GU Flashcards

Question

Von Hippel Lindau

Answer 1

Autosomal dominant multisystem disorder. 50-75% have renal cysts. 25-50% develop clear cell RCC. Pancreas: cysts, serous microcystic adenomas, neuroendocrine tumour Adrenal: Pheochromocytoma CNS: Hemangioblastoma of cerebellum, brain stem and spinal cord Urogenital: Epididymal cysts, cystadenomas

Answer 2

Autosomal dominant multisystem disorder Hamartomas everywhere (brain lung heart skin kidneys) Multiple bilateral AMLs Renal cysts and occasional RCC Lung: LAM thin walled cysts and chylothorax Cardiac: rhabdomyosarcoma Brain: Giant cell astrocytoma (SEGA), cortical and subcortical tubers, subependymal nodules Renal: AMLs, RCC in younger patient

Answer 3

Cysts are meant to be T2 bright. LIPID POOR AL Think tuberous sclerosis, 30% of their AMLs are lipid poor HAEMORRHAGIC CYST T1 bright and T2 dark PAPILLARY RCC Clear cell is T2 hyperintense Both clear cell and papillary will enhance

Answer 4

Paeds thing Multiple tiny cysts forming in utero from some form of insult. No functioning renal tissue - shown with MAG3 exam Contralateral renal anomalies occur 50% (reflux and UPJ obstructions MCDK vs hydro In hydro, cystic spaces communicate

Answer 5

PARAPELVIC Originates from parenchyma, may compress collecting system. Looks like cortical cysts but bulge in instead of out. PERIPELVIC Originates from renal sinus, mimics hydro.

Answer 6

Clinical diagnosis. Associated with stones. Most common organism is E.coli. Alternating bands of hypo and hyperattenuation (stirated nephrogram) Wedge shaped areas related to decreased perfusion

