|
|
What sex usually does NOT have symptoms related to urethritis?
|
WOMEN (men usually will have discharge)
|
|
|
Gram-negative intracellular diplococci...
|
N. gonorrhea
|
|
|
Are urethral infections identified after treatment usually reinfections or treatment failures?
|
Reinfections
|
|
|
Name 4 symptoms of disseminated gonococcal infection.
|
1. Petechial or pustular skin lesions
2. Asymmetrical arthralgias 3. Septic arthritis 4. Tenosynovitis |
|
|
Recommended treatment for NGU (choice and alternatives)?
|
Choice: doxy or azithromycin
Alternative: 7 days of EES or ofloxacin |
|
|
What testing should be done if epididymitis is associated with UTIs?
|
Evaluation of GU anatomic abnormalities
|
|
|
What finding is usually associated with epididymitis?
|
Hydrocele
|
|
|
What is the organism associated with chancroid?
|
Haemophilus ducreyi
|
|
|
In penicillin-allergic patients, what is the treatment of syphilis?
|
2 week course of Doxycycline or tetracycline
|
|
|
Main signs of chancroid?
|
Painful genital ulcer and the Bubo! (inguinal adenopathy)
|
|
|
Treatment of chancroid?
|
1. Azithromycin x 1
2. Ceftriaxone x 1 3. Ciprofloxacin x 3 days 4. Erythromycin base x 7 days |
|
|
Treatment of granuloma inguinale?
|
1. TMP/SMX BID x 3 weeks
2. Doxy BID x 3 weeks |
|
|
Treatment of lymphogranuloma venereum?
|
Doxy BID x 3 weeks
|
|
|
Causative organism of lymphogranuloma venereum is...
|
C. trachomatis (serotypes L1, L2, and L3)
|
|
|
Clinical presentation of lymphogranuloma venereum?
|
Tender inguinal or femoral LAD
|
|
|
What is the causative organism of granuloma inguinale?
|
Calymmatobacterium granulomatis (GN intracellular bacillus)
|
|
|
Granuloma inguinale aka...
|
Donovanosis
|
|
|
Clinical presentation of granuloma inguinale?
|
Painless beefy red progressive genital ulcers; usually NO LAD
|
|
|
What are some topical treatments for HPV warts?
|
1. Podophyllin
2. Imiquimod 3. Trichloracetic acid 4. Cryotherapy |
|
|
Which HIV type causes most HIV infections?
|
HIV-1
|
|
|
What are Bougie a boules used for?
|
To determine urethral and meatal size (sized from 8F to 40F)
|
|
|
In children, what is the usual size French for catheters?
|
8-12F
|
|
|
Bladder tumor may be fulgurated endoscopically with what device?
|
Bugbee electrode
|
|
|
Electrosurgical units provide two types of current:
|
1. High frequency (for cutting and vaporization of tissue)
2. Low frequency (for heating tissue and producing coagulation) |
|
|
What is the usual irrigating fluid used in transurethral surgery?
|
3% sorbitol
|
|
|
Name 6 complications of transurethral surgery.
|
1. Incontinence (usually resolves within 6 weeks)
2. Impotence 3. Retrograde ejaculation 4. Bleeding 5. Epidiymoorchitis 6. Urethral stricture and bladder neck contracture |
|
|
What is the classic triad of acute adrenal insufficiency?
|
1. Hyponatremia
2. Hyperkalemia 3. Hypotension |
|
|
What are the 4 principal types of congenital adrenal hyperplasia? Which is the most common?
|
1. 21-hydroxylase deficiency (most common: >90%)
2. 11beta-hydroxylase deficiency 3. 17alpha-hydroxylase deficiency 4. 3beta-hydroxydehydrogenase deficiency |
|
|
Which type of CAH is the only life-threatening one?
|
21-OH deficiency
|
|
|
How is CAH diagnosed?
|
Elevated 17-hydroxyprogesterone in plasma (or its metabolite pregnanetriol in urine)
|
|
|
How is CAH treated?
|
Prednisone (or hydrocortisone in infants)
|
|
|
What history should be asked in the case of acute urinary retention?
|
Any cold remedies containing nasal decongestants and antihistaminic compounds (anti-cholinergic properties)
|
|
|
50% of testicular torsion cases occur at what time of day?
|
During sleep
|
|
|
What are the 2 general types of testicular torsion?
|
1. Extravaginal (in neonates)
2. Intravaginal (associated bell-clapper deformity) |
|
|
What is the "bell-clapper" deformity?
|
A congenital high investment of the tunica vaginalis on the spermatic cord, allowing the testis to rotate on the cord
|
|
|
Which way do the testes usually rotate in torsion?
|
Always TOWARD the inner thigh
|
|
|
What is Prehn's Sign?
|
Elevating the testicle will decrease pain in epidiymoorchitis (+ Prehn's) and will increase pain in torsion (- Prehn's)
|
|
|
Where does Fournier's gangrene begin and where does it spread?
|
It begins in the scrotum or penis and spreads along fascial planes (beneath Scarpa's fascia) to the perineum and abdominal wall up to the axilla
|
|
|
What are the 3 usual sources of Fournier's gangrene?
|
1. GU (50%)
2. Colorectal (33%) 3. Cutaneous (20%) |
|
|
What is phimosis and how is it treated?
|
Inability to retract the foreskin over the glans. Treat with dorsal slit or circumcision
|
|
|
What is paraphimosis and how is it treated?
|
Condition in which foreskin becomes trapped in a retracted position behind the glans. Treat with firm compression of the glans with continuous traction of the foreskin and anesthesetics (lidocaine).
**SCHEDULE CIRCUMCISION 3-4 days afterwards (after inflammation and edema have subsided) |
|
|
Name 7 drugs associated with priapism.
|
1. Trazodone
2. Intracavernosal injection 3. Alcohol 4. Marijuana 5. Thorazine 6. Antihypertensives 7. Heparin |
|
|
What are some infiltrative causes of priapism?
|
Leukemia, lymphoma, bladder or prostate carcinoma
|
|
|
Name 3 miscellaneous causes of priapism.
|
1. Trauma
2. TPN 3. Dialysis |
|
|
Two types of priapism include:
|
1. Low flow (ischemic or venoocclusive)
2. High flow (nonischemic or arterial) |
|
|
How long should an erection last for it to be considered priapism?
|
>4 hours
|
|
|
What is used to treat priapism in sickle cell disease patients?
|
1. Hydration
2. Alkalinization 3. Transfusion 4. Viagra |
|
|
How is priapism treated medically?
|
Irrigation with NS and aspiration. If this fails, then intracorporal injection of phenylephrine (alpha agonist)
|
|
|
What anesthetic should be used to treat priapism?
|
Ketamine (achieves detumescence in 50% of cases)
|
|
|
What surgical procedure may be used to treat prolonged priapism?
|
Surgical shunting of corpora cavernosa by creation of fistula b/w glans penis and corpora cavernosa
|
|
|
What is the Winter procedure?
|
Surgical shunting for priapism with creation of fistula between glans penis and corpora spongiosum
|
|
|
What sx occur with autonomic dysreflexia?
|
1. Dangerous systolic HTN
2. Sweating 3. Paradoxic bradycardia |
|
|
What patients are prone to autonomic dysreflexia?
|
Patients with spinal cord injury above T6, viable distal cord and intact sympathetic outflow.
|
|
|
What are the GU causes of autonomic dysreflexia?
|
Usually occurs b/o overdistended bladder, urinary infection or stones.
|
|
|
Where do the deep dorsal veins of the penis empty?
|
Santorini's vesicoprostatic plexus
|
|
|
Name the IMPOTENCE mnemonic for causes of ED.
|
INFLAMMATORY: prostatitis, urethritis, stricture
MECHANICAL: chordee, Peyronie's, phimosis POSTOP: iatrogenic OCCLUSIVE: arteriogenic TRAUMATIC: pelvic fracture, urethral rupture ENDURANCE: chronic & systemic disease NEUROLOGIC: neuropathy, temporal lobe epilepsy, MS CHEMICAL: alcohol, MJ, prescription drugs ENDOCRINE: testicular failure, pituitary failure, hyperprolactinemia |
|
|
3 main types of endocrine disorders causing ED.
|
1. Hypogonadotropic hypogonadism (Prader-Willi, Laurence-Moon-Biedl)
2. Hypergonadotropic hypogonadism (Klinefelter's, mumps orchitis, surgical orchiectomy) 3. Hyperprolactinemia (pituitary adenoma, craniopharyngioma, drug therapy) |
|
|
How does pelvic irradiation predispose to ED?
|
May cause an accelerated occlusive atherosclerosis of the pelvic vessels
|
|
|
Name 3 shunt procedures done for priapism.
|
1. Winter
2. Quackles 3. El Ghorab |
|
|
What is the most significant long-term complication of intracavernosal pharmacotherapy?
|
Corporal fibrosis
|
|
|
Revascularization to correct ED in cases of pelvic trauma involves what?
|
Microsurgical reanastamosis of inferior epigastric artery to the dorsal penile artery
|
|
|
What % of children with UTIs have VUR?
|
50%
|
|
|
How should children with medically treated VUR be evaluated?
|
Cystograms q4-6 months and excretory urography q6-12 months
|
|
|
What is the operation for VUR?
|
Ureterovesicoplasty
|
|
|
What are 4 modes of entry for UTI?
|
1. Ascending
2. Hematogenous 3. Lymphatogenous (debatable) 4. Direct extension from adjacent organs |
|
|
What glycoprotein in urine inhibits bacterial adherence?
|
Tamm-Horsfall
|
|
|
Why is aging associated with UTIs?
|
In men, there is increased obstructive uropathy. In women, there is altered vaginal and periurethral flora after menopause.
|
|
|
What serogroups of E.coli are the most likely culprits of UTIs?
|
O (most common), K, and H
|
|
|
Bacteria causing UTIs overexpress what antigen and what does it do?
|
K capsular Ag - protects from phagocytosis by PMNs
|
|
|
What is the mechanism of hereditary UTIs?
|
The ease of bacteria to adhere to epithelial cells mediated by ligands on tips of bacterial fimbriae (pili) (usually P pili)
|
|
|
What are 3 main SEs of nitrofurantoin?
|
1. GI upset
2. Peripheral polyneuropathy 3. Hepatotoxicity |
|
|
What is the major co-morbidity in patients with emphysematous pyelonephritis?
|
DM (80-90% will have DM)
|
|
|
How long should emphysematous pyelo be treated?
|
3-4 weeks with IV abx
|
|
|
What is the difference between a perinephric and paranephric abscess?
|
Paranephric extends beyond Gerota's fascia
|
|
|
What is xanthogranulomatous pyelonephritis?
|
From a chronic bacterial infection of the kidney- affected kidney will be hydronephrotic and obstructed- foamy lipid-laden histiocytes
|
|
|
What is xanthogranulomatous pyelonephritis commonly confused with?
|
Clear renal cell ca (b/o the foamy lipid-laden histiocytes)
|
|
|
What is malacoplakia?
|
Uncommon inflammatory disease of the bladder that may also affect the upper GU tract- plaques, nodules made of large histiocytes with laminar inclusion bodies
|
|
|
What is the name of the large histiocytes found in malacoplakia?
|
von Hansemann cells
|
|
|
What is the name for the laminar inclusion bodies found in malacoplakia?
|
Michaelis-Gutmann bodies
|
|
|
Who is predisposed to malacoplakia?
|
Immunosuppressed women
|
|
|
What is malacoplakia often confused with?
|
A mass in the bladder (TCC or RCC)
|
|
|
How is malacoplakia treated?
|
Abx (surgical excision if involving the kidney or ureter)
|
|
|
How long and with what should acute prostatitis be treated?
|
TMP and fluoroquinolone x 4-6 weeks
|
|
|
What is the most common pathogen associated with acute prostatitis?
|
E.coli
|
|
|
What may cause granulomatous prostatitis?
|
Infection, BCG treatment, malacoplakia, or systemic granulomatous disease
|
|
|
What are the two types of granulomatous prostatitis and how are they treated differently?
|
1. Eosinophilic (tx with corticosteroid)
2. Non-eosinophilic (tx with abx, CS and temp bladder drainage) |
|
|
Treat gonococcal urethritis with...
|
Ceftriaxone or fluoroquinolone
|
|
|
Treat nongonococcal urethritis with...
|
tetracyclines or erythromycine or doxycycline x 7-10d
|
|
|
What are the causes of epididymitis in a) <35yo, b) kids and elderly?
|
a) <35yo: chlamydia and gonorrhea
b) kids & elderly: e. coli |
|
|
If a patient with epididymitis is pre-pubertal, what studies should be ordered... to look for what?
|
VCUG to look for VUR or ectopic ureter
|
|
|
How is epididymitis treated?
|
Bed rest, NSAIDs, Abx, and elevation of scrotum
|
|
|
Sulfonamides in pregnancy is associated with what fetal condition?
|
Kernicterus
|
|
|
TMP in pregnancy is associated with what fetal side effect?
|
Interference with NT development
|
|
|
Nitrofurantoin in pregnancy is associated with what fetal side effect?
|
Hemolysis and G6PD deficiency
|
|
|
PUV consists of congenital mucosal folds in what region of the urethra?
|
Membranous
|
|
|
What is the bas-fond deformity?
|
Hypertrophy of the vesical neck causes acute angulation b/w trigone and prostatic urethra
|
|
|
What is Bell's muscle?
|
Interureteric ridge
|
|
|
What is the difference between a cellule and diverticula?
|
Cellule is just pushing of mucosa by trabeculated bladder muscle. A diverticula (or saccule if larger) is pushed out beyond the muscle and cannot empty
|
|
|
What is a Hutch diverticulum and its significance?
|
diverticulum near ureteric orifice which may cause VUR
|
|
|
What is the bulbocavernous reflex?
|
Squeeze glans penis should elicit anal sphincter contraction
|
|
|
What are 3 classes of meds for BPH?
|
1. Alpha blocker
2. 5alpha-reductase inhibitors 3. Phytotherapy |
|
|
3 types of phytotherapy for BPH and their mechanisms?
|
1. saw palmetto (5aRI- like)
2. pygeum africanum (PGE2 and F2a inhibitors) 3. S African star grass |
|
|
Name 4 alpha blockers used in BPH.
|
1. Terazosin (hytrin)
2. Doxazosin (cardura) 3. Prazosin (minipres) 4. Tamsulosin (flomax) 5. Phenoxybenzamine (dibenzyline) |
|
|
What is the limitation of TUMT? (transurethral microwave therapy)
|
You cannot use it in small prostates (<3.5cm)... it only heats 3.5cm
|
|
|
What are 7 types of transurethral prostate therapies?
|
1. TUMT
2. TUNA (needle ablation) 3. TUIP (incision of the prostate) 4. TURP 5. HIFU (high intensity focused u/s) 6. TUVP (vaporization) 7. Laser prostatectomy |
|
|
Name 6 medical treatment for detrusor overactivity.
|
1. Oxybutynin (ditropan)
2. Tolterodine (detrol) 3. Hyoscyamine (levsin) 4. Flavoxate (urispas) -antispasmodic 5. Dicyclomine (bentyl) 6. Imipramine |
|
|
What are the two parts making up the mesodermal component of the UVJ?
|
1. Ureter & superficial trigone
2. Waldeyer's sheath & deep trigone |
|
|
What is Waldeyer's sheath?
|
The external layer of the longitudinal smooth muscle surrounding the ureter (beginning at a point 2-3 cm above the bladder)
|
|
|
What does ureterovesical competence rely on?
|
It is governed by the tone of the trigone which contracts vigorously just before voiding to help open the bladder neck and also eliminate reflux up into the ureter
|
|
|
Does ureterovesical competence rely on the bladder/detrusor action?
|
NO
|
|
|
What is likened to a Chinese finger trap?
|
The ureterovesical junction (the harder you pull, the tighter it gets)
|
|
|
What is the most common cause of VUR in children? What is a less common cause?
|
1. Congenital attenuation of the ureterotrigonal musculature (most common)
2. Shortened intravesical ureter (less common) |
|
|
How does the ureter acquire musculature embryologically?
|
Cranially to caudally
|
|
|
In a duplicated ureter, describe the superior and inferior ureters (what kidney pole it is attached to, problems, etc)
|
1. Superior ureter (lower pole)- associated with reflux
2. Inferior ureter (upper pole)- associated with obstruction and ureterocele |
|
|
Why is pyelonephritis of pregnancy associated with VUR?
|
Hormones of pregnancy contribute to loss of tone of the trigone
|
|
|
What characteristics occurs with prune belly syndrome?
|
1. Failure of normal development of abdominal muscles and smooth muscle of the ureters and bladder
2. B/L cryptorchidism 3. Occasional talipes equinovarus 4. Occasional hip displocation |
|
|
What is another name for prune belly syndrome?
|
Eagle-Barrett Syndrome
|
|
|
Resection of what part of the vesical neck is most likely to cause reflux?
|
Posterior
|
|
|
VUR damages the kidney via 2 mechanisms:
|
1. Pyelonephritis
2. Hydroureteronephrosis |
|
|
What is the Ksp (solubility product)?
|
Specific point in which concentrations above it are metastable and capable of initiating crystal growth and heterogeneous nucleation
|
|
|
What is the Kfp (formation product)?
|
Specific point that if you go above it, supersaturation levels are unstable and spontaneous homogeneous nucleation may occur
|
|
|
What is the nucleation theory of stone formation?
|
Urinary stones originate from crystals or foreign bodies immersed in supersaturated urine.
|
|
|
What is the crystal inhibitor theory of stone formation?
|
Calculi form owing to the absence or low concentration of natural stone inhibitors
|
|
|
Name 4 natural stone inhibitors.
|
1. Magnesium
2. Citrate 3. Pyrophosphate 4. Trace metals |
|
|
What are the 2 materials making up a calculus?
|
1. Crystal (major component)
2. Matrix |
|
|
2 theories for stone formation are...
|
1. Nucleation theory
2. Crystal inhibitor theory |
|
|
Name 3 main steps involved in stone formation.
|
1. Nucleation
2. Growth 3. Aggregation |
|
|
What is another name for heterogeneous nucleation?
|
Epitaxy
|
|
|
What is matrix composed of?
|
Mostly of protein with small amounts of hexose and hexosamine
|
|
|
What are the 2 principal precursors of oxalate?
|
1. Glycine
2. Ascorbic acid |
|
|
What toxin is associated with excess oxalate?
|
Ethylene glycol ingestion
|
|
|
What diseases are associated with hyperoxaluria and why?
|
1. IBD
2. Small-bowel resection 3. Bowel bypass B/c oxalate is reabsorbed by the small intestine and the rest gets filtered by the kidney |
|
|
Uric acid is the by-product of _____ metabolism.
|
Purine
|
|
|
Why is sodium restriction important in reducing stone formation?
|
Sodium may play a role in initiating crystal development and aggregation (b/c high dietary sodium intake increases urinary calcium excretion secondary to sodium-induced increase in bicarbonaturia.)
|
|
|
Name 3 patient-types who may have citrate deficiency.
|
1. RTA type I
2. Chronic diarrhea 3. Chronic thiazide therapy |
|
|
What might be a factor influencing the increased incidence of stones in pregnancy?
|
Estrogen increases citrate excretion
|
|
|
Name 4 main etiologies of calcium nephrolithiasis.
|
1. Elevated urinary calcium
2. Decreased urinary citrate 3. Elevated urinary uric acid 4. Elevated urinary oxalate |
|
|
Name 8 diseases associated with nephrocalcinosis.
|
1. Hyperparathyroidism
2. RTA 3. Sarcoidosis 4. Milk Alkali Syndrome 5. Excessive Vitamin D intake 6. Medullary sponge kidney 7. Osteolytic lesions 8. Multiple myeloma |
|
|
How is most dietary calcium excreted?
|
Stool
|
|
|
Where is most calcium absorbed?
|
Jejunum
|
|
|
Name 3 types of absorptive hypercalciuria.
|
1. Type I: independent of diet (15% of all calcareous calculi)
2. Type II: Dietary dependent (common) 3. Type III: Phosphate renal leak (5%) |
|
|
How is Type I absorptive hypercalciuria treated?
|
1. Cellulose phosphate with meals
2. Alternative treatment: thiazides |
|
|
How is Type II absorptive hypercalciuria treated?
|
Limit calcium intake to 400-600mg/day
|
|
|
How is Type III absorptive hypercalciuria treated?
|
Phosphate replacement with orthophosphate (neutra-phos) (after meals and before bedtime)
|
|
|
What is the mechanism of Type III absorptive hypercalciuria?
|
There's a renal phosphate leak which then stimulates 1,25(OH)2 vitamin D synthesis. This increases absorption of phosphate and calcium from the gut and increases renal excretion of calcium.
|
|
|
What causes resorptive hypercalciuric nephrolithiasis?
|
Hyperparathyroidism (renal damage is secondary to hypercalcEMIA)
|
|
|
How is hyperuricosuric calcium nephrolithiasis treated?
|
Allopurinol (alternative is potassium citrate)
|
|
|
How does allopurinol work?
|
Xanthine oxidase inhibitor (reduces uric acid synthesis and renal excretion of uric acid- and also inhibits uric acid-ca-oxalate crystallization).
|
|
|
Main side effects of allopurinol?
|
Bad skin rash & hepatotoxicity
|
|
|
What is primary hyperoxaluria?
|
A rare hereditary disease associated with Ca oxalate renal calculi, nephrocalcinosis, and distant deposits of oxalate, culminating in progressive renal failure & death.
|
|
|
What are 2 types of primary hyperoxaluria?
|
Type I: enzyme deficiency of 2-oxoglutarate:glyoxylate carboligase
Type II: increased excretory levels of L-glyceric acid associated with D-glycerate dehydrogenase enzyme deficiency |
|
|
What crystals are most common in transplanted kidneys?
|
Oxalate
|
|
|
How is primary hyperoxaluria treated?
|
Combined liver and kidney transplant
|
|
|
What 2 simple measures can help treat hypocitraturic calcium nephrolithiasis?
|
1. Potassium citrate supplementation
2. 6-8 glasses of lemonade daily |
|
|
Struvite stones are made of...
|
MAP (Mg, Ammonium, Phosphate)
|
|
|
Are struvite stones more common in men or women?
|
Women
|
|
|
Struvite stones are commonly associated with what organisms?
|
Urea-splitting organisms (Proteus, Pseudomonas, Providencia, Klebsiella, Staph, Mycoplasma)
|
|
|
What patients are predisposed to uric acid calculi?
|
1. Myeloproliferative disease
2. Gout 3. Tx with cytotoxic drugs 4. Rapid weight loss |
|
|
What is the urinary pH associated with uric acid stones?
|
<5.5
|
|
|
What is the pH associated with struvite stones?
|
>7.2
|
|
|
Classic cystinuria is inherited how?
|
AR
|
|
|
What is the medical therapy for cystine stones?
|
1. High fluid intake
2. Urinary alkalinization 3. Low methionine diet (not especially helpful) 4. Penicillamine (bad SE- rash) 5. Thiola (mercaptopropionylglycine)- drug of choice now |
|
|
What does a cystine stone look like?
|
Mildly opaque, smooth-edged, ground-glass appearance
|
|
|
What is cystine lithiasis secondary to?
|
Inborn error of metabolism resulting in abnormal intestinal (small bowel) mucosal absorption and renal tubular absorption of dibasic aa
|
|
|
Xanthine stones are secondary to...
|
Deficiency of xanthine oxidase (which catalyzes hypoxanthine--> xanthine--> uric acid)
|
|
|
What medication may cause nephrolithiasis and are they radioopaque or radiolucent?
|
1. Indinavir- radiolucent
2. Triamterene- radiolucent 3. Antacids (silicate) |
|
|
What do indinavir stones look like?
|
Radiolucent on noncontrast CT. Tannish-red and usually fall apart during basket extraction
|
|
|
What pain is experienced with a renal pelvic stone (at the UPJ)?
|
1. Severe, constant, boring CVA pain (just below 12th rib) with radiation to the flank
2. Pain in testicle |
|
|
What pain is experienced with an upper ureter stone?
|
1. CVAT and flank pain
2. Lumbar region pain |
|
|
Describe the pain experienced with a mid-ureter stone.
|
1. CVAT and flank pain
2. Pain radiating caudally and anteriorly toward mid and lower abdomen in curved, bandlike fashion |
|
|
Describe the pain experienced with a distal-ureter stone.
|
Pain radiating to the groin or testicle (or labia majora) (generated by the ilioinguinal or genital branch of the genitofemoral nerve)
|
|
|
What are the 3 most common INFECTION stones?
|
1. Struvite stones
2. Calcium phosphate (less common) 3. Matrix stones (associated with UTI) |
|
|
Is obesity a risk factor for stone formation?
|
Yes
|
|
|
Which RTA type is associated with renal stones?
|
Type I
|
|
|
Cystine crystals:
|
Hexagonal
|
|
|
Struvite crystals:
|
Coffin-lid
|
|
|
Calcium oxalate monophosphate
|
Bipyramids
|
|
|
Calcium oxalate diphosphate
|
Dumbbells
|
|
|
Uric acid crystals:
|
Amorphous powder
|
|
|
Brushite crystals:
|
Splinter-like and may aggregate with spokelike center
|
|
|
Why is climate a risk factor for stones?
|
In the heat, you can get dehydrated. Also, you get more exposure of Vitamin D which leads to increased Ca and oxalate excretion.
|
|
|
Stones 4-5mm have what chance of passing on their own?
|
40-50%
|
|
|
Stones >6mm have what chance of passing on their own?
|
5%
|
|
|
The vast majority of stones which pass do so within what period of time?
|
6 weeks
|
|
|
Does struvite stone dissolution require urine acidification or alkalinization? And by what 2 medications?
|
Acidification with...
