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Clin Med III Exam II > Nephrolithiasis, bladder cancer, renal cell carcinoma > Flashcards

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

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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

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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
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4
Q

Risk factors for uric acid stones

A
  • gout
  • hyperuricosuria
  • chronic diarrheal states
  • HTN
  • DM
  • obesity
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5
Q

Risk factors for struvite stones

A

UTI (urease producing organisms)

proteus, klebsiella, pseudomonas, staph

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6
Q

Risk factors of cytine stones

A

cystinuria bue to insolubility of cystine in the urine

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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
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8
Q

Where are kidney stone typically lodged

A

stuck in narrow areas

  • urteropelvic junction
  • pelvic brim
  • ureterovesicular junction
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9
Q

The site of the obstruction determines what

A

the location of the pain

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10
Q

Flank pain and tenderness would mean the stone is where..

A

upper ureteral or renal pelvic obstruction

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11
Q

Pain that radiates to ipsilateral groin means an obstruction where

A

lower ureteral obstruction

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12
Q

When do symptoms usually present with kidney stones

A

when stones pass from the renal pelvis into the ureter

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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

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14
Q

Sx if stone is in the kidney

A
  • vague flank pain

- hematuria

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15
Q

Sx if stone is in proximal ureter

A
  • renal colic
  • flank pain
  • upper abd pain
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16
Q

Sx if stone is in the middle of the ureter

A
  • renal colic
  • anterior abd/groin pain
  • flank pain
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17
Q

Sx if stone is in the distal ureter

A
  • renal colic
  • dysuria
  • urinary frequency/urgency
  • groin pain
  • flank pain
  • testicular/labia pain
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18
Q

What do you need to diagnose kidney stones

A
  • urinalysis
  • CBC
  • BMP
  • radiologic tests (KUB,IVP,US)
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19
Q

What is the fall back to US for kidney stones

A

poor visualization or ureteral stones unless at UPJ or UVJ

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20
Q

What does a US detect with kidney stones?

A

indirect signs of obstructions

  • hydroureter
  • loss of ureteric jet
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21
Q

When is an ultrasound the procedure of choice if kidney stones are expected

A
  • children
  • pregnant
  • women of childbearing age
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22
Q

What types of stones cant you see on a KUB

A
  • uric acid stones
  • cystine stones
  • indinavir stones
  • pure matrix stones
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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

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24
Q

What will an IVP study tell you about the kidney stones

A
  • size
  • location
  • radiodensity
  • degree of obstruction
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25
Q

What must you measure before you do an IVP? Why

A

check serum Cr because of the contrast

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26
Q

IVP studies have poor visualization of what

A

non-genitourinary structures

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27
Q

What is the benefit to a noncontrast helical CT

A

identifies most stone types in all locations (except pure matrix stones and Indinavir stones)

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28
Q

What findings on a noncontrast helical CT are consistent with calculi

A
  • uteral dilation
  • collecting system dilation
  • perinephric stranding
  • periureteric stranding
  • nephromegaly
  • “rim sign”
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29
Q

Acute management for pts with kidney stones

A
  • IV hydration
  • analgesia (NSAIDs, ketorolac)
  • anti emetics
  • tamulosin
  • abx if necessary
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30
Q

When is hospitalization needed for a patient with kidney stones

A

-cannot take PO
-refractory/ severe pain
elderly or comorbidities
-emergency situation (fever/sepsis, ARF, anuria)

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31
Q

When is extracorporeal shock wave lithotripsy indicated (ESWL)

A
  • proximal stones
  • radio opaque <2cm in kidney
  • <1cm in ureter
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32
Q

Complications of lithotripsy

A
  • perinephric hematoma

- ureteral obstruction

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33
Q

When is lithotrispy contraindicated

A
  • pregnancy
  • tighly impacted stones
  • untretable bleeding disorder
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34
Q

What is ureteroscopy indicated for stone tx

A
  • mid and distal uteral stones
  • <5mm
  • hard stones, cystine stones, impacted stones
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35
Q

What is done to treat stones during ureteroscopy

A
  • retrive with stone basket

- endoscpoic direct fragmenting device

36
Q

What is typically required when treating stones via ureteroscopy

A

ureteral stent

37
Q

When is a percutaneous nephrostolithotomy indicated

A
  • stones >2cm
  • stones in proximal collecting system
  • urosepsis w/ obstruction
  • failure of other modalities
38
Q

What is a percutaneous nephrostolithotomy (PNL)

A

percutaneous insertion of needle over wire though skin at flank into the kidney then insertion endoscope w/ extraction

39
Q

What are staghorn calculi

A

upper urinary tract stones that involve the renal pelvis and extend into at least 2 calyces

40
Q

What type of stone is a staghorn stone

A

struvite

41
Q

What is always associated with staghorn calculi

A

infection (urease producing bacteria)

most often proteus

42
Q

What medical therapy is used for staghorn calculi

A
  • abx
  • urease inhibitors

NOT ENOUGH BY ITSSELF

43
Q

What is the treatment of choice for staghorn calculi

A

PNL followed by PNL and ESWL combination

44
Q

When should a metabolic evaluation be done in a patient with kidney stones?