Answer 7

``` Acute ureteral obstruction Acute pyelonephritis Medullary sponge kidney Acute renal vein thrombosis Radiation nephritis Acutely following renal contusion Hypotension Infantile polycystic kidney ```

Answer 8

Pyelo may be complicated by abscess. Round or geographic low attenuation collections do not enhance centrally. >3cm may need drainage

Answer 9

Renal scarring, atrophy and cortical thinning with hypertrophy of residual normal tissue.

Answer 10

Life threatening necrotizing infection characterised by gas formation within or surrounding kidney. Diabetics get it. Echogenic foci with dirty shadowing on USS.

Answer 11

Gass localized to collecting system. More common in women, diabetics and people with urinary obstruction.

Answer 12

Infected or obstructed collecting system from variety of causes; stones, tumour, sloughed papilla secondary to pyelonephritis. Need urgent nephrostomy

Answer 13

Chronic destructive granulomatous process basically always seen with staghorn calculus acting as nidus for recurrent infection. Associated psoas abscess possible with minimal perirenal infection. 'bear paw' appearance on CT. Kidney non functional, sometimes get nephrectomy.

Answer 14

Ischemic necrosis of renal papillae involving pyramids. Diabetes most common but can be from pyelonephritis, sickle cell, TB, analgesic use and cirrhosis. Filling defects in calyces may be seen. Necrotic cavity in papillae with linear streaks of contrast inside calyx has been called lobster claw sign

Answer 15

Most common extra pulmonary site of infection is urinary tract. TB in kidneys similar to TB in lungs with prolonged latency. Calyceal blunting or moth eaten calyces (look pointy). Renal calcs common in TB. Punctate, curvilinear or replace whole kidney. 'putty kidney' is autonephrectomized end stage TB kidney. Multiple calcified mesenteric nodes can help you zero in on renal TB

Answer 16

Most common cause of renal impairment in AIDS CD4<200. Kidneys classically enlarged and echogenic. Big and bright in HIV positive patient clinically in nephrotic syndrome. Disseminated PCP in HIV patients can result in punctate calcs

Answer 17

Allergic reactions not considered a risk for CIN Risk factors include pre-existing renal insufficiency, diabetes, cardiovascular disease with CHF, dehydration and myeloma

Answer 18

CALCIUM OXALATE Most common 75% STRUVITE STONE More common in women, UTI URIC ACID Not seen on XRay. pH dependent can treat with medical therapy. CYSTINE Rare, metabolism disorder INDINAVIR HIV patients, only stones not seen on CT

Answer 19

Usually sequale of cortical necrosis seen in acute drop in BP (shock, post partum, burns). Begins as hypodensity that later calcifies. Mimic is disseminated PCP or TB

Answer 20

Hyperechoic renal papilla/pyramids which may or may not shadow Hyperparathyroidism common Medullary sponge kidney common Lasix in kids Renal tubular acidosis MEDULLARY SPONGE Congenital, usually asymmetric. Cystic dilataiton of connecting tubules, associated with Ehlers Danlos and Carolis. Also associated with Beckwidth Wiedemann.

Answer 21

Subcapsular haematoma causing renal compression which messes with RAAS and causes HTN. Classic history HTN post biopsy/lithotripsy/trauma

Answer 22

DELAYED One kidney enhances the other doesnt. Pressure on kidney from extrinsic or intrinsic due to obstructing stone PERSISTENT Hypotension/shock and ATN.

Answer 23

Wedge shaped hypodensity - can also be seen in tumour/infecton. CORTICAL RIM SIGN Absent immediately after insult but seen 8 days later. Dual blood supply allows cortex to stay perfused FLIP FLOP ENHANCEMENT Region of hypodensity becomes hyperdense on delayed

Answer 24

Dehydration, indwelling umbilical venous catheters and nephrotic syndrome. Can mimic stone presenting with flank pain, enlarged kidney and delayed nephrogram

Answer 25

For ESRF, better quality of life than dialysis. Usually in extraperitoneal iliac fossa to anastomose with iliac vasculature and bladder. If from cadaver, some aorta taken too. Living and cadaveric do end to side anasamosis to ext iliac artery and vein. Should have low resistance, brisk upstroke and forward flow in diastole (always 'on').

Answer 26

peak systolic - end diastolic /peak systolic Remember kidney has a capsule which is unforgiving. If swollen sick kidney with unforgiving kidney, blood vessels will get squeezed and diastolic flow will be impaired and resistance will increase Higher RI, sicker the kidney. RI should be <0.7.

Answer 27