1. Suby's G solution 2. Hemiacidrin (Renacidin) |
|
|
What dissolution agents help alkalinize urine?
|
1. Sodium bicarb
2. K citrate 2. Tromethamine-E |
|
|
What are the 2 types of shock wave sources in ESWL?
|
1. Supersonic emitters
2. Finite amplitude emitters |
|
|
What is the #1 absolute contraindication of ESWL?
|
Pregnancy
|
|
|
What is Steinstrasse?
|
Stone street (columnation of stone gravel in a ureter)
|
|
|
How is steinstrasse with associated pain and fever treated?
|
Percutaneous nephrostomy drainage to decompress the collecting system
|
|
|
What is a serious complication of flat wire baskets in ureteroscopic stone extraction?
|
If twisted, they can develop sharp knife-like edges resulting in ureteral injury
|
|
|
Surgical treatment of choice for distal ureteral stones?
|
Ureteroscopic stone extraction
|
|
|
Surgical treatment of choice for renal and proximal ureteral stones?
|
Percutaneous nephrolithotomy
|
|
|
How long do thiazides work for absorptive hypercalciuria?
|
Only 4-5 years- urinary Ca excretion values rebound to pretreatment levels in 50% of patients (unknown cause)
|
|
|
In penicillamine treatment for cystine stones, what other drug is a necessity?
|
Pyridoxine (B6) b/c penicillamine increases its requirement)
|
|
|
Are most bladder stones radiolucent or radioopaque?
|
Radiolucent (uric acid stones)
|
|
|
Are most bladder stones single or multiple?
|
Single
|
|
|
Can you get stones in the prostate or seminal vesicles?
|
Yes but they are extremely rare
|
|
|
Where do urethral stones in men usually present?
|
In the prostatic or bulbous urethra
|
|
|
If a female has a urethral stone, where is it located?
|
In a urethral diverticula
|
|
|
Are bladder stones more common in men or women?
|
Men
|
|
|
Where do renal stones form?
|
Collecting tubules and pass into calyces, renal pelvis and ureter
|
|
|
List the 4 most common types of stones found in North America (in decreasing order of frequency).
|
1. Calcium-containing (70%)
2. Infection (MAP) (15-20%) 3. Uric acid (5-10%) 4. Cystine (1-5%) |
|
|
What is the most common stone found in American women and why?
|
Struvite b/c women are more prone to UTIs than men
|
|
|
What stone is inherited as an AR trait?
|
Cystine
|
|
|
Is stone pain related to activity?
|
NO
|
|
|
What % of stones are radioopaque?
|
90%
|
|
|
What are the 4 indications for surgical stone removal?
|
1. Recurrent, gross hematuria
2. Persistent pain 3. Obstruction with progressive renal damage 4. Recurrent UTI |
|
|
What type of stone may be consistently dissolved by taking oral medication? What med?
|
Pure uric acid stones (oral alkalinization with K citrate or Na bicarb)
|
|
|
What treatment options exist to treat renal calculi?
|
1. ESWL (if <=2.5cm)
2. Percutaneous nephrostolithotomy (>=2.5cm) 3. Open stone removal (if these fail) |
|
|
Which stones are usually refractory to ESWL?
|
Cystine (or any stone >2.5cm)
|
|
|
Do staghorn stones need to be removed even if they are not causing symptoms?
|
Yes
|
|
|
In the past, what the main procedure to remove staghorn calculi?
|
Anatrophic nephrolithotomy
|
|
|
How does anatrophic nephrolithotomy work?
|
1. Clamp renal artery
2. Cool the kidney 3. Cut it open via bloodless plane 4. Remove the stone & sew it up |
|
|
What are the symptoms of calyceal stones?
|
Usually asymptomatic but will show gross hematuria
|
|
|
Are R or L ureteral calculi more common?
|
They're equal in incidence
|
|
|
What are phleboliths (in relation to stones) and how are they different?
|
Calcifications within the pelvic veins... They are different b/c they're rounder, cast shadows lateral to the course of the ureter and have radiolucent centers
|
|
|
What are the invasive treatment options for ureteral calculi?
|
1. ESWL
2. Ureteroscopy 3. Ureterolithotomy |
|
|
In ureteroscopy, what are 4 methods necessary for fragmentation of >=6mm stones?
|
1. Ultrasound
2. Electrohydraulic 3. Laser 4. Impact lithotripsy |
|
|
What are primary and secondary bladder calculi?
|
1. Primary: endemic in children
2. Secondary: adult men secondary to urinary stasis |
|
|
What is the composition of pediatric bladder calculi?
|
Ammonium acid urate, calcium oxalate or a mixture
|
|
|
How does stone composition in US differ from Europe?
|
US- calcium oxalate are more common
Europe- Uric acid more common |
|
|
Terminal hematuria and stones suggest...
|
Bladder calculi
|
|
|
How is the diagnosis of bladder calculi made?
|
Cystoscopy is the best (b/c many are radiolucent)
|
|
|
How are primary bladder calculi treated?
|
Remove them and change the diet
|
|
|
How are secondary bladder calculi treated?
|
Correct the underlying obstructive lesion and remove the foreign body if appropriate
|
|
|
Is chemodissolution appropriate for bladder calculi?
|
No- it takes way too much time
|
|
|
What dietary advice is appropriate for calcium oxalate stone-formers?
|
1. High fluid intake (#1!)
2. Diet low in oxalates |
|
|
When should a patient be evaluated for metablic risk factors?
|
1. Recurrent stones
2. Single kidney stone in a child |
|
|
What should a metabolic evaluation for stones include?
|
1. 24-hour urine: Na, citrate, oxalate, uric acid, sodium, and creatinine (to ensure proper collection)
2. Serum: Ca, P, BUN, Cr, Uric acid |
|
|
What is a reasonable definition for "idiopathic hypercalciuria"?
|
In men: >300mg/day
In women: >250mg/day OR >4mg/kg/day |
|
|
Can calcium stones be dissolved?
|
No
|
|
|
What country/area has a high incidence of uric acid stones?
|
Israel (and other Middle Eastern countries)
|
|
|
In what other mammal do uric acid calculi form?
|
Dalmations
|
|
|
Why are humans affected by uric acid calculi but not other mammals?
|
Humans don't possess uricase found in other mammals (which changes uric acid--> allantoin which is freely soluble)
|
|
|
What are the 4 categories of uric acid nephrolithiasis?
|
1. Idiopathic uric acid lithiasis: normal serum and urinary levels but chronically low urine pH
2. Hyperuricemia: usually with gout, myeloproliferative d/o, and Lesch-Nyhan syndrome 3. Chronic dehydration 4. Hyperuricosuria without hyperuricosemia |
|
|
What is normal urinary excretion of uric acid?
|
800mg in males
750mg in females |
|
|
What are the 3 factors responsible for uric acid calculi formation?
|
1. Low urine volume
2. Urinary pH (<5.5) 3. Uric acid concentration |
|
|
What is the normal serum levels of uric acid?
|
Male: <7mg/dL
Female: <5.5 mg/dL |
|
|
How are uric acid calculi unique in treatment?
|
They're the most easily dissolved with diet and pharmacologic therapy (hydration and alkalinization with Na bicarb or K citrate)
|
|
|
What does a struvite stone consist of?
|
MAP (Mg, ammonium, phosphate) & carbonate apatite
|
|
|
What % of staghorn calculi are struvite?
|
60-90%
|
|
|
Is it possible to dissolve struvite calculi?
|
Yes- with 10% hemiacidrin irrigation
|
|
|
What is an absolute contraindication for hemiacidrin?
|
Presence of an uncontrolled UTI
|
|
|
The tubular defect resulting in cystine stones affects the reabsorption of what four dibasic amino acids?
|
COLA: (but only cystine is insoluble in urine pH)
1. Cystine 2. Ornithine 3. Lysine 4. Arginine |
|
|
How can cystine stones be prevented?
|
3-4 quarts of oral fluids/day and alkalinize the urine
|
|
|
What is the #1 invasive treatment for cystine stones?
|
Ureteroscopic or percutaneous procedures (least amenable stone for ESWL)
|
|
|
List six causes of acute scrotal swelling in children.
|
1. Testicular torsion
2. Torsion of the appendix testis 3. Epididymo-orchitis 4. Hernia 5. Hydrocele 6. Testis tumor |
|
|
Is the cremasteric reflex present or absent in testicular torsion?
|
Absent (and the testicle is usually high-riding)
|
|
|
What is the difference between intravaginal and extravaginal testicular torsion?
|
Intravaginal occurs WITHIN the tunica vaginalis- tunica vaginalis is not adherent to the surrounding dartos fascia. Extravaginal means that the testis and processus vaginalis and tunica vaginalis torse as a unit.
|
|
|
Which torsion type only occurs in newborns and why?
|
Extravaginal b/c the tunica vaginalis becomes adherent to the dartos fascia within the first weeks of life.
|
|
|
How can the "bell-clapper" deformity be detected on physical exam?
|
The testes have a horizontal lie with the long axis oriented in the AP direction.
|
|
|
How is testicular torsion treated surgically?
|
Bilateral scrotal orchidopexy-- the torsed testis is detorsed and if viable, fixed to the scrotal wall at three points.
|
|
|
How is appendiceal torsion treated?
|
NSAIDs (ibuprofen)... with resolution in 1-2 weeks
|
|
|
What lab test is essential in a patient with acute scrotal swelling (and why)?
|
UA-- significant pyuria is present with epididymitis
|
|
|
What radiographic study should be obtained in a young boy with epididymitis (and why)?
|
Renal ultrasound- b/c an ectopic ureter inserts into the wolffian duct structures and may present with epididymitis. (Detect with hydroureteronephrosis on u/s)
|
|
|
How long before a torsed testicle is no longer salvageable?
|
Usually 6 hours
|
|
|
Pus in the scrotum of a young boy is suggestive of what? (and why?)
|
Appendicitis... b/c the processus vaginalis is patent in young patients (especially premature infants) and is the window into the peritoneum
|
|
|
What exactly is hydronephrosis?
|
Dilatation of the urinary tract
|
|
|
What is the Whitaker test?
|
Pressure perfusion test in which the collecting system of the kidney is percutaneously accessed and fluid is infused at constant rates and pelvic pressures are measured. An increase in pressure suggests the pressure of obstruction to the collecting system.
|
|
|
In a diuretic renal scan, what is the normal washout?
|
<10-15 minutes
|
|
|
When would you see false-positives with a diuretic renal scan?
|
1. Poor renal function
2. Technicalities (timing of administration of the diuretic) |
|
|
What leads to false-negatives with a diuretic renal scan?
|
If the cursor is not over the area of concern
|
|
|
Why was the Whitaker (pressure perfusion) test developed?
|
It was created to distinguish obstructed ureters from nonobstructed ureters in PUV patients. Whitaker developed it in 1973 to confirm his hypothesis that most of these urinary systems were dilated but not obstructed.
|
|
|
What is the normal pressure of the urinary system?
|
Kidneys: <=7 cmH2O (range is up to 15cmH2O with perfusion)
|
|
|
What perfusion rate is used in the Whitaker test?
|
>=10mL/min (to stress at superphysiologic pressures)
|
|
|
What pressures in the Whitaker test suggest obstruction?
|
Intrarenal pressures >22 cm H2O (subtracted pressure, with bladder pressure eliminated)
|
|
|
If in utero hydronephrosis is noted, when should the kidney be evaluated?
|
Ultrasound on day 1 or 2 of life (but caution on interpretation). If not ill and no evidence of PUV, then repeat U/S in 1 month.
|
|
|
What size of the renal pelvis in the newborn is considered abnormal?
|
A renal pelvis >12mm
|
|
|
Name 5 possible treatments for localized CaP?
|
1. Watchful waiting
2. Prostatectomy 3. External beam radiotherapy 4. Brachytherapy 5. Cryoablation |
|
|
What is the temperature at the edge of the "iceball" in prostatic cryosurgery? Is this sufficient for death of cells?
|
0 to -2 Celsius... no, it requires -25 to -50 degrees C for actual cell destruction. So, the edges are spared.
|
|
|
How are most patients with Stage 3 CaP treated?
|
Neoadjuvant hormonal therapy followed by XRT
|
|
|
How can PSA assist in determining recurrent CaP as a systemic relapse?
|
1. Persistently detectable serum PSA immediately after surgery
2. PSA becomes detectable early post-op 3. PSA doubles over a very short amount of time |
|
|
How can PSA assist in determining recurrent CaP as a localized recurrence?
|
1. Prolonged PSA doubling times
2. PSAs which become detectable very far-out from surgery |
|
|
What is used to treat recurrence after radiation-treated CaP?
|
Androgen ablation therapy
|
|
|
What % of CaP is hormone-dependent?
|
70-80%
|
|
|
What are the most common forms of androgen deprivation for metastatic CaP?
|
1. Bilateraly orchiectomy
2. LHRH |
|
|
What drug is used in patients with advanced CaP who present with spinal cord compression or DIC?
|
Ketoconazole b/c it has a rapid onset of action
|
|
|
At what level does ketoconazole work as an androgen ablator?
|
Adrenal
|
|
|
What does "complete" androgen blockade mean?
|
Suppressing BOTH testicular and adrenal androgens (so combining an antiandrogen with LHRH or orchiectomy)
|
|
|
How do antiandrogens work?
|
They competitively bind to the DHT receptor
|
|
|
How should you treat CaP patients with microscopic lymph node involvement after prostatectomy?
|
Early endocrine therapy
|
|
|
How are CaP patients managed who demonstrate a rise in serum PSA after being treated with complete androgen blockade?
|
Stop the anti-androgen (20-30% of these will have a secondary PSA response).
|
|
|
Why does the secondary PSA response occur with anti-androgens?
|
Antiandrogen withdrawal syndrome- anti-androgens stimulate emergence of a hormone-refractory state resulting from mutations in the androgen receptor.
|
|
|
What races predominate with bladder cancer?
|
W>B
|
|
|
What are the agents responsible for smoking as a risk factor for bladder cancer?
|
Alpha and beta-naphthylamine (secreted in urine of smokers)
|
|
|
Name 5 risk factors for bladder cancer.
|
1. Smoking
2. Benzidine 3. 4-aminobiphenyl 4. Cyclophosphamide 5. Physical trauma to urothelium |
|
|
What are some genetic markers heavily associated with bladder cancer?
|
1. Loss of chromosome 9
2. Deleted 17p (p53) 3. Increased expression of p21 (c-Ha-ras) |
|
|
Name the staging used in bladder cancer.
|
Tis
Ta (epithelium) T1 (lamina propria) T2a (superficial muscle) T2b (deep muscle) T3 (perivesical fat or peritoneum) T3a (microscopic) T3b (macroscopic) T4 (invasion of contiguous organs) T4a- prostate, uterus, vagina T4b- abdominal or pelvic wall |
|
|
What is the general histologic categorization of most bladder tumors?
|
98% are epithelial
|
|
|
What is the most common histologic type of bladder tumor and how does it usually appear on cystoscopy?
|
Transitional cell (90%)- Papillary, exophytic lesions
|
|
|
Name 4 uncommon histologic types of bladder cancer.
|
1. Adenocarcinoma (2%)
2. SCC (5-10%) 3. Undifferentiated (2%) 4. Mixed (4-6%) |
|
|
How does SCC of the bladder usually present and what is it associated with?
|
Usually nodular and invasive at diagnosis. Associated with schistosoma haematobium infection.
|
|
|
Name 4 rare epithelial bladder tumors.
|
1. Villous adenoma
2. Carcinoid tumors 3. Carcinosarcoma 4. Melanoma |
|
|
What are the 6 most common cancers that metastasize to the bladder?
|
1. Melanoma
2. Lymphoma 3. Stomach 4. Breast 5. Kidney 6. Lung |
|
|
What is the most common sign associated with bladder cancer?
|
None-- but there may be a palpable mass from muscular thickening
|
|
|
What labs may be present with bladder cancer?
|
1. UA (hematuria & pyuria)
2. CBC (anemia) 3. Urine cytology |
|
|
What imaging is appropriate for diagnosis of bladder cancer?
|
IV urography, cystoscopy and tumor resection
|
|
|
How do you treat Tis and T1 bladder cancer?
|
TUR followed by intravesical BCG (chemo or immunotherapy)
|
|
|
How is T2-T4 bladder cancer treated?
|
Neoadjuvant chemo & radical cystectomy
|
|
|
Name 4 main types of intravesical chemo used for bladder cancer.
|
1. Mitomycin C
2. Thiotepa 3. Doxorubicin 4. BCG |
|
|
How long should intravesical chemo for bladder cancer last?
|
Usually 6 weeks
|
|
|
What is the most common side effects of intravesical chemo?
|
Irritative bladder symptoms
|
|
|
What is the mechanism of mitomycin C?
|
Antibiotic and alkylating agents which inhibits DNA synthesis
|
|
|
What are the main 2 side effects of mitomycin C?
|
1. Irritative bladder symptoms
2. Rash on hands and genitalia in 6% which can be prevented by washing after each cycle |
|
|
What is the mechanism of thiotepa?
|
Alkylating agent
|
|
|
What are the side effects of intravesical thiotepa?
|
1. Mild, self-limited cystitis
2. Myelosuppression (thrombocytopenia and leukopenia) |
|
|
What is the mechanism of doxorubicin?
|
Intercalating agent
|
|
|
What is the main side effect of intravesical doxorubicin?
|
None really except for irritative bladder symptoms
|
|
|
What is intravesical BCG made from?
|
M. bovis
|
|
|
Main side effects of intravesical BCG include:
|
1. Hemorrhagic cystitis
2. Distant infection |
|
|
How do you treat BCG-induced hemorrhagic cystitis or distant infection?
|
INH
|
|
|
When should patients have another cysto after TUR for a bladder tumor?
|
In 3 months (and if clear, another 1 year)
|
|
|
Who are candidates for partial cystectomy?
|
Those with localized disease (T1 to T3) along posterior/lateral wall or dome of bladder (also give time-limited radiation and intravesical chemo too)
|
|
|
What is the gold standard treatment for muscle invasive cancer?
|
Radical cystectomy
|
|
|
What is removed in a radical cystectomy is a man or woman?
|
1. Man: Bladder, perivesical fat and perineal attachments, prostate and seminal vesicles
2. Woman: Bladder, perivesical fat and perineal attachments, uterus, cervix, anterior vaginal vault, urethra, and ovaries |
|
|
Who are candidates for external beam radiation therapy with bladder cancer?
|
Those who are poor surgical candidates
|
|
|
What chemotherapy is used for bladder cancer?
|
1. MVAC (MTX, vinblastine, doxorubicin, cisplatin)
2. Gemcitabine 3. Ifosfamide 4. Paclitaxel 5. Gallium nitrate |
|
|
What is the usual age/sex for ureteral & renal pelvic cancer?
|
65yo M>W
|
|
|
List 5 risk factors for ureteral & renal pelvic cancer.
|
1. Same risks as for bladder cancer
2. Patients with recurrent, superficial/in situ bladder cancer treated with BCG and TUR 3. Balkan nephropathy 4. Excessive analgesic use 5. Thorotrast |
|
|
What is the patient population for ureteral & renal pelvic cancer associated with excessive analgesic use?
|
Young females
|
|
|
What are the 3 most common metastatic sites from ureteral & renal pelvic cancer?
|
1. Lymph nodes
2. Bone 3. Lung |
|
|
What are the usual symptoms associated with ureteral & renal pelvic cancer?
|
1. Hematuria
2. Flank pain (from obstruction 2/2 blood or sloughed tumor) 3. Irritative symptoms |
|
|
What is a sign of ureteral & renal pelvic cancer on IV urography?
|
Goblet sign-- dilation of ureter distal to the lesion
|
|
|
How is ureteral & renal pelvic cancer treated?
|
Nephroureterectomy
|
|
|
How is recurrence of ureteral & renal pelvic cancer treated?
|
BCG or mitomycin C via single or double J ureteral catheters
|
|
|
What is the most common treatment for metastatic bladder and ureteral & renal pelvic cancer?
|
Cisplatin-based chemotherapy
|
|
|
Name 7 benign renal parenchymal tumors.
|
1. Adenoma
2. Oncocytoma 3. Lipoma 4. Leiomyoma 5. Angiomyolipoma 6. Hemangioma 7. Juxtaglomerular tumors |
|
|
How can one tell the difference between renal adenomas and RCC?
|
There is no difference now histologically, clinically or immunohistochemically. Both are removed.
|
|
|
What does renal ococytoma look like histologically?
|
Large epithelial cell with granular, eosinophilic cytoplasm (oncocytes)
|
|
|
Is oncocytoma more common in men or women?
|
Men:Women::2:1
|
|
|
What does renal oncocytoma look like and is it usually U/L or B/L?
|
Central, stellate scar- usually solitary and unilateral but may be multiple/bilateral (oncocytomatosis)
|
|
|
What is Birt-Hogg-Dube syndrome?
|
Involves oncocytoma, benign tumor of hair follicles (fibrofolliculoma), colon polyp/tumor, and pulmonary cysts
|
|
|
What do oncocytomas originate from?
|
Possibly proximal convoluted tubular cells
|
|
|
List 3 angiographic features of oncocytoma.
|
1. Spokewheel appearance of tumor arterioles
2. "Lucent rim sign" of capsule 3. Homogeneous capillary nephrogram phase |
|
|
What disease are angiomyolipomas associated with?
|
Tuberous sclerosis
|
|
|
Name the findings associated with tuberous sclerosis.
|
1. Angiomyolipoma
2. Adenoma sebaceum 3. MR 4. Epilepsy |
|
|
What is the major risk of angiomyolipomas?
|
Rupture with hemorrhage into the retroperitoneum
|
|
|
What is lymphangioleiomyomatosis?
|
1. Multiple renal and hepatic angiomyolipomata
2. Multiple pulmonary cysts 3. Enlarged abdominal LNs 4. Lymphangiomyomas |
|
|
What is used to diagnose angiomyolipomas?
|
MRI (b/c bleeding may mimic angiomyolipomas)
|
|
|
How are angiomyolipomas treated?
|
1. >4cm without sx: semi-annual U/S
2. >4cm with mod/severe sx: renal-sparing surgery or renal artery embolization |
|
|
How is the JG cell tumor different from all other benign renal tumors?
|
It is the only one that causes a symptom (HTN) completely cured by surgery
|
|
|
What findings on lab analysis suggests the diagnosis of JG cell tumor?
|
HTN with secondary hyperaldosteronism and confirmed with selected renal vein sampling for renin
|
|
|
What age, sex, and race predominates in RCC?
|
50-60yo (M:F::2:1)
Blacks>Whites (Asians with lowest incidence) |
|
|
What are 4 main risks for RCC?
|
1. Smoking
2. Asbestos 3. Cadmium 4. Solvents |
|
|
What hereditary syndromes are associated with RCC?
|
1. VHL (chromosome 3)
2. Hereditary papillary RCC (with multiple, bilateral tumors) |
|
|
Describe the findings in VHL.
|
1. RCC (bilateral clear cell)
2. Cerebellar hemangioblastomas 3. Retinal angiomata |
|
|
Where does RCC originate from?
|
Proximal renal tubular epithelium
|
|
|
Where does RCC begin in the kidney (grossly)?
|
1. No preference for kidney side
2. Random distribution in upper and lower poles 3. Begins in the cortex and spreads into perinephric tissue |
|
|
Name 7 histologic types of RCC.
|
1. Conventional clear cell
2. Rhabdoid 3. Papillary (chromophilic) 4. Chromophobic 5. Collecting duct 6. Neuroendocrine 7. Unclassified |
|
|
Name 2 ways in which RCC spreads.
|
1. Direct extension through renal capsule into perinephric fat
2. Direct extension into renal vein |
|
|
Name 7 sites of metastasis of RCC.
|
1. Lung
2. Liver 3. Bone (osteolytic) 4. Ipsilateral LN 5. Adrenal 6. Brain 7. Opposite kidney |
|
|
How is RCC staged?
|
TNM:
T1: Tumor <=7.0cm confined to kidney T2: Tumor >7cm confined to kidney T3a: Tumor extends into adrenal or perinephric tissue (but not beyond Gerota's) T3b: Extends into renal v. or IVC (but not beyond Gerota's) T3c: Extends into vena cava above diaphragm (but not beyond Gerota's) T4: Invades beyond Gerota's fascia |
|
|
How is RCC graded?
|
Furhman classification (Grades 1-4)
|
|
|
What is the classic triad of RCC and what % of patients experience it?
|
10-15%
1. Hematuria 2. Flank pain 3. Palpable mass |
|
|
Name 4 relatively common paraneoplasic syndromes associated with RCC.
|
1. Erythrocytosis
2. Hypercalcemia 3. HTN 4. Non-metastatic hepatic dysfunction (cured by nx) |
|
|
What is the mechanism of paraneoplastic erythrocytosis in RCC?
|
1. EPO from tumor
2. Renal regional hypoxia promotes EPO production elsewhere in kidney |
|
|
What is the mechanism of paraneoplastic hypercalcemia in RCC?
|
PTHrP
|
|
|
What is Stauffer syndrome and what is it secondary to?
|
Non-metastatic hepatic dysfunction in RCC secondary to GM-CSF.
|
|
|
Name 5 laboratory abnormalities found in the paraneoplastic hepatic dysfunction found in RCC (aka Stauffer syndrome)?
|
1. Elevated alk phos
2. Elevated bilirubin 3. Elevated PT 4. Hypoalbuminemia 5. Hypergammaglobulinemia |
|
|
Are the paraneoplastic syndromes in RCC associated with prognosis and if so, how?
|
No they're not (unless they persist after nephrectomy- then it's a terrible prognosis)
|
|
|
What labs should be expected with RCC?
|
1. Anemia
2. Hematuria 3. Elevated ESR |
|
|
What is the gold standard radiograph for RCC?
|
CT (mass enhances with IV contrast but is still low density with low Hounsfield units)
|
|
|
When do you order an MRI with RCC?
|
When you suspect invasion into vasculature
|
|
|
How is RCC treated?
|
Rad nx (remove kidney, adrenal, proximal 1/2 ureter, and lymph nodes)
|
|
|
When is it unnecessary to remove the adrenal in a radical nx for RCC?
|
When the tumor is in the lower pole
|
|
|
What can be done preoperatively the day before a radical nx for RCC?
|
Renal artery embolization
|
|
|
Side effects of renal artery embolization?
|
Post-infarction syndrome: leukocytosis, fever, and flank pain
|
|
|
Who with RCC are candidates for partial nx?
|
Those with tumors <4cm in periphery
|
|
|
How is RCC treated in VHL?
|
Enucleation of tumors
|
|
|
What is a treatment option for RCC in patients who are poor surgical candidates?
|
Cryoablation or RFA
|
|
|
List 4 treatments for disseminated RCC.
|
1. Radical nx (to reduce burden)
2. Radiation 3. Hormonal treatment 4. Biologic response modifiers |
|
|
Name 2 biologic response modifiers used to treat metastatic RCC.
|
1. INF-alpha
2. IL-2 |
|
|
What chemotherapy is used to treat RCC?
|
NONE- it is one of the most chemo-resistant tumors in the body
|
|
|
What is the peak age for nephroblastoma? What sex predominates?
|
3 yo; M=F
|
|
|
What are the GU abnormalities associated with Wilms's tumor?
|
1. Cryptorchidism
2. Hypospadias 3. Renal fusion |
|
|
What is the genetic basis for Wilms?
|
2-hit hypothesis
|
|
|
What are nephrogenic rests?
|
Classification of Wilms' precursor lesions
|
|
|
3 syndromes associated with Wilms'?
|
1. Beckwith-Weidemann syndrome (with hemihypertrophy)
2. Trisomy 18 3. Isolated aniridia |
|
|
List 3 ways that Wilms' tumor spreads.
|
1. Direct extension through renal capsule
2. Hematogenously through IVC or renal vein 3. Lymphatic spread |
|
|
List 3 places that Wilm's tumor spreads to?
|
1. Lungs
2. Liver 3. Lymph nodes |
|
|
What are symptoms associated with nephroblastoma?
|
1. Usually none except a mass
2. Anorexia 3. N/V 4. Fever 5. Abdominal pain/distension 6. HTN |
|
|
What is the initial radiographic study of choice for suspected nephroblastoma?
|
Ultrasound
|
|
|
What are 3 ways to distinguish neuroblastoma from nephroblastoma?
|
1. Neuroblastoma can cross the midline
2. Neuroblastoma may displace kidney downward and outward (drooping lily) 3. Neuroblastoma will have catecholamine (e.g. VMA) |
|
|
How is Wilms' tumor treated?
|
1. Rad nx via transabdominal incision
2. Chemo 3. Radiation |
|
|
Name 4 primary cancers that may metastasize to the kidney.
|
1. Lung
2. Breast 3. Stomach 4. Renal |
|
|
What is cavernosography?
|
Contrast is infused into the corpora cavernosa, and radiographic imaging is performed to document pathways of any venous leakage from the corpora
|
|
|
What is cavernosometry?
|
It measures intracavernosal pressures while saline flow rates needed to obtain and maintain full erection are determined. It evaluates the veno-occlusive mechanisms of the corpora cavernosa.
|
|
|
List 9 therapies for ED.
|
1. Medical therapy
2. Sex therapy (psychogenic) 3. Vaccuum erection devices 4. Intracavernosal injection 5. Intraurethral pharmacotherapy 6. Penile prosthesis implantation 7. Arterial revascularization 8. Penile venous ligation 9. Combined therapy |
|
|
Does sildenafil produce an erection?
|
No- it improves the quality and increases the duration of erections produced by sexual stimulation.
|
|
|
What is intraurethral pharmacotherapy?
|
Alprostadil is placed in the distal urethra and is absorbed into the corpora cavernosa.
|
|
|
How effective is arterial revascularization in the penis?
|
In young men with trauma, it's 70% effective.
|
|
|
Define infertility.
|
Inability of a couple to conceive after 1 year of unprotected intercourse.
|
|
|
Which partner is usually the cause of the infertility?
|
50% male and 50% female
|
|
|
What is the first objective test sought to evaluate the male partner of an infertile couple?
|
Semen analysis
|
|
|
What defines "subfertility" via semen analysis?
|
1. Sperm concentration < 13.5 times 10^6/mL of semen
2. Motility <32% of sperm 3. <9% of sperm with normal morphology |
|
|
What are 8 categories of subfertility causes in the male?
|
1. Varicocele
2. Nonobstructive azoospermia 3. Obstructive azoospermia 4. Oligospermia 5. Asthenospermia (poor motility) 6. Low semen volume or poor morphology 7. Prostatitis 8. Ejaculatory problems |
|
|
What are 3 causes of obstructive azoospermia?
|
1. Congenital absence of the vas deferens
2. Obstruction of vas at level of epididymis due to infection 3. Obstruction at level of ejaculatory ducts due to prostatic cyst |
|
|
What is the most likely cause of non-obstructive azoospermia?
|
Testicular failure
|
|
|
How are varicoceles graded?
|
Grade 1: subclinical (only seen on PE)
Grade 2: Seen on PE but may not be seen on visual exam Grade 3: Large and easily identifiable by visual exam |
|
|
What are 5 methods for managing a varicocele?
|
1. Inguinal approach with ligation of varicose veins
2. Retroperitoneal approach with incision made near ASIS- veins ligated as they exit the internal ring 3. Subinguinal approach- Small incision inferior to external ring and veins ligated here 4. Laparoscopic- ligate veins high in retroperitoneum 5. VIR- Embolize veins by access through femoral vein, vein cannulated in retrograde fashion and embolized with coils |
|
|
How successful is varicocele ligation?
|
95% (without recurrence!)
|
|
|
What should men do prior to radiation treatment for testicular cancer?
|
Bank their sperm!!
|
|
|
Name 2 diseases which may affect fertility.
|
1. Leukemia
2. Lymphoma |
|
|
What is the cardinal sign of testicular failure?
|
FHS elevation 1-3 times normal
|
|
|
How does the physician treat ejaculatory failure?
|
1. Vibratory ejaculation (with vibrator on glans)
2. Electroejaculation (placed in rectum) |
|
|
How is retrograde ejaculation treated with regard to infertility?
|
1. Use drugs that tighten the bladder neck to prevent retrograde movement (e.g. pseudofed)
2. Have patient ejaculate, then collect first-voided sample of urine and use for intrauterine insemination or IVF |
|
|
Describe the autonomic nervous system's effect on micturition.
|
Parasympathetic innervation of the bladder originates in S2-S4 nerve roots and travels via the pelvic nerve or nervi erigents. These nerve fibers stimulate the cholinergic fibers in the bladder, responsible for bladder ctx and emptying.
|
|
|
Describe the autonomic nervous system's effect on bladder storage.
|
Sympathetic innervation begin in T10-L2 and richly supply bladder neck and proximal urethra. Stimulation of SNS causes ctx of alpha fibers of bladder neck, which closes bladder neck and relaxes bladder body, resulting in storage of urine.
|
|
|
How does the somatic nervous system fit into micturition?
|
It provides voluntary control to striated muscle of external urinary sphincter.
|
|
|
Where is the micturition control center located?
|
Brainstem
|
|
|
At what vertebral level does the spinal cord end in adults?
|
Between L1 and L2 vertebrae.
