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1770 Cards in this Set

  • Front
  • Back
What separates the prostate posteriorly from the rectum?
2 layers of Denonvilliers' fascia
What is Denonvilliers' fascia remnants of?
Serosal rudiments of pouch of Douglas
What is the bloodless plane demarcated by the posterior segment of the renal artery?
Brodel's line
What forms the ejaculatory ducts and where do these enter the urethra?
Seminal vesicles and vas deferens --> veru montanum in the prostatic urethra
What are the layers of the penis (from outside in)?
Skin, Colles' Fascia, Buck's Fascia, Tunica albuginea (around the corpora cavernosa)
Lowsley Classification of prostate anatomy
5 lobes: anterior, posterior, median, right lateral and left lateral
McNeal Classification of prostate anatomy
Peripheral zone, central zone, transitional zone, anterior segment, and preprostatic sphincteric zone
Which glands lie just beneath the transitional epithelium of prostatic urethra?
Periurethral glands
Arterial supply to the prostate
Inferior vesical arteries, middle rectal arteries, internal pudendal
What is the main chain of lymph nodes into which the prostate empties?
Obturator nodes
What does the spermatic cord contain?
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
What fasical layer separates the testis from the scrotal wall?
Parietal tunica vaginalis
2 types of cells in the seminiferous tubules?
Supporting (Sertoli) cells and spermatogenic cells
Blood supply to the testes is closely associated with blood supply to what other organ?
kidneys b/o common embryologic origin
What structure encloses the urethra in the male?
Corpus spongiosum
Each corpus cavernosum is surrounded by ____ which is then enclosed by ____
1. Tunica albuginea
2. Buck's fascia
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
What glands are located in the submucosa of the male urethra?
Glands of Littre
Arterial supply of penis and urethra?
Internal pudendal artery (dividing into deep artery of the penis (supplies CC), dorsal artery of penis,and bulbourethral artery)
Where do the superficial dorsal vein and deep dorsal vein lie in relation to Buck's fascia?
Superficial lies external; deep lies beneath
What are the names of the periurethral glands, opening on the floor of the female urethra just inside the meatus?
Glands of Skene
Four different phases in kidney CT and timing
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)
Stone protocol consists of...
Non-contrast spiral CT
Why no contrast for stone protocol?
It leads to difficulties in defining bowel diverticula and distinguishing appendix from calculi
Protocol for evaluating renal masses...
CT without, then with IV contrast
If a renal mass is indeed detected after CT, what is the next radiographic study to be ordered?
Chest CT
What is the protocol for evaluating renal infection?
CT without contrast (if questions still remain, use IV contrast next)
Name the 9 steps in an IV urogram (IVU) - aka IVP or excretory urogram
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
Why is a compression device used in an IVU?
It causes partial obstruction of the ureters, to improve visualization of intrarenal collecting system and ureters
When during an IVU is the best time to visualize the ureters?
At the release film
Current indications for IVU include:
1. Evaluation of calyces and ureters
2. Detailed eval of calyces, UPJ, and UVJ
In Peyronie's disease, where is the most common location of the fibrotic scar?
Within the tunica albuginea of corpora cavernosa- dorsal aspect
At what age should DREs begin to be performed?
40yo (or any male presenting for urologic evaluation)
What is suggested by the presence of a soft, cystic mass palpable in the midline near the base of the prostate?
Presence of a mullerian duct cysts or enlarged utricle (remants of the female mullerian system)
An enlarged utricle is occasionally seen in patients with what other congenital abnormality?
Proximal hypospadias
What physical exam maneuvers should be attempted with a varicocele?
1. Valsalva (should increase the size)
2. Supine (should reduce)
On what side is a varicocele usually detected?
One French = __ mm
How is rigid cystoscopes better than flexible?
Rigid provide a greater field of vision and allows more therapeutic options
Normal pH of urine is between
5 and 8
What is the normal value of creatinine clearance?
90-110 mL/min
What abnormality may be seen on CBC in patients with renal insufficiency and why?
Anemia b/o decreased production of EPO
3 main risks of IV contrast material?