OBSTRUCTION Transplant kidneys all hive minor hydro due to denervation. Obstruction will be at level of ureteric implant to bladder (oedema/scarring/kinking). Transplants morelikely to have stones HAEMATOMA Common immediately post op but usually resolves. Complex collection. URINOMA In first 2 weeks. Rapidly increasing anechoic collection. Most leaks at ureterovesical anastomosis. MAG3 accumulates. LYMPHOCOELE 1-2 months after. Leakage of lymph from surgical disruption of lymphatics in setting of inflammation. Most common collection to cause hydro. With all can get ipsilateral lower limb oedema from compression of femoral vein

Answer 28

HYPERACUTE REJECTION Immediate failure of graft. Rarely see this imaged. ACUTE REJECTION Week 1-3. Antibody/cell mediated. 20% transplants will have some early rejection. Graft may swell and RI go up. Rejection vs ATN is question. MAG3 may help but biopsy is gold standard. ACUTE TUBULAR NECROSIS Common and occurs on many transplants. Ischaemia between harvesting and implanting. CYCLOSPORIN TOXICITY Immunosuppressive therapy necessary to keep body from rejecting graft can poison it. Usually around one month after. MAG3 can look like ATN. CHRONIC REJECTION Gradual process months to years. Kidney enlarges, loses corticomedullary differentiation and raised RI.

Answer 29

RENAL ARTERY THROMBOSIS Within first month but usually within minutes to hours. Tehcnical factors, kinking or torsion of vessel. ``` RENAL ARTERY STENOSIS Within first year, usually weeks to months. Most common vascular complication. Occurs at anastomosis. CMV is risk factor. Refractory HTN buzzword. PSV>200-300, PSV ratio ?1.8-2.5 Tardus Parvus Anastomotic jetting ``` RENAL VEIN THROMBOSIS Within first week. Kidney is swollen. Artery has reversed diastolic flow (reverse M sign) ARTERIOVENOUS FISTULA Secondary to biopsy. 20% time post biopsy usually small and asymptomatic. Tissue vibration artefact, high arterial velocity, pulsatile flow in vein PSEUDOANEURYSM Secondary to biopsy but less common. Or in graft infection or anastomotic dehiscence. yin yang colour picture. Biphasic flow at neck of aneurysm

Answer 30

EARLY Renal Allograft Compartment Syndrome (RACS). Kidney too big for chosen pelvic extraperitoneal space. Kidney gets squeezed (<2 hours) Renal artery thrombosis (mins to hours) MID Renal vein thrombosis (first 5 days) LATE Renal artery stenosis (3 months - 2 years). POST TRAUMA AV fistula Pseudoaneurysm Traumatic haematoma

Answer 31

Prolonged immunosuppression therapy puts these patients at greatly increased risk cancer. In particular, skin cancer, lymphoma and colon. Annulad ksin exams recommended. RCC Increased risk, with most occuring in native kidney. Likely risk of dialysis and immunosuppression. Risk of primary cancer in the transplant kidney is 6x and will be papilary POST TRANSPLANT PROLIFERATIVE DISORDER (PTLD) Uncommon complication of organ transplant associiated with B cell proliferation.. EBV is a risk factor and patients will go onto rituximab. Most common first year post transplant. involves multiple organs.Mass lesion ecasing the hilum RENAL TRANSPLANT +BK VIRUS = UROTHELIAL MALIGNANCY BK = urothelial cancer CYCLOPHOSPHAMIDE Significant exposure to this increases risk of urothelial cancer

Answer 32

FRACTURED Laceration which extends full depth of parenchyma. Must connect two cortical surfaces. SHATTERED More severe form of fractured. Kidney with 3 or more fragments.

Answer 33

WEDGE SHAPED PERFUSION ANOMALY Think segmental arterial injury DIFFUSE NON PERFUSION Think devascularized kidney PERSISTENT NEPHROGRAM Think renal vein injury/thrombosis Transplant kidney increased risk of injury due to no overlying ribs and superficial location

Answer 34

AAST American Association for Surgery of Trauma Get arterial chest and PV abdo/pelvis. Add delays if ureteral or bladder injury suspected 5-15 mins. DELAYS Show urine leak - hyperdense outside collecting system Focal collections of decreased attenuation may be pseudoaneurysm or AV fistula Focal collections of increased attenuation may be active bleeding 1: Subcapsular haematoma, no laceration 2: Haematoma around kidney within perirenal space or <1cm laceration 3: Moderate laceration >1cm with no involvement of renal pelvis and no urine leak. Acitve bleeding within perirenal space 4: Laceration that extends to hilum (fractured kidney). Segmental infarcts. Bleeding outside perirenal space. 5: Shattered kidney. Renal hilum injury (urine leak, main renal vein/artery injury). Devascularised kidney.

Answer 35