|
|
|
What type of bladder dysfunction is seen in diabetics?
|
Sensory neurogenic bladder- treat with timed voids and double voids.
|
|
|
What is the most common urologic finding in MS?
|
Uninhibited bladder contractions and bladder-sphincter dyssynergia
|
|
|
What are the urologic manifestations after stroke?
|
1. Acute urinary retention
2. After recuperation, urinary urge incontinence (treated with anticholinergics) |
|
|
What is the most consistent urodynamic finding in patients with neurogenic voiding dysfunction secondary to disc disease?
|
Detrusor areflexia
|
|
|
What is autonomic dysreflexia and what are the classic s/sx?
|
Unopposed sympathetic discharge in patients with spinal cord injuries at T6 or above. Patient will experience H/A, sweating, piloerection, HTN and bradycardia.
|
|
|
How is autonomic dysreflexia treated?
|
Drain the bladder and put patient in sitting position. If BP remains high, may use nitroprusside or nifedipine.
|
|
|
What is the ONLY known risk factor for RCC?
|
Smoking
|
|
|
There is an increased incidence of RCC in what 4 diseases?
|
1. VHL
2. Adult PCKD 3. Horseshoe kidney 4. Acquired renal cystic disease from uremia |
|
|
What are the 2 primary staging systems for RCC?
|
1. Robson (easy to use but not good with prognosis)
2. TNM |
|
|
What is essential when operating to remove a RCC with IVC thrombus?
|
Obtain control of IVC ABOVE the thrombus to prevent embolization
|
|
|
What is a pheochromocytoma derived from?
|
Chromaffin cells
|
|
|
Where are most pheos located?
|
90% in adrenal (10% extra-adrenal)
|
|
|
What are extra-adrenal pheochromocytomas called?
|
Paragangliomas
|
|
|
What are 4 syndromes associated with pheochromocytoma?
|
1. MEN II: pheo, medullary thyroid ca, hyperparathyroidism
2. MEN III: pheo, medullary thyroid ca, mucosal neuroma, thickened corneal nerves, alimentary tract ganglioneuromatosis, marfanoid habitus 3. Neurofibromatosis 4. VHL |
|
|
What is the rule of 10s?
|
10% are:
1. Extra-adrenal 2. Bilateral 3. In children 4. Malignant 5. Associated with MEN syndromes |
|
|
What is the most common physical finding of a pheo?
|
HTN (also may show orthostatic hypotension)
|
|
|
What pharmacologic testing can be done to distinguish between pheochromocytoma and essential HTN?
|
1. Clonidine suppression test (will suppress plasma catecholamines to <500pg/mL in essential HTN but will not change pheos)
2. Glucagon stimulation test: will cause increased catecholamines in Pheos with no change in other HTN types |
|
|
3 radiographic ways to localize a pheo?
|
1. CT of abdomen/pelvis (most commonly used)
2. MRI 3. Metaiodobenzylguanidine (MIBG)- accumulates in pheos- useful if the first 2 fail |
|
|
Describe the preoperative management of a pheo.
|
1. Noncompetitive alpha-adrenergic blocker (phenoxybenzamine) for 4 weeks before surgery
2. Vigorous re-hydration |
|
|
What is the biggest problem postoperatively after pheo surgery and how is it managed?
|
1. Hypotension- manage with volume repletion
2. Also, hypoglycemia |
|
|
How should pheo patients be monitored with follow-up after surgery?
|
Annual BP checks for recurrence or metastatic disease
|
|
|
What are the 2 general causes of primary aldosteronism and why is the distinction important?
|
1. Adrenal cortical adenoma (60-80% of cases)
2. Bilateral adrenal hyperplasia (20-40% of cases) The first is treated surgically while the second is treated medically. |
|
|
What is the central sign of primary hyperaldo?
|
HTN
|
|
|
List 4 biochemical features of primary hyperaldo.
|
1. Hypokalemia
2. High plasma aldo 3. Low plasma renin 4. Metabolic alkalosis |
|
|
What are 3 ways to screen for primary hyperaldo?
|
1. Hypokalemia
2. Plasma renin activity (PRA) is usually low (PRA<3.0ng/mL/hr) 3. PA/PRA ratio > 20 (Plasma aldosterone itself is variable) |
|
|
How is the diagnosis of primary aldo confirmed?
|
Demonstrate nonsuppressible aldo secretion during prolonged salt repletion.
|
|
|
What are 3 localization procedures for primary aldo? Which is most accurate?
|
1. CT of adrenals (1st study!)
2. Scintigraphy with radiolabeled iodocholesterol (NP59) differentiates b/w adenoma and hyperplasia 3. Adrenal vein sampling for aldosterone (most accurate localization technique) (ipsi/contra aldo concentration ratio >10 implies adenoma) |
|
|
What is the limitation of CT of adrenals looking for adenomas?
|
Resolution can only pick up adenomas >1.0cm in size
|
|
|
What are indications for surgery with primary hyperaldo?
|
Unilateral adenoma
|
|
|
What surgical approach is used in treating primary hyperaldo secondary to adenoma?
|
Laparoscopic adrenalectomy
|
|
|
What meds are used to treat primary hyperaldo?
|
1. Spironolactone
2. Trimaterene or amiloride |
|
|
Can primary aldo tumors be malignant?
|
Very rarely (<1%)
|
|
|
What is Cushing's Syndrome?
|
Excessive adrenal secretion of corticosteroid with resulting clinical presentation of truncal obesity, buffalo hump, virilization of female, impotence/gynecomastia in male, increased bruising/striae, HTN, osteoporosis, peripheral muscle wasting, and variable mental aberrations.
|
|
|
What is the difference between Cushing's syndrome and Cushing's disease?
|
The disease is secondary to a pituitary adenoma while the syndrome is all-encompassing and may include Cushing's disease as well as an ectopic ACTH-producing tumor or primary adrenal cortical tumor.
|
|
|
Which radiographic imaging tests are indicated in patients with suspected adrenal cortical adenoma or carcinoma?
|
1. U/S
2. MRI 3. CT |
|
|
What are 4 features which distinguish primary adrenal carcinoma from adenoma?
|
Carcinomas...
1. Lesions >6cm 2. Mixed hormonal pattern 3. Markedly elevated urinary 17-ketosteroids 4. Hyperintense signal from mass upon T2-weighted MRI |
|
|
What is the treatment for Cushing's disease?
|
Transsphenoidal hypophysectomy
|
|
|
What treatment options are available for patients with adrenal cortical carcinoma?
|
Complete surgical excision (not sensitive to chemo or radiation)
|
|
|
What is the prognosis for treated adrenal cortical carcinoma?
|
Poor
|
|
|
What is the standard diagnostic regimen for renal pelvic TCC?
|
1. IVP
2. Retrograde pyleography 3. Ureteroscopy 4. Selective upper urinary tract cytology studies |
|
|
What was the old staging system for TCC of the renal pelvis?
|
Batata system (now we use the TNM)
|
|
|
Is radiation effective in TCC of the renal pelvis?
|
No
|
|
|
Do hereditary forms of Wilms' present at an earlier or later age than sporadic forms?
|
Earlier age
|
|
|
What is the major pathologic event thought to account for development of Wilms tumor?
|
Arises from abnormal proliferation of metanephric blastema without differentiation into glomeruli and tubules.
|
|
|
What are the microscopic characteristics of Wilms tumor?
|
The tumor is triphasic:
1. Blastemal components (nephrogenic cells with tubuloglomerular pattern) 2. Stromal component 3. Epithelial component |
|
|
The Wilms tumor suppressor gene has been localized to which chromosome?
|
11p13
|
|
|
What is listed on the nonrenal ddx of childhood abdominal masses?
|
1. Mesenteric and choledochal cysts
2. Intestinal duplication cysts 3. Splenomegaly 4. Neuroblastoma 5. Rhabdomyosarcoma 6. Lymphoma 7. Hepatoblastoma |
|
|
What is listed on the renal ddx of childhood abdominal masses?
|
1. Wilms
2. Multicystic dysplastic kidney 3. Hydronephrosis 4. Polycystic kidney 5. Congenital mesoblastic nephroma |
|
|
What is WAGR syndrome?
|
1. Wilms
2. Anirida 3. GU anomalies 4. Retardation (MR) |
|
|
What is the Beckwith-Wiedemann syndrome?
|
1. Visceromegaly (adrenal cortex, kidney, liver, pancreas, gonads)
2. Hemihypertrophy 3. Omphalocele 4. MR 5. Microcephaly 6. Macroglossia 7. 10% with neoplasms |
|
|
After ultrasound and CT of contralateral kidney, what other radiologic studies would be next to assess Wilms tumor?
|
CXr or chest CT to check for pulmonary metastases
|
|
|
What are 3 unfavorable histologic subtypes of Wilms tumor?
|
1. Anaplastic
2. Rhabdoid (most lethal) 3. Clear cell sarcoma (mets to the brain) |
|
|
What is a congenital mesoblastic nephroma?
|
Renal tumor presenting early in infancy with male predilection. Resembles a leiomyoma. Benign course once it is completely excised.
|
|
|
What are nephrogenic rests and how are they subdivided?
|
Abnormally persistent nephrogenic cells that can be induced to form a Wilms tumor. They are subdivided into perilobular (peripheral) and intralobular (central) rests.
|
|
|
What is the most important prognostic determinants in children with Wilms?
|
Histopathology
|
|
|
What are the 4 most common sites of mets for Wilms? (in order of decreasing frequency)
|
1. Lungs
2. Liver 3. Bone 4. Brain |
|
|
What is the preferred initial surgical approach for Wilms?
|
Transverse supraumbilical transperitoneal incision.
|
|
|
What happens if a Wilms tumor is unresectable?
|
Preop chemo then renal exploration
|
|
|
What 3 chemo agents are most effective in Wilms patients?
|
1. Actinomycin D
2. Vincristine 3. Doxorubicin |
|
|
What is the initial treatment of a child with suspected Wilms who presents with pulmonary mets?
|
Radical nephrectomy
|
|
|
What is the incidence of bilateral Wilms?
|
5%
|
|
|
What is the incidence of secondary neoplasm following treatment for Wilms with radiotherapy?
|
17%
|
|
|
What is the treatment for bilateral Wilms?
|
Get a biopsy and determine if favorable or unfavorable. Start chemo and then surgical exploration after tumor has shrunk.
|
|
|
Does Wilms have a good prognosis?
|
In general yes- with 80-97% survival. (but 55% if unfavorable histology and stage IV disease)
|
|
|
What % of all primary testicular tumors are germ cell origin?
|
90-95%
|
|
|
What are the two groups of germ cell testicular tumors?
|
Seminoma & non-seminoma
|
|
|
What are the non-germ cell testicular tumors?
|
Leydig cell, Sertoli cell and gonadoblastoma
|
|
|
Is one side more common than the other with testicular cancer?
|
Yes- R side is slightly more common than the L (which parallels the increased incidence of cryptorchidism on the R)
|
|
|
What % of testicular tumors occur in men with h/o cryptorchidism?
|
50%
|
|
|
What is the most common bilateral tumor of the testis?
|
Lymphoma
|
|
|
What is the most common primary bilateral testicular tumor?
|
Seminoma (also the most common among cryptorchid men)
|
|
|
Does placement of the cryptorchid testis into the scrotum alter the malignant potential of the testis?
|
No- it just facilitates exam and tumor detection
|
|
|
What are some risk factors for testicular tumor?
|
1. Cryptorchid testis
2. Mom taking estrogen during pregnancy 3. Trauma 4. Infection-related testicular atrophy |
|
|
What are the different types of nonseminomatous germ cell tumor?
|
1. Embryonal
2. Choriocarcinoma 3. Teratoma 4. Mixed tumors |
|
|
Why do 10-15% of seminomas produce hCG?
|
Because 10-15% will have syncytiotrophoblast
|
|
|
What are the three histologic subtypes of seminoma? Which has the worst prognosis stage for stage?
|
1. Classic
2. Anaplastic 3. Spermatocytic (All have same prognosis stage for stage) |
|
|
What age is classic seminoma most common?
|
4th decade
|
|
|
What age is most common for spermatocytic seminoma?
|
>50yo
|
|
|
What are the two variants of embryonal cell carcinoma?
|
1. Adult type
2. Infantile type (aka yolk sac tumor aka endodermal sinus tumor) |
|
|
What is the most common testicular tumor found in infants and children?
|
Yolk sac tumor
|
|
|
Which testicular tumor produces AFP?
|
Yolk sac tumor
|
|
|
Within the category of mixed cell type testicular tumors, what is the most common mix?
|
Teratocarcinomas (combined teratoma and embryonal cell carcinoma)- up to 25% of all testicular tumors
|
|
|
How is CIS of the testis managed?
|
EBRT
|
|
|
How do germ cell tumors of the testis usually spread? What is the exception to this?
|
Usually lymphatogenously. Choriocarcinomas behave aggressively and spread hematogenously.
|
|
|
Lymph nodes of the testis are concentrated where?
|
At the kidney hilum b/o common embryologic origin
|
|
|
Where is the primary landing site for the R testis lymph nodes? For the L?
|
R: interaortocaval area at R renal hilum
L: para-aortic area at level of L renal hilum |
|
|
Can there be R to L or L to R crossover mets with testicular tumors?
|
R to L yes but no L to R
|
|
|
What are 8 common sites of metastatic disease from testicular cancer in decreasing order of frequency?
|
1. Lung
2. Liver 3. Brain 4. Bone 5. Kidney 6. Adrenal 7. GI tract 8. Spleen |
|
|
Which testicular tumor has a predilection for the spleen?
|
Choriocarcinoma
|
|
|
What is the TNM staging for testicular tumors?
|
Tis: Intratubular cancer (CIS)
T1: Limited to testis and epididymis, no vascular invasion T2: Invades beyond tunica albuginea or has vascular invasion T3: Invades spermatic cord T4: Invades scrotum |
|
|
What is the most common metastatic symptom with testicular cancer?
|
Back pain
|
|
|
Is AFP ever found in seminomas?
|
NO!
|
|
|
Besides AFP and hCG, what are 3 other tumor markers in testicular tumors and for which ones?
|
1. LDH- correlates with tumor burden in NSGCTs and also in some seminomas.
2. Placental Alk phos (PLAP) 3. Gamma-glutamyl transpeptidase (GGT) |
|
|
What imaging is used if testicular cancer is suspected?
|
1. Scrotal U/S
2. CT to look for mets in lung and retroperitoneum |
|
|
What is the most common misdiagnosis in patients with testis cancer? 2nd most common?
|
1. Epididymitis or epidiymoorchitis (#1)
2. Hydrocele (#2) |
|
|
How is suspected testicular cancer treated?
|
Inguinal exploration with cross-clamping of the spermatic cord vasculature and delivery of the testis into the field, followed by radical orchiectomy
|
|
|
How is low-stage seminoma (I, IIA) managed?
|
Radical orchiectomy plus radiation (exquisitely radiosensitive)
|
|
|
How is relapsing low-stage seminoma treated?
|
Salvage chemotherapy
|
|
|
How is high-stage seminoma (IIB, III) managed?
|
Chemotherapy with platinum-based therapy
|
|
|
What is the standard management for low-stage nonseminomatous germ cell tumors?
|
1. RPLND
2. Modified RPLND 3. Watchful waiting |
|
|
How are patients with high-stage NSGCTs managed?
|
Primary platinum-based combo chemo following orchiectomy
|
|
|
What % of testis tumors are non-germ cell tumors?
|
5-6%
|
|
|
What is the most common non-germ cell tumor of the testis?
|
Leydig cell tumors
|
|
|
What age groups present with Leydig cell tumors?
|
Bimodal (5- to 9-yo & 25- to 35-yo)
|
|
|
Reinke crystals are pathognomonic for...
|
Leydig cell testicular tumor
|
|
|
How do prepubertal children and adults with Leydig cell testicular tumors present?
|
Children: Virilization (and tumors are usually benign)
Adults: asymptomatic but some with gynecomastia |
|
|
What are common lab findings with Leydig cell tumors?
|
Elevated serum and urinary 17-ketosteroids and estrogens
|
|
|
What is the treatment for Leydig cell testicular tumors?
|
Radical orchiectomy, RPLND if malignant
|
|
|
How is the prognosis for Leydig cell tumors?
|
Great if benign; poor if disseminated
|
|
|
What ages get Sertoli cell tumors?
|
<=1yo and 20- to 45-yo
|
|
|
What % of sertolic cell testicular tumors are malignant?
|
10%
|
|
|
Management of Sertoli cell tumors?
|
Same as Leydig cell tumors (radical orchiectomy, then RPLND if malignant)
|
|
|
What patient population gets gonadoblastoma of the testis?
|
Those with some form of gonadal dysgenesis- usually occur <30yo
|
|
|
What are the 3 cell types seen with gonadoblastoma of the testis?
|
1. Sertolic cells
2. Interstitial cells 3. Germ cells |
|
|
What fraction of patients with gonadoblastoma are phenotypic females?
|
4/5
|
|
|
What GU abnormality occurs with men with gonadoblastoma?
|
Cryptorchidism or hypospadias
|
|
|
Treatment of choice for gonadoblastoma?
|
Radical orchiectomy (contralateral recommended too b/o high incidence of bilaterality-50%)
|
|
|
What are 3 categories of secondary testicular tumors?
|
1. Lymphoma
2. Leukemia 3. Metastatic tumors |
|
|
What are the common features of lymphoma testicular tumor?
|
Hemorrhage and necrosis
|
|
|
In lymphomatous testicular tumors, what % are bilateral?
|
50%
|
|
|
Treatment of lymphomatous testicular tumor?
|
Radical orchiectomy
|
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|
The testis is a common site of relapse for children with...
|
ALL
|
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|
What is the diagnostic procedure of choice for leukemic infiltration of the testis?
|
Biopsy (not orchiectomy)-- then treat with irradiation and adjuvant chemo
|
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|
What are the 5 most common cancers which met to the testis?
|
1. Prostate
2. Lung 3. GI tract 4. Melanoma 5. Kidney |
|
|
List the 4 most common sites of extragonadal germ cell tumors (in decreasing order).
|
1. Mediastinum
2. Retroperitoneum 3. Sacrococcygeal area 4. Pineal gland |
|
|
Metastatic spread of extragonadal germ cell tumors is to where?
|
1. Regional LNs
2. Lung 3. Liver 4. Bone 5. Brain |
|
|
How are extragonadal germ cell tumors treated?
|
Same as testicular tumors:
1. Low-volume seminoma: radiotx 2. High-volume seminoma: primary chemo |
|
|
What are the 2 most common types of epididymal tumor and what ages do they present? Also, what initial symptoms?
|
1. Adenomatoid tumors- 3rd and 4th decade- asymptomatic
2. Leiomyomas- painful and associated with a hydrocele |
|
|
Which epididymal tumor occurs in association with VHL?
|
Cystadenomas- bilateraly in 30%
|
|
|
What is leukoplakia of the penis and who gets it?
|
Rare condition with white plaque involving the meatus (considered a precancerous lesion). Most commonly occurs in diabetics.
|
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|
Name 3 precancerous penile lesions.
|
1. Leukplakia
2. Balanitis xerotica obliterans 3. Giant condylomata acuminata |
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|
What are 2 types of CIS of the penis?
|
1. Bowen disease
2. Erythroplasia of Queyrat |
|
|
What is Bownen disease and what is its usual appearance?
|
SCC in situ involving penile shaft- red plaque with encrustations.
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What is Erythroplasia of Queyrat and what is its usual appearance?
|
Velvety,red lesion with ulcerations typically involving the glans.
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|
What composes most penile invasive cancers?
|
SCC (verrucous carcinoma is a variant of SCC, and this also occurs)
|
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|
Where are most penile cancers located?
|
1. Glans (most common)
2. Prepuce 3. Shaft |
|
|
How are penile cancers disseminated?
|
Via lymphatic channels ot femoral and iliac nodes
|
|
|
Where does penile carcinoma metastasize?
|
1. Lung
2. Liver 3. Bone 4. Brain |
|
|
How is penile cancer staged?
|
Stage I: Confined to glans/prepuce
Stage II: Involves penile shaft Stage III: Operable inguinal node metastasis Stage IV: Tumor extends beyond penile shaft with inoperable inguinal or distant metastases |
|
|
What represents a barrier for hematogenous spread of penile cancer?
|
Buck's fascia
|
|
|
To which lymph nodes do the shaft and prepuce drain?
|
Superficial inguinal nodes (superficial to fascia lata) --> pelvic nodes
|
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|
To which lymph nodes do the glans and corporal bodies drain?
|
Deep inguinal nodes (deep to the fascia lata) --> pelvic nodes
|
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|
What lab findings may be present with penile cancer?
|
Usually none... but with mets:
1. Anemia 2. Leukocytosis 3. Hypercalcemia (in absence of osseous mets) |
|
|
What imaging is required with penile carcinoma?
|
1. CXR
2. Bone scan 3. CT scan abd/pelvis |
|
|
How is invasive penile carcinoma treated?
|
1. If involving prepuce: simple circumcision
2. If involving glans or distal shaft: partial penectomy with 2cm margins 3. If involving proximal shaft: complete penectomy with perineal urethrostomy |
|
|
How is penile CIS treated?
|
Fluorouracil cream or neodymium:YAG laser treatment
|
|
|
With regard to penile cancer, does inguinal node enlargement usually mean metastasis?
|
Not actually-- up to 50% will have enlargement from inflammation-- give these people 4-6 week course of broad spectrum abx
|
|
|
How do lymph nodes direct penile cancer treatment?
|
1. If clinically negative LN and Tis or T1 stage: observe
2. If clinically palpable LN: 1st try 4-6 weeks abx, if persist, ilioinguinal LND 3. If clinically negative LN at higher stage (T2-T4), limited node sampling (if negative, observe; if positive, LND) |
|
|
What are the 4 chemo agents shown to have activity against penile carcinoma?
|
1. Bleomycin
2. MTX 3. Cisplatin 4. 5-FU |
|
|
Name 4 very rare penile tumors (not SCC)?
|
1. Melanoma
2. Basal cell ca 3. Kaposi sarcoma (painful papule with blue-purple color) 4. Paget disease |
|
|
What is the most common tumor of the scrotum?
|
Sebaceous cyst
|
|
|
What is the most common malignant tumor of the scrotum?
|
SCC
|
|
|
Is resection of the scrotal contents necessary in scrotal cancer?
|
Not usually
|
|
|
What indicates prognosis in scrotal cancer?
|
Presence or absence of nodal involvement
|
|
|
Where is the most common site for stoma placement in urinary diversion?
|
Along a line between the ASIS and umbilicus at the lateral edge of the rectus abdominis
|
|
|
What is the most common form of urinary diversion in the United States?
|
Ureteroileal urinary diversion
|
|
|
What segment of ileum is taken for ureteroileal urinary diversion?
|
Segment approximately 15-20cm proximal to the ileocecal valve
|
|
|
If the colon were to be used for urinary conduits, what part is best?
|
Sigmoid colon or transverse colon
|
|
|
Can the ureters be implanted directly into the colon (without a stoma)?
|
Yes-- a submucosal tunnel in the colonic wall is created to prevent ureteral reflux of urine
|
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|
What is one worrisome complication of ureterosigmoidostomy (in which the ureters are reimplanted into the sigmoid colon taenia coli)?
|
The development of adenocarcinoma at the site of reimplantation
|
|
|
What followup is required of patients who undergo ureterosigmoidostomy?
|
Annual sigmoidoscopy starting 5 years after the procedure
|
|
|
What are some late complications of bladder substitution?
|
1. Stones
2. Metabolic disorders 3. Stomal stenosis 4. Pyelonephritis 5. Spontaneous neobladder rupture (rare) |
|
|
If the jejunum is used in constructing a neobladder, what metabolic abnormality results?
|
Hyponatremic, hypochloremic, hyperkalemic, metabolic acidosis
|
|
|
How should one test for pyelonephritis in a patient with urinary diversion (stoma)?
|
Take off the pouch, clean stoma with antiseptic, and get a catheterized specimen
|
|
|
Why do stones form in patients who undergo urianry diversion or bladder substitution?
|
1. Nonabsorbale staples, sutures, and mesh may act as a nidus
2. Colonization of bacteria is more common- resulting in infection stones 3. Hypercalciuria and alkaline urine predipose. 4. Excess bile salts bind calcium and result in increased oxalate absorption. 5. Patients have hypocitrauria |
|
|
When do tissues express radiation damage?
|
When the target cells enter mitosis
|
|
|
What are the typical units used in radiation?
|
Gray units (100 rads= 1 Gy)
|
|
|
What is the median age of diagnosis for neuroblastoma?
|
22 months
|
|
|
Where do neuroblastomas occur?
|
Anywhere in the neuroectodermal chain (50% arise in the adrenal medulla, and most others along the sympathetic chain in the abdomen or mediastinum)
|
|
|
What is the histologic appearance of neuroblastoma?
|
"Small blue tumors of childhood"- with pseudorosettes of one or two layers of neuroblasts surrounding pink material
|
|
|
How is the initial presentation of neuroblastoma different from Wilms tumor?
|
Neuroblastoma often has systemic symptoms like fever, abdominal pain, mass, weight loss, anemia, bone pain and periorbital ecchymosis and proptosis
|
|
|
What radiographs are ordered for the work-up of neuroblastoma?
|
1. Ultrasound
2. CT or MRI to further charactize or stage the lesion |
|
|
Where are the most likely sites for metastasis from neuroblastoma?
|
1. Regional and distant LNs
2. Bone marrow 3. Cortical bone 4. Liver 5. Skin |
|
|
List 3 biochemical markers of prognostic significant in neuroblastoma.
|
1. Urinary ratio of VMA/HMA (inverse relationships between ratio and survival)
2. Serum ferritin (bad if elevated) 3. Serum neuron-specific enolase (bad if elevated) |
|
|
The amplification of what oncogene indicates poor prognosis with neuroblastoma?
|
N-myc
|
|
|
What is an MIBG scan?
|
Very sensitive test for detecting neuroblastomas (and also occasionally helpful in distinguishing them from Wilms)
|
|
|
How are patients with Stage 4S neuroblastoma treated?
|
Nothing
|
|
|
What is the Bosniak classification?
|
CT criteria to differentiate renal cysts from RCC. Types I-IV with I being completely benign and IV being 90% malignant.
|
|
|
What is Type II Bosniak classification?
|
Few internal septations, thin peripheral calcifications, or attenuation value >20 HUs on CT. Almost always benign but 10-15% carcinoma.
|
|
|
What is Type III Bosniak classification?
|
May have internal debris, thick walls or septations, or irregular calcifications. 40-50% are malignant.
|
|
|
What is Type IV Bosniak classification?
|
Lesions are complex cystic masses with enhancing nodular elements and are considered RCC until proven otherwise. Incidence of cancer approaches 90%.
|
|
|
What is Type I Bosniak classification?
|
Seen on CT or U/S- requires no further management
|
|
|
How do renal cysts appear on ultrasound?
|
Smooth-walled, anechoic, demarcated from surroudning parenchyma.
|
|
|
How do renal cysts appear on IV urography?
|
Mass effect and may distort renal outline or collecting system.
|
|
|
On angiography, are simple cysts vascular?
|
Yes
|
|
|
How do oncocytomas look like grossly?
|
Well-circumscribed with mahogany-brown surface.
|
|
|
What is the most common primary retroperitoneal tumor? What are some other tumors?
|
1. Liposarcoma (predominates)
2. Leiomyosarcoma 3. Fibrosarcoma 4. Neurogenic sarcoma |
|
|
With respect to ureteral tumors, are all parts of the ureter affected with equal frequency?
|
No- the proximal ureter is less likely to be involved while the distal ureter is more common.
|
|
|
How is the diagnosis of a ureteral tumor made?
|
IVP showing a filling defect
|
|
|
How does one differentiate a ureteral tumor from a calculus?
|
Ultrasound or CT (CT is better)
|
|
|
Is urine cytology helpful in diagnosing ureteral tumors?
|
Not really because of its high false negative rate
|
|
|
What is the single most accurate way to diagnose ureteral tumor?
|
Upper tract endoscopy with semi-rigid or flex ureteroscopes. May even biopsy at this time or get cytology with a brush
|
|
|
What is the staging for ureteral tumors?
|
The same as for the bladder.... T1: confined to lamina propria
T2, T3a: Muscularis Teb and T4: periureteral tissue or LN involvement |
|
|
Can you remove just part of the ureter if the ureteral tumor is in the proximal or mid-ureter?
|
No- b/c the risk of ipsilateral recurrence is highest if you leave the ureter BELOW the level of the tumor
|
|
|
Are they any roles for radiation or chemo in ureteral cancer?
|
Radiation- not really
Combo chemo helpful in advanced invasive disease |
|
|
Name 8 proliferative lesions in bladder urothelium which may be confused with TCC.
|
1. Epithelial hyperplasia
2. Atypical hyperplasia 3. Inverted papilloma 4. Cystitis cystica 5. von Brunn's nests 6. Cystitis glandularis 7. Nephrogenic adenoma 8. Squamous metaplasia |
|
|
What are von Brunn's nests?
|
Islands of benign-appearing urothelium residing the submucosa and resulting from inward proliferation of the basal cell layer. Normal variant of urothelial histology
|
|
|
What are inverted papilloma and nephrogenic adenoma?
|
Both are benign lesions that occur in the bladder urothelium secondary to trauma or infection.
|
|
|
What markers in voided urine help in detection of TCC of the bladder?