1. Allergic reaction
2. Renal toxicity
3. Local tissue reaction (if IV needle infiltrates at time of injection)
How should a patient be prepared for urography?
Administer clear liquids beginning the evening before the study and NPO 6h before study
What drug should NOT be given when a diabetic is given IV contrast?
Metformin (stop 24h before and wait 24h after to restart)
5 steps in usual film sequence for urography?
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)
IVU showing a tear-drop shaped bladder suggests...
Pelvic lipomatosis
IVU showing a Christmas-tree shaped bladder suggests...
Neurogenic bladder
3 indications for renal venography
1. Evaluate tumor thrombus (RCC)
2. Definitive eval of renal vein thrombosis
3. Renal vein renin determination in renovascular HTN
2 main indications for angiographic renal embolization
1. RCC (to facilitate operative management of large tumors with venal caval thrombi)
2. Control hemorrhage from perc bx, AVM, or primary/met tumor
How does a renal cyst appear on ultrasound?
Homogeneously hypoechoic with very thin walls
Who is most often associated with ureteroceles?
Girls with duplicated collecting systems who present with UTIs
What does a ureterocele appear as on U/S? What is the name of this?
A thin but clearlyl defined membrane (called Chawala's membrane)
How can one use U/S to confirm varicocele?
Use doppler while patient performs valsalva (and it will demonstrate retrograde flow into the testicle)
What is the typical TRUS findings for CaP?
Hypoechoic area within peripheral zone
What is the PSAD and how is it used?
It is the PSA density (serum PSA divided by the prostate volume measured by TRUS). A value >= 0.15, suggests CaP
What is a Hounsfield unit of -1000, 0 and +1000
-1000 is lung (air)
0 is soft tissue
+1000 is bone
What are the 3 most important contributions of CT to urology?
1. Assessment of renal masses
2. Renal trauma evaluation
3. Nephrolithiasis
What is T1 MRI best for?
Defining anatomy
What is T2 MRI best for?
Demonstrating pathology (e.g. differentiating renal cysts from solid tumors)
How will a renal cyst and tumor appear differently on a T2 MRI?
The cyst will be very bright (tumor only somewhat bright)
What are the 3 radiopharmaceuticals based on technetium 99 and how are each handled by the kidney?
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)
On a renogram, what is the normal time delay between peak aortic flow and renal flow?
<6 seconds
3 phases of a renogram?
1. Renal blood flow
2. Parenchymal function
3. Excretion
On a renogram, what is the normal time that peak uptake should occur in renal parenchyma?
Within 5 minutes after injection
A normal DTPA renogram will demonstrate 50% emptying of nuclide from the kidney within how much time?
20 minutes
How may scintigraphy be used to diagnose AIN?
Gallium 67 is useful and will show uptake persisting greater than the normal 72 hours
Name 3 agents used to image infectious or inflammatory processes within the kidney.
1. WBC labeled with In111
2. Gallium 67
3. Tc99-DMSA
What is a lasix renal scan used for?
Differentiating between obstructive and nonobstructive hydronephrosis
What is a "normal" lasix scan?
50% emptying of the kidney and pelvis within 20 minutes after injection
How is radionuclide cystography helpful for VUR?
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
What nerves innervate the penis and are responsible for tumescence and detumescence?
Cavernous nerves
What structures do the cavernous nerves innervate that are most responsible for erections?
1. Helicine arteries
2. Trabecular smooth muscle
What are the 3 main types of erections?
1. Genital-stimulated (contact or reflexogenic)
2. Central-stimulated (noncontact or psychogenic)
3. Central-originated (nocturnal)
At what stage of sleep do nocturnal erections occur?
Why do nocturnal erections occur during REM?
Cholinergic neurons in lateral pontine tegmentum are activated while the serotonergic neurons in the midbrain raphe are silent.
What is the main arterial supply to the penis- and what are its 3 branches?
Internal pudendal arteries:
1. Cavernous artery
2. Dorsal artery
3. Bulbourethral artery
What does the cavernous artery supply?