A
  • recurrent stones
  • strong family hx

serum PTH, 24hr urinalysis, serum Ca, BMP

45
Q

Long term therapy for recurrent calcium stones

A
  • thiazide
  • tx hyperparthyroid
  • oxalate
46
Q

Long term therapy for recurrent uric acid stones

A
  • K citrate
  • allopurinol
  • dietary restrict purines
47
Q

Long term therapy for recurrent cytine stones

A
  • high fluid intake (3-4L output a day)

- urinary alkalinization w/ rx (penicillamine)

48
Q

Long term therapy for recurrent struvite stones

A
  • PNL
  • phx abx
  • acetohydroxamic acid
49
Q

Pathology of bladder cancer

A
  • transitional cell carcinoma
  • squamous cell carcinoma
  • adenocarcinoma
50
Q

Which type of bladder cancer is most common

A

transitional cell carcinoma

51
Q

What are some risk factors for bladder cancer

A
  • smoking
  • chronic urinary inflammation
  • occupational exposure (organic chemicals, rubber, paint, dye)
  • family hx
  • Balkan nephropathy
52
Q

What are the signs and symptoms of bladder cancer

A
  • painless hematuria

- urinary voiding symptoms

53
Q

What are symptoms of advanced bladder cancer

A
  • swelling in lower extremities secondary to a lymphatic obstruction
  • bony/pelvic/flank pain
  • palpable mass
54
Q

What is the diagnostic standard for bladder cancer

A

cystoscopy w/ biopsy

55
Q

What other things are done to work up bladder cancer

A
  • urinalysis (M and S, cytology)
  • CT w/ contrast
  • US
  • MRI
  • bone scan
  • CXR
56
Q

What is cytology helpful in diagnosing

A

high grade tumors and carcinoma in situ

57
Q

What is a benefit to cystoscopy

A

can resect papillary tumors while doing procudure

58
Q

Non-invasive bladder cancers are treated surgically how?

A
  • endoscopic TURBT

- radical cystectomy

59
Q

When would a cystectomy be indicated

A
  • failure of intravesical therapy
  • bulky tumor
  • involvement of prostatic urethra
60
Q

Immunotherapy and chemotherapy treatment options for bladder cancer

A
  • intravesicle instillation of BCG vaccine weekly for 6 to 12 weeks
  • failure of BCG–> mitomycin, valrubicin, doxorubicin
61
Q

When should the BCG vaccine be given

A

2-4 weeks following endoscopic resection of any visible papillary tumors or bladder biopsy

62
Q

Treatment of muscle invasive bladder cancer

A
  • neoadjuvant chemo
  • radical cystectomy w/ regional LN dissection
  • radiation if bladder preserving surgery done
63
Q

Which cancers are non muscle invasive

A

Ta, T1, CIS

64
Q

Which cancers are muscle invasive disease

A

T2 and greater

65
Q

What is the tissue of origin for renal cell carcinoma

A

proximal renal tubular epithelium

66
Q

What are some risk factors for renal cell carcinoma

A
  • smoking
  • obesity
  • HTN
  • s/p renal transplant, dialysis`
67
Q

What is the classic triad associated with renal cell carcinoma

A

flank pain, hematuria, flank mass

68
Q

What are other sx associated with renal cell carcinoma

A
  • weight loss
  • fever
  • night sweats
  • varicocele
69
Q

Where does renal cell carcinoma metastasize to

A

lung, soft tissue, bone, liver, CNS, cutaneous sites

70
Q

Renal cell carcinoma typically occurrs with

A

paraneoplastic syndromes

71
Q

Labs for diagnosis of renal cell carcinoma

A
  • anemia
  • hematuria
  • elevated ESR
72
Q

Diagnostic method of choice for renal cell carcinoma

A

Ct w/ contrast

73
Q

Imaging for diagnosis and staging of renal cell carcinoma

A
  • US
  • MRI
  • CT
  • PET scan
  • bone scan
74
Q

What makes renal cell carcinoma a stage II or greater

A

> 7cm

75
Q

Stage IIIA renal cell carcinoma

A

involves main renal vein or inferior vena cava

76
Q

Stage IIIB renal cell carcinoma

A

regional lymph node involvement

77
Q

Stage IIIC renal cell carcinoma

A

involves both local vessels and regional lymph nodes

78
Q

Treatment for RCC T1a <4cm

A

partial nephrectomy

79
Q

Treatment for T1b-T2 RCC

A

nephrectomy

80
Q

Treatmetn fcor locally advanced RCC (lymph nodes)

A
  • radical nephrectomy
  • LN dissection
  • IVC thrombectomy
81
Q

What can occur in locally advanced RCC (lymph nodes)

A

venous tumor thrombosis

dx. w/ MRI

82
Q

Treatment of RCC that has invaded other organs

A
  • nephrectomy

- en bloc resection of adjacent organs

83
Q

Treatment of disseminated RCC

A
  • palliative nephrectomy
  • surgical resection of metastatic site if possible
  • radiation/ chemo (typically resistant)
  • IL2
  • VEGF, multikinase inh
84
Q

When is IL-2 used in RCC treatment

A
  • pts with minimal tumor burden

- lung or nodal metastases only

85
Q

When would you use VEGF or multikinase inhibitor

A

progression of disease after a trial of immunotherapy or not a candidate for high dose IL-2 therapy

Clin Med III Exam II (11 decks)

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