|
1. Bladder tumor antigen
2. NMP22 3. Telomerase |
|
|
What is the risk of developing upper tract TCC after diagnosis of bladder TCC? And vice versa, the risk of developing bladder TCC after upper tract TCC?
|
5% risk of developing upper tract TCC (after bladder ca)
40-70% riks of developing bladder TCC (after upper tract TCC) |
|
|
What are the commonest sites of metastasis from invasive TCC?
|
1. Lymphatic: pelvic LN (obturator, external iliac, paravesical, and common iliac)
2. Hematogenous: liver, lung, bone, adrenal and bowel |
|
|
What are the most popular forms of urinary diversion after radical cystectomy?
|
1. Ileal (or Bricker) conduit- simplest and least prone to complication.
2. Continent urinary diversion |
|
|
What are the most popular forms of continent urinary diversions?
|
1. Indiana pouch
2. Kock pouch 3. Orthotopic diversions (pouches from ileum, colon or both are anastamomsed to the urethra) |
|
|
What are the different types of prostate cancer?
|
1. Adenocarcinoma (#1)
2. TCC 3. Sarcoma |
|
|
Name 4 variations of prostatic adenocarcinoma.
|
1. Neuroendocrine
2. Endometrioid 3. Small cell 4. Mucinous |
|
|
What is the most common malignancy diagnosed in American men?
|
CaP
|
|
|
In which portion of the prostate does cancer typically form?
|
Usually the peripheral zone (70%). 20% occur in the transition zone and 10% in the central zone.
|
|
|
What is PSA?
|
A serine protease of the kallikrein family- associated with liquefying semen.
|
|
|
Describe the staging used in CaP?
|
T1: Clinically apparent tumor not palpable or visible by imaging
T1a: Incidental finding in <=5% from TURP T1b: Incidental finding in >5% from TURP T1c: Identified by needle biopsy after elevated PSA T2: Palpable tumor confined to the prostate T2a: Involves one lobe T2b: Involves both lobes T3: Tumor extends beyond prostatic capsule T3a: Extracapsular extension T3b: Tumor invades seminal vesicles T4: Tumor fixed or invades adjacent structures other than seminal vesicles |
|
|
What PSA level would necessitate a bone scan?
|
PSA >20
|
|
|
What is salvage prostatectomy?
|
Performed in patients in whom radiation therapy has failed.
|
|
|
How do LHRH analogs function in CaP?
|
They reduce LH levels and therefore interfere with secretion of testosterone by the Leydig cells.
|
|
|
What is total androgen blockade?
|
The use of both LHRH analogs as well as anti-androgens. So, they not only interfere with testosterone production but also with the binding of DHT to a specific receptor.
|
|
|
Why does endocrine therapy work for CaP?
|
Because the malignant prostatic cell requires testosterone for growth.
|
|
|
What binds the prostate laterally?
|
The levator muscles
|
|
|
What does the prostate do?
|
It provides the bulk of the ejaculate and its secretions include nutrients for sperm cells and proteases (which function to liquefy the ejaculate).
|
|
|
How is testosterone metabolized by the prostate?
|
Free testosterone enters the prostate via passive diffusion and then gets converted to DHT by 5-alpha-reductase.
|
|
|
Which zone is most affected with BPH?
|
The transition zone
|
|
|
What scoring system is used to grade BPH?
|
the International Prostate Symptom Score (IPSS) developed by the AUA
|
|
|
What are the 7 questions posed in the IPSS for BPH?
|
1. Incomplete emptying
2. Frequency 3. Intermittency 4. Urgency 5. Weak stream 6. Straining |
|
|
Why are alpha-blocking agents effective in treating patients with BPH?
|
Alpha-receptors are located in the trigone of the bladder and fibromuscular stroma of the prostate. The muscle in both relax under alpha-blockade.
|
|
|
What electrolyte abnormality may occur after TURP and why?
|
Hyponatremia (because of absorption of irrigating fluids)
|
|
|
List the 4 most common premalignant lesions of the penis.
|
1. Leukoplakia
2. Erythroplasia of Queyrat 3. Balanitis xerotica obliterans 4. Buschke-Lowenstein tumor |
|
|
What is the most commonly used staging system for carcinoma of the penis?
|
The Jackson staging system
|
|
|
What is the single most important prognostic factor in penile carcinoma?
|
Status of the inguinal nodes
|
|
|
What treatment is recommended for Jackson stage 4 penile carcinoma?
|
Palliative radiotherapy and/or chemotherapy (usually a single-agent like MTX, cisplatin or bleomycin)
|
|
|
What 3 premalignant lesions of the penis are associated with HPV?
|
1. Condyloma acuminatum
2. Bowenoid papulosis 3. Buschke-Lowenstein tumors |
|
|
Define Buschke-Lowenstein tumor.
|
AKA giant condyloma- similar to condyloma acuminatum in appearance but may cause invasive erosion into the surrounding tissue. Treat with surgical excision
|
|
|
What is Moh's micrographic surgery?
|
Surgical technique of removing layers of malignant cutaneous tissue for excision
|
|
|
Is MMS indicated in the treatment of penile cancer?
|
In patients with small distal lesions, it has cure rates approaching partial penectomy
|
|
|
Most urethral cancers in both sexes are of what type?
|
SCC
|
|
|
How do male and female urethral cancer histology compare?
|
Both are usually SCC. But in men, it may be TCC near the prostate and in women, it may be TCC near the bladder. Adenocarcinoma accounts for 10-15% of cancer in women and is a poor prognosis. Adeno is uncommon in males.
|
|
|
What is the only known etiologic factor for urethral cancer?
|
Chronic irritations (urethral stricture in men & urethral diverticulae in women)
|
|
|
Most common symptoms associated with urethral cancer?
|
Hematuria or urethral bleeding
|
|
|
What is the best way to diagnose urethral cancer?
|
Cystoscopy (may also do MRI/CT, Cxr, and bone scan for mets)
|
|
|
What is the treatment for female urethral cancer?
|
1. Low-grade, low-stage: resection, fulguration, laser ablation
2. High-grade: Anterior exenteration with wide excision of vaginal wall |
|
|
What is the treatment for male urethral cancer?
|
1. Low-grade, low-stage: Resection, fulguration, laser ablation
2. Distal, High-grade: Partial penectomy 3. Proximal, High-grade: Aggressive surgical removal of penis, pubis, prostate and bladder |
|
|
What is anatomic incontinence (genuine stress incontinence) usually secondary to?
|
Hypermobility of the vesicourethral segment owing to pelvic floor weakness.
|
|
|
What are the basic features of true urge incontinence?
|
Detrusor instability with normal sphincteric component, normal anatomy, and no neuropathy
|
|
|
What are 3 types of neuropathic incontinence?
|
1. Active (detrusor hyperreflexia)
2. Passive (sphincteric atony) 3. Mixed |
|
|
What are the causes of congenital incontinence?
|
Ectopic ureters (duplicate or single system) with episapdias, exstrophy or cloacl malformations
|
|
|
What is false incontinence?
|
Overflow incontinence due to an obstructive or neuropathic lesion.
|
|
|
What may cause traumatic incontinence?
|
Fractured pelvis or surgical damage to sphincter during bladder neck resection or extensive internal urethrotomy.
|
|
|
The striated external sphincter provides what % of the static urethral resistance responsible for continence?
|
50%
|
|
|
Which nerve supplies the voluntary external sphincter component of continence?
|
Pudendal
|
|
|
Which nerves supply the smooth sphincteric elements of continence?
|
The pelvic nerves
|
|
|
Is the urethral length changed in genuine stress incontinence?
|
No-- but the functional length is
|
|
|
What part of the urethra has the functional loss of length?
|
Proximal urethral segment
|
|
|
How should the patient with GSI be examined?
|
Standing with a full bladder
|
|
|
What is the principal treatment for GSI?
|
Proper suspension and support of the vesicourethral segment in a normal position
|
|
|
What is the suprapubic approach to GSI?
|
Marshall-Marchetti-Krantz (MMK) retropubic suspension
|
|
|
What is the Burch modification for GSI?
|
Anterior vaginal wall is fixed to Cooper's ligament
|
|
|
What is the most popular sling procedure?
|
Anterior rectus sheath sling (mcGuire) and tension free vaginal tape
|
|
|
Active neuropathic incontinence is due to what kind of lesion?
|
UMN
|
|
|
Passive neuropathic incontinence is usually associated with lesions involving...
|
Micturition center or more distal lesions
|
|
|
Failure of reservoir function may be found in patients with what condition?
|
Myelomeningocele (or LMN lesions)
|
|
|
What are the 3 categories for treating reservoir dysfunction?
|
1. Anticholinergic drugs (e.g.oxybutynin)
2. Antihistaminic drugs 3. Musculotropic relaxants (e.g. flavoxate) |
|
|
Name 4 common anticholinergic drugs used to treat reservoir dysfunction in neuropathic incontinence.
|
1. Oxybutynin (ditropan)
2. Tolterodine (detrol) 3. Imipramine (tofranil) 4. Propantheline bromide (pro-banthine) |
|
|
Why does imipramine work on neuropathic bladder?
|
Because it has anticholinergic antimuscarinic properties
|
|
|
Why do antihistaminic drugs work to treat reservoir dysfunction in neuropathic bladder?
|
Because they antagonize the histamine-mediated release of ACh to produce an anticholinergic effect
|
|
|
What is an example of a musculotropic relaxant used to treat reservoir dysfunction in neuropathic incontinence?
|
Flavoxate
|
|
|
Besides pharmacologic management, what is a non-invasive way to treat neuropathic incontinence?
|
Intermittent self-cath
|
|
|
List 6 methods of surgical management for reservoir dysfunction in neuropathic incontinence.
|
1. Sphincterotomy
2. Bladder augmentation 3. Artificial sphincter 4. Continent urinary diversion 5. Neurostimulation 6. Dorsal rhizotomy |
|
|
What tumor specific antigens have been identified for CaP?
|
1. PSA
2. Prostatic acid phosphatase 3. Prostate-specific membrane Ag (PSMA) |
|
|
What tumor specific antigens have been identified for RCC?
|
None
|
|
|
What tumor specific antigens have been identified for bladder cancer?
|
1. Beta-hCG
2. Carcinoembryonic antigen (CEA) |
|
|
What tumor specific antigens have been identified for germ cell tumors?
|
1. hCG
2. AFP |
|
|
AFP is pathognomonic for what tumor?
|
Nonseminomatous germ cell tumor
|
|
|
How are germ cell tumors risk-stratified?
|
By how much tumor specific antigen (AFP and hCG) they produce
|
|
|
What monoclonal antibody (already used succesfully for another cancer) is now being investigated for its use with TCC?
|
Anti-HER2-neu
|
|
|
In what CMI cells does the specificity of tumor rejection reside?
|
T lymphocytes (at least)
|
|
|
Which urologic cancer is the prototypical immune-mediated tumor?
|
RCC
|
|
|
What is the hypothesis for why after RCC-induced nephrectomy, there is regression of mets?
|
Elimination of inhibitors of CMI.
|
|
|
Both autologous and allogenic vaccination are under study in which two urologic cancers?
|
CaP & RCC
|
|
|
IFN-alpha has anticancer activity in which two urologic cancers?
|
Superficial bladder cancer and RCC
|
|
|
What is the difference between adjuvant and neoadjuvant chemotherapy?
|
Adjuvant chemo is systemic therapy administered after a patient has been rendered free of disease surgically.
Neoadjuvant chemo is administered before definitive surgical resection. |
|
|
The usefulness of antineoplastic chemotherapeutic agents lies in what number?
|
The therapeutic index (ratio of toxicity to malignant cells over normal, nonmalignant cells)
|
|
|
What is the basic premise for local BCG intravesicla treatment for bladder cancer?
|
Local BCG will result in a local immune response causing tumor cell kill.
|
|
|
What is the most common multiagent chemo regimen for the treatment of Germ cell tumors?
|
PEB (cisplatin, etoposide, and bleomycin) q21 days
|
|
|
Who gets chemo for stage I and II GCTs?
|
Those with Stage II nonseminomatous microscopic disease identified at lymphadenectomy
|
|
|
By definition, which germ cell tumor is NEVER in the poor prognosis category?
|
Seminomas
|
|
|
For patients who have been exposed to bleomycin in the past, what should be considered when undergoing surgery?
|
Keep the FiO2 as low as possible because O2 may induce O2-related pulmonary toxicity in these patients.
|
|
|
The development of successful therapy of metastatic bladder TCC has been based on the use of what chemotherapeutic agent?
|
Cisplatin
|
|
|
What chemo combination is now replacing MVAC for advanced bladder cancer and may even be considered the standard of care?
|
Cisplatin & gemcitabine
|
|
|
What is the first step after diagnosing hormone refractory CaP?
|
Stop the antiandrogen! 15-30% will have a corresponding decrease in PSA
|
|
|
What is the median survival for hormone-refractory CaP?
|
15-20 months
|
|
|
What drug has now been approved for treatment of progressive, symptomatic hormone refactory CaP?
|
Mitoxantrone
|
|
|
What is the standard of care for HRPC (hormone-refractor CaP) patients?
|
1. Stop anti-androgen first
2. Estramustine/taxane combination |
|
|
What is the second-line treatment for HRCP (hormone-refractory CaP)?
|
Mitoxantrone & prednisone
|
|
|
What is involved in the metabolic evaluation of stone formers?
|
1. Serum: Ca (2 separate draws), uric acid, bicarbonate, and possibly PTH
2. 2 to 3 24-hour urine samples: Na, Cr (to ensure a 24-hour sample), citrate, oxalate, calcium, uric acid 3. UA: pH, concentration, and sediment |
|
|
Why is serum bicarb measured in stone-formers?
|
Because it can be low in distal RTA (Type 1) which predisposes to calcium phosphate stones
|
|
|
When should 24-hour urine collections be obtained?
|
2 to 3 months after the stone has passed or removed
|
|
|
If you are unable to obtain a 24-hour urine, what else can you use?
|
Ca:Cr ratio from a spot urine... Calcium excretion = 1.1 x the ratio (in g/day)
|
|
|
Calcium phosphate stones prefer what environment?
|
Alkaline urine
|
|
|
When should you avoid citrate supplementation?
|
When urine pH is >6.0-- you're dealing with stones in alkaline urine (like calcium phosphate or MAP) and citrate can increase citrauria and cause alkaline urine
|
|
|
What is the general treatment for apenia?
|
Gender reassignment to female
|
|
|
What is the definition of megalopenis?
|
Penis size >2 standard deviations above the norm
|
|
|
When should you start treatment for micropenis?
|
By 1yo (and do orchiopexy before 2 yo)
|
|
|
What is the usual treatment for micropenis?
|
Androgen replacement (provide enough testosteron to stimulate penile growth without altering growth and closure of the epiphyses)
|
|
|
What is the treatment for duplication of the urethra?
|
Resect one of them
|
|
|
What is the usual cause of megalopenis in young boys?
|
Increased production of testosterone from interstitial cell tumors of the testicle, hyperplasia or tumors of the adrenal cortex
|
|
|
Where are the 2 most common sites for urethral stricture in boys?
|
1. Fossa navicularis
2. Membranous urethra |
|
|
What diagnostic modalities are used for diagnosing urethral strictures in boys?
|
VCUG first, then if suspicious findings, do cysto or URS
|
|
|
Where are poosterior urethral valves usually found?
|
Distal prostatic urethra
|
|
|
What are the most common findings associated with PUVs?
|
1. Hydro/palpable mass
2. UTIs 3. FTT |
|
|
What is the best imaging for diagnosing PUV and what does it show?
|
VCUG shows elongation and dilatation of posterior urethra with prominent bladder neck- also hydroureter or hydronephrosis if long-standing
|
|
|
How are PUVs treated?
|
Transurethral fulguration; if severe, may need vesicostomy or even percutaneous loop ureterostomies
|
|
|
What is the issue with percutaneous loop ureterostomies as treatment for very severe PUV?
|
The period should be as short as possible because vesical contracture can be permanent after prolonged supravesicular diversion
|
|
|
What % of PUV patients have VUR? And what % of these patients have no more reflux after PUV treatment?
|
50%-- and only 1/3 of these will be cured of VUR after treatment; the rest will require surgery (ureteroneocystostomy)
|
|
|
Is there such a thing as anterior urethral valves?
|
Yes- but they're rare
|
|
|
Where are AUVs located?
|
Urethral dilatation or diverticuli proximal to the valve- bladder outlet obstruction
|
|
|
How are AUVs treated?
|
Transurethral electrofulguration
|
|
|
How early may PUVs be diagnosed?
|
As early as 28 weeks in utero (via ultrasound)
|
|
|
Congenital urethrorectal and vesicorectal fistulas are rare and almost always associated with...
|
Imperforate anus
|
|
|
How do congenital urethrorectal and vesicorectal fistulas occur?
|
Failure of the urorectal septum to develop completely
|
|
|
In hypospadias, the urethral meatus opens up on which side of the penis?
|
Ventral side- proximal to the tip of the glans
|
|
|
How is the urethra formed embryologically? What happens with hypospadias?
|
Fusion of the urethral folds along the ventral surface of the penis- extending to the corona on the distal shaft-- so in hypospadias there is incomplete fusion of the urethral folds
|
|
|
What factors increase the incidence of hypospadias?
|
Estrogens and progestins given during pregnancy
|
|
|
What are the 5 types of hypospadias?
|
1. Glandular
2. Coronal 3. Penile shaft 4. Penoscrotal 5. Perineal |
|
|
Hypospadias in a male is evidence of ...
|
Feminization
|
|
|
What common practice should NOT be done in infants with hypospadias?
|
Circumcision-- because the skin may be used later for reconstruction!
|
|
|
What relatively common congenital urethral defect may cause infertility in the future?
|
Hypospadias
|
|
|
What should always be checked on exam in boys with hypospadias?
|
Testicles to see if they've descended (increased incidence of cryptorchidism)
|
|
|
When should labs be drawn in hypospadias (and which labs)?
|
With hypospadias of the perineal or penoscrotal types... may have ambiguous genitalia - buccal smear and karyotyping
|
|
|
When should hypospadias be repaired?
|
Before age 2 (before the patient reaches school age)
|
|
|
What else is repaired in a hypospadias repair?
|
Chordee removal-- confirm by producing an artificial erection
|
|
|
Is there such a thing as chordee without hypospadias?
|
Yes- but it's much more rare.
|
|
|
What is a chordee without hypospadias caused by?
|
Caused by a short urethra, fibrous tissues surrounding the spongiosum or both.
|
|
|
What are 3 types of epispadias?
|
1. Glandular (meatus on dorsal glans)
2. Penile (meatus between pubic symphysis and coronal sulcus) 3. Penopubic (meatus at penopubic junction with the rest of the penis with a dorsal groove) |
|
|
What do females with epispadias look like?
|
Bifid clitoris and separation of the labia
|
|
|
What is a major problem with epispadias?
|
Incontinence b/o disruption of the sphincter
|
|
|
Epispadias is a mild form of...
|
Bladder exstrophy
|
|
|
What is currently the most common cause of priapism?
|
Intracavernous injection therapy for impotence
|
|
|
What are the two general categories of priapism and examples of each?
|
1. Low flow or ischemic (e.g. sickle cell)
2. High flow or nonischemic (e.g. perineal trauma, aneurysms) |
|
|
What is believed to be the major abnormality with ischemic priapism?
|
Physiologic obstruction of the venous drainage
|
|
|
What happens if a prolonged priapism occurs?
|
Interstitial edema and fibrosis of the corpora cavernosa, resulting in impotence
|
|
|
What is the first technique of treating priapism?
|
Inject a needle through the glans and evacuate blood, while injecting alpha-adrenergic agents via intracavernous irrigation
|
|
|
If irrigation and evacuation is unsuccessful, what is another form of treating priapism?
|
Winter (and McDowell) shunt- Travenol biopsy needle removes multiple wedges of tissue-- creating a shunting fistula between the glans and corpora cavernosa-- must exert pressure every 15 minutes on the body of the penis to keep the fistula draining
|
|
|
For priapism, what 4 other shunts can you do if the Winter shunt fails?
|
1. The Barry shunt- anastomosing superficial dorsal vein to corpora cavernosa
2. CC to corp spongiosum by perineal anastamosis 3. Saphenous vein to corpora cavernosa 4. Pump decompression |
|
|
How should sicklers be treated with priapism?
|
The usual treatments plus...
1. Hyperbaric oxygen 2. Massive transfusion |
|
|
Besides sickle cell, what other systemic disease may result in priapism- and how is it treated?
|
Leukemia- prompt chemotherapy
|
|
|
In Peyronie's Disease, where is the plaque?
|
Tunica albuginea- usually near the dorsal midline of the shaft
|
|
|
What is the pathophysiologic basis of Peyronie's (as far as we can tell)?
|
It looks like severe vasculitis- and also is associated with Dupuytren's contracture
|
|
|
Can Peyronie's spontaneously remit- if so, what % will do so?
|
Yes-- 50%
|
|
|
What is the treatment for Peyronie's if it does not spontaneously remit?
|
1. p-aminobenzoic acid powder or tablets
2. Vitamin E tablets (for several months) |
|
|
What surgical methods may be used for Peyronie's?
|
Plaque excision with replacement with derma or vein graft; or tunica vaginalis grafts
|
|
|
What is the difference between phimosis and paraphimosis?
|
Phimosis is a condition in which the foreskin cannot be retracted over the glans. Paraphimosis is a condition in which the foreskin, once retracted over the glans, cannot be replaced to its normal position
|
|
|
What might develop under the foreskin in a phimosis?
|
1. Stones
2. SCC |
|
|
Do children under 2yo have phimosis?
|
No
|
|
|
How is paraphimosis treated?
|
1. Squeeze the glans for 5 minutes to reduce the tissue edema and decrease the size of the glans.
2. Draw the skin forward over the glans 3. Occasionally, will require incision under local 4. Give abx afterwards and schedule for circumcision once inflammation has subsided |
|
|
What is the #1 cause of acquired urethral stricture?
|
Infection
|
|
|
What is the usual cause for acquired membranous urethral stricture?
|
Trauma
|
|
|
What is the usual cause for acquired bulbar urethral stricture?
|
Straddle injuries
|
|
|
What is the most common cause of recurrent UTIs in a 50yo man?
|
Prostatitis
|
|
|
What is the most common complaint of acquired urethral stricture?
|
Decrease in urinary stream
|
|
|
What labs should be obtained if acquired urethral stricture is suspected?
|
1. Urinary flow rates over the day-- to get a mean rate
2. UCx 3. Urethrogram or VCUG (or both) 4. U/S (sometimes) 5. Urethroscopy |
|
|
What is the normal urinary flow rate?
|
It should be >=20mL/sec... if strictures, it would be <10mL/sec
|
|
|
What instrument can calibrate a urethral stricture?
|
Bougies a boule
|
|
|
What are 3 methods used to treat acquired urethral stricture?
|
1. Dilation (fractures the scar and temporarily enlarges lumen, but will reform)
2. Urethrotomy under endoscopic direct vision 3. Surgical reconstruction |
|
|
How is dilation of urethral strictures performed?
|
Using filiforms and followers or urethral sounds
|
|
|
With respect to urethrotomy for urethral stricture, where is the incision made?
|
Dorsally (but multiple incisions may be made elsewhere to open the narrowed segment)
|
|
|
What French size should pass with ease after successful urethrotomy for urethral stricture?
|
22F
|
|
|
When should surgical reconstruction for acquired urethral stricture be performed?
|
If all else fails
|
|
|
In surgical reconstruction for acquired urethral stricture, how much urethra should be excised?
|
1. If <2cm: 1cm proximal and distal to narrowed segment
2. If >2cm: 0.5cm proximal and distal to segment (use patch graft urethroplasty from penile skin or buccal mucosa) |
|
|
When is an acquired urethral stricture considered "cured"?
|
Observed for at least 1 year after therapy
|
|
|
What virus may affect the urethra?
|
HPV-- urethral condylomata acuminata
|
|
|
What % of urethral condylomata acuminata are in the distal and proximal urethra?
|
90% distal
10% proximal |
|
|
How are urethral condylomata acuminata treated?
|
1. Meatus: local excision
2. Deeper: transurethral fulguration with resectoscope or Bugbee electrode (or CO2 laser) 3. Multiple: FU 5% solution or cream- instill 20 minutes twice a week for 5 weeks (but protect penile skin and scrotum) |
|
|
What is a more severe version of urethral condylomata acuminata and how should it be managed?
|
Giant condylomata (Buschke-Lowenstein tumors)- treat with surgical excision
|
|
|
What is the usual cause of meatal stenosis in newborns?
|
Ammonia dermatitis following circumcision (and resulting in prolonged irritative meatitis)
|
|
|
A newborn's urethra should easily accept what size french tube?
|
8F pediatric feeding tube
|
|
|
What caliber of catheter should indicate meatal stenosis?
|
5 French in children <10yo-- indication for meatotomy
|
|
|
What is penile thrombophlebitis and lymphatic occlusion- and what is the usual etiology?
|
Superficial veins and lymphatic vessels become irritated and inflamed-- usually from minor trauma. Will feel tender, indurated, cordlike structure on distal penile shaft with slight erythema.
|
|
|
How should penile thrombophlebitis and lymphatic occlusion be treated?
|
Reassurance- they will resolve spontaneously.
|
|
|
Is a distal ring of urethral stenosis normal in girls?
|
Yes-- at a few months of age, it's normal. Then it will disappear after puberty
|
|
|
Why does a distal ring of urethral stenosis occur in young girls?
|
Absence of estrogens leads to the ring
|
|
|
If a young girl has recurrent UTIs and hesitancy in initiating micturition, what can be done regarding the distal ring of urethral stenosis?
|
Overdilatation with sounds up to 32-36F or with Kollman dilator
|
|
|
Does recurrence occur with dilatation of the distal ring in young girls?
|
No- because it cuts the external sphincter (on the other hand, urethrotomy does not and will thus result in recurrence)
|
|
|
When should the distal ring urethral stenosis be treated?
|
If a young girl has recurrent UTIs and hesitancy severe enough to bring her to the urologist
|
|
|
What exterior anatomic abnormality may lead to recurrent UTIs?
|
Fused labia minora (allows the urine to pool in the vagina)
|
|
|
How are fused labia minora treated?
|
Local application of estrogen cream BID for 2-4 weeks (and some may forcefully separate/dissect)
|
|
|
What are the usual panendoscopic findings in chronic urethritis?
|
1. Reddened and stenotic urethral mucosa with granular areas and polypoid masses just distal to bladder neck
2. Reddened trigone (trigonitis) |
|
|
What abx should be used for ureaplasma urealyticum urethritis in females?
|
Tetracycline or EES
|
|
|
What abx should be used for chlamydia urethritis?
|
Tetracyclines or sulfonamides
|
|
|
What does senile urethritis look like?
|
1. Dry and pale vaginal mucosa
2. Reddened, hypersensitive urethral orifice 3. Eversion of its posterior lip from foreshortening of urethrovaginal wall |
|
|
What is senile urethritis most commonly misdiagnosed as?
|
Urethral caruncle
|
|
|
What are the similarities & differences between a urethral caruncle and senile urethritis?
|
1. Both have eversions of the posterior lip of the urinary meatus
2. Urethral caruncle will show a hypersensitive vascular tumor (and senile urethritis will not) |
|
|
How is senile urethritis diagnosed?
|
Dry smear of vaginal epithelial cells stained with Lugol's solution. Then wash in water and examine immediately. Epithelial cells will be yellow (b/c they do not take up iodine)- normal mucosa would be dark brown b/o the high glycogen content
|
|
|
What is the usual treatment for senile urethritis?
|
1. Diethylstilbestrol vaginal suppositories (0.1mg nightly for 3 weeks)-- usually 3 courses
2. Estrogen vaginal creams 3. If these cause too much bleeding, may try methyltestosterone buccal tablets as vag supp |
|
|
What is the prognosis for senile urethritis?
|
Good-- usually responds promptly to estrogen or androgen therapy
|
|
|
What is a urethral caruncle?
|
Benign, red raspberrylike friable tumor involving the posterior lip of the external urinary meatus
|
|
|
What age do urethral caruncles present?
|
Almost always after the menopause
|
|
|
What are the clinical findings with urethral caruncles?
|
1. Pain on urination and intercourse
2. Bloody spotting from even mild trauma 3. Sessile or pedunculated red, friable, tender mass at posterior lip of meatus |
|
|
What are 3 conditions included in the ddx of a urethral caruncle?
|
1. Urethral carcinoma
2. Senile urethritis 3. Thrombosis of the urethral vein (bluish swollen, tender lesion involving posterior lip of urethral meatus)- just observe |
|
|
What is the treatment for a urethral caruncle?
|
Local excision (if sx are troublesome)- most will not recur
|
|
|
What are three etiologies of a urethral diverticulum?
|
1. Obstetric trauma
2. Severe urethral infection 3. Rare- carcinoma |
|
|
How are urethral diverticula usually diagnosed?
|
Palpate rounded cystic mass in anterior wall of vagina that when pressed leaks pus from the urethral orifice
|
|
|
How is a urethral diverticulum treated?
|
1. Removal of the entire sac through an incision in the anterior vaginal wall (being sure not to damage the urethral sphincteric musculature) and repair the defect
2. Leave a suprapubic cystostomy in place for 15 days after surgical excision of the diverticulum |
|
|
Is urethral stricture common or uncommon in females?
|
Uncommon
|
|
|
What is lichen simplex chronicus?
