Chapter 39 - Urology Flashcards
Where is Gerota’s fascia?
Around kidney
Does the right renal artery cross anterior or posterior to the IVC?
Posterior
Do ureters cross over or under the iliac vessels?
Over
Why can the left renal vein be easily ligated from the IVC?
Secondary to increased collaterals (L. adrenal, L. gonadal, L. ascending lumbar vein)
What is the most common cause of acute renal insufficiency following surgery?
Hypotension
Symptoms of kidney stones? UA findings?
Severe colicky pain, restlessness
Blood or stones
What are the most common type of kidney stone? Who is at risk for them?
Calcium oxalate - 75%
Radiopaque
Pts with terminal ileum resection due to increased oxalate absorption in colon
What are struvite stones? Why do they occur?
Mg ammonium phosphate - 15%
Infection that are urease producing - Proteus mirabilis
What type of stones are radiolucent?
Uric acid, cysteine
Who gets uric acid stones?
Pts with ileostomies, gout, myeloproliferative disorders
Who gets cysteine stones?
Congenital disorders in the reabsorption of cysteine
When is surgery for kidney stone indicated?
Intractable pain or infection, progressive obstruction, progressive renal damage, solitary kidney, >6mm not likely to pass
What is the #1 cancer killer in men 25-35?
Testicular cancer
Treatment for testicular mass?
Orchiectomy through inguinal incision (not transscortal, do not want to disrupt lymphatics)
What lab value correlates with testicular tumor bulk?
LDH
What other lab values are needed for testicular cancer?
B-HCG, AFP level
What type of tumor is most common in testicular cancer?
Germ cells (90%) - seminoma or nonseminoma
What type of cancer is most commonly associated with undescended testicle?
Seminoma
What is the #1 testicular tumor?
Seminoma
Where do seminomas spread?
Retroperitoneum
Treatment of seminoma?
Orchiectomy and retroperitoneal XRT
What are the types of nonseminomatous testicular CA?
Embryonal, teratoma, choriocarcinoma, yolk sac
What are the tumor markers of nonseminomatous testicular cancers?
90% have AFP and beta-HCG
What is the spread of nonseminomatous testicular cancer?
Hematogenously to lungs and retroperitoneum
Treatment of nonseminomatous testicular cancers?
Stage I: orchiectomy, prophylactic retroperitoneal node dissection
Stage II+: orchiectomy, XRT, chemo; surgical resection of residual mets
What is the most common site of prostate cancer?
Posterior lobe
What is the most common site of mets from prostate cancer?
Bone
Complications of prostate resection?
Impotence, incontinence, urethral strictures
Where should PSA go after prostatectomy?
To 0 after 3 weeks
What is a normal PSH in a patient with a prostate gland?
<4
What does elevated alk phos indicate in a patient with prostate cancer?
Mets or extracapsular disease
What is the #1 tumor of kidney?
Renal cell carcinoma
Risk factor for RCC?
Smoking
What fraction of pts have metastatic disease at time of dx of RCC? Treatment for mets?
1/3
Wedge resection of isolated lung and colon mets
Most common location for RCC mets?
Lung
What hematologic abnormality can occur with RCC?
Erythrocytosis secondary to elevated erythropoietin
Treatment for RCC?
Radical nephrectomy with regional nodes, XRT, chemo
What does a radical nephrectomy include?
Kidney, adrenal, fat, Gerota’s fascia, regional nodes
What is done for tumor thrombus in IVC?
Pull it out
What is the most common tumor in the kidney?
Mets from breast
Paraneoplastic syndromes associated with RCC?
Erythropoietin, PTHrp, ACTH, insulin
Treatment for transitional cell CA of renal pelvis?
Radical nephroureterectomy
Tuberous sclerosis is related to what type of renal tumor?
Angiomyolipomas
What renal (and other) tumors are associated with Von Hippel-Lindau syndrome?
Multifocal and recurrent RCC, renal cysts, CNS tumors, pheochromocytomas
What is the usually bladder cancer type?
Transitional cell CA
Painless hematuria indicates what until proven otherwise?
