chapter 39: urology Flashcards
fascia around the kidney
gerota’s fascia
how does the vasculature lie in the kidney?
anterior to posterior: renal vein, renal artery, and renal pelvis
how does the right renal artery lie in relation to the IVC?
right renal artery crosses posterior to the IVC
what vessels do the ureters cross?
ureters cross over iliac vessels
renal vein: right vs left ligation at the IVC
left renal: can be ligated from SVC secondary to increased collaterals
right renal vein lacks collaterals
collaterals of left renal vein
left adrenal vein
left gonadal vein
left ascending lumbar vein
how is the left renal vein associated with the aorta?
left renal vein usually crosses anterior aorta
connects to vas deferens
epididymis
most common cause of acute renal insufficiency following surgery
hypotension
symptoms: severe colicky pain, restlessness
kidney stones
- UA: blood or stones
kidney stones: abdominal CT
can demonstrate stones and associated hydronephrosis
MC stone (75%); radiopaque
calcium oxalate
why are calcium oxalate stones increased in patients with terminal ileum resection?
due to increased oxalate absorption in colon
- magnesium ammonium phosphate
- radiopaque
- occur with infections (proteus mirabilis) that are urease producing; cause stag horn calculi (fill renal pelvis)
struvite stones
what are struvite stones composed of?
magnesium ammonium phosphate
- radiolucent stones
- increased in patients with ileostomies, gout, and myelproliferative disorders
uric acid stones
- radiolucent stones
- associated with congenital disorders in the reabsorption of cysteine
cysteine stones
surgical indications for kidney stones
intractable pain or infection
progressive obstruction
progressive renal damage
solitary kidney
size of stone not likely to pass
> 6 mm
% of kidney stones that are radiopaque
90%
tx: kidney stones
ESWL (extra-corporeal shock wave lithotripsy); other options: stereoscopy with stone extraction or placement of stent past obstruction, percutaneous nephrostomy tube, open nephrolithotomy
4 types of kidney stones
- calcium oxalate (radiopaque)
- struvite (radiopaque)
- uric acid (radiolucent)
- cysteine (radiolucent)
1 cancer killer in men 25-35
testicular cancer
symptoms: painless hard testicular mass
testicular cancer
management: testicular mass
patient needs an orchiectomy through an inguinal incision (not a trans-scrotal incision -> do not want to disrupt the lymphatics)
- the testicle and attached mass constitute the biopsy specimen
are most testicular masses benign or malignant?
malignant
how can you diagnose testicular cancer?
- ultrasound can help with diagnosis
- chest and abdominal CT - to check for retroperitoneal and chest metastases
testicular cancer: lab value correlating with tumor bulk
LDH correlates with tumor bulk; also check B-HCG and AFP level
percent of testicular cancers that are germ cell
90% are germ cell - summon and nonseminoma
are undescended testicles (cryptorchidism) a problem?
increased risk of testicular cancer
- most likely to get seminoma
1 testicular tumor
seminoma
- 10% have beta-hcg elevation
- should not have AFP elevation
- extremely sensitive to XRT
seminoma
tx: seminoma
all stages get orchiectomy and retroperitoneal XRT
- chemo reserved for mets or bulky retroperitoneal disease (cisplatin, bleomycin, VP-16)
- surgical resection of residual disease after above
chemo regimen: seminoma
cisplatin
bleomycin
VP-16
types of nonseminomatous testicular cancer
embryonal
teratoma
choriocarcinoma
yolk sac
90% have these markers in nonseminomatous testicular CA
alpha fetoprotein
beta-hcg
nonseminomatous testicular CA: classically this type of tumor are more likely to metastasize to the retroperitoneum
classically, tumors with increased teratoma components are more likely to metastasize to the retroperitoneum
tx: nonseminomatous testicular ca
all stages get orchiectomy and retroperitoneal node dissection
- stage 2 or greater: also give chemo (cisplatin, bleomycin, BP-16)
- surgical resection of residual disease after above
what part of the prostate is most common for cancer?
