Nephrolithiasis, Bladder Cancer, Renal Cell Carcinoma - Exam 2 Flashcards
1
Q
how does nephrolithiasis occur?
A
Stone formation occurs when normally soluble material (Ca, PO4, Uric acid) supersaturate the urine and begins the process of crystal formation
occurs d/t low flow state in the kidney (dehydration) -> sit at base of collecting duct and get bigger
2
Q
most common type of kidney stone?
A
calcium stones (Ca oxalate > Ca phosphate)
3
Q
other types of kidney stones?
A
struvite, uric acid (radiolucent stones), cysteine stones
4
Q
uric acid acid stones are what?
A
radiolucent - meaning you can’t see them on KUB or CT scan
5
Q
can the same pt have more than 1 type of stone at the same time/
A
YES!!!
6
Q
is it common for there to be recurrence of kidney stones? what about getting hospitalized?
A
YES!!! - 50% have recurrence w/in 10 years and common for hospitalization
7
Q
whats the biggest risk factor for calcium stones?
A
history of prior calcium urolithiasis
8
Q
other common risk factors for calcium stones?
A
diet - dehydration
short bowel syndrome
soft drinks w/ phosphoric acid
9
Q
medications that are risk factors for calcium stones?
A
Thiazides (M/C)
Glucocorticoids (long-term)
Probenecid (uric acid and Ca Stones)
10
Q
risk factors for uric acid stones?
A
gout, hyperuricosuria, chronic diarrheal states, HTN, DM, obesity
11
Q
risk factors for struvite stones
A
UTI -> urease producing organisms
-Proteus = M/C
12
Q
risk factors for cysteine stones?
A
Pt with cysteinuria due to insolubility of cysteine in the urine
Pure cysteine are radiolucent
13
Q
indinavir stones?
A
radiolucent stone
HIV pt on indinavir and indinavir will precipitate it’s own stones
14
Q
meds that produce their own stones?
A
indinavir, acyclovir, triameterene
15
Q
clinical presentation of nephrolithiasis?
A
renal colic pain begins SUDDENLY
severe unilateral flank pain (that can radiate to groin/testicle/labia d/t T10-S4 dermatome)
CAN’T STOP MOVING!!! (vs peritonitis - don’t want to move)
Vomiting b/c of vagal response
maybe CVAT but abdomen is unremarkable (NOT TENDER)
16
Q
what should a pt with kidney stones abdomen be like?
A
NON-TENDER -> SHOULD BE UNREMARKABLE ABDOMEN
17
Q
what is one thing to NOT miss on exam of pt with kidney stones?
A
testicle exam - make sure not tender or swollen b/c don’t want to miss testicular torsion
18
Q
what determines the location of pain for kidney stones?
A
the site of obstruction
19
Q
what narrow areas do the stone get stuck?
A
Ureteropelvic junction (UPJ) -where ureter meets the kidney
Pelvic brim
-mid-ureter
Ureterovesicular junction (UVJ) - M/C -b/w ureter and bladder
20
Q
where is the M/C place for a kidney stone to get stuck?
A
Ureterovesicular junction (UVJ) -b/w ureter and bladder
21
Q
if do imaging and see inflammation/edema of ureter, what does this usually mean?
A
that the pt has already passed the stone
22
Q
when are sx’s for kidney stone produced?
A
when stone pass from the renal pelvis into the ureter (NOT WHEN THEY ARE IN THE KIDNEY!!!)
23
Q
do stones in the kidney cause pain?
A
NO!!!! - ONLY WHEN THEY PASS FROM THE RENAL PELVIS INTO THE URETER
24
Q
is the pain for kidney stones constant?
A
no, usually waxes and wanes in severity
- waves are related to ureteral spasm
- waves last for 20-60min
25
what are signs that a stone is obstructing the ureter?
hydrometer (swollen ureter) and hydronephrosis (swollen kidney)
26
sx's for kidney stone stuck at UPJ?
vague flank pain, microscopic hematuria
27
sx's for kidney stone stuck at proximal ureter?
renal colic, flank pain, upper abdominal pain
28
sx's for kidney stone stuck at middle section of ureter?
renal colic, anterior abd/groin pain, flank pain
29
sx's for kidney stone stuck at distal ureter?