Corpora cavernosa
What does the dorsal artery of the penis supply?
The skin, subcutaneous tissue and glans penis
What does the bulbourethral artery supply?
Corpus spongiosum
Describe the mechanics of an erection.
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
Where do the emissary veins lie in the penis and why is this imortant?
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)
Is androgen absolutely necessary for erection?
No-- it enhances it a lot though
Do hypogonadal men show a decrease in nocturnal erections?
What is the principal neurotransmitter for penile erection and from what nerve terminals does it come from?
NO from parasympathetic NANC nerve terminals
Describe the signal transduction which occurs in penile erection.
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.
Name 3 conditions in which peripheral neuropathy may result in ED.
1. DM
2. Alcohol abuse (chronic)
3. Vitamin deficiency (B12)
Name 5 endocrine disorders which may result in decreased libido and ED.
1. Hyogonadism
2. Hyperthyroidism
3. Hypothyroidism
4. Addison's Disease
5. Cushing syndrome
What are the 2 classifications of arterial disease leading to ED?
1. Extrapenile (amenable to surgical repair)
2. Intrapenile
Name 3 causes of intrapenile arterial disease.
1. Aging
2. Arteriosclerosis
3. DM
Name 5 types of cavernous (venous) impotence.
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)
What are 3 main classes of drugs listed as causes of ED?
1. Antipsychotics
2. Antidepressants
3. Centrally acting anti-hypertensives
With regard to ED, what do alpha-adrenergic antagonists do?
May cause retrograde ejaculation due to relaxation of the bladder neck
How do beta-blockers cause ED?
They potentiate alpha1 adrenergic activity
What diuretics cause ED?
Spironolactone and thiazides (mechanism unknown)
How does alcohol affect ED?
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
ED severity is classified into how many categories? What's the name of the self-reporting measure?
5 (severe, moderate, mild to moderate, mild and no ED)

International Index of Erection Function (IIEF)
The average man has how many episodes of NPT per night and how long should each last?
3-5 per night, each lasting 30-60 minutes
Name 5 neurologic tests for ED.
1. Biothesiometry
2. Bulbocavernosus reflex latency
3. Genitocerebral evoked potential
4. Smooth muscle EMG
5. Tests for penile vascular function
What is CIS and what does it detect?
Combined intracavernous injection and stimulation test- it detects vascular status of penis
What is a normal CIS result?
A rigid erection lasting for more than 20 minutes (indicates normal venous function)
What is used to inject in the CIS test?
1. Alprostadil
2. Phentolamine and papaverine
Name 5 methods of evaluating penile vascular function.
1. CIS
2. Duplex US
3. Cavernous arterial occlusion pressure
4. Cavernosometry and cavernosography
5. Arteriography
What are two lifestyle changes that may be attempted with ED?
1. Better diet & exercise
2. No long-term bicycling or sitting
What antidepressants are preferred for those with ED?
Trazodone & buproprion
What is the most common laboratory abnormality in men being treated with testosterone?
What surveillance labs should be ordered for a patient on testosterone therapy?
1. LFTs
2. H&H
3. Cholesterol & lipid profile
How does papaverine injection therapy work?
It inhibits PDE leading to increased cAMP and cGMP
2 major disadvantages of papaverine injections are...
1. Corporal fibrosis (1-33%) due to low acidity
2. Occasional LFTs
What is the mechanism of phentolamine injection therapy?
Competitive alpha-adrenergic antagonist (= affinity for alpha 1 and alpha 2)
3 types of intracavernous injection therapy?
1. Papaverine
2. Phentolamine
3. Alprostadil (PGE1)
What is the best regimen for treating priapism due to injection therapy?
Intracavernous injection of diluted phenylephrine 250-500ug q3-5 minutes until detumescence
In what 3 patients is intracavernous injection contraindicated?
1. Sickle cell
2. Schizophrenia or severe psychiatric disorder
3. Severe venous incompetence
What is the most commonly used technique for penile revascularization?
Bypass from inferior epigastric artery to dorsal artery or deep dorsal vein of penis
What are 3 types of penile prostheses?