posterior lobe
prostate CA: most common site of metastases
bone
prostate mets to bone: XR
osteoblastic; xr demonstrates hyperdense areas
potential complication after prostate resection
many patients become impotent after resection; can get incontinence
- can also get urethral strictures
dx: prostate CA
- transrectal BX
- chest/ab/pelvic CT
- PSA
- alkaline phosphatase
- possible bone scan
options for tx: prostate CA - intracapsular tumors and no metastases (T1 and T2)
- XRT or
- Radical prostatectomy + pelvic LN dissection (if life span > 10 years) - or -
- nothing (depending on age and health)
tx: prostate CA - extracapsular invasion or metastatic disease
XRT and androgen ablation (leuprolide [LH-RH blocker], flutamide [testosterone blocker], or bilateral orchiectomy
tx: prostate CA - stage 1a disease found with TURP
Nothing
how does PSA trend with prostatectomy?
with prostatectomy, PSA should go to 0 after 3 weeks -> if not, get bone scan to check for metastases
what is a normal PSA?
what can increase PSA?
prostatitis, BPH, chronic catheterization
increased alkaline phosphatase in a patient with prostate CA?
worrisome for metastases or extra capsular disease
1 primary tumor of kidney (15% calcified)
renal cell carcinoma (RCC, hypernephroma)
risk factor: renal cell carcinoma
smoking
abdominal pain, mass, hematuria
renal cell carcinoma
how does renal cell carcinoma present?
1/3 have metastatic disease at the time of diagnosis -> can perform wedge resection of isolated lung or colon metastases
most common location for RCC metastases
lung
what causes erythrocytosis in renal cell carcinoma?
secondary to increased erythropoietin (HTN)
tx: renal cell carcinoma
radical nephrectomy with regional nodes; XRT; chemotherapy
what composes radical nephrectomy?
takes kidney, adrenal, fat, Gerona’s basic, and regional nodes
where does renal cell carcinoma like to grow?
predilection for growth in the IVC; can still resect even if going up IVC -> call pull the tumor thrombus out of the IVC
when should you consider partial nephrectomy in management of renal cell carcinoma?
partial nephrectomies should be considered only for patients who would require dialysis after nephrectomy
most common tumor in kidney
metastasis from the breast CA
Renal cell carcinoma paraneoplastic syndromes
erythropoietin, PTHrp, ACTH, insulin
tx: transitional cell CA of renal pelvis
Radical nephroureterectomy
benign or malignant: oncocytomas
benign
hamartomas; can occur with tuberous sclerosis; benign
angiomyolipomas
multifocal and recurrent RCC, renal cysts, CNS tumors, and pheochromocytomas
Von Hippel-Lindau syndrome
- usually transitional cell CA
- painless hematuria
- males; prognosis based on stage and grade
bladder cancer
risk factors: bladder cancer
smoking, aniline dyes, and cyclophosphamide
dx: bladder cancer
cystoscopy
tx: bladder cancer
intravesical BCG or transurethral resection if muscle is not involved (T1)
- if muscle wall is invaded (T2 or greater) -> cystectomy with ileal conduit, chemotherapy, and XRT
- mets: chemo
chemo regimen: T2 or greater bladder cancer
MVAC:
- methotrexate
- vinblastine
- adriamycin (doxorubicin)
- cisplatin
standard reconstruction option stage T2 or greater in bladder cancer
ileal conduit is standard reconstruction option
why is ileal conduit standard reconstruction option for stage T2 or greater bladder cancer?
avoid stasis as this predisposes to infection, stones (calcium resorption), and ureteral reflux
possible options for reconstruction in management of bladder cancer
- ileal conduit
- reservoirs
- neobladders
cause of squamous cell CA of bladder
schistosomiasis infection
- peaks in 15 year olds
- tx: bilateral orchioplexy (if testicle not viable, resection and orchioplexy of contralateral testis)
testicular torsion
testicular torsion: usual location
torsion is usually toward the midline
ureteral trauma: if going to repair end to end…
- spatulate ends
- use absorbable suture to avoid stone formation
- stent the ureter to avoid stenosis
- place drains to identify and potentially help treat leaks
why avoid stripping soft tissue on ureter in repair of ureteral trauma?