Renal colic, dysuria, urinary frequency/urgency/hesitancy, anterior abd/groin pain, testicular/labia flank pain
30
what ddx must you think of for women/men that present with sx's of kidney stones?
Women
-ovarian torsion and ectopic pregnancy
Men
-testicular torsion
31
what makes your dx for kidney stones?
Urinalysis - should be performed on all pts
32
what will you see on urinalysis for kidney stones?
microhematuria
33
do you have to run a CBC for kidney stones?
NO!!!
34
will you get anemia from kidney stones?
NO b/c have microhematuria for kidney stones
35
imaging that makes dx for kidney stones?
US and NCCT (non-contrast CT)
-CT done for new onset pts or pts with recurrent kidneys stones that haven't felt like they have before
US for people with recurrent stones or pt is pregnant
36
how specific is US for kidney stones?
97% - when see it and it's positive, then it's a kidney stone
37
cons about US for kidney stones?
can't see stone unless at UPJ or UVJ
hard to measure stone size if stone not at UPJ or UVJ
38
pros about US for kidney stones?
detects indirect signs of obstruction
39
US procedure of choice for what pts with kidney stones?
Procedure of choice for pts who should avoid radiation, including children, pregnant women, and women of childbearing age
40
cons about using KUB for kidney stone dx/
stones are frequently obscured by stool or bowel gas, ureteral stones overlying the bony pelvis or transverse processes of vertebrae
41
when is IVP study done for kidney stone dx? cons?
when CT is unavailable, but it does require contrast (so need perfect kidney fxn for use)
Poor visualization of non-genitourinary structures
42
what's so good about the Non-contrast Helical CT for kidney stone dx?
Fast, accurate, and readily identifies all stone types in all locations (except for indinavir stones and pure matrix stones)
43
when is CT not used as first line test for kidney stone dx?
with pregnant/child/suspicion of gynecologic etiology
44
findings consistent with calculi on CT for kidney stones?
- Ureteral dilation
- Collecting system dilatation
- Perinephric stranding (inflammation)
- Periureteric stranding (inflammation)
- Nephromegaly
- "Rim sign"
45
what does stranding mean in terms of finding on CT for kidney stones?
sign of inflammation
46
acute tx for kidney stones?
IV NSAIDs - ketorolac
Narcotics - if no response to NSAIDs and in b/w time waiting for NSAIDs to work
Anti-emetics (metoclopramide IV/IM)
Abx if bacteria in urine or infection
47
when to give Tamulosin for acute tx for kidney stones?
Give to patients with large (5-10mm sized stones) distal (UJV) stones (not small distal stones)
theory is that it's an alpha-blocker that will dilate the UVJ and stone will fall into bladder
48
when can pt with kidney stones be managed at home?
if they are able to take oral medication (pain meds) and fluids
49
pts with kidney stones should be instructed to do what?
to strain their urine and bring in any stone that passes for analysis (urologist or regular doctor)
50
hospitalization for kidney stones is required when?
Who can't take PO (intractable vomiting)
Refractory/severe pain
Elderly/comorbidity
-Single kidney? Renal transplant? Multiple myeloma? Pre-existing CKD?
Emergency situation
- Fever/sepsis w/obstructing lithiasis = emergent decompression
- ARF
- Anuria
51
tx for >5mm-2cm proximal kidney stones?
Extracorporeal shock wave lithotripsy
52
Extracorporeal shock wave lithotripsy C/I when?
Contraindicated w/ pregnancy, tightly impacted stones, cysteine stones, untreatable bleeding d/o's
53
Extracorporeal shock wave lithotripsy complications?
perinephric hematoma and ureteral obstruction
54
tx for >5mm mid and distal ureteral stones?
Ureteroscopy
55
Ureteroscopy good for what stones?
>5mm mid and distal ureteral stones
effective for hard stones, cysteine stones, impacted stones
56
Ureterscopy tx for kidney stones requires what?
ureteral stent
| -keeps ureter open so stone fragments can pass through slowly incase pt has ureteral spasm
57
tx for stones >2cm and in proximal collecting system?
Percutaneous nephrostolithotomy
FOR LARGER AND COMPLEX RENAL STONES AND IF FAILURE OF OTHER MODALITIES
58
what are staghorn stones?