|
Circumscribed neurodermatitis caused by the itch-scratch cycle
|
|
|
How is lichen simplex chronicus treated?
|
Topical steroids (1% hydrocortisone ointment or 1% pramasone (hydrocortisone 1% plus pramoxine) ointment)
|
|
|
What is intertrigo?
|
Moist plaques occurring in areas of persistent maceration- often complicated by bacterial or yeast overgrowth
|
|
|
How is intertrigo treated?
|
1. Allowing the area to be dry
2. BID soaks with Burrow's solution 1:20 followed by application of nystatin ointment plus 1% hydrocortisone ointment |
|
|
What are three drugs that commonly cause genitalia drug eruptions?
|
1. Sulfonamides
2. NSAIDs 3. Laxatives (Phenolphthalein) |
|
|
How is psoriasis different in the genital region?
|
1. It's on flexural areas (instead of extensors)
2. Often no plaques |
|
|
What does lichen planus of the genitalia look like?
|
Polygonal, violet-hued, flat-topped papules about 0.5-1cm in diameter
|
|
|
What does lichen sclerosus of the genitalia look like?
|
Parchment paper-- with severe pruritus or painful erosions
|
|
|
How is lichen sclerosus treated?
|
1. Superpotent topical steroids: BID with gradual taper to daily, then several times weekly. (initial trial should be for 6 weeks)
2. Then maintenance with milder steroids |
|
|
What is pediculosis pubis and how is it treated?
|
Pubic lice (crabs)-- treat with lindane 1% shampoo for 4 minutes (alternative is permethrin cream)
|
|
|
How is scabies treated?
|
1. Wash entire body in 5% permethrin cream (from neck down)-- repeat in 1 week (lindane 1% alternative)
2. Treat entire household 3. Wash all clothing, beeding and towels |
|
|
How can tinea cruris and candidiasis be differentiated?
|
Tinea cruris does not affect the scrotum and is less intense in the deep inguinal area(whereas candida is opposite)
|
|
|
How is tinea cruris treated?
|
Antifungal topical cream (most are applied BID)
|
|
|
What is the most common bacterial infection in the genital area?
|
Staph aureus
|
|
|
What are the two most common lesions caused by staph?
|
1. Follicular impetigo (folliculitis)
2. Superficial blister (impetigo) |
|
|
Treatment of choice for staph bacterial folliculitis? How long should the patient be treated?
|
Penicillinase-resistant penicillin or first generation cephalosporin (doxy if pen-allergy)-- treat until lesions are all healed
|
|
|
What should be added to the treatment of bacterial folliculitis IF frequent recurrences?
|
Rifampin
|
|
|
How is treatment of bullous impetigo different from bacterial folliculitis?
|
Same treatment but bullous impetigo can be treated for a shorter duration
|
|
|
What are the "high-risk" HPV types?
|
16 and 18
|
|
|
What are health-care provider applied therapy for HPV?
|
1. Liquid nitrogen cryotherapy
2. Electrocautery 3. Laser and intralesional or systemic interferon (both 2nd-line and rarely used) |
|
|
What are the patient-applied therapies for HPV?
|
1. Podophyllotoxin BID (contraindicated in pregnancy)
2. Imiquimod QD 3x/week (results in local production of IFN) |
|
|
Is molluscum contagiosum contagious in adults?
|
YES! sexually transmitted
|
|
|
Genital HSV is caused by what type usually?
|
Type 2
|
|
|
Does acyclovir resistance exist?
|
Yes-- especially in immunosuppression
|
|
|
What is acyclovir-resistant HSV treated with?
|
Foscarnet
|
|
|
What is the most common tumor type affecting the testis?
|
90% are germ cell tumors
|
|
|
Which testicle is more commonly affected?
|
R slightly more than L
|
|
|
What % of patients with testicular tumors have bilateral tumors?
|
1-2%
|
|
|
What non-germ cell tumors affect the testis?
|
1. Leydig cell tumors
2. Sertoli cell tumors 3. Mixed 4. Stromal tumors (gonadoblastoma, adenocarcinoma of the rete testis, carcinoid and mesenchymal tumors) 5. Secondary tumors (leukemia, lymphoma, mets) |
|
|
What are the 5 histologic subtypes of germ-cell tumors?
|
1. Seminoma
2. Yolk sac 3. Embryonal carcinoma 4. Teratoma 5. Choriocarcinoma |
|
|
What is the most common histology of testicular tumors in men between 15-40yo?
|
Seminoma (but mixed tumors are more common than pure)
|
|
|
What is the most common solid tumor in men between ages 15-40yo?
|
Germ-cell tumors of the testis
|
|
|
What are the known risk factors for germ-cell tumors?
|
1. Age
2. Race 3. Cryptorchidism |
|
|
Does family history increase the risk of testis cancer?
|
It hasn't been established so far...
|
|
|
How does histology of testis tumors change with age?
|
1. Infants: yolk sac tumors and pure teratomas
2. <40yo: seminoma and mixed germ-cell tumor 3. >50yo: Spermatocytic seminoma, lymphoma or other secondary tumors |
|
|
Does testicular trauma cause testis cancer?
|
No-- but it might bring it to attention
|
|
|
What are the most frequent sites of metastasis for nonseminomatous germ-cell tumors?
|
1. Retroperitoneal lymph nodes
2. Lung 3. Liver 4. Bone 5. Kidney |
|
|
Where do the R and L testis drain?
|
R: Interaortocaval area at L2
L: Paraaortic area lateral to aorta and medial to ureter |
|
|
How do germ-cell tumors metastasize to inguinal nodes?
|
If they invade the scrotum (or if there has been prior inguinal or scrotal surgery), they can drain to inguinal nodes
|
|
|
Does delay in diagnosis of testicular tumors matter?
|
YES!!! Increased morbidity, mortality and higher stage/grade
|
|
|
If a testicular tumor is suspected, what tumor markers should be ordered?
|
1. LDH
2. AFP 3. Beta-HCG 4. Placental Alk phos (PLAP) |
|
|
If a testicular tumor is suspected, what imaging should be ordered?
|
1. Scrotal ultrasound
2. CXr 3. CT of chest, abdomen, pelvis |
|
|
What is the sine qua non for diagnosis of germ-cell tumor?
|
Inguinal orchiectomy with pathologic examination of testis
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How are testicular germ-cell tumors staged?
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Tis: Intratubular germ-cell neoplasia
T1: Limited to testis and epididymis, may involve tunica albuginea, vascular/lymphatic invasion absent T2: Same as T1 but vascular/lymphatic invasion present T3: Invades spermatic cord T4: Invades scrotum (N, M and S staging) |
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What is the S stage in germ-cell testicular tumors?
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Serum tumor marker staging:
S1: <1.5x LDH, <5,000 hCG, <1,000 AFP S2: 1.5-10x LDH, 5-50K hCG, 1-10K AFP S3: >10x LDH, >50K hCG, >10K AFP |
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What is AFP and which histologic types of testicular tumors secrete it?
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It's a glycoprotein present in developing fetus. Detectable in 50-70% of germ-cell tumors (including embryonal ca, yolk sac tumor, and mixed tumors containing these elements)
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What is hCG and which histologic types of testicular tumors secrete it?
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Glycoprotein with alpha (indistinct) and beta (distinct) subunits. Found in 40-60% patients with testis cancer- including choriocarcinoma, embryonal, and some cases of pure seminoma
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What other diseases (besides testicular cancer) cause elevations in serum AFP and hCG?
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1. Hepatocellular ca (and benigng liver conditions)
2. Gastric ca 3. Pancreatic ca 4. Lung ca 5. Multiple myeloma |
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What are the serum half lives for AFP and hCG?
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AFP: 5-7 days
hCG: 24-36 hours |
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What testicular tumor secretes placental alkaline phosphatase (PLAP)?
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Some seminomas
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What cytogenetic abnormalities are characteristics of germ-cell tumors?
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Deletion of chromosome 12 (aka isochromosome 12p or i(12p))
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Does elevated beta-hCG after orchiectomy always indicate presence of residual tumor?
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NO-- some assays will cross-react with LH and lead to false-positive testing. LH levels are elevated after orchiectomy.
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What is the significance of an elevated serum beta-HCG in a patient with a histologically pure seminoma?
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Suggests presence of syncytiotrophoblasts that secrete HCG- believed to be identical to non-HCG-secreting pure seminomas and are treated as such.
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What is the significance of elevated serum AFP in a patient with germ-cell tumor?
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Implies presence of nonseminomatous elements and thus should be treated as mixed or nonseminomatous tumors
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What 3 pathologic factors in the primary tumor are associated with high risk of metastases?
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1. Advanced local stage (T2-T4)
2. Presence of lymphatic or vascular invasion 3. % of embryonal carcinoma |
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What are the three histologic variants of pure seminoma? How common are each?
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1. Classic (85%)
2. Anaplastic (5-10%) 3. Spermatocytic (5%) |
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Stage for stage, is anaplastic worse than classic seminoma?
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No-- it is the same stage for stage (but it just usually is higher stage...)
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What is the prognosis for spermatocytic seminoma?
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Generally pretty good
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What is the treatment for clinical stage T1-2N0M0 pure seminoma?
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Inguinal orchiectomy and radiation therapy to the retroperitoneal and ipsilateral iliac lymph nodes
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What is the treatment for advanced clinical stage TanyN3M0-1 seminoma?
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Inguinal orchiectomy followed by platinum-based combination chemotherapy
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What is the management of residual mass in retroperitoneum after chemo for seminoma?
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Controversial-- could do retroperitoneal lymphadenectomy, radiation therapy, and observation
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What is the treatment for clinical stage T1-2N0M0 nonseminomatous tumor?
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Inguinal orchiectomy with careful path analysis for retroperitoneal mets. If no adverse histo factors, surveillance or nerve-sparing RPLND (esp if 1 or more adverse histo factors)
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What is the main disadvantage of RPLND and how has this changed over time?
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In the past, it was associated with loss of seminal emission, but nerve-sparing techniques result in preservation of emission and ejaculation in virtually 100% with Stage I disease
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What is nerve-sparing RPLND?
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Prospective identification and preservation of postganglionic sympathetic nerves arising from lumbar sympathetic chains and forming anastomotic network (hypogastric plexus) anterior to the abdominal aorta and surrounding origin of IMA
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How do nerves from the hypogastric plexus travel?
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Anteriorly along aorta, across aortic bifurcation, and descend into pelvis to innervate bladder neck and enter seminal vesicles, vas deferens, prostate, and external urinary sphincter, and subserve emission and ejaculation
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What is the treatment for T1-2N0M0 nonseminomatous tumor found to have metastatic cancer at time of RPLND?
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If N1, observe
If N2 or greater, 2 cycles of adjuvant chemotherapy |
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Describe treatment for small-volume (<5cm) clinical stage T1-2N1-2M0 nonseminomatous tumor.
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1. If normal serum markers, RPLND
2. If metastatic disease confirmed, adjuvant chemotherapy 3. If elevated serum markers, systemic chemo followed by surgical resection of any residual tumor |
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What is the treatment of advanced (TanyN3M0-1) nonseminomatous germ-cell tumors?
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Systemic platinum-based multiagent chemotherapy, followed by surgical excision of residual pulmonary or retroperitoneal masses
If dx made by LN or retroperitoneal biopsy, the ipsilateral testis should also be removed. |
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Describe the clinical presentation of gonadal stromal tumors.
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Similar to germ cell tumors- painless mass or swelling. EXCEPT for Leydig cell tumors, which may present with feminization or endocrinologic manifestations.
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Do gonadal stromal tumors produce clinically useful tumor markers?
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Nothing like AFP or hCG, but Leydig cell tumors do produce estrogen and its metabolites
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How are gonadal tumors treated?
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90% are benign and cured by inguinial orchiectomy. RPLND may be considered if histologic appearance suggests malignancy.
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List the 4 most common mesenchymal tumors to occur in the testis.
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1. Fibromas
2. Angiomas 3. Leiomyomas 4. Neurofibromas |
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What do epidermoid cysts look like?
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Round, sharply circumscribed lesions composed of fibrous tissue and keratinized squamous epithelium.
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How are epidermoid cysts treated?
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They're benign-- inguinal orchiectomy (and some by partial excision, especially in children)
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What is the most common secondary tumor in the testis?
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Lymphoma
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What are the 5 most common metastatic tumors to the testis?
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1. Prostate
2. Lung 3. GI tract 4. Kidney 5. Melanoma |
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What is N1, N2 and N3 with respect to testicular tumors?
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N1: <2cm
N2: 2-5cm N3: >5cm |
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What is the most common testicular tumor in children?
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Yolk sac tumor (60% of all testicular tumors in children)
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What are the best diagnostic tests for testicular tumors in children?
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1. Ultrasound
2. Serum AFP |
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What tests should be ordered after a diagnosis of yolk sac tumor is made?
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1. CXr
2. U/S or CT of retroperitoneum |
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How many half lives does it take for something to clear the system?
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4-5
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What is the survival rate for yolk sac tumor in children?
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>90%
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Is teratoma in children benign, malignant or both?
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Always benign
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Is there a role for radiation in treatment of childhood testicular tumors?
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No- orchiectomy is curative almost always (and if that's not, chemo will do the job)
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Can testicular tumors be seen in the newborn? If so, which ones?
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All of them may be seen
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What are the 2 most common testicular tumors in the newborn?
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1. Granulosa cell tumor
2. Yolk sac tumor |
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What is a newborn testicular tumor often mistaken for?
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In utero torsion of the testis
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Should a RPLND be performed for yolk sac tumors?
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No- tumor mets via both hematogenous and lymphogenous routes... do the RPLND ofnl if radiologic evidence of metastatic disease
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Which prepubertal tumor of the testis is seen in genetic d/o such as Peutz-Jeghers syndrome?
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Sertoli cell tumor
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What is the most likely diagnosis in a child who has CAH and presents with a bilateral testicular mass?
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Hyperplastic nodules (testicular tumor of CAH)
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Why would leukemia present in the testis but not be detected anywhere else?
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Most believe there is a blood-testis barrier- allowing the testis to be a protected haven from chemotherapy.
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Is teratoma in children the same as those in adults?
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No- Adults may undergo malignant changes and mets while children are always benign.
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What pressure is instilled into the peritoneal cavity during laparoscopic surgery?
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10-15mmHg
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How is the patient positioned during a laparoscopic radical nephrectomy?
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In the 45-60 degree flank position for the transperitoneal approach, and in the 90-degree position for the retroperitoneal approach
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What is occurring if a patient suddenly develops a "mill-wheel" murmur while undergoing laparoscopic surgery?
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The patient has developed a gas embolism
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How do you deal with a gas embolism during surgery?
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Immediate desufflation and placement of patient in the steep L lateral decubitus Trendelenberg position (to minimize RV outlet obstruction)
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What should be suspected when a patient undergoing laparoscopic surgery gradually has dropping BP, difficult ventilation, and development of arrhythmias?
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Tension pneumoperitoneum (IVC compression occurs, leading to decreased venous return and hypotension)
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How is tension pneumoperitoneum associated with laparoscopic surgery treated?
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1. Immediate desufflation
2. Correcting the Trendelenberg position 3. Hyperventilation with 100% O2 4. IV fluids |
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85-90% of lymphatic metastases from CaP are from what nodal chains?
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Obturator-hypogastric
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During a laparoscopic PLND, urine in the Foley suddenly becomes pink-tinged. What does this indicate?
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Probable bladder injury
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What is the most common postop complication after laparoscopic PLND?
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Urinary retention
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What are 3 general contraindications for laparoscopic surgery?
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1. Severe cardiopulmonary risk factors
2. Uncorrected coagulopathy 3. Abdominal sepsis and distension |
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What is the difference between polycystic kidney disease and a multicystic kidney?
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Polycystic kidney diseases are congenital cystic diseases in which otherwise normal renal elements become cystically dilated.
Multicystic disease cysts are not due to dilatation of specific renal elements but instead the entire kidney is dysplastic and composed of immature dysplastic stroma and cysts of various sizes |
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What is the prognosis of an infant with b/l multicystic kidney?
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Dismal
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What is the most common cause of an abdominal mass in a newborn?
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Congenital multicystic dysplastic kidney (UPJ obstruction is a close second)
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How do you distinguish a multicystic kidney from a severe UPJ obstruction?
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Usually ultrasound will make the distinction. Cysts of a multicystic kidney do not communicate while the cystic dilatation of a hydronephrotic kidney will communicate.
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Are there any urologic anomalies associated with a multicystic dysplastic kidney?
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Yes- contralateral UPJ obstruction and VUR
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What are the absolute indications for surgical removal of a multicystic kidney?
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1. HTN
2. Massive size |
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Name 4 differences between AR and AD polycystic kidney disease.
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1. AR is massively enlarged but still uniform. AD has renal contour distorted by cysts.
2. AR only involves collecting ducts and tubules. AD involves all parts of the nephron including glomeruli 3. AR also involves proliferation/dilatation of biliary ducts with periportal fibrosis. AD involves hepatic, pancreatic and splenic cysts as well as cerebral berry aneurysms 4. AR is infancy/childhood onset. AD is adulthood onset |
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Can ARPKD be detected by prenatal ultrasound?
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Yes- in 50% of cases
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How is AD and AR PKD treated?
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Aggressive management of complications such as HTN and UTI
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Are simple renal cysts common in children?
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No
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What is familial juvenile nephronophthisis (FJN)?
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Type of hereditary interstitial nephritis associated with medullary and cortico-medullary cysts. Most inherited as AR trait- and progress to renal failure by 2nd or 3rd decade.
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What is Cushing's syndrome?
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Endocrine d/o characterized by excessive secretion of glucocorticoids (cortisol)
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How is Cushing's disease different from the syndrome?
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Disease describes a particular type of the syndrome... in which a pituitary adenoma or hyperplasia results in overproduction of cortisol
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What are 4 tests to diagnose Cushing's syndrome?
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1. AM and PM cortisol (normally highest in AM and lowest in PM-- lost in the syndrome- unchanged throughout the day)
2. 24-hour urinary cortisol (best and most widely available test) 3. Overnight dexamethasone suppression test (failure to suppress cortisol in AM = cushing's) 4. Low-dose DST |
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How are patients with Cushing's syndrome imaged?
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1. If ACTH low, CT or MRI of adrenals
2. If ACTH nmL or elevated, MRI of pituitary 3. If ectopic ACTH, CT of abdomen and chest |
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What is the best way to distinguish between benign and malignant adrenal tumors?
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Tumors >6cm should be considered malignant until proven otherwise
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Is there any perioperative treatment required for adrenalectomy?
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Steroid preparation before and supplemental steroid after (b/c contralateral adrenal is suppressed)
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What are 4 adrenolytic agents?
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1. Mitotane
2. Aminoglutethimide 3. Ketoconazole 4. Metyrapone |
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When is bilateral adrenalectomy indicated?
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1. Macronodular adrenal hyperplasia (b/l)
2. Medical treatment has failed |
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What are the three types of ADPKD?
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1. PKD1 (chromosome 16)- 85%
2. PKD2 (chromosome 4)- 10% 3. PKD3 (unknown chromosome)- <5% |
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Does ADPKD only occur in adults?
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No-- disease truly begins in utero in most patients but do not get picked up until adults with symptoms
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What are Randall's plaques?
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White/yellow precipitation of crystalline substance occurring on the tips of renal papillae as submucosal plaques (seen on endoscopy of upper urinary tract)
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Where do most cysts in ADPKD arise from?
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1. Tip of Henle's loop
2. Boyman's space 3. Proximal convoluted tubule |
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What are two early functional changes occurring with ADPKD?
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1. Renal concentrating ability decreases
2. HTN |
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What is the preferred imaging for diagnosis of APKD?
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Ultrasound
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How many cysts are required before PKD can be diagnosed?
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The standard is usually 3 or more bilateral cysts in a person with a FH of dominantly expressed renal cystic disease
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At what age does the absence of renal cysts exclude the diagnosis of APKD?
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40yo
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List 4 lab abnormalities which may be associated with APKD?
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1. Defect in renal concentrating ability (proteinuria, pyuria, bacteriuria, hematuria)
2. Polycythemia 3. Azotemia 4. Anemia |
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Describe the 7 most common signs, sx and complications associated with APKD?
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1. Palpable flank/abdominal mass
2. HTN 3. Pain 4. Hematuria 5. Nephrolithiasis 6. UTI 7. ESRD |
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How is APKD treated?
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1. ACEI
2. Low-protein, low sodium diet 3. Analgesics 4. Activity limitations to avoid trauma 5. If stones, K citrate 6. Eventual dialysis or transplantation |
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Can cyst decompression prevent the progression of renal failure and control HTN?
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No (rarely)
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What are the results of dialysis and transplantation in patients with APKD?
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Very good... much better than diabetics.
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If APKD is hereditary, can family members safely donate kidneys?
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Yes- current ultrasound and genetic technology can reliably assess family members for presence of APKD (esp those >25-35yo)
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What is acquired renal cystic disease?
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Development of cystic degeneration of kidneys in patients without a congenital predisposition to form renal cysts
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How many cysts are required to diagnose ARCD?
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No precise number- generally accepted concensus is at least 4-5 individual cysts that encompass >=25% of the renal mass
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Where do the cysts of ARCD develop?
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Renal cortex (although cysts may be found in the medulla or corticomedullary junction)
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How is ARCD different from PKD?
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ARCD is...
1. Found in renal failure patients 2. Absent a FH of cystic disease 3. Isolated to the kidney 4. Lacks the arboral-like proliferation found in cases of PKD |
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Is ARCD more common in men or women?
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M:F::2:1
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Does the type of renal replacement therapy affect the risk of ARCD?
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No- they now have found that cysts have been reported in patients with slowly progressive renal insufficiency prior to initation of dialysis.
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Are some patients more likely to develop ARCD?
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Yes- those with tubulointerstitial disease.
Less likely in MPGN and Type I DM |
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Do the cysts in ARCD ever go away?
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Yes- cysts will regress in the native kidney after transplantation of a new kidney
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Why do cysts form in ESRD kidneys? (Name 6 theories...)
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Theories:
1. Occlusive: obstruction of renal tubules by combo of interstitial fibrosis, epithelial proliferation and/or intratubular oxalate crystals leads to cyst formation 2. Chemical: Toxic endogenous substances or metabolites are responsible 3. Ischemic: Ischemia and obstruction to a renal segment experimentally can induce cyst formation. 4. Growth factor: Unidentified polypeptides with renotrophic activity could be locally released and induce cystic degeneration 5. Immune: Uremia is immunosuppressive.. susceptible to escape mechanisms & predisposing to cellular proliferation. 6. Hormonal: Alterations in sex steroid production and metabolism induced by uremia may predispose to cyst formation (M > F) |
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What are the cysts of ARCD?
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Fusiform tubular dilations or saccular outpouchings of renal tubules-- from dilation and hyperplasia of remaining nephrons
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Are there any other reasons to worry about cysts in ESRD kidneys?
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There is an increased incidence of renal tumors. (45x increased incidence)
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Are all renal tumors found in ARCD patients malignant?
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No- only 1-2% with ARCD will develop a frank adenocarcinoma and 15% of those will develop mets.
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What is the best way to determine if ARCD kidney contains a renal tumor?
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Renal ultrasound (CT and MRI are actually better, but the price is too much to justify)
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How often should a patient with ARCD be evaluated for renal adenocarcinoma?
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Q3 years (or more)
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What is the best treatment for a solid renal mass in an ARCD kidney?
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If the mass >3cm, radical nephrectomy. If <3cm, watchful waiting.
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Do both kidneys need to be removed if a patient has a solid renal mass?
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No- unless a solid renal mass is suspected in the contralateral kidney
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What are the main 3 items involved in a hematuria workup?
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1. Urine cytology
2. CT of abdomen/pelvis (to look for renal tumor) 3. Cystoscopy |
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How is UPJ obstruction treated in the neonate?
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Pyeloplasty (several types- but the most common type is the dismembered pyeloplasty)
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Are there any other causes of UPJ obstruction in children (other than congenital)?
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It may be that VUR may cause a secondary UPJ obstruction.
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How is a UPJ obstruction diagnosed in children?
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Diuretic renal nuclide scanning
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Is UPJ obstruction more common in male or female children?
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Males (5:2)
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Is UPJ obstruction more common on L, R, or bilateral?
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R > L (5:2); bilateral occurs in 15% of cases
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How is UPJ obstruction treated in the adult?
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Dismembered pyeloplasty
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What are the different types of pyeloplasty done for UPJ obstruction?
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1. Dismembered pyeloplasty
2. Endopyelotomy 3. Retrograde endopyelotomy |
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What is low-pressure reflux?
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VUR that occurs during bladder filling
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What is high-pressure reflux?
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VUR that occurs during micturition.
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How long does the ureter run in the bladder?
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1-2cm
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What is the trigone?
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The triangle formed from the 2 ureteral orifices and the bladder neck
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What is Waldeyer's sheath?
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External layer of longitudinal smooth muscle surrounding the ureter that passes through the bladder wall. As this layer enters the bladder lumen, the fibers diverge to join with the contralateral ureter, forming the deep trigonal layer.
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How does VUR occur?
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It occurs when the intravesical (intramural) ureteral length is too short. Usually, the ureter is positioned superolateral to the normal position.
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What is the embryologic reason for congenital VUR?
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If the ureteral bud is too close to the urogenital sinus on the wolffian (mesonephric) duct, then it may not acquire sufficient mesenchymal tissue around it to have sufficient support to prevent reflux.
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What is the normal ratio of length of intramural ureter to diameter of the ureteral orifice?
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2.5 : 1 (if the ratio is less, reflux occurs)
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What is the ratio of boys to girls with reflux?
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Equal (but because girls have a higher likelihood of developing UTIs, they are diagnosed more commonly in girls-- 1:6)
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Who is more likely to have higher grade reflux (boys or girls)?
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Boys-- Grade IV or V
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What is secondary reflux?
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Anatomic or clinical abnormality in which reflux occurs... examples would include ureterocele, PUVs, and neuropathic bladder
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What is the significance of VUR?
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May result in renal injury (termed reflux nephropathy)
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What are 3 ways in which a UTI causes renal injury?
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1. Bacteria may produce an endotoxin directly toxic to the renal tubule
2. By chemotaxis, there is granulocyte aggregation in the area of bacteria resulting in capillary obstruction which causes focal renal ischemia. During ischemia, the purine pool is consumed; then during reperfusion, the remaining hypoxanthine pool is converted to xanthine which is converted to uric acid and superoxide (converted to radicals) 3. Endotoxin causes C' activation leading to phagocytosis (respiratory burst of phagocytosis results in release of superoxide with formation of radicals). Urine unlike everywhere else in the body lacks superoxide dismutase allowing the radicals to act on the renal tubules unopposed. |
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How common is primary reflux in children with UTI?
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50% of children with UTI have reflux
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Who should be evaluated for reflux?
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1. Any child with pyelo (febrile UTI)
2. All boys with UTI 3. All girls <5yo with UTI 4. Girls >5yo with 2 or more episodes of cystitis |
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How is reflux detected?
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VCUG under fluoro or x-ray (alternatively, you may use radionuclide cystogram)
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Describe the grading system for VUR.
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Grade I: contrast enters ureter but not renal pelvis
Grade II: Contrast reaches renal pelvis but doesn't distend collecting system Grade III: Collecting system is filled and either ureter or pelvis is distended but calyceal demarcations are not distorted Grade IV: Dilated ureter slightly tortuous and calyces blunted significantly Grade V: Entire collecting system is tremendously dilated without a visible papillary impression, and significant ureteral tortuosity |
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What % of children have bilateral reflux?
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50%
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What is the main advantage/disadvantages of the VCUG and radionuclide cystogram in VUR?
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VCUG is better-- International System for grading reflux is based on it. Also, better visualization. BUT higher radiation exposure.
Radionuclide cystogram has only 1-2% of the radiation exposure of VCUG but not as great a picture. |
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When is VUR most likely to cause renal injury?
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In the first year of life
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Does sterile reflux cause renal injury?
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Not usually-- but in high-pressure voiding situations, renal injury possibly may occur.
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What is the likelihood of renal scarring in patients with VUR?
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I: 5-10%
II: 15% III: 30% IV: 50% V: 85% |
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What is the long-term consequence of renal scarring from VUR?
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HTN and renal insufficiency or ESRD
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Why does HTN result with VUR?
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Segmental ischemia and renin-driven HTN due to arterial damage in the area of renal scarring
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Of children with reflux, what % of their siblings also have reflux?
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30-35%
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Should all siblings of index patients with reflux undero a VCUG?
|
If a sibling is <2-3 yo, then radionuclide cystogram should be orderd. In children >3yo, renal U/S is appropriate.
If abnormality then is discovered, may proceed to VCUG |
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What imaging studies are commonly used to detect renal scarring? Which is most sensitive?
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1. DMSA renal scan (areas of diminished uptake in the cortex)- most sensitive test
2. SPECT 3. IVP (blunted calyx, renal cortical thinning, or cortical atrophy of a segment of the entire kidney) |
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What is the Weigert-Meyer law?
|
This law applies to children with complete duplication of the urinary tract resulting from 2 ureteral buds leading to formation of 2 separate ureters and separate renal pelves within one kidney.
Ureter draining the lower pole is more cephalolateral and the ureter draining the upper pole is more inferomedial to the bladder, and is prone to becoming ectopic. Ureter to the upper segment arises from a cephalad position on the mesonephric duct, remains attached to duct longer and thus migrates farther (ending inferomedial to ureter draining the lower segment). |
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What is the significance of the Weigert-Meyer law in reflux?
|
Because the ureter draining the lower pole of the kidney drains in a more lateral position in the bladder, its intramural tunnel is shorter, predisposing to reflux
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How is patient's age related to the likelihood of spontaneous resolution of reflux?