avoid stripping the soft tissue on the ureter, as it will compromise blood supply
where does BPH arise in the prostate?
arises in the transitional zone
nocturia, dysuria, weak stream, urinary retention.
benign prostatic hypertrophy
initial therapy: BPH
- alpha blockers (terazosin, doxazosin - relaxes smooth muscle)
- 5 alpha reductase inhibitors - finasteride (inhibits the conversion of testosterone to dihydrotestosterone -> inhibits prostate hypertrophy
inhibits the conversion of testosterone to dihydrotestosterone -> inhibits prostate hypertrophy
finasteride (5-alpha reductase inhibitors)
when do you consider TURP for BPH?
for recurrent UTIs, gross hematuria, stones, renal insufficiency, or failure of medical therapy
post-TURP syndrome
hyponatremia secondary to irrigation with water; can precipitate seizures from cerebral edema
tx: post-TURP syndrome
careful correction of Na with diuresis
complication of most patients s/p TURP
retrograde ejaculation
- most commonly secondary to spinal compression
- patient urinates all the time
- nerve injury above T12
neurogenic bladder
tx: neurogenic bladder
surgery to improve bladder resistance
- incomplete emptying
- nerve injury below T12; can occur with APR
neurogenic obstructive uropathy
tx: neurogenic obstructive uropathy
intermittent catheterization
- incontinence due to cough, sneeze
- because of hypermobile urethra or loss of sphincter mechanism; women
stress incontinence
tx: stress incontinence
kegel exercises, alpha-adrenergic agents, surgery for urethral suspension or pubovaginal sline
- incomplete emptying of an enlarged bladder
- obstruction (BPH) leads to the distention and leakage
- Tx: TURP
overflow incontinence
tx: ureteropelvic obstruction
pyeloplasty
tx: vesicoureteral reflux
reimplantation with long bladder portion
most common urinary tract abnormality
ureteral duplication
tx: ureteral duplication
reimplantation if obstruction occurs
tx: ureterocele
resect and implant if symptomatic
ventral urethral opening
hypospadias
tx: hypospadias
repair at 6 months with penile skin
dorsal urethral opening
epispadias
tx: epispadias
surgery
- usually joined at lower poles
- complications: UTI, urolithiasis, and hydronephrosis
- tx: may need pyeloplasty
horseshoe kidney
tx: polycystic kidney disease
resection only if symptomatic
- occurs in patients with bladder outlet obstructive disease (wet umbilicus)
- connection between umbilicus and bladder
failure of closure of the urachus
tx: failure of closure of the urachus
resection of sinus/cyst and closure of the bladder; relieve bladder outlet obstruction
what can cause epididymitits?
sterile epididymitis can occur from increased abdominal straining
worrisome for renal cell CA (left gonadal vein inserts into left renal vein; obstruction by renal tumor causes varicocele); could also be caused by another retroperitoneal malignancy
varicocele
fluid-filled cystic structure separate from and superior to the testis along the epididymis
- tx: surgical removal if symptomatic
spermatocele
management: hydrocele in adult
if acute, suspect tumor elsewhere (pelvic, abdominal); translucent
MCC is diverticulitis and subsequent formation of colovesical fistula
- Dx: cystoscopy
pneumaturia
cause of WBC casts
pyelonephritis, glomerulonephritis
cause of RBC casts
glomerulonephritis
fever, rash, arthralgias, eosinophils
interstitial nephritis
pregnancy rate after repair of vasectomy
50%
tx: priapism
aspiration of the corpus cavernosum with dilute epinephrine or phenylephrine
- may need to create a communication thru the glans with scalpel
risk factors: priapism
sickle-cell anemia, hyper coagulable states, trauma, intracorporeal injections for impotence
tx: SCC of penis
penectomy with 2 cm margin
used to check for urine leak
indigo carmine or methylene blue
tx: phimosis found at time of laparotomy
dorsal slit
decreased production in patients with renal failure
erythropoietin