STONES PUJ, pelvic brim and VUJ URETERAL WALL CALCS TB or Schistosomiasis URETERITIS CYSTICA Numerous tiny subepithelial fluid filled cysts within wall of ureter. Chronic inflammation from stones/infection. Diabetics recurrent UTI. Increased risk cancer URETERAL PSEUDODIVERTICULOSIS Similar to above. Chronic inflammation from stones/infection. Multiple small outpouches. Bilateral 75% and favour upper/middle. Increased risk cancer MALAKOPLAKIA Rare chronic granulomatous condition. Soft tissue nodularity/plaques in bladder and ureters. Chronic UTIs often in female immunocompromised patients. Can manifest as mucosal mass with renal obstruction. Michaelis Gutmann bodies. NOT premalignant, gets better with antibiotics LEUKOPLAKIA Squamous metaplasia secondary to chronic irritation. Mural filling defects. Premalignant and cancer is squamous NOT transitional

Answer 36

RETROPERITONEAL FIBROSIS Proliferation of aberrant fibroinflammatory tissue which surrounds aorta/IVC/iliac vessels and frequently traps and obstructs the ureters. 75% idiopathis or can be radiation, medication, inflammatory or malignant 75% idiopathic - Ormonds disease IgG4 disorder (autoimmune pancreatitis, Riedels thyroiditis, inflammatory pseudotumour) Medial deviation ureters Men > women Malignancy associated 10% SUBENDOTHELIAL RENAL PELVIS HAEMATOMA Long term anticoagulation or history of haemophilia. Thickened upper tract wall, mimic for TCC. Hyperdense clot on noncon

Answer 37

LATERAL Retroperitoneal adenopathy Aortic aneurysm Psoas hypertrophy prox ureter ``` MEDIAL Retroperitoneal fibrosis Retrocaval ureter right side Pelvic lipomatosis Psoas hypertrophy distal ureter ```

Answer 38

TCC (UROTHELIAL CARCINOMA) 90% collecting system cancers. 'goblet' or 'champagne glass' on CT IVP. Cancer will usually first be where urine sits static so bladder >renal pelvis/ureter. RFs are smoking, cyclophosphamide, stones, horseshoe kidney, HNPCC, ureteral pseudodiverticulosis TCC bladder 100x more common than TCC ureter In ureter 75% TCC in bottom third BALKAN NEPHROPATHY Degenerative nephropathy endemic to Balkan states. Very high rate of renal pelvis and upper ureter TCC SQUAMOUS CELL Much less common than TCC in ureter. If it is, likely from schistosomiasis

Answer 39

HAEMATOGENOUS METS Rare mets to ureter. Typically infiltrate periureteral soft tissues and demonstrate transmural involvement FIBROEPITHELIAL POLYP Benign entity. Filling defect in renal pelvis or prox ureter which mimics TCC. Assumption usually TCC so diagnosis made post nephrectomy. Filling defect either clot/calcium/cancer

Answer 40

PRUNE BELLY (EAGLE BARRETT SYNDROME) Occurs in males. Shown on babygram with wide belly. Deficiency of abdominal musculature Hydrouretonephrosis Cryptorchidism (bladder distension interferes with escent of testes) URACHUS Primary concern is development of midline adenocarcinoma. Usually midline mass makes it obvious although if calcs should think cancer BLADDER DIVERTICULA More common in boys. Acquired seconary to chronic outflow obstruction. Ehlers Danlos HUTCH DIVERTICULUM NOT associated with urethral valves or neurognic bladder. Associated with ipsilateral reflux. Bladder diverticula usually at lateral walls near ureteric orifices. Anterior/superior is more likely to be urachal diverticular Most are acquired BLADDER EARS Transitory extraperitoneal herniation of bladder. Not a diverticulum, transient lateral protrusion of bladder into inguinal canal.

Answer 41

Gross haematuria 4x more risk than microscopic haematuria. If >50 with gross haematuria needs triphasic and cystoscopy. MARCELUS WALLUS BLADDER CANCER Soft tissue in bladder. Focal wall thickening or nodules considered cancer till proven otherwise. DIFFUSE CIRCUMFERENTIAL BLADDER WALL THICKENING Usually isnt cancer. Inflammation or infection likely or chronic outlet obstruction. ENHANCEMENT Usually hypovascular but can enhance early but if on MCQ it is on delayed phase

Answer 42

RHABDOMYOSARCOMA Most common bladder tumour <10yo. Infiltrative , hard to tell where it originated. Paratesticular mass buzzword. Met to lungs/bones/nodes. Grape like TCC Bladder most common site and this is most common subtype 90%. Superficial papillary (frond like) most common subtype. Smoking and site or urinary stasis SQUAMOUS CELL CARCINOMA S for S. Schistosomiasis. Heavily calcified bladder and distal ureters. also longstanding Suprapubic catheter. ADENOCARCINOMA Think of urachus or bladder extrophy. 90% in midline bladder dome. 70% will have calcs. LEIOMYOMA (FIBROID) Benign tumour usually at trigone.

Answer 43

After radical cystectomy for badder cancer. Several urinary diversion procedures can be done. Incontinent vs continent. Piece of bowel made into conduit then ureters attached to it. EARLY COMPLICATION Adynamic ileus 25% cases. Urinary leakage 5% usually at ureteral reservoir anastomosis. Fistula - uncommon LATE COMPLICATION Urinary infection Stones Parastomal hernia Urinary stricture, left side higher risk secondary to angulation (brought through under mesentery) Tumour recurrence more advanced than original disease.