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The younger the child, the greater is the likelihood that reflux will resolve.
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What is the likelihood of spontaneous resolution of reflux in a child with bilateral grade III or IV reflux?
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10%
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WHat is the mean age at diagnosis of reflux?
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2-3yo
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What is the mean age at spontaneous resolution of reflux?
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5-6yo
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At what age is reflux no longer likely to resolve?
|
10-11yo (but if low grade, may take until 14-15yo)
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How are children with reflux managed medically?
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1. Timed voids
2. Anticholinergics if bladder instability 3. Treat constipation aggressively 4. Abx prophylaxis to prevent UTIs with septra, TMP or macrobid (1/4 to 1/3 the dose) |
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Why are only TMP/SMX, TMP or nitrofurantoin used for abx prophylaxis in VUR?
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Because these have the least effect on the bacterial flora in the stool
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What is breakthrough UTI and what is the incidence in children with VUR?
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UTI that occurs while the patient is receiving prophylaxis. 25-35%
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What are the indications for surgical management of children with reflux?
|
1. Grade V reflux
2. Failure of medical management with lesser grades 3. Primary grade IV reflux (controversial) |
|
|
What is used for surveillance for VUR?
|
1. UA and culture every 3-4 months
2. Follow-up cystogram q12-18 months to monitor reflux 3. Upper tract study (IVP, U/S or DMSA) to assess renal growth q12-18months |
|
|
What constitute a failure of medical management for VUR?
|
1. Child who develops breakthrough UTI
2. Allergy to antibx 3. Poorly compliant 4. Persistent reflux to 10-11yo |
|
|
What are the principles of surgical management for VUR?
|
1. Creation of intramural ureter that is 4-5x as long as wide
2. Ureter is placed in the submucosal layer between the mucosa and detrusor muscle |
|
|
What is the term for the surgery for VUR?
|
Ureteroneocystostomy
|
|
|
What is the most common method of ureteroneocystostomy?
|
Cohen or transtrigonal repair- open bladder, mobilize ureter and advance it across the trigone
|
|
|
What are the 3 techniques for ureteroneocystostomy?
|
1. Cohen or transtrigonal
2. Leadbetter-Politano (ureter reinserted in a higher more medial position in bladder and brought down to normal position) 3. Lich-Gregoir or detrusorrhaphy (extravesical repair in which ureter is anchored in bladder base and bladder muscle is sutured around the ureter) |
|
|
In a child with duplication of the urinary tract and reflux into the lower pole, how is the reflux managed surgically?
|
Perform a "common sheath" ureteroneocystostomy in which both ureters are mobilized together and reimplanted as one unit.
|
|
|
What is the success rate of ureteroneocystostomy?
|
95-98%
|
|
|
What are the complications of ureteroneocystostomy?
|
Obstruction of the UVJ and reflux in 1-2% of cases
|
|
|
In children with primary reflux, which patients are most likely to experience a complication?
|
Children who have untreated voiding dysfunction
|
|
|
What is J-hooking of the ureter?
|
AKA high reimplant syndrome-- in children undergoing Leadbetter-Politano repair, if the ureter is anastomosed to a mobile portion of the bladder, kinking of the ureter can occur especially when the bladder fills, leading to obstruction and hydroureteronephrosis
|
|
|
What are the four cysto appearances of ureteral orifice in children with reflux?
|
1. Stadium
2. Horseshoe 3. Golf hole 4. Patulous (progressively abnormal appearances of the ureter in the bladder) |
|
|
What is the endoscopic form of antireflux surgery?
|
STING (subtrigonal injection)- inject deep into ureter to create an intramural tunnel
|
|
|
How does STING compare to ureteroneocystostomy?
|
STING is inferior (70%) compared to surgery (98%)
|
|
|
Can reflux be diagnosed prenatally?
|
Yes- by detecting hydro
|
|
|
Of children with prenatally diagnosed reflux, what % are boys?
|
80% (b/c boys have higher grades of reflux than girls)
|
|
|
What is a ureterocele?
|
A cystic dilatation of the distal end of the ureter in the intravesical segment
|
|
|
In what settings does a ureterocele occur?
|
More commonly seen in duplicated ureters (ectopic ureteroceles) (and come from the ureter draining the upper segment)
|
|
|
What are the 3 theories for why ureteroceles occur?
|
1. Ureteral meatal obstruction
2. Inadequate muscularization of the distal ureter 3. Excessive dilatation of the distal ureter during development |
|
|
Do ureteroceles occur equally in both sexes?
|
No- single system is much more common in boys and rarely in girls. Vice versa in duplicated systems (much more common in girls than boys)
|
|
|
How do ureteroceles present?
|
Usually diagnosed by in-utero ultrasound (hydro dx is made, which is corrected to ureterocele during eval in postpartum period)
|
|
|
What are the 3 best ways to diagnose ureterocele?
|
1. Ultrasound (best initial step)
2. VCUG (confirms U/S findings) 3. Renal scan (assesses function of upper tracts) |
|
|
What is the preferred treatment for a single-system (orthotopic) ureterocele?
|
Simple, endoscopic incision of the ureterocele. If reflux occurs and kidney is salvageable, surgical reimplantation may be performed.
|
|
|
Does reflux occur in ureteroceles?
|
Yes- can occur in up to 50% of ipsilateral ureters that are associated with ureteroceles
|
|
|
Can reflux associated with ureteroceles disappear spontaneously?
|
Yes if mild. But not if severe or moderate
|
|
|
Can ureteroceles be bilateral?
|
Yes- in 10%
|
|
|
What is a cecoureterocele?
|
Ectopic ureterocele that extends suburethrally into the proximal or even distal urethra
|
|
|
What are the 6 symptomatic types of urinary incontinence?
|
1. Total
2. Urge 3. Stress 4. Overflow 5. Transient (e.g. change in med) 6. Functional (e.g. cognitive d/o) |
|
|
What are 3 causes of pelvic floor weakness?
|
1. Anatomic
2. Hormonal 3. Neurologic (congenital or traumatic) |
|
|
What is the underlying problem in GSI?
|
Urethral incompetence
|
|
|
What causes urethral incompetence?
|
Damage to the sympathetic neural input to the bladder neck and proximal urethra. (innervated by the hypogastric nerve)
|
|
|
What are the 2 types of stress incontinence?
|
1. Hypermobility of vesicourethral junction
2. No hypermobility- bladder outlet is well-supported but not functioning properly |
|
|
What is the Q-tip test?
|
Helps determine the amount of urethral hypermobility on straining.
1. With patient in lithotomy, insert a lubricated Q-tip into the urethra to level of urethrovesical junction 2. Measure angle between Q-tip and horizontal when patient strains maximally. 3. Normal angle is 10-15 degrees above horizontal at rest with minimal change while straining. In GSI, angle increases by >20 degrees with straining.-- suggests weakness of anatomic supporty |
|
|
What is the Stress Test?
|
1. Patient with a full bladder stands with one leg on a stool.
2. While watching urethral meatus, patient coughs 3. If a short spurt of urine escapes with increased pressure, GSI is diagnosed |
|
|
What is the Bonney Test?
|
1. Place 2 fingers in vagina to elevate neck of bladder up toward pubic bone
2. If patient has had a + stress test, teh Bonney test usually stops the urinary loss by elevating and compressing the urethra |
|
|
What is the Marshall test?
|
Similar to the Bonney test except there is local anesthesia and the vagina is clamped and elevated. Bonney & Marshall tests aren't very helpful.
|
|
|
What 3 muscle groups does urodynamic testing evaluate?
|
1. Bladder
2. Smooth muscle of urethra 3. External striated muscle sphincter |
|
|
How should the patient be positioned for urodynamic testing?
|
Standing upright
|
|
|
Once the diagnosis of GSI has been established, what medical treatments are available?
|
The only medical treatment available is estrogen for postmenopausal women
|
|
|
What are some nonsurgical methods of treating GSI?
|
1. Kegel exercises
2. Biofeedback 3. Bladder drills 4. Timed voids |
|
|
What are the major risks of vaginal sling surgery?
|
1. Bleeding, infection, bladder/ureter injury
2. Erosion of graft materials into the urethra or vagina 3. De novo urge incontinence 4. Recurrent stress incontinence 5. Neurologic injury 6. Pain |
|
|
What are 3 methods for treating intrinsic sphincteric deficiency?
|
1. Pubovaginal sling
2. AUS 3. Injectable treatment |
|
|
What is TVT?
|
Tension free vaginal tape- supports the mid-urethra and aids continence
|
|
|
What is the leading cause of vesicovaginal fistula worldwide?
|
Obstetric trauma
|
|
|
When is a VVF detected post-operatively?
|
POD #7-14
|
|
|
How can you determine whether continuous vaginal discharge is urine?
|
Send the fluid for creatinine (Cr in urine is several factors higher than that of serum and other fluids). You could also instill dye into the bladder
|
|
|
What are 3 conservative management options for VVF?
|
1. Estrogen replacement therapy
2. Hyperbaric oxygen therapy 3. Adjuvant corticosteroids (controversial) |
|
|
When VVFs are the result of obstetric injury, how long should one wait until surgical repair?
|
3-6 months
|
|
|
When VVFs are a result of radiation therapy, how long should one wait until surgical repair?
|
12 months
|
|
|
When uncomplicated VVFs are a result of iatrogenic injury, how long should one wait until surgical repair?
|
2-3 weeks
|
|
|
What is the usual surgical approach for repairing VVFs?
|
Transvaginal (abdominal is reserved for minority of women with complicated (multiple) or complex (involvement of 2 or more organs) fistula repairs)
|
|
|
Should the fistulous tract be excised in the case of VVFs?
|
Yes usually...
|
|
|
What is the most common cause of incontinence following the repair of VVF?
|
Persistent stress incontinence
|
|
|
What urine volume is associated with oliguria?
|
<400mL/day
|
|
|
What is the name of the retropubic space?
|
Space of Retzius
|
|
|
What is the arterial supply to the prostate?
|
Inferior vesical artery (& middle rectal)
|
|
|
What are the 3 zones of the prostate, and what % of each makes up the prostate?
|
Peripheral zone (70%)
Central zone (25%) Transition zone (5%) |
|
|
What are 2 environmental risks for CaP?
|
1. Increased fat in diet
2. Cadmium (smoke, alkaline batteries) |
|
|
What are the 3 most common histologic types of CaP?
|
1. Adenocarcinoma (95%)
2. TCC (90% of those NOT adeno) 3. Neuroendocrine (small cell) or sarcomas |
|
|
Describe the histologic appearance of Gleason 3.
|
Usually variable-sized glands or cribriform pattern
|
|
|
Describe the histologic appearance of Gleason 4.
|
Incomplete gland formation
|
|
|
Describe the histologic appearance of Gleason 5.
|
No gland formation
|
|
|
What is the usual pattern of progression for CaP mets?
|
Lymphatic mets usually involve the obturator lymph nodes, then the axial skeleton (osteoblastic), lung, liver, adrenals
|
|
|
Is CaP bone mets osteolytic or osteoblastic?
|
Osteoblastic
|
|
|
What are the usual symptoms of CaP?
|
None-- but if there are symptoms, usually irritative/obstructive symptoms, lymphedema of lower extremities, or cord compression
|
|
|
What are the symptoms associated with CaP cord compression?
|
1. Weak lower extremities
2. Hyperreflexic bulbocavernosus reflex |
|
|
Name 4 labs to obtain to evaluate CaP.
|
1. CBC (anemia)
2. Chem7 (azotemia) 3. Alk phos 4. Serum acid phosphatase |
|
|
What is the upper limit for PSA velocity?
|
>0.75 ng/mL/year
|
|
|
What is the threshold for PSA density for CaP?
|
>0.12 ng/mL/gram
|
|
|
What is the cut-off for free PSA with regard to CaP?
|
<15% of total PSA is suggestive of CaP (90% of PSA is usually bound to alpha1-antichymotrypsin)
|
|
|
What are the age-adjusted normal PSA levels?
|
40-49yo: 0-2.5
50-59yo: 0-3.5 60-69yo: 0-4.5 70-79yo: 0.6.5 |
|
|
What does CaP look like on TRUS?
|
Hypoechoic lesion in peripheral zone
|
|
|
When can one omit bone scans in newly diagnosed CaP?
|
PSA <10 ng/mL
|
|
|
What are the clinical criteria for extracapsular extension of CaP?
|
Bulging of the prostate contour or angulated appearance of the lateral margin
|
|
|
What are the clinical criteria for seminal vesicle invasion?
|
Posterior bulge at base of seminal vesicle or asymmetry in echogenicity of seminal vesicle associated with hypoechoic areas at base of prostate.
|
|
|
What is one proposed criteria for CT/MRI (axial) imaging for CaP to exclude LN mets?
|
Negative bone scan and either:
1. T3 cancer OR 2. PSA>20 and primary Gleason 4 or 5 |
|
|
Is blood loss more common with an RRP or RPP?
|
RRP (but rectal injury more common with the RPP approach)
|
|
|
What is the single most important factor in the restoration of continence after prostatectomy?
|
Age
|
|
|
Why should nerve-sparing prostatectomy be performed selectively?
|
Because extracapsular extension is a common finding in patients with presumed localized CaP
|
|
|
How much radiation is delivered with XRT (external beam radiotherapy) in CaP?
|
6500-7000 cGy
|
|
|
How many probes are placed in prostate cryotherapy?
|
5 (2 anteromedial, 2 posterolateral, and 1 posteriorly)
|
|
|
How are patients with T3 CaP treated currently?
|
Neoadjuvant hormonal therapy followed by XRT
|
|
|
What treatment is used for recurrent CaP?
|
Androgen ablation (if post-XRT, may try salvage prostatectomy)
|
|
|
How is metastatic CaP treated?
|
1. Androgen blockade (LHRH agonists (e.g. lupron) or orchiectomy)
2. Ketoconazole (if spinal cord compression or DIC) 3. Complete androgen blockade with anti-androgen |
|
|
What is the difference between anti-androgen and LHRH agonists?
|
LHRH agonists stimulate LHRH and eventually downregulate androgen release.
Antiandrogens act by competitively binding the receptor for DHT, the intracellular androgen responsible for prostatic cell growth and development. |
|
|
What is the first thing to try in endocrine therapy failure for metastatic CaP?
|
Stop the anti-androgen (20-30% have a response known as antiandrogen withdrawal syndrome)
|
|
|
What is the etiology of BPH?
|
Not completely understood... it is clearly under endocrine control and seems to be multifactorial. Association b/w aging and BPH might result from increased estrogen levels of aging causing induction of the androgen receptor, which sensitizes the prostate to free testosterone.
|
|
|
What area of the prostate does BPH develop in?
|
Transition zone
|
|
|
How does the composition of BPH affect medical treatment efficacy?
|
If BPH involves more smooth muscle, alpha blockers work better. If it involves more epithelium, then 5a-reductase inhibitors work better. And if it contains more collagen, it might not respond to either therapy.
|
|
|
What is the surgical capsule with regard to BPH?
|
As the prostate grows, they compress the outer zones of the prostate resulting in the capsule, and separating the transition zone from teh peripheral zone (to serve as a cleavage plan for open nucleation of the prostate)
|
|
|
What is the prostatic stroma made up of?
|
Collagen and smooth muscle
|
|
|
What is the etiology of BPH?
|
Not completely understood... it is clearly under endocrine control and seems to be multifactorial. Association b/w aging and BPH might result from increased estrogen levels of aging causing induction of the androgen receptor, which sensitizes the prostate to free testosterone.
|
|
|
What area of the prostate does BPH develop in?
|
Transition zone
|
|
|
How does the composition of BPH affect medical treatment efficacy?
|
If BPH involves more smooth muscle, alpha blockers work better. If it involves more epithelium, then 5a-reductase inhibitors work better. And if it contains more collagen, it might not respond to either therapy.
|
|
|
What is the surgical capsule with regard to BPH?
|
As the prostate grows, they compress the outer zones of the prostate resulting in the capsule, and separating the transition zone from teh peripheral zone (to serve as a cleavage plan for open nucleation of the prostate)
|
|
|
What is the prostatic stroma made up of?
|
Collagen and smooth muscle
|
|
|
What is the questionnaire used to evaluate symptoms of BPH?
|
AUA Symptom Score questionnaire
|
|
|
How many items are included on the AUASS and what scores indicate mild, moderate, or severe symptoms?
|
7 questions (on scale 0-5) with score from 0 to 35
0-7: mild 8-19: moderate 20-35: severe |
|
|
Should one obtain upper tract imaging in the case of BPH?
|
Only if concomitant urinary tract disease OR complications from BPH
|
|
|
Is progression in BPH inevitable?
|
NO!
|
|
|
Why do alpha blockers work with regard to BPH?
|
Alpha receptors are present both in the bladder base as well as prostate
|
|
|
Which alpha subtype does the prostate best respond to and what happens?
|
Alpha-1... agonist causes contractile activity in the prostate (so antagonist allows the prostate to release its hold on the urethra)
|
|
|
Why are phenoxybenzamine and prazosin not used often in BPH?
|
High side effect profile... must titrate these medications (take at night to avoid orthostatic hypotension)
|
|
|
What are 6 typical SEs of alpha blockers?
|
1. Orthostatic hypotension
2. Dizziness 3. Retrograde ejaculation 4. Tiredness 5. Rhinitis 6. H/A |
|
|
What are the 7 questions asked in the AUASS?
|
1. Incomplete emptying
2. Frequency 3. Intermittency 4. Urgency 5. Weak stream 6. Straining 7. Nocturia |
|
|
What is the difference between tamsulosin, terazosin, prazosin, and phenoxybenzamine?
|
They're all alpha blockers:
1. Tamsulosin is alpha-1a selective. 2. Terazosin is alpha-1 selective (long-acting) 3. Prazosin is alpha-1 selective (short-acting) 4. Phenoxybenzamine is nonselective alpha-blocker |
|
|
What does finasteride (a 5-alpha reductase inhibitor) act upon?
|
The epithelial component of the prostate
|
|
|
How long does it take to see the maximum effects of finasteride?
|
6 months
|
|
|
What are the 3 main SEs of 5a-reductase inhibitors?
|
1. Decreased libido
2. Decreased ejaculate 3. ED |
|
|
What is TUR syndrome?
|
Complication of TURP in which patient becomes hypervolemic and hyponatremic due to absorption of hypotonic irrigating solution
|
|
|
What are the clinical manifestations of TUR syndrome?
|
1. N/V
2. Confusion 3. HTN 4. Bradycardia 5. Visual disturbances |
|
|
What increases the risk of TUR syndrome?
|
Resection times >90 minutes
|
|
|
How is TUR syndrome treated?
|
1. Diuresis
2. If very severe, hypertonic saline administration |
|
|
What is TUIP?
|
Transurethral incision of the prostate- if severe symptoms but a small prostate, these men may have posterior commissure hyperplasia (best treated with TUIP)- 2 incisions at 5 and 7 o'clock (extend outward toward the veru)
|
|
|
What size glands for BPH are considered for open prostatectomy?
|
>100g
|
|
|
What is the open procedure of choice for BPH?
|
Simple suprapubic prostatectomy (transvesically)
|
|
|
What is HIFU?
|
High-intensity focused ultrasound used for BPH. Dual-function U/S probe placed in rectum allowing imaging of the prostate as well as delivering short bursts of high-intensity focused U/S energy which heats the prostate and results in coagulative necrosis.
|
|
|
Chronic interstitial nephritis represents a nonspecific reaction to a variety of causes. List 8 possible such causes.
|
1. Analgesic abuse
2. Lead & Cadmium toxicity 3. Balkan nephropathy 4. Urate nephropathy 5. Nephrocalcinosis 6. Radiation nephritis 7. Sarcoidosis 8. Obstructive uropathy |
|
|
What analgesic was initially implicated in the cause of CIN?
|
Phenacetin
|
|
|
What other symptom accompanies chronic hereditary nephritis (and what is the syndrome called)?
|
Deafness (Alport Syndrome)
|
|
|
What is the initial manifestation of medullary cystic disease?
|
Anemia
|
|
|
Is life expectancy affected (and if so, by how much) by medullary sponge kidney?
|
No it's not
|
|
|
What is the problem associated with cystinuria?
|
Defect in absorption of dibasic amino acids in the jejunum (COLA: cystine, ornithine, lysine, arginine)
|
|
|
What characterizes De Toni-Fanconi-Debre Syndrome?
|
1. Aminoaciduria
2. Phosphaturia 3. Glycosuria 4. Variable degree of RTA |
|
|
How is De Toni-Fanconi-Debre Syndrome treated?
|
1. Replace cations (potassium)
2. Correct acidosis with bicarb or citrate 3. Replace phosphate 4. Ensure liberal calcium intake |
|
|
What should be done in traumas before inserting a urethral catheter?
|
Careful inspection of the urethral meatus for blood
|
|
|
If one finds blood at the meatus after adult blunt trauma, what is the next step?
|
Retrograde urethrogram (RUG)
|
|
|
What study is called for if there is no blood at the urethral meatus but positive blood in the urine?
|
CT or IVP and cystogram
|
|
|
What is the best imaging modality to help detect and stage retroperitoneal and renal injury?
|
CT
|
|
|
In urologic trauma, what is the benefit of retrograde cystography?
|
To evaluate for bladder perforation (fill bladder with 300mL of contrast- obtain film with bladder filled and a second film after bladder has emptied itself via gravity)
|
|
|
What is a RUG and how does it work?
|
Retrograde urethrogram-
1. A small 12F catheter inserted into urethral meatus 2. 3mL of water placed in a balloon to hold catheter in place. 3. Inject 20mL of water-soluble contrast retrograde into the urethra |
|
|
What does extravasation into the deep bulbar area on RUG indicate?
|
Straddle injury
|
|
|
What does extravasation into the retropubic space on RUG indicate?
|
Prostatomembranous disruption
|
|
|
What does IV urography detect?
|
Renal and ureteral injury
|
|
|
Lacerations from blunt trauma usually occur in what plane of the kidney?
|
Transverse
|
|
|
What are the pathologic classification of renal injuries?
|
Grade I (most common): renal contusion or bruising of parenchyma
Grade II: Renal parenchymal laceration into renal cortex. Perirenal hematoma small. Grade III: Renal parenchymal lac through cortex and into medulla. Bleeding may be significant esp if large retroperitoneal hematoma. Grade IV: Renal parenchymal lac extending into renal collecting system. Main renal artery thrombosis from blunt trauma, segmental renal vein, or both. or artery injury with contained bleeding Grade V: Multiple Grade IV lacs, renal pedicle avulsion, or both. Main renal vein or artery injury from penetrating trauma. |
|
|
What are 4 late pathologic findings in renal injury?
|
1. Urinoma
2. Hydronephrosis 3. AV fistula 4. Renal vascular HTN |
|
|
Explain how hydronephrosis may result as a late complication after renal injury?
|
Large hematomas in retroperitoneum and associated urinary extrav may result in perinephric fibrosis engulfing the UPJ, causing hydro.
|
|
|
How is major renal injury followed after hospital discharge?
|
Must get excretory urography to evaluate for possibility of hydronephrosis.
|
|
|
Why does renal vascular HTN occur as an occasional late consequence of renal trauma?
|
Because blood flow in tissue rendered nonviable by injury is compromised.
|
|
|
What clinical signs are present to indicate retroperitoneal hematoma?
|
1. Shock
2. Ecchymosis over flanks or upper quadrants of abdomen 3. Acute abdomen (pain) 4. Often, lower rib fractures may be found |
|
|
Why are urinomas bad?
|
They are prone to abscess formation and sepsis.
|
|
|
Can fever distinguish between a urinoma and retroperitoneal hematoma?
|
Not exactly...a resolving RP hematoma may show low-grade fever (101). Usually sepsis/abscess would be higher temperatures.
|
|
|
When should the follow-up excretory urogram or CT scan be performed after major renal trauma?
|
3-6 months
|
|
|
How should penetrating renal injuries be managed?
|
Always explore EXCEPT when staging has been complete and only minor parenchymal injury is found with no urinary extravasation.
|
|
|
What is the most common cause of non-iatrogenic ureteral injury?
|
Rapid deceleration accidents which avulse the ureter from the renal pelvis
|
|
|
What is the most common cause of ureteral injury?
|
Iatrogenic (we did it!)
|
|
|
Name 4 iatrogenic etiologies of ureteral injury.
|
1. Large pelvic masses (or inflammatory pelvic disorders) which displace the ureter laterally and engulf it in reactive fibrosis leave it prone to iatrogenic injury (since it is malpositioned anatomically)
2. Extensive colon ca may engulf the ureter, so it may need to be resected along with the cancer 3. Devascularization may occur with extensive pelvic LN dissections or after radiation therapy to pelvis for pelvic cancer 4. Endoscopic manipulation of a ureteral calculus with a stone basket or ureteroscope-- perforation or avulsion |
|
|
What are the usual symptoms if the ureter has been ligated during an operation?
|
1. Fever
2. Flank 3. Lower quadrant pain |
|
|
If a ureterovaginal or cutaneous fistula develops post-operatively after a ureter is cut, within what time frame is it?
|
10 days postop
|
|
|
What labs/techniques may be employed if ureter ligation is suspected?
|
1. If watery discharge is escaping the wound, send it for creatinine concentration (urine has many times the [Cr] of serum)
2. IV inject 10mL indigo carmine (will appear in urine as dark blue) |
|
|
What imaging studies are useful for diagnosing ureteral injury?
|
Excretory urography (or retrograde ureterography)
|
|
|
How is ureteral injury managed?
|
1. If recognized intraoperatively, fix it
2. If recognized after 7-10days without sx, immediate reexploration and repair 3. If complications, proximal urinary drainage via perc nephrostomy or formal nephrostomy |
|
|
What is the procedure of choice for lower ureteral injuries?
|
Reimplantation into the bladder combined with a psoas-hitch procedure to minimize tension on the ureteral anastamosis
|
|
|
What is the procedure of choice for upper ureteral injuries?
|
Primary ureteroureterostomy
|
|
|
Are stents used postoperatively in ureteral operations, and if so, which kind and for how long?
|
Yes- Double J for 3-4 weeks
|
|
|
Bladder injuries are most often a result from what trauma?
|
Pelvic fractures
|
|
|
What imaging technique is preferred for diagnosis of bladder injury?
|
Cystography
|
|
|
After repair of a bladder laceration, what kind of catheter is preferred and for how long?
|
SPT for 10 days
|
|
|
What sutures may be used to close bladder?
|
Polyglycolic acid or chromic absorbable sutures
|
|
|
What are the 2 general anatomic divisions of the urethra?
|
1. Posterior (prostatic and membranous)
2. Anterior (bulbous and pendulous) |
|
|
How is an incomplete laceration of the posterior urethra managed?
|
Self-limiting... keep a suprapubic cystostomy for 2-3 weeks-- and remove only after VCUG shows no persistent extravasation
|
|
|
How long does it take before urethral reconstruction after prostatic disruption can be undertaken?
|
3 months (if no infection)
|
|
|
Should patients follow-up after removal of their SPT following urethral injury?
|
YES! Urethrogram within 2 months to watch for stricture development
|
|
|
What are 3 major consequences of posterior urethral injury?
|
1. Stricture
2. Impotence (10% will be permanent) 3. Incontinence (<2%) |
|
|
If there is a laceration of the anterior urethra, where does the blood and urine extrav collect?
|
Under Colles' fascia
|
|
|
How is an anterior urethral injury managed?
|
SP tube (if a complete lac with extensive urinary extrav, drain it first, then the SP tube)
|
|
|
What anatomically is disrupted in a penile fracture?
|
The tunica albuginea
|
|
|
Is bladder exstrophy more common in boys or girls?
|
Boys (3-4:1)
|
|
|
What causes exstrophy of the bladder?
|
Failure of the cloacal membrane to retract
|
|
|
What are the usual associated anomalies with exstrophy of the bladder?
|
1. VUR
2. Inguinal hernias 3. Epispadias (always) 4. Widely spaced pubic symphysis |
|
|
Are upper urinary tract changes common at birth in patients with bladder exstrophy?
|
No-- but sometimes may find horseshoe kidney or dysplasia so always order a renal ultrasound
|
|
|
Name 2 obstetric/gynecologic complications that occur in women with a history of bladder exstrophy.
|
1. Uterine prolapse
2. Fetal malpresentation |
|
|
What problems does the exposed bladder mucosa in exstrophy represent?
|
Very few:
1. Protect mucosa from injury 2. Prevent mucosal edema (which will make bladder closure more difficult) |
|
|
What precautions are taken while awaiting surgery for bladder exstrophy?
|
Cover bladder with piece of Silastic or plastic wrap (and prevent irritation from diapers and umbilical cord clamp)
|
|
|
What are the 3 operations used for boys with bladder exstrophy?
|
1. Primary bladder closure at 1-2do
2. Epispadias repair at 6-18mo 3. Bladder neck reconstruction |
|
|
How successful are the standard procedures for correcting bladder exstrophy?
|
70% are continent
|
|
|
What is the most common reason for failure in surgery for bladder exstrophy?
|
Persistently small bladder (treat with bladder augmentation)
|
|
|
What is cloacal exstrophy?
|
Rare, complex disorder resulting from premature rupture of cloacal membrane before separation of the cloaca into an anterior and posterior portion. Resulting in 2 halves of an exstrophied bladder separated by an exstrophied ileocecal segment.
|
|
|
Describe the 5 anatomic divisions of the male urethra (from distal to proximal).
|
1. Glanular
2. Pendulous or penile (corona to distal fusion of ischiocavernosus muscles) 3. Bulbous (covered by the fusion of the ischiocavernosus muscles, extending proximally to perineal membrane) 4. Membranous (surrounded by striated urethral sphincter) 5. Prostatic (proximal to the verumontanum and surrounded by the prostate) |
|
|
At the bulbous portion of the urethra, where does the urethra lie with respect to the spongiosum?
|
More dorsal than ventral
|
|
|
What are the most common causes of urethral strictures?
|
Iatrogenic or trauma
(2nd most common after these is inflammatory urethritis) |
|
|
Describe the reconstructive ladder approach to treatment of urethral strictures.
|
Start with simplest procedure and add only if that doesn't work.
