Nephrolithiasis, bladder cancer, renal cell carcinoma Flashcards
1
Q
When do kidney stones form
A
when normally soluble material supersaturates the urine and begins the process of crystal formation
2
Q
What are the 4 types of kidney stones? Which is most common
A
- calcium (Ca oxylate)
- struvite
- uric acid
- cystine
calcium is most common
3
Q
What puts a patient at risk for calcium stones
A
- hx of prior calcium stones
- family fx
- diet (dehydration,high salt, high protein)
- medication (loop diuretic, glucorticoids)
- hyperparathyroid
- hypercalcemia of malignancy
- sarcoid
- medullary sponge kidney
4
Q
Risk factors for uric acid stones
A
- gout
- hyperuricosuria
- chronic diarrheal states
- HTN
- DM
- obesity
5
Q
Risk factors for struvite stones
A
UTI (urease producing organisms)
proteus, klebsiella, pseudomonas, staph
6
Q
Risk factors of cytine stones
A
cystinuria bue to insolubility of cystine in the urine
7
Q
How would a patient with a kidney stone present
A
- sudden onset of renal colic (writhing pain)
- pain radiating to groin
- N/V
- hematuria with frequency/urgency/dysuria
8
Q
Where are kidney stone typically lodged
A
stuck in narrow areas
- urteropelvic junction
- pelvic brim
- ureterovesicular junction
9
Q
The site of the obstruction determines what
A
the location of the pain
10
Q
Flank pain and tenderness would mean the stone is where..
A
upper ureteral or renal pelvic obstruction
11
Q
Pain that radiates to ipsilateral groin means an obstruction where
A
lower ureteral obstruction
12
Q
When do symptoms usually present with kidney stones
A
when stones pass from the renal pelvis into the ureter
13
Q
What is the characteristic of pain with kidney stones
A
waxes and wanes in severity related to the stone getting stuck in the ureter as it moves
14
Q
Sx if stone is in the kidney
A
- vague flank pain
- hematuria
15
Q
Sx if stone is in proximal ureter
A
- renal colic
- flank pain
- upper abd pain
16
Q
Sx if stone is in the middle of the ureter
A
- renal colic
- anterior abd/groin pain
- flank pain
17
Q
Sx if stone is in the distal ureter
A
- renal colic
- dysuria
- urinary frequency/urgency
- groin pain
- flank pain
- testicular/labia pain
18
Q
What do you need to diagnose kidney stones
A
- urinalysis
- CBC
- BMP
- radiologic tests (KUB,IVP,US)
19
Q
What is the fall back to US for kidney stones
A
poor visualization or ureteral stones unless at UPJ or UVJ
20
Q
What does a US detect with kidney stones?
A
indirect signs of obstructions
- hydroureter
- loss of ureteric jet
21
Q
When is an ultrasound the procedure of choice if kidney stones are expected
A
- children
- pregnant
- women of childbearing age
22
Q
What types of stones cant you see on a KUB
A
- uric acid stones
- cystine stones
- indinavir stones
- pure matrix stones
23
Q
What are the draw backs in using a KUB to diagnose kidney stones
A
- stones are frequently obscured by stool, gas, bones
- non urologic radioopacities can be misinterpreted as stones
24
Q
What will an IVP study tell you about the kidney stones
A
- size
- location
- radiodensity
- degree of obstruction
25
What must you measure before you do an IVP? Why
check serum Cr because of the contrast
26
IVP studies have poor visualization of what
non-genitourinary structures
27
What is the benefit to a noncontrast helical CT
identifies most stone types in all locations (except pure matrix stones and Indinavir stones)
28
What findings on a noncontrast helical CT are consistent with calculi
- uteral dilation
- collecting system dilation
- perinephric stranding
- periureteric stranding
- nephromegaly
- "rim sign"
29
Acute management for pts with kidney stones
- IV hydration
- analgesia (NSAIDs, ketorolac)
- anti emetics
- tamulosin
- abx if necessary
30
When is hospitalization needed for a patient with kidney stones
-cannot take PO
-refractory/ severe pain
elderly or comorbidities
-emergency situation (fever/sepsis, ARF, anuria)
31
When is extracorporeal shock wave lithotripsy indicated (ESWL)
- proximal stones
- radio opaque <2cm in kidney
- <1cm in ureter
32
Complications of lithotripsy
- perinephric hematoma
| - ureteral obstruction
33
When is lithotrispy contraindicated
- pregnancy
- tighly impacted stones
- untretable bleeding disorder
34
What is ureteroscopy indicated for stone tx
- mid and distal uteral stones
- <5mm
- hard stones, cystine stones, impacted stones
35
What is done to treat stones during ureteroscopy
- retrive with stone basket
| - endoscpoic direct fragmenting device
36
What is typically required when treating stones via ureteroscopy
ureteral stent
37
When is a percutaneous nephrostolithotomy indicated
- stones >2cm
- stones in proximal collecting system
- urosepsis w/ obstruction
- failure of other modalities
38
What is a percutaneous nephrostolithotomy (PNL)
percutaneous insertion of needle over wire though skin at flank into the kidney then insertion endoscope w/ extraction
39
What are staghorn calculi
upper urinary tract stones that involve the renal pelvis and extend into at least 2 calyces
40
What type of stone is a staghorn stone
struvite
41
What is always associated with staghorn calculi
infection (urease producing bacteria)
most often proteus
42
What medical therapy is used for staghorn calculi
- abx
- urease inhibitors
NOT ENOUGH BY ITSSELF
43
What is the treatment of choice for staghorn calculi
PNL followed by PNL and ESWL combination
44
When should a metabolic evaluation be done in a patient with kidney stones?