Upper urinary tract stones that involve the renal pelvis and extend into at least 2 calcyces of the kidney (ENORMOUS STONE)
-typically struvite stone, so associated w/infection - Proteus M/C
59
do staghorn stones present with pain?
rarely!!!
may just be picked up with imaging
60
how do you treat staghorn stones?
these stones must be broken up and surgically removed (med therapy not enough b/c so big)
use suppressive abx therapy (to prevent recurrence)
use urease inhibitors (acetohydroxamic acid)
PNL surgical tx of choice followed by PNL & ESWL
61
tx of choice for staghorn stones?
Percutaneous nephrostolithotomy (PNL) followed by PNL & Extracorporeal shock wave lithotripsy (ESWL)
62
do pts with FIRST kidney stone (symptomatic or asymptomatic) need metabolic evaluation?
NO!!! unless strong family hx then need metabolic evaluation
63
dietary counseling for pts with FIRST kidney stone?
- Reduce dietary sodium
- Reduce dietary animal protein
- ***Increase PO fluid intake such that 2L/day urinary output
64
who requires metabolic evaluation for kidney stones?
pts with recurrent stones (M/C uric acid, cysteine) or strong fam hx
65
what is key to treating pts with recurrent stones?
24hr urinalysis
| -can see what is precipitating out and then decide how to treat them
66
what should be initiated for pts with recurrent stones and to prevent them?
long-term therapy to prevent recurrence
67
drug therapy for recurrent calcium stones depends on what? what is the tx?
depends on 24hr urine (what is precipitating out)
- Thiazide for hypercalciuria (renal)
- Tx hyperparathyroidism (resorptive hypercalciuria)
- Dietary restrict purines or allopurinol (uric acid in urine) or oxalate/increase Ca to bind oxalate (high oxalate urine) and then excreted
68
tx for recurrent uric acid stones?
K-citrate to alkalinize the urine (stone dissolution and ppx) - helps dissolve stones
Allopurinol (prevention) - just like you do for a gout pt and restrict purines too
Dietary restrict Purines
69
tx for recurrent cysteine stones?
High fluid intake 3-4L urinary output per day
Urinary alkalinization w/drugs such as penicillamine
70
tx for recurrent Struvite stones?
(NEED TO BREAK THESE STONES UP!!!)
- PNL
- Ppx abx
- Acetohydroxamic acid (urease inhibitor)
71
M/C cells for bladder cancer? where can it arise?
transitional cell carcinoma
| -can arise in places other than bladder
72
bladder cancer is a cancer of who?
older patients (>55 y/o)
73
what are the biggest risk factors for bladder cancer?
cigarette smoking and occupational exposures (organic chemicals, rubber, paint, dye)
also chronic urinary inflammation from chronic indwelling catheter
74
what are the signs and sx's of bladder cancer?
***painless hematuria (also for renal cell cancer)
urinary voiding sx's (lower urinary tract sx's like urgency, frequency, burning)
75
sx's of advanced bladder cancer?
swelling in LE's, palpable mass
76
dx studies for bladder cancer?
Urinalysis - cytology (look for malignant cells TCC)
Cystoscopy w/bx (GOLD STANDARD)
77
what is the gold standard for dx bladder cancer?
Cystoscopy w/bx
78
if see malignant cells - signs of TCC on cytology, then do what?
do cystoscopy
79
if cytology is negative, but still suspicious of bladder cancer, then do what test?
cystoscopy
80
what imaging helps with staging for bladder cancer? what imaging for mets?
CT scan w/ contrast, US, and/or MRI
-evaluates upper urinary tract to see how advanced bladder cancer is
bone scan for mets
81
what is T1 stage for bladder cancer?
tumor in wedge subepithelial connective tissue
82
what is T2 stage for bladder cancer?
tumor in wedge muscle
83
what is T3 stage for bladder cancer?
tumor through muscle layer of the bladder and into surrounding adipose
84
what is T4 stage for bladder cancer?
spread beyond the adipose and into nearby organs or structures
85
tx for non-muscle invasive bladder cancer?