1. Start with urethral dilation 2. Internal urethrotomy 3. Open urethral reconstruction |
|
|
Where are the incisions made during endoscopic direct-vision internal urethrotomy (DVIU)?
|
12-o'clock (through spongiofibrosis into underlying healthy corpus spongiosum) (some may say 10 and 2 o'clock)
|
|
|
Which patients are good candidates for direct-vision internal urethrotomy?
|
1. Stricture length >1cm
2. Location within bulbous urethra 3. No previous urethrotomy |
|
|
What is the most common graft currently used for urethral reconstruction?
|
Buccal mucosa graft harvested from the inner cheek
|
|
|
In what situations are grafts most effective in urethral reconstruction?
|
When used for bulbous urethral strictures with mild to moderate spongiofibrosis
|
|
|
What may a flap be preferred over a graft during urethral reconstruction?
|
If strictures involve penile urethra and when severe or full-thickness spongiofibrosis is present
|
|
|
What are the most common flaps used in urethral reconstruction?
|
1. Penile skin islands
2. Mid-scrotal (raphe) islands |
|
|
What is the preferred form of management of a membranous urethral stricture after TURP?
|
Urethral dilatation b/c DVIU or open carries a high risk of urinary incontinence (striated urethral sphincter encompasses the membranous urethra and may be compromised)
|
|
|
Define verumontanum.
|
Located on dorsal aspect of prostatic urethra, small mount of tissue into which drain the two ejaculatory ducts and prostatic utricle.
|
|
|
What is the significance of the verumontanum during cystoscopy?
|
It is an important landmark b/c it is just proximal to the external sphincter
|
|
|
What is the incidence of PUVs?
|
1 in 8000 males
|
|
|
How are PUVs diagnosed?
|
VCUG
|
|
|
After a PUV is diagnosed (via VCUG), what other studies should be ordered?
|
Renal ultrasound and renal scan to ascertain how well the kidneys are functioning
|
|
|
What are the three types of congenital PUV?
|
Type I: obstructing membrane extending distally from each side of the veru toward the membranous urethra where they fuse anteriorly
Type II: Folds extending cephalad from veru to bladder neck (doesn't exist!) Type III: Diaphragm or ring-like membrane with central aperture just distal to the verumontanum |
|
|
Do the types of PUV matter?
|
NO! In fact, researchers believe that Types I and III are the same thing
|
|
|
What % of boys with PUVs have VUR?
|
50%
|
|
|
How should a boy with PUV be initially managed?
|
1. 5 or 8-F feeding tube placed into bladder to drain it (no balloon)
2. Broad-spectrum IV abx 3. Measure Cr, electrolytes and manage before surgery 4. Get a renal ultrasound |
|
|
What is the usual treatment for PUV?
|
Transurethral valve ablation with cuts and 5- and 7-o'clock positions. (If the urethra is too small to accomodate the peds resectoscope, you may visualize with an 8F and ablate the PUV under direct vision with a Bugbee electrode)
|
|
|
What is the urethra with the PUV is too small to accommodate a small cystoscope and Bugbee?
|
Use a small insulated crochet hook ("Whitaker hook")- engage valve leaflets at 5- and 7-o'clock positions
|
|
|
What is the role of fetal surgery in the treatment of PUVs?
|
None really-- the mortality rate is very high (43%) and there's no evidence that it actually helps in the patient's future
|
|
|
What is the most common complication of valve ablation for PUVs?
|
Urethral stricture (#2 is incomplete valve resection)
|
|
|
What are 4 favorable prognostic factors following treatment for PUVs?
|
1. Following serum Cr (below 1.0)
2. Absence of VUR on VCUG 3. Preservation of the corticomedullary junction of kidneys by ultrasound 4. Evidence of radiogrpahic "pop-off valve" |
|
|
What is a "pop-off valve"?
|
Mechanism in which the high intravesical or intrapelvic pressure is dissipated, allowing for normal development of one or both kidneys
|
|
|
What are 3 types of "pop-off valves"?
|
1. Urinary ascites (urine leaks from fornices of kidneys or bladder rupture)
2. VURD syndrome (massive unilateral reflux into a nonfunctioning kidney) 3. Presence of a large bladder diverticulum causing aberrant micturition into diverticulum and taking pressure off developing kidneys |
|
|
What % of PUVs have a "pop-off" feature?
|
20%
|
|
|
What does VURD syndrome stand for?
|
VUR with renal dysplasia-- it only applies to children with PUV
|
|
|
List 5 adverse prognostic factors in children with PUV.
|
1. Presentation <1yo
2. Failure of serum Cr to fall below 1.0mg/dL 1 month following initial therapy 3. B/L VUR 4. Diurnal incontinence beyond 5 years of age 5. Prenatal dx in 2nd trimester |
|
|
In a neonate with severe PUV, what is the most likely cause of death?
|
Pulmonary hypoplasia
|
|
|
Why does pulmonary hypoplasia occur with boys with PUV?
|
In the first trimester, amniotic fluid is a transudate from the placenta. In the 2nd and 3rd trimesters, amniotic fluid comes from urine voided by the fetus.
|
|
|
What is the source of tissue for augmentation cystoplasty in boys with valves?
|
1. Stomach tissue (can reduce acidosis that results from valve condition)
2. Dilated ureter (ureterocystoplasty) 3. Ileum 4. Large bowel |
|
|
At what intravesical pressure is there impaired upper urinary tract drainage?
|
35cm of water pressure
|
|
|
Where are anterior urethral valves located?
|
All occur in the bulbous or pendulous urethra
|
|
|
What are 3 clinical findings of an anterior urethral valve?
|
1. Cystic mass on ventral aspect of penoscrotal junction increases in size during voiding
2. Prolonged urinary strain 3. Compression of cystic mass results in urinary dribbling |
|
|
What is an anterior urethral valve?
|
Not a true valve-- it is a wide-mouth anterior urethral diverticulum with the distal lip of the diverticulum filling during voiding, compressing the distal urethra
|
|
|
A urethral diverticulum is a defect in what anatomic layer?
|
Periurethral fascia
|
|
|
What are the causes of urethral diverticula?
|
1. Congenital
2. Acquired (surgery, trauma or infection)-- most common |
|
|
Where are urethral diverticula in females located?
|
Always on the vaginal aspect of the urethra on the distal 2/3 of the urethra where the periurethral glands are known to open
|
|
|
How do female urethral diverticula form?
|
Infection/obstruction of the periurethral glands lead to retention cysts which will then burst, leaving a diverticulum in its place.
|
|
|
What are the 3 most common offending organisms causing infection with female urethral diverticula?
|
1. E. coli
2. Gonococci 3. Chlamydia |
|
|
How do most patients present with a urethral diverticulum?
|
Non-specific irritative symptoms of the lower urinary tract (similar to those of cystitis) and classic 3D (dribbing, dysuria, dyspareunia)
|
|
|
Are any disease processes associated with diverticulum formation?
|
Yes- stone formation and urethral carcinoma (within the diverticulum)
|
|
|
What is the most common cancer found in a urethral diverticulum?
|
Adenocarcinoma (less common are SCC and TCC)
|
|
|
How is the diagnosis of urethral diverticulum confirmed? What is the gold standard?
|
1. VCUG (sometimes helpful)
2. Positive-pressure retrograde urethrography (RUG) 3. MRI T2 is the GOLD STANDARD |
|
|
How are urethral diverticula treated?
|
1. If very close to meatus, marsupialization (Spence procedure)
2. Urethroscopic electrocautery 3. Standard approach is complete urethral diverticulectomy |
|
|
What is a complete urethral diverticulectomy?
|
Incision through vagina to expose and mobilize a urethral diverticulum.
|
|
|
Which side is the dorsal side of the penis?
|
The top side
|
|
|
Do all children with hypospadias have a hooded foreskin?
|
No-- most do, but an uncommon variant with a large meatus (megameatal hypospadias) does have an intact foreskin- detected at circumcision
|
|
|
Do all children with a hooded foreskin have hypospadias?
|
No
|
|
|
What is the most common site for hypospadias?
|
Distal hypospadias (distal portion of the penis)- usually subcoronal or glandular (80-85%)
|
|
|
Is the incidence of hypospadias changing?
|
Yes- it's increasing
|
|
|
Do boys with hypospadias require urologic eval to detect other anomalies?
|
No- only if severe hypospadias and sexual ambiguity
|
|
|
What is the optimal age for hypospadias repair?
|
6-15 months
|
|
|
How does one repair a severe hypospadias on a small penis?
|
Give testosterone first
|
|
|
Name 7 potential complications of hypospadias surgery.
|
1. Urethrocutaneous fistula
2. Urethral stricture 3. Meatal stenosis 4. Urethral diverticulum 5. Excess skin 6. Persistent chordee 7. Persistent hypospadias |
|
|
What is the most common operation for distal hypospadias?
|
Tubularization of the incised urethral plate (Snodgrass), meatal advancement (MAGPI), and meatal-based flaps (Mathieu)
|
|
|
What is female epispadias?
|
Bifid clitoris, patulous urethra, and unformed bladder neck
|
|
|
How is exstrophy and epispadias connected?
|
When caudal migration of the cloacal membrane fails, bladder exstrophy results. When partial migration occurs, epispadias alone occurs.
|
|
|
What abnormality on KUB is universally present in patients with epispadias?
|
Separation of the pubic symphysis
|
|
|
Are most patients with epispadias incontinent?
|
Yes
|
|
|
What bladder abnormalities are found in most epispadias patients?
|
1. Small bladder capacity
2. VUR |
|
|
What are the 3 principles of epispadias repair?
|
1. Penile lengthening
2. Correction of chordee 3. Urethroplasty |
|
|
What is the ddx of interlabial masses in young girls?
|
1. Urethral prolapse
2. Paraurethral cysts 3. Prolapsed ectopic ureterocele 4. Sarcoma botryoides 5. Imperforate hymen 6. Uterovaginal prolapse |
|
|
What is the treatment of urethral prolapse?
|
Topical estrogen cream BID or TID for 1-2 weeks and sitz baths. If intermittent bleeding, surgical excision indicated.
|
|
|
What is a paraurethral cyst?
|
Results from retained secretion in Skene's glands (secondary to ductal obstruction)
|
|
|
How is a paraurethral cyst treated?
|
Usually will regress spontaneously during first 4-8 weeks of life, occasionally may need to remove them
|
|
|
What is a prolapsed ectopic ureterocele?
|
Cystic dilatation of the distal ureter within the wall of the bladder. In girls, it almost always drains the upper pole of a completely duplicated urinary tract. Usually is ectopic (extends beyond the bladder neck)
|
|
|
What is the typical age of presentation for girls with an ectopic ureterocele?
|
1 month to 3 years
|
|
|
How does a prolapsed ectopic ureterocele differ from a paraurethral cyst on exam?
|
The ureterocele appears to come from the urethra and may be pale, erythematous, and purplish or black. The paraurethral cyst appears to be coming from the wall of the urethra and is pale.
|
|
|
What is sarcoma botryoides?
|
Rhabdomyosarcoma of the vagina
|
|
|
What does sarcoma botryoides look like?
|
Firm grape-like mass protruding from the introitus
|
|
|
What is imperforate hymen?
|
Stenosis of the hymen resulting in retained vaginal secretions that originate from stimulation by maternal estrogens
|
|
|
How does imperforate hymen present?
|
White bulging interlabial mass in the newborn
|
|
|
Which type of patient is most likely to develop uterovaginal prolapse?
|
Those with myelodsyplasia (thought to be secondary to partial or complete denervation of the levator ani which supports the uterus and vagina)
|
|
|
What is the major cause of death in patients with ESRD?
|
Cardiovascular disease (infectious complications are the 2nd most common)
|
|
|
What is the most dangerous electrolyte imbalance associated with ESRD?
|
Hyperkalemia
|
|
|
What are the contraindications of renal transplantation?
|
1. Malignancy (except certain skin cancers)
2. Active systemic renal disease 3. Oxalosis 4. Active infection 5. Severe extrarenal disease (high surgical risk) 6. Active IV drug abuse or EtOH abuse 7. Repeated noncompliance 8. Uncontrolled psychiatric disorders |
|
|
Kidneys are ideally transplanted within how many hours?
|
24-36hours
|
|
|
What kind of rejection accounts for the majority of graft losses in renal transplantation?
|
Chronic rejection (90%)
|
|
|
What are the 4 types of rejection associated with renal transplantation?
|
1. Hyperacute (within first 24h)- mediated by preformed cytotoxic antibodies resulting from previous Ag exposure
2. Accelerated (within 4-7 days)- humoral and cellular aspects 3. Acute (within 3-6 months) 4. Chronic |
|
|
What is the mainstay for rejection prevention?
|
1. Corticosteroids
2. Mycophenolate mofetil (azathioprine) 3. Cyclosporine (FK506) |
|
|
What are the 2 most common causes of renal artery disease?
|
Atherosclerosis and fibrous dysplasia (both resulting in stenosis)
|
|
|
What are the four most helpful clues to the diagnosis of renovascular HTN?
|
1. Abdominal bruit with both systolic and diastolic components
2. Abrupt onset or exacerbation of HTN with rapid progression 3. Onset of HTN <30yo or >55yo 4. Retinal vascular changes |
|
|
What are the 5 screening tests used for RVH?
|
1. Rapid sequence IVP (not used much anymore due to lots of FP and FN)
2. Isotope renography 3. Duplex ultrasound scanning 4. MRA 5. Renal arteriography |
|
|
What are the 4 treatment options for patients with renal artery disease (RAD)?
|
1. Medical antihypertensive therapy
2. Surgical revascularization or nephrectomy 3. Percutaneous transluminal angioplasty (PTA) 4. Endovascular stenting |
|
|
How does the indifferent gonad become the testis or ovary?
|
The indifferent gonad begins at 6 weeks to become differentiated. The presence of a Y chromosome and genetic material in the short arm of Y direct the gonad toward the testis.
|
|
|
What hormones does the testis produce that are important in sexual differentiation?
|
Testosterone and mullerian-inhibiting substance
|
|
|
How does testosterone affect sexual differentiation?
|
Stimulates internal genitalia and wolffian duct to develop
|
|
|
What does the Wolffian duct become in a male?
|
Epididymis, vas and seminal vesicles
|
|
|
What does the Wolffian duct become in a female?
|
Gartner's duct at one edn and epoophoron at other end near ovary
|
|
|
What does the Mullerian duct regress to in the male?
|
Appendix testis at one end and prostatic utricle at the other end
|
|
|
What is the most common cause of ambiguous genitalia in the newborn?
|
CAH (and it's the only cause that is life-threatening)
|
|
|
What causes masculinization of the male external genitalia?
|
Testosterone converted to DHT by 5a reductase
|
|
|
At what GA does the male external genitalia develop?
|
By end of the third month, the development is complete
|
|
|
Which physical characteristic is best to help assess male differentiation in the newborn?
|
Palpable gonads
|
|
|
What is the most common enzymatic defect in congenital adrenal hyperplasia?
|
21-hydroxylase deficiency (accounts for 90%)
|
|
|
Can a blood test confirm CAH?
|
Yes- plasma 17-hydroxyprogesterone is a sensitive marker for CAH
|
|
|
How do children with 21-hydroxylase deficiency and 11-beta hydroxylase deficiency differ clinically?
|
Those with 11beta-hydroxylase may have HTN secondary to buildup of DOCA (deoxycorticosterone)
|
|
|
What is true hermaphroditism?
|
Having both ovarian and testicular tissue
|
|
|
What is the karyotype of true hermaphroditism?
|
50% are 46XX and 50% are divided between mosaicism and 46XY
|
|
|
What tumors are most often seen in the gonads of intersexual patients?
|
1. Gonadoblastoma
2. Dysgerminoma |
|
|
How do children with complete testicular feminization come to clinical attention?
|
Testis found during inguinal surgery or more likely during an eval of primary amenorrhea
|
|
|
How are testosterone and LH levels affected in patients with complete testicular feminization?
|
Both are significantly elevated because the pituitary can't detect testosterone (therefore gonadotropins are increased and stimulate testis to release more testosterone)
|
|
|
What are the 4 syndromes associated with partial androgen insensitivity?
|
1. Reifenstein
2. Gilbert-Dreyfus 3. Lubs 4. Rosewater |
|
|
What is the second most common cause of ambiguous genitalia in the newborn?
|
Mixed gonadal dysgenesis
|
|
|
What is the classic karyotype for mixed gonadal dysgenesis?
|
45XO/46XY
|
|
|
Describe the internal genitalia in mixed gonadal dysgenesis.
|
Almost always a testis on one side and a streak gonad on the other. On the side of the testis are the vas and epididymis. Usually on the side of the streak are fallopian tube and uterus.
|
|
|
What is Denys-Drash syndrome?
|
Children with ambiguous genitalia, glomerulonephritis, or other renal anomalies (e.g. Wilms)
|
|
|
What is the difference between an ectopic and cryptorchid testis?
|
Cryptorchid means that it is located along the normal path of descent. Ectopic is located elsewhere.
|
|
|
Why is the finding of hypospadias in association with cryptorchidism significant?
|
It raises the possibility of intersex. Often the male would have mixed gonadal dysgenesis and the female with CAH.
|
|
|
How can one distinguish between a retractile or an undescended testis?
|
1. Parents report they feel it when child is bathing
2. Testis can be milked into scrotum and remains there temporarily without tension 3. Hemiscrotum well developed on the side in question 4. Serial exams 5. Hormonal therapy |
|
|
What is the most common treatment for an undescended testis?
|
Orchiopexy
|
|
|
What hormonal therapy is used with cryptorchidism?
|
hCG injections over 2-4 weeks OR GnRH nasal spray (not yet approved in the US but used in Europe)
|
|
|
What is the true efficacy of hormonal therapy in cryptorchidism?
|
Only 10-20%
|
|
|
What are the roles of CT, MRI, and ultrasound in localizing an impalpable testis?
|
None really
|
|
|
What biochemical test may be used to prove anorchia in a patient with bilateral impalpable testis?
|
Elevated serum gonadotropin levels and castrate levels of testosterone after hCG stimulation
|
|
|
How do you definitively locate an impalpable testis?
|
Surgical exploration is the gold standard
|
|
|
If blind-ending vessels and vas are discovered at laparoscopy, what should be done?
|
Nothing... this confirms anorchia (you MUST have blind-ending vessels to confirm b/c blind-ending vas does NOT confirm)
|
|
|
What is a peeping testis?
|
Undescended testis at internal ring which can move into and out of the abdomen
|
|
|
What is a vanishing testis?
|
Testis descends beyond the internal ring and then is lost, probably to prenatal torsion
|
|
|
What are 4 complications of an undescended testis?
|
1. Testicular cancer (5-10x more common)
2. Torsion 3. Patent processus vaginalis (hernia) 4. Infertility |
|
|
What is the most common tumor in a cryptorchid testis?
|
Seminoma
|
|
|
Where are most undescended testis located?
|
Inguinal canal
|
|
|
Is the contralateral testis of an undescended testis at risk for tumor?
|
Yes
|
|
|
What is the significance of testicular torsion of a cryptorchid testis in an adult?
|
>50% will be found to have a tumor (consider dx in a man with abdominal pain and empty hemiscrotum)
|
|
|
Do patients with a unilateral cryptorchidism have a normal contralateral testis?
|
No- there is a significant decrease in sperm density of the contralateral testis with a mild decrease in clinical fertility
|
|
|
Define a hydrocele.
|
Collection of serous fluid between the 2 layers of the tunica vaginalis
|
|
|
What causes a hydrocele to form?
|
Any process acting to stimulate increased production of serous fluid by tunica vaginalis or to decrease resorption of this fluid by scrotal lymphatics or venous system
|
|
|
How are hydroceles treated?
|
Small asymptomatic hydroceles: patient reassurance. Excise surgically if the hydrocele is large and symptomatic
|
|
|
What is a spermatocele?
|
Sperm-containing cyst that usually arises from the head of the epididymis
|
|
|
How does one differentiate between a spermatocele and hydrocele on exam?
|
Spermatocele is palpable as a cystic, nontender nodule, usually arising superior to the testicle. Unlike a hydrocele, spermatocele allows complete palpation of the entire testis.
|
|
|
When is surgical excision indicated for spermatocele?
|
When it's large and symptomatic or disfiguring to the patient
|
|
|
What % of men have varicoceles?
|
15%
|
|
|
Do varicoceles occur equally on the left and right sides?
|
No-- more common on the left
|
|
|
Why are varicoceles more common on the left side?
|
The L testicular vein drains into the L renal vein and inserts at a 90 degree angle, whereas the R testicular vein inserts obliquely into the IVC
|
|
|
What is the clinical significance of varicocele?
|
Infertility
|
|
|
What are the 5 surgical approaches to correcting a varicocele?
|
1. Inguinal
2. Sub-inguinal 3. Retroperitoneal 4. Laparoscopic clipping 5. Transvenous embolization |
|
|
Which surgical approach is considered best for correction of a varicocele?
|
Inguinal or sub-inguinal
|
|
|
What are the 2 common systems to grade pelvic organ prolapse?
|
1. Halfway system of Baden & Walker (0-4)
2. POP-Q system (0-4) |
|
|
Why is it that voluntary control of the urinary bladder is missing in infants?
|
Because myelinization of the CNS is not complete and so the baby cannot suppress the sacral reflex in which a sensation of fullness is transmitted to cause powerful and sustained detrusor contraction
|
|
|
What are the 2 sphincteric elements present in the urinary system?
|
1. Internal involuntary smooth muscle sphincter at the bladder neck
2. External voluntary striated-muscle sphincter |
|
|
Where is the external voluntary sphincter located in men and women?
|
Men: Prostate to membranous urethra
Women: Mid urethra |
|
|
What might cause detrusor-sphincter dyssynergia?
|
Upper spinal cord injury (with disruption of pontine control) which leads to contraction of the detrusor without sphincteric relaxation.
|
|
|
What is the general pathway of the micturition reflex?
|
1. Afferents from the bladder travel via the spinal cord to the pons (medial pontine micturition center)
2. Electrical/chemical stimulation of the medial pontine micturition center results in: a. Stimulation of sacral parasympathetic neurons and interneurson--> contraction of detrusor b. Inhibition of sacral somatic neurons and interneurson--> relaxation of sphincter generates contraction of the detrusor and relaxation of the external sphincter |
|
|
Describe the pathways associated with urine storage.
|
1. Cerebral cortex sends a signal to the lateral pontine micturition center
2. The center stimulates sympathetic neurons resulting in inhibition of parasympathetic neurons/interneurons--> detrusor relaxation 3.The center also stimulates somatic neurons and interneurons--> sphincteric contraction 4. All of this results in a closed bladder neck and proximal sphincter |
|
|
What is the normal peak flow rate in men and women on uroflowmetry?
|
Men: 20-25mL/sec
Women: 20-30mL/sec |
|
|
What is normal bladder capacity?
|
400-500mL
|
|
|
List 6 characteristics of the spastic neuropathic bladder.
|
1. Reduced capacity
2. Involuntary detrusor contractions 3. High intravesical voiding pressures 4. Marked hypertrophy of the bladder wall 5. Spasticity of the pelvic striated muscle 6. Autonomic dysreflexia in cervical cord lesions |
|
|
What is the main sign/symptom of a lesion above the sacral micturition center?
|
Bladder spasticity from loss of inhibition from higher cetners
|
|
|
List 5 characteristics of flaccid neuropathic bladder.
|
1. Large capacity
2. Lack of voluntary detrusor contraction 3. Low intravesical pressure 4. Mild trabeculation (hypertrophy) of the bladder wall 5. Decreased tone of the external sphincter |
|
|
What injuries result in a flaccid neuropathic bladder?
|
Lesions at or below the sacral micturition center (polio, herpes zoster, radiation/surgery and myelodysplasias)
|
|
|
What is the usual result of spinal shock after spinal cord injury?
|
Flaccid paralysis with numbness below the point of injury-- result is detrusor overfilling to the point of overflow incontinence and rectal impaction
|
|
|
How long might spinal shock last?
|
A few weeks to 6 months
|
|
|
What is a good cheap test which may indicate early return of detrusor reflex activity?
|
Instillation of ice water-- would cause a strong detrusor contraction
|
|
|
Where is the conus medullaris located?
|
T12
|
|
|
Spastic neuropathic bladder results from partial or extensive neural damage above what point?
|
Conus medullaris (T12)
|
|
|
What spinal levels are being checked with penis sensation, levator tone, perianal region sensation and anal tone?
|
Penis sensation: S2
Perianal sensation: S2-3 Anal tone: S2 Levator tone: S3-4 |
|
|
What is the management used for spinal shock atonic bladder?
|
1. Intermittent cath
2. Fluid intake >2-3L/day to avoid infection |
|
|
How do bladder pacemakers work?
|
Electrodes are implanted on the motor (ventral) nerve roots of the sacral nerves that will produce detrusor contraction on stimulation (always S3, occasionally S4), Bladder continence can then be controlled by an external transmitter.
|
|
|
What is the Crede maneuver?
|
Manual suprapubic pressure
|
|
|
List 3 options to managing flaccid neuropathic bladder.
|
1. Bladder training (timed voids q2h)
2. Intermittent cath 3. Surgery (transurethral resection, AUS) 4. Parasympathomimetic drugs (bethanechol is the drug of choice) |
|
|
What is the name of the clamp used for urinary incontinence?
|
Cunningham clamp
|
|
|
As a rule, autonomic dysreflexia occurs in spastic lesions above which level?
|
T1
|
|
|
Why is anal sphincteric pressure recorded as part of urodynamics?
|
It's a function of muscular activity of the pelvic floor
|
|
|
What flow rate is the cutoff for definite evidence of obstruction?
|
<10 mL/sec
|
|
|
In terms of outlet resistance, which sphincter is the usual culprit?
|
External (the smooth sphincter is rarely involved if ever)
|
|
|
Can a person have a normal flow rate but inability to detrusor contract or sphincter relax?
|
YES!
|
|
|
When does the bladder first sense fullness?
|
At 100-200mL
|
|
|
What drug is often used to assess bladder muscle function in patients with low bladder pressure associated with lack of detrusor conraction?
|
Bethanechol
|
|
|
How does the bladder's response to bethanechol assess the bladder's muscle function?
|
1. No response indicates myogenic damage
2. Normal response indicates bladder of large capacity with normal musculature 3. Hyperactive response indicates lower motor neuron lesion |
|
|
How is intravesical pressure measured?
|
SP tube or via a transurethral catheter
|
|
|
What is true detrusor pressure?
|
Pressure recorded from the bladder cavity (intra-vesical pressure) minus intra-abdominal pressure
|
|
|
How is intra-abdominal pressure recorded?
|
Small balloon catheter inserted high into the rectum and connected to a separate transducer
|
|
|
What is a normal bladder pressure during voiding?
|
20-50 cmH2O
|
|
|
What sign on cystometry signifies that the bladder is full to normal capacity and that the patient is perceiving it?
|
A slight rise in intravesical pressure
|
|
|
When is the sign of slight rise in intravesical pressure (when bladder is full and patient perceiving it) absent?
|
Pure sensory neuropathy and mixed sensory and motor loss
|
|
|
What is the pressure profile measurement (profilometry)?
|
Recording the activity of both smooth and voluntary components of the sphincteric unit
|
|
|
How is profilometry carried out?
|
2 ways:
1. Via the membrane catheter technique which record pressure profiles 2. Microtransducer technique |
|
|
How does the microtransducer technique for profilometry work?
|
2 microtransducers mounted on the same catheter, one at tip for recording bladder pressure and other 5-7cm from the tip to record urethral pressure profile as catheter is gradually withdrawn to below the sphincteric unit
|
|
|
What provides the most accurate information regarding the urethral sphincter?
|
Needle EMG directly into the sphincter
|
|
|
What does the normal EMG activity of the anal sphincter look like during voiding?
|
Completely absent activity
|
|
|
What is the net closure pressure?
|
Difference between bladder pressure and urethral pressure
|
|
|
What is the normal functional length of the sphincteric unit in men and women?
|
Men: 6-7cm
Women: 4cm |
|
|
What are four dynamic changes in pressure profile that should be examined during urodynamics?
|
1. Changes in position (sitting/standing)
2. Changes in intra-abdominal pressure (coughing) 3. Voluntary contractions of the pelvic floor musculature to assess activity of voluntary sphincter 4. Bladder filling |
|
|
What is a normal closure pressure in women?
|
90-100cmH2O
|
|
|
What are the classic pressure changes noted in urinary stress incontinence?