Answer 44

Procedure done when youve had an injury/pathology with long segment of distal ureter involved. Excise distal ureter and if remaining ureter is too short the ipsilateral bladder portion is brought up and hitched to psoas muscle. Unique appearance.

Answer 45

EMPHYSEMATOUS CYSTITIS Gas forming organ in wall of bladder. Diabetic usually. E.coli. TB Upper GU tract more commonly effected with secondary involvement of bladder. Can lead to thickened contracted 'thimble' bladder. May have calcs SCHISTOSOMIASIS Third world common. Eggs deposited in bladder wall which leads to chronic inflammation. Entire bladder will calcify and you get squamous cell cancer ``` FISTULA Diverticulitis, Crohns and cancer Women after hysterectomy also at risk. Colovesical fistula - diverticular Ileovesical fistula - Crohns Rectovesical fistula - neoplasm or trruma ```

Answer 46

NEUROGENIC BLADDER Small contracted bladder or atonic large bladder 'pine cone bladder'. Can lead to urinary stasis (and cancer), stones and infection ACQUIRED BLADDER DIVERTICULA Usually from outlet obstruction. Most common at VUJ. Leads to stasis (and cancer), stones and infection BLADDER STONES Dropped kidney stones or developing in bladder from stasis or neurogenic bladder. Chronic irritation can follow RF for TCC and SCC PEAR SHAPED BLADDER Pelvic lipomatosis and haematoma

Answer 47

Cystography is gold standard with retrofilled bladder via foley catheter. Either fluro or CT. Need 300-400mls EXTRAPERITONEAL RUPTURE 80-90% almost always associated with pelvic fracture. If pelvic fracture chance of bladder injury is 10%. molar tooth sign is contrast surrounding bladder in prevesicle space of Retzius. Often medically managed. INTRAPERITONEAL RUPTURE Less common. Direct blow to full bladder and it pops and blows top off (dome is weakest part). Contrast outlining bowel loops. and in paracolic gutters. Needs surgery. Pseudorenal failure. If bladder rupture and creatinine in urine reabsorbed by peritoneal lining giving falsely elevated creatinine level. Kidneys normal.

Answer 48

ANTERIOR penile and bulbar urethra Most anterior part is fossa navicularis Fills with retrograde study POSTERIOR membranous and prostatic urethra Verumontanum is ovoid mound in posterior wall prostatic urethra where prostatic utricle is Fills with antegrade study

Answer 49

Trauma and blood in meatus - do retrograde urethrogram (RUG) ``` ANTERIOR INJURY Straddle injury (bicycle). ``` POSTERIOR INJURY Pelvic fracture and bladder injury often associated GRADING 1: stretched. 2: membranous urethra tear 3: membranous and bulbar urethra tear 4: bladder base injury extending into prostatic urethra 5: bulbous urethra

Answer 50

STRADDLE INJURY Most common external cause of traumatic stricture. Compression of urethra against inferior edge of pubic symphysis. Bulbous urethra is site of injury. Short segment. GONOCOCCAL URETHRAL STRICTURE Long irregular stricture. Distal bulbous urethra

Answer 51

PANCREATIC TRANSPLANT Has been known to cause urethral injuries. Usually from pancreatic enzymes damaging the ureter. CONDOLYMA ACUMINATUM Multiple small filling defects on RUG. URETHRORECTAL FISTULA Can occur post radiation and classicaly described with brachytherapy URETHRAL DIVERTICULUM Long term foley placement in male CANCER Malignant tumours of urethra rare. 80% squamous apart from prostatic urethra which is TCC URETHRAL DIVERTICULUM CANCER Adenocarcinoma

Answer 52

FEMALE URETHRAL DIVERTICULUM More common in females. Repeated infection in pereiurethral glands. Usually on sag MRI. Middle third urethra on posterolateral wall. can coexist with urinary incontinence and infection. Saddle bag configuration. Stones can develop in these. Increased risk of cancer and is most commonly adenocarcinoma

Answer 53

CLEAR CELL Enhances equal to cortex on corticomedullary phase. Most common. VHL. PAPILLARY Enhances less than cortex on corticomedullary phase. Hereditary papillary renal carcinoma. Transplant kidney. CHROMOPHOBE Birt Hogg Dube MEDULLARY Sickle cell TRANSLOCATION Denser than cortex. Most common in kids and post chemo.

Answer 54

Location of urinary stasis. Renal pelvis 2x more common than ureter.Distal third of ureter most common in ureter. Bladder cancer 100x more common. Ureteral cancer usually also has bladder TCC 90%. Favours base. 40% multiple. frond like papillary most common. SQUAMOUS CELL Calcs. favours trigone and lateral wall. Schistosomiasis, stasis, suprapubic ADENOCARCINOMA Midline, urachus, bladder exstrophy Prostatic urethra: 90% TCC Urethral diverticulum: Adenocarcinoma Bulbar/penile urethra: 80% squamous