1. Malleable (semirigid)
2. Mechanical
3. Inflatable (2 and 3 piece)
Which penile prostheses last longer than others?
Malleable last longer than inflatable
What are potential complications of IPP?
1. Mechanical failures
2. Cylinder leaks
3. Tubing leaks
4. Infection
5. Perforation
6. Persistent pain
7. Autoinflation
What is the 5-year failure rate of IPP?
How long do penile prostheses generally last?
10-15 years (and then will need a replacement)
What is the mechanism of retrograde ejaculation?
Dysfunction of the internal sphincter or the bladder neck
In what 3 states/conditions does retrograde ejaculation occur?
1. After prostatectomy
2. Alpha-blocker therapy
3. Autonomic neuropathy (DM)
What is used to treat retrograde ejaculation?
Alpha sympathomimetics (or eliminate the alpha blocker therapy)
What are 4 things which can be used to treat premature ejaculation?
1. Desensitization
2. The Squeeze technique
3. Application of local anesthetic or condom
4. SSRIs
What is the treatment of choice for renal AV fistulas?
Transcatheter embolization
Optimal time delay between embolization and nephrectomy for RCC is...
1 day
What is post-embolization syndrome?
Pain, n/v, fever, leukocytosis following tumor embolization (very common & should not delay surgery!)
What material is used for renal tumor embolization?
What approach is preferred for embolization of varicocele?
IJV to the L gonadal vein
Recurrence rate for embolization of varicocele?
What are 7 indications for treatment of renal artery aneurysms?
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
What is the usual anatomic relationship between the renal artery and vein?
Artery is posterior to the vein
With a R-sided nephrectomy, what plane is crossed to direct one from the IVC to the R renal vein?
Plane of Leriche
Where is the most likely location of a urethral stricture after straddle injury?
Bulbar urethral injury
Patients with what disorder should you be wary of latex allergy?
What is a good alternative for a urethral catheter in those with latex allergy?
What element forms the basis of MRI?
How do blood vessels appear on MRI?
How does calcium appear on MRI?
What is Technetium 99c's half life?
6 hours
What radionuclide agent is best used for renal vascular imaging?
What radionuclide agents may be used in patients with renal failure?
123-I and 131-I hippurate (b/c renal concentration may occur with as little as 3% of normal renal function)
What is a "superscan"?
When the kidneys can't be imaged b/c the bone (from prostatic boney mets) has intensely uptaken the radionuclide
How many Hounsfield units would be typical of a renal cyst on noncontrast CT?
What is a renal pseudotumor?
An area of normal renal parenchyma that gives the appearance of a solid renal mass
What % of RCCs are avascular?
Is routine biopsy of solid renal masses recommended? Why or why not?
NO- because of the high incidence of false negative findings in patients with RCC
In a newborn, what is the #1 and #2 most common causes of an abdominal mass?
1. Hydronephrosis (usually secondary to UPJ obstruction)
2. Multicystic kidney
What is the most common malignancy of the newborn?
Neuroblastoma (50% of all neonatal malignant tumors)
In a neonate, what is the most common cause of hydronephrosis?
UPJ obstruction
If US shows hydronephrosis in a child, what is the next study that should be ordered?
At what age is neuroblastoma and Wilms's tumors most common?
Neuroblastoma: <2yo
Wilms' Tumor: >2yo
What is aniridia and what is it associated with?
Developmental absence of most of the iris-- associated with Wilms tumor
What urologic abnormality is microcephaly associated with?
PUVs and Beckwith-Wiedemann syndrome
Macroglossia should make you think of......
Hemihypertrophy should make you think of...
Webbing of the neck should make you think of what syndrome (and what associated renal abnormality)?
Turner's Syndrome & horseshoe kidney
What is the significance of bright pink or bluish subcutaneous nodules in the newborn?
May indicate the presence of disseminated neuroblastoma
What is the significance of HTN in a child with an abdominal mass?
It may suggest the presence of neuroblastoma, congenital mesoblastic nephroma, and less commonly Wilms tumor, hydronephrosis or multicystic kidney
What is the significance of hematuria in a newborn with an abdominal mass?