|
1. Low urethral closure pressure
2. Short urethral functional length at expense of proximal segment 3. Weak response to stress 4. Loss of urethral closure pressure with bladder filling 5. Fall in closure pressure on assuming the upright position 6. Weak responses to stress in the upright position |
|
|
What are the classic pressure changes noted in urinary urge incontinence?
|
Normal or high closure pressures with normal responses to stress, bladder filling and position change
|
|
|
What are 3 mechanisms leading to urge incontinence seen on urodynamics? Which is most common?
|
1. Detrusor hyperirritability with active detrusor contractions
2. Exact reverse- constant detrusor pressure without evidence of detrusor instability but with urethral instability 3. Combination of the 2 preceding mechanisms (most common type) |
|
|
What determines the degree of postprostatectomy incontinence?
|
The functional length of the sphincteric segment above the GU diaphragm
|
|
|
At the minimum, what should be included on a urodynamics study?
|
1. Intravesical pressure
2. Intraabdominal pressure 3. Urine flow rate 4. Voided volume 5. Urethral pressure or EMG |
|
|
For a complete urodynamics study, what all is involved?
|
1. Intravesical pressure
2. Intraabdominal pressure 3. Urine flow rate 4. Voided volume 5. Anal sphincteric pressure (as function of pelvic floor activity) 6. Urethral sphincteric pressure at various (at least 2) levels 7. EMG of anal or urethral striated sphincter |
|
|
Most cases of Cushing syndrome is due to what?
|
80% are due to bilateral adrenocortical hyperplasia stimulated by overproduction of pituitary ACTH (Cushing disease)
|
|
|
What % of Cushing syndrome cases are due to ectopic ACTH?
|
10%
|
|
|
Most cases of Cushing syndrome secondary to ectopic ACTH are from what disease?
|
Small cell lung cancer
|
|
|
What is the most common cause of Cushing syndrome in children?
|
Adrenocortical carcinoma
|
|
|
Why does HTN result from Cushing syndrome despite the aldosterone level not being affected?
|
Cortisol exerts a HTN effect when present in excessive amounts (as does 11-deoxycorticosterone)
|
|
|
What type of Cushing syndrome causes the fastest onset?
|
Ectopic ACTH
|
|
|
What does the CBC and chem7 reveal with Cushing syndrome?
|
1. WBC count elevated to 12-20
2. 50% with polycythemia although some with anemia 3. High Na+ and CO2 4. Low K+ 5. Hyperglycemia |
|
|
What are 3 specific tests for Cushing syndrome?
|
1. 24-h urinary cortisol level
2. Late night salivary cortisol determination 3. Suppression of ACTH and plasma cortisol by dexamethasone |
|
|
How is the dexamethasone suppression test carried out?
|
1. 1mg dexamethasone given at 11pm
2. Draw blood at 8-9am for measurement of plasma cortisol 3. If <5ug/dL, syndrome ruled out. If >10ug/dL, syndrome ruled in. If 5-10ug/dL, equivocal- either repeat the test or do a urinary cortisol test |
|
|
Why is dexamethasone used for a test for Cushing syndrome?
|
Because it has 30 times the potency of cortisol as an ACTH suppressor and also is not measured in current plasma or urinary cortisol methods
|
|
|
Are there any drugs that should be stopped before performing the dexamethasone suppression test?
|
Yes! Birth control pills (estrogen stimulates production of cortisol-binding globulin)- withhold for 3 weeks
|
|
|
What are 4 conditions which may cause false positives in the dexamethasone suppression test?
|
1. Acute illness
2. Alcoholism 3. Depression 4. General obesity (15%) |
|
|
What are 2 specific tests for differentiation of causes of Cushing syndrome?
|
1. Plasma ACTH level
2. Plasma androgen level |
|
|
How does the plasma ACTH level differentiate between different causes of Cushing?
|
1. ACTH-dependent causes are Cushing disease (plasma 10-200pg/mL) and ectopic ACTH syndrome (plasma >200pg/mL)
2. ACTH-independent causes are adrenal tumors (plasma ACTH<5pg/mL) |
|
|
How do plasma androgen levels test for the cause of Cushing syndrome?
|
1. In patients with adrenal adenomas, androgen levels are normal or low
2. In patients with adrenocortical carcinoma, levels are markedly elevated |
|
|
After determining the presence of Cushing syndrome clinically, what is the next step to search for the location?
|
MRI to look for the most common cause (Cushing disease) in the pituitary
|
|
|
What imaging should be ordered for Cushing syndrome and suppressed ACTH?
|
CT of the abdomen with 3-mm sections through the adrenals
|
|
|
How does size differentiate between adrenal adenomas and adrenal carcinoma?
|
Adenomas are usually 3-6cm while carcinomas are usually >5cm and are frequently locally invasive or metastatic to the liver and lungs at time of diagnosis
|
|
|
What does the contralateral adrenal look like with Cushing disease or adrenal adenoma?
|
1. Cushing disease-- both will be enlarged
2. Adrenal adenoma-- the contralateral adrenal will be suppressed and appears atrophic or normal on CT |
|
|
List 6 complications of Cushing syndrome.
|
1. Osteoporosis
2. Diabetes 3. Infection 4. Kidney stones (from OP) 5. Psychosis |
|
|
How is a pituitary microadenoma treated?
|
Transsphenoidal resection
|
|
|
How is ectopic ACTH syndrome treated?
|
1. Remove the primary tumor
2. If residual or metastatic tumors, try adrenal inhibitors first and if unsuccessful, bilateral adrenalectomies |
|
|
What is the best method of access for total bilateral adrenalectomy?
|
Laparoscopic
|
|
|
What is involved in the preoperative preparation for bilateral adrenalectomy?
|
Administer cortisol on the day of surgery (200mg) and continue substitution therapy postoperatively with a gradual downward taper until oral meds provide sufficient control (20-3mg cortisol and 0.1mg fludrocortisone)
|
|
|
Is there anything involved in the preoperative preparation for removal of an adrenal adenoma or adenocarcinoma?
|
YES- same as for bilateral adrenalectomy (cortisol replacement) b/c the contralateral adrenal is atrophic
|
|
|
What is the current medical therapy of choice for inhibiting ACTH secretion in Cushing syndrome?
|
Ketoconazole but only if patient cannot undergo surgery
|
|
|
List 5 medications used to suppress ACTH.
|
1. Ketoconazole
2. Metyrapone 3. Aminogultethimide (uncommonly used) 4. Trilostane (uncommonly used) 5. Mitotane |
|
|
What is the prognosis for adrenal adenocarcinoma?
|
Poor
|
|
|
Are adrenal androgenic syndromes more common in men or women?
|
Women
|
|
|
What clinical symptom of adrenal androgenic syndrome is irreversible?
|
Deepening of the voice- b/c it is due to enlargement of the larynx
|
|
|
With respect to congenital bilateral adrenal androgenic hyperplasia, a block at P450scc leads to...
|
Rare congenital lipoid adrenal hyperplasia with complete absence of any steroidal hormone production. Death at an early age without full replacement.
|
|
|
With respect to congenital bilateral adrenal androgenic hyperplasia, a block at 3beta-hydroxydehydrogenase/isomerase leads to...
|
Prevents formation of progesterone, aldo and cortisol. DHEA is produced in excess.
|
|
|
What are the clinical characteristics of men and women with a block at 3beta-hydroxydehydrogenase/isomerase?
|
Men: pseudohermaphroditism
Women: Unusual sexual development with hirsutism Both: adrenal insufficiency |
|
|
What is the most common cause of congenital adrenal hyperplasia?
|
Block at P450c21
|
|
|
With respect to congenital bilateral adrenal androgenic hyperplasia, a block at P450c21 leads to...
|
Prevention of the transformation of 17-alpha-hydroxyprogesterone to cortisol.
|
|
|
What are the 2 forms of P450c21 block?
|
1. Salt-losing variety
2. Non-salt losing |
|
|
How do infants and young children present with P450c21 block?
|
Infants: adrenal insufficiency and ambiguous genitalia
Older children: pseudoprecocious puberty and accelerated growth and skeletal maturation |
|
|
With respect to congenital bilateral adrenal androgenic hyperplasia, a block at P450c17 leads to...
|
Lack of 17-alpha hydroxylase which causes low cortisol levels, high ACTH levels, primary amenorrhea, sexual infantilism, and HTN due to 11-deoxycorticosterone excess
|
|
|
What sex is most affected by P450c17 block?
|
Usually females (and usually discovered at puberty)
|
|
|
Elevation of what steroid in the plasma is most likely to be found in CAH?
|
17-alpha-hydroxyprogesterone
|
|
|
With respect to congenital bilateral adrenal androgenic hyperplasia, a block at P450c11 leads to...
|
Lack of 11-beta hydroxylase preventing formation of cortisol and corticosterone, leading to overproduction of adrenal androgens and 11-deoxycorticosterone
|
|
|
What are the clinical findings associated with P450c11 block (deficiency of 11-beta-hydroxylase)?
|
1. HTN
2. Hypokalemia 3. Mild androgen excess features |
|
|
With respect to congenital bilateral adrenal androgenic hyperplasia, a block at P450aldo leads to...
|
Inability to produce aldo in zona glomerulosa-- hypotension, hyponatremia and hyperkalemia
|
|
|
What urinary findings confirm CAH?
|
Urinary 17-ketosteroid levels (higher than normal for age and sex)
|
|
|
What do CT scans show in CAH?
|
Hypertrophied adrenals
|
|
|
What are the usual causes of primary hyperaldosteronism?
|
1. Aldosteronoma
2. Spontaneous bilteral hyperplasia of the zona glomerulosa of the adrenal cortex |
|
|
Primary hyperaldosteronism resembles what other endocrine syndrome?
|
Diabetes insipidus
|
|
|
What medications must be stopped before evaluating the cause of primary aldosteronism?
|
1. Estrogens and birth control pills
2. Diuretics |
|
|
What lab tests are ordered to determine primary aldosteronism diagnosis?
|
1. Patient first receives a loading dose of 6g of salt for 2 days
2. Then, electrolytes are measured (Na and CO2 would be elevated, K very low <3mEq/L) |
|
|
What is used for the definitive diagnosis of primary aldosteronism?
|
Elevated urine or plasma aldosterone level
|
|
|
How is primary aldosteronism localized?
|
1. CT to look for adenoma
2. Adrenal vein sampling of aldo and cortisol will correctly differentiate between adenoma and hyperplasia |
|
|
Management of aldosteronoma?
|
Unilateral laparoscopic adrenalectomy
|
|
|
Management of bilateral nodular hyperplasia associated with primary aldosteronism?
|
Medical treatment (surgery NOT recommended)
|
|
|
What is the medical treatment used to manage primary aldosteronism?
|
1. Spironolactone
2. Amiloride 3. Other anti-hypertensives as necessary |
|
|
Does pheochromocytoma affect systolic or diastolic BP?
|
BOTH
|
|
|
What catecholamines in the urine are used to detect pheochromocytoma?
|
Urine NE, Epi, normetanephrine and metanephrine and VMA
|
|
|
What catecholamines in the plasma are used to detect pheochromocytoma?
|
NE and Epi
|
|
|
If a pheo is extra-adrenal, where is it most likely located?
|
Somewhere along the sympathetic chain, periarotic areas or bifurcation of the aorta OR the bladder
|
|
|
Are most pheos larger than the limits of CT resolution?
|
YES!
|
|
|
What is the initial imaging modality of choice for localizing pheochromocytoma?
|
CT scan
|
|
|
How can one distinguish whether an adrenal mass is in fact a pheochromocytoma?
|
A pheo will light up intensely on T2 MRI (compared with liver) much more than with adrenal adenomas
|
|
|
If CT or MRI does not localize the suspected pheo, what else may be used?
|
MIBG scan
|
|
|
What is the medication of choice for preop preparation for pheo surgery? What is its mechanism of action?
|
Phenoxybenzamine (long-acting alpha-adrenergic blocker)
|
|
|
What is the principle of managing incidentalomas?
|
Do a metabolic workup first- if normal, then do nothing.
|
|
|
Which adrenal masses should be removed?
|
1. All functional masses
2. All masses >5cm |
|
|
How do metastases of neuroblastoma spread?
|
Bloodstream and lymphatics
|
|
|
What lab findings are common with neuroblastoma?
|
1. Anemia
2. Increased NE/Epi 3. Increased urinary VMA and HVA |
|
|
How is neuroblastoma managed?
|
Stage I/II: resect
Stage III/IV: chemo then radiation for residual disease |
|
|
What external abnormality is associated with kidney anomalies?
|
External ear and facial bones
|
|
|
List 4 features of Von Hippel-Lindau disease.
|
1. Angiomatous cerebellar cysts
2. Retinal angiomatosis 3. Tumors or cysts of the pancreas 4. ADPKD |
|
|
List 4 features of tuberous sclerosis.
|
1. Convulsive seizures
2. Mental retardation 3. Adenoma sebaceum 4. Angiomyolipomas of the kidney |
|
|
What is a major complication of ADPKD?
|
Pyelonephritis (may be asymptomatic)
|
|
|
How is ADPKD treated?
|
Supportively with low-protein diet and fluids forced to >3L a day
|
|
|
Simple cysts usually involve what portion of the kidney?
|
Lower pole
|
|
|
Do simple cysts communicate with the renal pelvis?
|
NO
|
|
|
In horseshoe kidney, where do the pelves lie?
|
Anterior to the kidney
|
|
|
Why does crossed renal ectopy occur with horseshoe kidney?
|
One ureter must cross the midline in order to empty into the bladder at the proper point
|
|
|
What are 4 complications associated with horseshoe kidney?
|
1. Ureteral obstruction
2. Hydronephrosis 3. Infection 4. Stones |
|
|
What is medullary sponge kidney?
|
Congenital AR defect characterized by widening of the distal collecting tubules
|
|
|
What are the symptoms of medullary sponge kidney?
|
Infection & Stones
|
|
|
What is the treatment for medullary sponge kidney?
|
None-- just direct therapy to the complications
|
|
|
What is the overall prognosis for medullary sponge kidney?
|
Good
|
|
|
What deleterious effect does aneurysmal dilatation of the renal artery have on the kidney?
|
None unles the mass compresses the renal artery
|
|
|
What does a KUB show with renal artery aneurysm?
|
A large intrarenal or extrarenal ringlike calcification
|
|
|
If a renal artery aneurysm is located, should it be operated upon?
|
Yes- because a significant number go on to rupture (especially during pregnancy!)
|
|
|
What is the treatment of choice for renal infarction?
|
Anticoagulation therapy (infusion of streptokinase may dissolve the embolus)
|
|
|
What is renal vein thrombosis usually associated with?
|
Membranous glomerulonephritis and nephrotic syndrome
|
|
|
In children, what is the most common cause of renal vein thrombosis?
|
Dehydration and hemoconcentration from severe diarrhea from ileocolitis
|
|
|
What are the common causes of AV fistula in the kidney?
|
1. Post-needle biopsy
2. Trauma 3. Post-nephrectomy secondary to suture or ligature occlusion of the pedicle 4. Adenocarcinoma of the kidney |
|
|
What are the findings on physical exam leading to diagnosis of AV fistula?
|
Thrill palpated and murmur heard both anteriorly and posteriorly
|
|
|
What establishes the diagnosis of AV fistula?
|
Renal angiography or isotopic scan
|
|
|
How are AV fistula treated?
|
If involving the renal artery or vein, surgical repair. Most, however, can be occluded by embolization, balloon or steel coil. Those secondary to renal biopsy can heal spontaneously.
|
|
|
What is an AV aneurysm?
|
Rare-- most follow trauam.
|
|
|
Symptoms of an AV aneurysm?
|
HTN and high-output cardiac failure with bruit
|
|
|
Treatment for AV aneurysm?
|
Nephrectomy
|
|
|
What causes renoalimentary fistula?
|
Pyonephrosis or RCC
|
|
|
What causes renobronchial fistula?
|
Rupture of an infected, calculous kidney through the diaphragm
|
|
|
What causes ureteral atresia?
|
Failure of the ureteric bud to form from the mesonephric duct or by an arrest in its development before it comes in contact with the metanephric blastema
|
|
|
What is the best treatment for ureteral atresia (and consequent kidney dysplastic kidney)?
|
Just observation- it will involute by itself
|
|
|
What kidney is associated with ureteral atresia?
|
Absent or multicystic, dysplastic kidney
|
|
|
What is the mode of inheritance for a partial or completely duplicated ureter?
|
AD
|
|
|
What are the classic studies for detecting duplication of the ureter?
|
Excretory urography and VCUG
|
|
|
How do ureteroceles form?
|
Delayed or incomplete canalization of the ureteral bud leading to an early prenatal obstruction and expansion of the ureteral bud prior to its absorption into the urogenital sinus.
|
|
|
What are the most common presentations of ureteroceles?
|
1. Infection (most common)
2. Bladder outlet obstruction 3. Incontinence |
|
|
What is the best test for diagnosis of a ureterocele?
|
Sonography (but also do VCUG as part of workup)
|
|
|
What is the treatment for ureteroceles?
|
Usually transurethral incision (but may need an open procedure)
|
|
|
What genes are involved in ectopic ureteral orifices and duplicated systems?
|
PAX-2 and RET
|
|
|
In the case of ectopic ureteral orifices, where are the most usual sites of drainage?
|
Males: vas deferens or seminal vesicles
Females: vagina, urethra, or perineum |
|
|
What are the clinical s/sx of ectopic urethral orifice?
|
1. Continual dribbling despite normal voiding (PATHOGNOMONIC)
2. Incontinence is the rule 3. Infection (common) |
|
|
What imaging is used to detect an ectopic ureteral orifice?
|
VCUG and sonography
|
|
|
What is the most common congenital abnormality of the ureter?
|
UPJ obstruction
|
|
|
Does UPJ obstruction occur more often in males/females or left/right?
|
Males>Females
Left>Right |
|
|
What is the standard protocol for surgery for UPJ obstruction?
|
Creation of a dependent and funnel-shaped UPJ of adequate caliber
|
|
|
What is the most preferred procedure to correct UPJ obstruction if the obstruction is from a dyskinetic segment of proximal ureter?
|
Dismembered pyeloureteroplasty
|
|
|
Is obstruction of the UVJ more common in boys/girls or left/right?
|
Boys:Girls::4:1
Left slightly more common that right |
|
|
What is the most usual finding on sonography for UVJ obstruction?
|
Dilated distal ureter, less dilated proximal ureter and normal renal pelvis and calyces blunted out of proportion to eh renal pelvis
|
|
|
What surgical procedure treats UVJ obstruction?
|
Ureteral reimplantation with excision of the distal ureter
|
|
|
Is every dilated upper urinary tract obstructed?
|
NO!
(could be residual dilatation in a previously obstructed system, dilatation associated with bacterial infection, neonatal hydro, or prolonged polyuria from DI) |
|
|
What test is best for distinguishing obstructive from non-obstructive dilation?
|
Whitaker test
|
|
|
What are the 3 most common causes of intrinsic ureteral obstruction?
|
1. Ureteral stones
2. TCC of the ureter 3. Chronic inflammatory changes (e.g. TB or schistosomiasis) |
|
|
What are the 7 most common causes of extrinsic ureteral obstruction?
|
1. Severe constipation
2. Secondary obstruction due to kinks or fibrosis around redundant ureters 3. Benign gyn d/o such as endometriosis or right ovarian vein syndrome 4. Local neoplastic infiltration associated with cancer of the cervic, bladder or prostate 5. Pelvic LAD 6. Iatrogenic ureteral injury 7. Retroperitoneal fibrosis |
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What specific medication has been associated with retroperitoneal fibrosis?
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Methysergide (sansert)- ergot derivative used to treat migraine headaches
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What is the name for idiopathic retroperitoneal fibrosis?
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Ormond disease
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What are the symptoms of retroperiteonal fibrosis?
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Nonspecific:
1. Low back pain 2. Malaise 3. Anorexia 4. Weight loss 5. Uremia |
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How is the diagnosis of retroperitoneal fibrosis made?
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Excretory urography- usually will show medial deviation of ureters with proximal dilation
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What is the treatment for retroperitoneal fibrosis?
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May trial of corticosteroids... if unsuccessful, surgery (careful dissection of ureter from fibrous plaque)
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What should the surgeon do after she has dissected the ureter from the fibrous plaque in retroperitoneal fibrosis?
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Place it intraperitoneally OR wrap it in omentum in an attempt to prevent recurrence
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What else should be done (on top of dissection and placement of the ureter) during surgery for retroperitoneal fibrosis?
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Multiple biopsies of the fibrous tissue to determine whether there is malignant tumor
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Where (by spinal cord location) is retroperitoneal fibrosis usually centered on and where does it usually extend?
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L4-L5 and extends caudally to sacral promontory and cephalad to renal hilum
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What are the lateral margins of retroperitoneal fibrosis?
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Outer edges of the psoas muscle
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Name 5 general categories of known causes of retroperitoneal fibrosis.
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1. Infection
2. Drugs (methysergide) 3. Malignancy 4. Radiation 5. Inflammatory conditions |
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What is the hypothesis for Ormond disease (idiopathic retroperitoneal fibrosis)?
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It's a result of an immunologic response to leakage of material from diseased (atherosclerotic) blood vessels
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What ages does retroperitoneal fibrosis occur in?
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Between 30-60yo
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What is the most common lab abnormality in patients with retroperitoneal fibrosis?
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Elevated ESR
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After IV urography, what imaging modalities can help better delineate the extent of retroperitoneal fibrosis?
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CT and MRI
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List some conditions which sometimes mimic retroperitoneal fibrosis.
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1. Long-standing severe prostatism (but won't deviate ureters medially)
2. Large abdominal or pelvic mass 3. Trauma |
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How many cores are usually taken in a prostate biopsy?
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10-12
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How do you know where to inject the local anesthetic in a prostate biopsy?
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"Mount Everest sign" -- ultrasound finding- lateral to the junction of the prostate and seminal vesicle
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Why do apical prostate biopsies hurt more?
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The needle traverses the rectal mucosa below the dentate line- so now we try to bring the needle through the rectal mucosa above the dentate line and then angle anteriorly to biopsy the apex
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How long should patients lay off NSAIDs before prostate biopsy?
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7-10days
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Should patients get antibiotics for prostate biopsy?
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Yes- one dose of a fluoroquinolone 30 minutes before bx
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What is "saturation biopsy"?
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Bx with 18-24 cores
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What should be done if PIN or atypica comes back on path report from prostate bx?
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Repeat biopsy if any clinical suspicion persists on follow-up rectal or PSA testing 3-6 months later
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How does vasectomy produce sterilization?
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Interruption of the vas prevents sperm from reaching the seminal vesicles, where they would normally complete maturation
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How long does it take after vasectomy for a patient to be offically sterile?
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2-3 months but you must have 2 successive specimens clear
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What is the failure rate of vasectomy?
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1/200 and 1/1000
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How does failure rate of vasectomy compare to all female methods?
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It's better than all of them... 0.5-1% rate (while BTL is 1-2%)
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What is the name of the small swelling that might occur at the site of the vasectomy and what is it?
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Sperm granuloma (nodular tissue reaction to irritating nature of sperm)
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Does vasectomy prevent AIDS or other STDs?
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NO although these men do have less HIV titer in semen than controls
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How is vasectomy performed?
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1. Traditional vasectomy
2. Percutaneous vasectomy 3. No-scalpel vasectomy |
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How is a no-scalpel vasectomy performed?
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1.Vas is grasped through skin using a special ringed clamp before making incision
2. After puncture wound made, vas speared with a sharp clamp which is rotated 180 degrees 3. While this is being done, ringed clamp released and vas regrasped, divided and ligated |
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When is pyelonephritis confused with RCC?
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In the case of xanthogranulomatous pyelonephritis (due to proteus and e.coli and chronic infection stones)
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What imaging helps define the extent of pyelo?
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CT
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Why is a plain abdominal radiograph recommended in diabetics with pyelo?
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It is used to screen for emphysematous pyelonephritis
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What imaging study is useful for determining the extent of renal scar from successive episodes of pyelonephritis?
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DMSA renal scan (b/c DMSA concentrates in the cortex)
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What is good empiric therapy for pyelo?
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One-drug therapy with a 3rd-generation cephalosporin or ureido penicillin (if severe, can do two-drug therapies for synergism)
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How long should acute pyelo be treated?
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2 weeks of combined IV and oral abx
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How is xanthogranulomatous pyelo treated?
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Surgery
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How is emphysematous pyelo treated?
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Extended aggressive IV abx course-- if doesn't resolve, may need to percutaneously drain and/or nephrectomy
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Where are perirenal abscesses located?
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Within Gerota's fascia
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What bacteria are involved in renal and perirenal abscesses if spread hematogenously?
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Staph aureus
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What imaging modalities are fundamental in diagnosing renal and perirenal abscesses?
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Ultrasound and CT (CT is really #1)
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What is the treatment of renal and perirenal abscesses?
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1. Empirical before C&S found--> Aminoglycoside and broad-spectrum penicillin parenterally for 7-14 days followed by several weeks of oral therapy
2. Drainage (open or perc) |
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Which 4 organs are most commonly involved in extrapulmonary TB?
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1. Lymph nodes
2. Intestine 3. Bone 4. Kidneys |
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Renal TB represents what % of extrapulmonary TB?
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20%
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What are characteristic physical findings of GU TB?
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1. Beaded vas deferens
2. Thickened epididymis or prostate 3. Upper abdominal bruits |
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What does the UA reveal in renal TB?
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1. 50% with microscopic hematuria
2. Almost all with pyuria 3. Proteinuria common |
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How many urine specimens are needed to culture AFB successfully?
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3 early morning specimens (at minimum)
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What blood work should be obtained in patients with renal TB?
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1. Baseline renal and hepatic function tests-- to determine baseline (abx therapy is hepatotoxic)
2. ESR to monitor response to treatment |
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Is the tuberculin skin test usually positive in patients with renal TB?
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Yes- in >90%
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What are the characteristic IVP findings of renal TB?
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1. Renal calcifications
2. Contrast excretion poor 3. Minor calyces dilated and irregular 4. Intrarenal fistulae may be seen 5. Ureters may be straightened or strictured 6. Decreased bladder capacity |
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What are the characteristic ultrasound findings of renal TB?
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1. Normal appearance on u/s
2. Later, development of profound calyectasis and contraction fo renal pelvis ("daisy sign") |
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What are the 2 consequences of chronic inflammation of the urothelium in renal TB?
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1. Stricture formation
2. Squamous neoplasia, with resultant SCC |
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How is renal TB treated?
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INH and rifampin for 9 months
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What is used to treat resistant renal TB?
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Streptomycin and pyrazinamide or ethambutol
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What testing should be done prior to initiating abx therapy for GU TB?
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1. Baseline renal and hepatic function tests
2. CXr 3. Sputum for AFB |
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Is surgery ever indicated in the treatment of renal TB?
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Very rarely (effective abx cure >95%)
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How are patients with renal TB followed?
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DOTS; urine for AFB at 2-3 month intervals to assess both adequacy of therapy and possible emergence of resistant organisms
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What is the key drug to use in treatment of acute BCG sepsis?
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Cycloserine (inhibits growth of tubercle bacillus within 24 hours)- used in combo with INH, rifampin and ethambutol
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How long are patients with renal TB infectious after being started on an abx regimen?
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2-3 weeks
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What is the major side effect of cycloserine?
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Lowers the seizure threshold
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How is interstitial cystitis diagnosed?
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It is a diagnosis of exclusion
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What three diseases are associated with IC?
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1. Multiple allergies
2. IBS 3. Fibromyalgia |
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What is the characteristic constellation of symptoms associated with IC?
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Irritative voiding and bladder pain (often relieved after voiding)
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What is a Hunner's ulcer?
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A pink ulceration of the bladder mucosa seen in 10% of IC patients
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What procedures must be done to come to a diagnosis of IC?
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1. UA and UCx
2. Complete GU exam 3. Urodynamics 4. Cystoscopy |
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How is hydrodistension performed?
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Fill bladder to capacity until water leaks around cystoscope. Then drain and refill and then inspect to identify glomerulations.
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What are glomerulations?
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Pinpoint, petechial sites of hemorrhage of urothelium that are visible after the bladder has been distended, drained and redistended
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What are the required criteria for diagnosis of IC?
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1. Pain associated with bladder or urinary urgency
AND 2. Diffuse glomerulations or Hunner's ulcer on cysto exam |
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What is the leading hypothesis for IC etiology?
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A defective GAG layer on the urothelium allows leakage of urine past the luminal surface
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List 6 hypotheses for IC.
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1. Defective GAG layer
2. Infection leads to autoimmune response or caused by cryptic organisms that aren't appropriately treated 3. Neurogenic mechanism whereby abnormal sensory impulses lead to an inflammatory response 4. Reflex sympathetic dystrophy affecting the bladder 5. Urine that contains substances that the urothelium perceives as toxic, inducing an inflammatory response 6. Pelvic floor dysfunction |
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What medical therapies are available for IC?
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1. Amitriptyline
2. Elmiron (pentosan polysulfate)- similar properties to GAG |
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What are 3 types of therapies for IC?
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1. Hydrodistension (but short-lived)
2. Medical therapy 3. Intravesical therapy with DMSO, lidocaine, hydrocortisone or sodium bicarb |
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Is surgical treatment necessary for IC?
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Rare patients with Hunner's ulcer may benefit from transurethral resection, fulguration or laser coagulation
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What are some new treatments for IC that are on the horizon?
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1. Systemic cyclosporine
2. Intravesical BCG 3. Sacral nerve stimulation |