- recurrent stones
- strong family hx
serum PTH, 24hr urinalysis, serum Ca, BMP
45
Long term therapy for recurrent calcium stones
- thiazide
- tx hyperparthyroid
- oxalate
46
Long term therapy for recurrent uric acid stones
- K citrate
- allopurinol
- dietary restrict purines
47
Long term therapy for recurrent cytine stones
- high fluid intake (3-4L output a day)
| - urinary alkalinization w/ rx (penicillamine)
48
Long term therapy for recurrent struvite stones
- PNL
- phx abx
- acetohydroxamic acid
49
Pathology of bladder cancer
- transitional cell carcinoma
- squamous cell carcinoma
- adenocarcinoma
50
Which type of bladder cancer is most common
transitional cell carcinoma
51
What are some risk factors for bladder cancer
- smoking
- chronic urinary inflammation
- occupational exposure (organic chemicals, rubber, paint, dye)
- family hx
- Balkan nephropathy
52
What are the signs and symptoms of bladder cancer
- painless hematuria
| - urinary voiding symptoms
53
What are symptoms of advanced bladder cancer
- swelling in lower extremities secondary to a lymphatic obstruction
- bony/pelvic/flank pain
- palpable mass
54
What is the diagnostic standard for bladder cancer
cystoscopy w/ biopsy
55
What other things are done to work up bladder cancer
- urinalysis (M and S, cytology)
- CT w/ contrast
- US
- MRI
- bone scan
- CXR
56
What is cytology helpful in diagnosing
high grade tumors and carcinoma in situ
57
What is a benefit to cystoscopy
can resect papillary tumors while doing procudure
58
Non-invasive bladder cancers are treated surgically how?
- endoscopic TURBT
| - radical cystectomy
59
When would a cystectomy be indicated
- failure of intravesical therapy
- bulky tumor
- involvement of prostatic urethra
60
Immunotherapy and chemotherapy treatment options for bladder cancer
- intravesicle instillation of BCG vaccine weekly for 6 to 12 weeks
- failure of BCG--> mitomycin, valrubicin, doxorubicin
61
When should the BCG vaccine be given
2-4 weeks following endoscopic resection of any visible papillary tumors or bladder biopsy
62
Treatment of muscle invasive bladder cancer
- neoadjuvant chemo
- radical cystectomy w/ regional LN dissection
- radiation if bladder preserving surgery done
63
Which cancers are non muscle invasive
Ta, T1, CIS
64
Which cancers are muscle invasive disease
T2 and greater
65
What is the tissue of origin for renal cell carcinoma
proximal renal tubular epithelium
66
What are some risk factors for renal cell carcinoma
- smoking
- obesity
- HTN
- s/p renal transplant, dialysis`
67
What is the classic triad associated with renal cell carcinoma
flank pain, hematuria, flank mass
68
What are other sx associated with renal cell carcinoma
- weight loss
- fever
- night sweats
- varicocele
69
Where does renal cell carcinoma metastasize to
lung, soft tissue, bone, liver, CNS, cutaneous sites
70
Renal cell carcinoma typically occurrs with
paraneoplastic syndromes
71
Labs for diagnosis of renal cell carcinoma
- anemia
- hematuria
- elevated ESR
72
Diagnostic method of choice for renal cell carcinoma
Ct w/ contrast
73
Imaging for diagnosis and staging of renal cell carcinoma
- US
- MRI
- CT
- PET scan
- bone scan
74
What makes renal cell carcinoma a stage II or greater
>7cm
75
Stage IIIA renal cell carcinoma
involves main renal vein or inferior vena cava
76
Stage IIIB renal cell carcinoma
regional lymph node involvement
77
Stage IIIC renal cell carcinoma
involves both local vessels and regional lymph nodes
78
Treatment for RCC T1a <4cm
partial nephrectomy
79
Treatment for T1b-T2 RCC
nephrectomy
80
Treatmetn fcor locally advanced RCC (lymph nodes)
- radical nephrectomy
- LN dissection
- IVC thrombectomy
81
What can occur in locally advanced RCC (lymph nodes)
venous tumor thrombosis
dx. w/ MRI
82
Treatment of RCC that has invaded other organs
- nephrectomy
| - en bloc resection of adjacent organs
83
Treatment of disseminated RCC
- palliative nephrectomy
- surgical resection of metastatic site if possible
- radiation/ chemo (typically resistant)
- IL2
- VEGF, multikinase inh
84
When is IL-2 used in RCC treatment
- pts with minimal tumor burden
| - lung or nodal metastases only
85
When would you use VEGF or multikinase inhibitor
progression of disease after a trial of immunotherapy or not a candidate for high dose IL-2 therapy