Renal vein thrombosis
Offspring of which mothers are at increased risk for renal vein thrombosis?
Diabetic moms
What is the most likely diagnosis of an abdominal mass in a female neonate with a bulging interlabial mass?
Hydrocolpos secondary to imperforate hymen
What is the significance of stippled calcification in a retroperitoneal solid mass?
50% of patients with neuroblastoma have stippled calcification
Which tumor is more likely to be fixed rather than mobile- neuroblastoma or Wilms?
What are the 2 primary causes of masses arising from the female genital system?
1. Hydrocolpos
2. Ovarian cysts
How often are the kidneys palpable in the neonate
Very often
What is the usual age for urinary TB?
Young adults (60% between 20-40)
What are the primary sites of TB infection in the GU system?
Kidneys & possibly the prostate
What is the route of infection for GU TB?
Descending from the kidney
Chronic draining scrotal sinus should make you think of...
TB of the GU tract
How is GU TB diagnosed?
Demonstration of tubercle bacilli in urine by culture
What are the usual earliest symptoms of renal TB?
Vesicular sx including burning, frequency and urgency
A thickened and beaded vas deferens suggests...
What is the "great mimicer" of GU TB?
Schistosomiasis (b/c both present with sx of cystitis and some hematuria)
Is surgery necessary for GU TB?
Not usually... medical treatment with 3-drug protocol is appropriate
Who does abacterial cystitis usually affect?
Usually adult men
What is the suspected etiology of abacterial cystitis?
Mycoplasmas and chlamydiae. Possibly adenovirus
How are the initial presentations of renal TB and abacterial cystitis different?
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.
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)
How is vesical candidiasis treated?
Alkalinize urine with sodium bicarb for urine pH of 7.5. If this fails, amphotericin B instilled into bladder.
Yellow bodies called "sulfur granules" are pathognomonic for what infection?
Actinomyces israelii
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?
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?
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?
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?
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?
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...
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?
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?
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?
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?
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?
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?
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?
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?
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?
2. TUNA (needle ablation)
3. TUIP (incision of the prostate)
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?
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?
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?
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.
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?
Where is most calcium absorbed?
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?
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?
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?
What is the pH associated with struvite stones?
Classic cystinuria is inherited how?
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?
Which RTA type is associated with renal stones?
Type I
Cystine crystals:
Struvite crystals:
Calcium oxalate monophosphate
Calcium oxalate diphosphate
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?
Stones >6mm have what chance of passing on their own?
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?
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?
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?
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?
Is stone pain related to activity?
What % of stones are radioopaque?
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?
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?
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?
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?
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?
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?
What are the most common forms of androgen deprivation for metastatic CaP?
1. Bilateraly orchiectomy
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?
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?
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.
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?
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?
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?
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?
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?
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?
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?
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?
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?
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?
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?
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?
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?
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?
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?
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?
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?
What is the incidence of secondary neoplasm following treatment for Wilms with radiotherapy?
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?
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?
What is the most common bilateral tumor of the testis?
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?
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?
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?
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?
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?
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?
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?
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?
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?
Treatment of lymphomatous testicular tumor?
Radical orchiectomy
The testis is a common site of relapse for children with...
What is the diagnostic procedure of choice for leukemic infiltration of the testis?
Biopsy (not orchiectomy)-- then treat with irradiation and adjuvant chemo
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.
Name 3 precancerous penile lesions.
1. Leukplakia
2. Balanitis xerotica obliterans
3. Giant condylomata acuminata
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.
What is Erythroplasia of Queyrat and what is its usual appearance?
Velvety,red lesion with ulcerations typically involving the glans.
What composes most penile invasive cancers?
SCC (verrucous carcinoma is a variant of SCC, and this also occurs)
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
To which lymph nodes do the glans and corporal bodies drain?
Deep inguinal nodes (deep to the fascia lata) --> pelvic nodes
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?
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
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?
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?
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?
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?
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?
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?
Which nerve supplies the voluntary external sphincter component of continence?
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?
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?