Bladder cancer
Risk factors for bladder cancer?
Smoking, aniline dyes, cyclophosphamide
Treatment for bladder cancer?
Intravesical BCG or transurethral resection if muscle not involved
If muscle invaded, cystectomy with ileal conduit, chemo, XRT
Squamous cell cancer of the bladder is related to what infection?
Schistosomiasis
Peak age of testicular torsion?
15
Treatment for testicular torsion?
Bilateral orchiopexy vs. resection and contralateral orchiopexy
Technique for ureteral trauma if going to repair end to end?
Spatulate ends
Use absorbable suture to avoid stone formation
Stent ureter
Place drains
Avoid stripping soft tissue, may compromise blood supply
Where does BPH arise?
Transitional zone
Initial therapy for BPH?
Alpha blockers: terazosin, doxazosin
5-alpha-reductase inhibitors: finasteride
Indications for TURP?
Recurrent UTIs, gross hematuria, stones, renal insufficiency, failure of medical therapy
What is post-TURP syndrome?
Hyponatremia secondary to irrigation with water, can precipitate seizures from cerebral edema
Treatment for post-TURP syndrome?
Careful correction of Na with diuresis
Post-TURP ejaculatory complication?
Most patients will have retrograde ejaculation
What is the most common cause of neurogenic bladder?
Secondary to spinal compression
What level is the injury in neurogenic bladder?
Above T-12
What is neurogenic obstructive uropathy? Level of injury? Treatment?
Incomplete emptying
Below T12
Intermittent cath
What is the cause of stress incontinence? Treatment?
Hypermobile urethra or loss of sphincter mechanism
Kegels, alpha-adrenergics, surgery for urethral suspension
What is the cause of urge incontinence? Treatment?
Sense of urgency or frequency because of involuntary detrusor contraction without neurologic disorder
Anticholinergics, behavior modification, cystoplasy, urinary diversion
What is the cause of neuropathic incontinence? Treatment?
Urgency or frequency due to dec. bladder capacity; associated with neurologic conditions
Treat underlying neurologic disorder, behavior modifications, surgical options
What is the cause of overflow incontinence? Treatment?
Incomplete emptying and enlarged bladder; BPH –> distention and leakage
TURP
What is the cause of congenital incontinence? Treatment?
Continuous leakage and nocturnal enuresis; sphincter mechanism bypassed
Surgical correction
Treatment for ureteropelvic obstruction?
Pyeloplasty
Treatment for vesicoureteral reflux?
Reimplantation with long bladder portion
What is the most common urinary tract abnormality?
Ureteral duplication
What is the treatment for ureterocele?
Resect and reimplant
Treatment for hypospadias?
(Ventral) repair at 6mo with penile skin
Treatment for epispadias?
(Dorsal) surgery
Complications of horseshoe kidney?
UTI, urolithiasis, hydronephrosis
What happens if there is failure of closure of the urachus? Treatment?
Connection between umbilicus and bladder; in pts with bladder outlet obstructive disease
Resection of sinus/cyst, closure of bladder
Concern when varicocele diagnosed?
RCC: L. gonadal v inserts into L. renal v., obstruction by renal tumor causes varicocele
What is the most common cause of pneumaturia?
Diverticulitis and subsequent formation of colovesical fistula
What is indicated by WBC casts?
Pyelonephritis, glomerulonephritis
What is indicated by RBC casts?
Glomerulonephritis
How will interstitial nephritis present?
Fever, rash, arthralgias, eosinophils
What is the pregnancy rate after repair of vasectomy?
50%
What is the treatment for priapism?
Aspiration of the corpus cavernosum with dilute epi or phenylephrine
Risk factors for priapism?
Sickle-cell anemia, hypercoagulable states, trauma, intracorporeal injections for impotence
Treatment for SCC of penis?
Penectomy with 2cm margin
What is the treatment for phimosis found at time of laparotomy?
Dorsal slit
Where is a spermatocele found? Treatment?
Separate from and superior tot he testis along epididymis
Surgical removal
