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