Ta, T1
surgery (Endoscopic TURBT) followed by BCG tx
86
when is radical cystectomy done for non-muscle invasive bladder cancer?
failure of intravesical therapy, bulk tumor too large to endoscopically resect, prostatic urethra involved
87
what is immunotherapy and chemotherapy tx for non-muscle invasive bladder cancer?
intravesicle instillation (w/ urethral catheter) or BCG vaccine
88
when is intravesicle instillation (w/ urethral catheter) or BCG vaccine given for non-muscle
2-4 weeks following endoscopic resection or biopsy
weekly BCG for 6-12 weeks
89
if fail BCG or intravesicular chemo, then?
Mitomycin, valirubicin, doxorubicin
90
tx for muscle-invasive bladder cancer?
T2 and greater
neoadjuvant chemotherapy before radical cystectomy (also take out lymph nodes)
91
what is the neoadjuvant chemotherapy for muscle-invasive bladder cancer?
MVAC
- methotrexate
- vincristine
- adriamycin
- cisplatin
92
what is the tx modality of choice for muscle-invasive bladder cancer?
radical cystectomy w/LN dissection
urinary diversion required with this tx (get urostomy)
93
who is radiation therapy for bladder cancer?
pts that aren't surgical candidates
94
what is the tissue of origin for renal cell carcinoma (RCC)?
proximal renal tubular epithelium
95
what decades does RCC most commonly occur?
5th to 6th decade
96
risk factors for RCC?
smoking
s/p renal transplant/dialysis if develop cystic renal disease
97
signs and sx's for RCC?
painless hematuria
maybe just constitutional sx's b/c very indolent
supraclavicular LN = virchow's node = BAD!!!
Classic Triad:
-flank pain, hematuria, flank mass
98
RCC has a frequent occurrence with what syndromes?
paraneoplastic syndromes
- hypercalcemia (tumor makes PTHrP)
- non-metastatic liver dysfunction
- HTN
- erythrocytosis
99
RCC labs for dx?
Anemia/Erythrocytosis
-anemia b/c been bleeding for so long or erythrocytosis b/c have paraneoplastic syndrome associated with it
Hematuria
-Cytology performed on urine but rarely aids w/ dx for RCC
100
is cytology helpful for dx of RCC?
o Cytology not helpful with RCC unless cancer itself is in the renal pelvis and cells are being spilled off into the urine
101
what is the dx imaging of choice for RCC?
CT w/ contrast
| -it's definitive
102
when is MRI used for RCC?
good for staging, but superior w/assessing IVC involvement
103
stage 1 of RCC?
tumor <7cm and tumor is confined w/in kidney parenchyma
104
stage 2 of RCC?
tumor >7cm
| -involves perinephric fat, but confined w/in fascia
105
stage 3A of RCC?
involves main renal vein or IVC
106
stage 3B of RCC?
involves LN
107
stage 4A of RCC?
involves adjacent organs other than the adrenal like colon, pancreas
108
stage 4B of RCC?
distant mets
109
what is RCC resistant to?
chemo and radiation
110
tx for localized RCC (w/in kidney)
T1a <4cm -> partial nephrectomy (wedge resection)
T1b-T2 -> radical nephrectomy w/regional LNectomy
111
unique feature of growth of locally advanced RCC?
venous tumor thrombus -> IVC thrombus
112
findings suspicious for IVC thrombus from RCC?
ANYTHING THAT MAKES YOU SUSPICIOUS FOR IVC CONGESTION
- LE edema
- dilated superficial abd veins
- PE
- right atrial mass
113
tx for locally advanced RCC?
Radial nephrectomy, LN dissection and IVC thrombectomy (doesn't invade wall of IVC)
114
tx for locally invasive RCC?
excision of tumor and en bloc resection of adjacent organs (resect bowel, spleen, or abd wall muscle = aim of therapy)
TAKE OUT A LOT OF THE ABDOMEN
115
what meds are the future of disseminated (Stage 4) RCC tx?
Multikinase-inhibitor, VEGF (vascular endothelial growth factor) inhibitor treatment
- Sorafenib
- Sunitinib
- Temsirolimus
116
IL-2 tx for disseminated RCC tx is for who?
pts with minimal tumor burden (i.e., primary kidney tumor removed), lung or nodal metastases only, and an excellent performance status
117
when do you use VEGF inhibitor tx for disseminated RCC tx?
Progression of disease after a trial of immunotherapy or not candidate for high dose IL-2 therapy or fail IL-2 therapy
