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Clin Med 3 > Nephrolithiasis, Bladder Cancer, Renal Cell Carcinoma - Exam 2 > Flashcards

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

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2
Q

most common type of kidney stone?

A

calcium stones (Ca oxalate > Ca phosphate)

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3
Q

other types of kidney stones?

A

struvite, uric acid (radiolucent stones), cysteine stones

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4
Q

uric acid acid stones are what?

A

radiolucent - meaning you can’t see them on KUB or CT scan

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5
Q

can the same pt have more than 1 type of stone at the same time/

A

YES!!!

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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

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7
Q

whats the biggest risk factor for calcium stones?

A

history of prior calcium urolithiasis

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8
Q

other common risk factors for calcium stones?

A

diet - dehydration

short bowel syndrome

soft drinks w/ phosphoric acid

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9
Q

medications that are risk factors for calcium stones?

A

Thiazides (M/C)

Glucocorticoids (long-term)

Probenecid (uric acid and Ca Stones)

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10
Q

risk factors for uric acid stones?

A

gout, hyperuricosuria, chronic diarrheal states, HTN, DM, obesity

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11
Q

risk factors for struvite stones

A

UTI -> urease producing organisms

-Proteus = M/C

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12
Q

risk factors for cysteine stones?

A

Pt with cysteinuria due to insolubility of cysteine in the urine

Pure cysteine are radiolucent

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13
Q

indinavir stones?

A

radiolucent stone

HIV pt on indinavir and indinavir will precipitate it’s own stones

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14
Q

meds that produce their own stones?

A

indinavir, acyclovir, triameterene

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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)

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16
Q

what should a pt with kidney stones abdomen be like?

A

NON-TENDER -> SHOULD BE UNREMARKABLE ABDOMEN

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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

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18
Q

what determines the location of pain for kidney stones?

A

the site of obstruction

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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
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20
Q

where is the M/C place for a kidney stone to get stuck?

A 
Ureterovesicular junction (UVJ)
-b/w ureter and bladder
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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

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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!!!)

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23
Q

do stones in the kidney cause pain?

A

NO!!!! - ONLY WHEN THEY PASS FROM THE RENAL PELVIS INTO THE URETER

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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
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25
Q

what are signs that a stone is obstructing the ureter?

A

hydrometer (swollen ureter) and hydronephrosis (swollen kidney)

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26
Q

sx’s for kidney stone stuck at UPJ?

A

vague flank pain, microscopic hematuria

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27
Q

sx’s for kidney stone stuck at proximal ureter?

A

renal colic, flank pain, upper abdominal pain

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28
Q

sx’s for kidney stone stuck at middle section of ureter?

A

renal colic, anterior abd/groin pain, flank pain

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29
Q

sx’s for kidney stone stuck at distal ureter?

A

Renal colic, dysuria, urinary frequency/urgency/hesitancy, anterior abd/groin pain, testicular/labia flank pain

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30
Q

what ddx must you think of for women/men that present with sx’s of kidney stones?

A

Women
-ovarian torsion and ectopic pregnancy

Men
-testicular torsion

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31
Q

what makes your dx for kidney stones?

A

Urinalysis - should be performed on all pts

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32
Q

what will you see on urinalysis for kidney stones?

A

microhematuria

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33
Q

do you have to run a CBC for kidney stones?

A

NO!!!

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34
Q

will you get anemia from kidney stones?

A

NO b/c have microhematuria for kidney stones

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35
Q

imaging that makes dx for kidney stones?

A

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

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36
Q

how specific is US for kidney stones?

A

97% - when see it and it’s positive, then it’s a kidney stone

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37
Q

cons about US for kidney stones?

A

can’t see stone unless at UPJ or UVJ

hard to measure stone size if stone not at UPJ or UVJ

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38
Q

pros about US for kidney stones?

A

detects indirect signs of obstruction

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39
Q

US procedure of choice for what pts with kidney stones?

A

Procedure of choice for pts who should avoid radiation, including children, pregnant women, and women of childbearing age

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40
Q

cons about using KUB for kidney stone dx/

A

stones are frequently obscured by stool or bowel gas, ureteral stones overlying the bony pelvis or transverse processes of vertebrae

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41
Q

when is IVP study done for kidney stone dx? cons?

A

when CT is unavailable, but it does require contrast (so need perfect kidney fxn for use)

Poor visualization of non-genitourinary structures

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42
Q

what’s so good about the Non-contrast Helical CT for kidney stone dx?

A

Fast, accurate, and readily identifies all stone types in all locations (except for indinavir stones and pure matrix stones)

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43
Q

when is CT not used as first line test for kidney stone dx?

A

with pregnant/child/suspicion of gynecologic etiology

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44
Q

findings consistent with calculi on CT for kidney stones?

A
  • Ureteral dilation
  • Collecting system dilatation
  • Perinephric stranding (inflammation)
  • Periureteric stranding (inflammation)
  • Nephromegaly
  • “Rim sign”
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45
Q

what does stranding mean in terms of finding on CT for kidney stones?

A

sign of inflammation

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46
Q

acute tx for kidney stones?

A

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

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47
Q

when to give Tamulosin for acute tx for kidney stones?

A

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
Q

when can pt with kidney stones be managed at home?

A

if they are able to take oral medication (pain meds) and fluids

49
Q

pts with kidney stones should be instructed to do what?

A

to strain their urine and bring in any stone that passes for analysis (urologist or regular doctor)

50
Q

hospitalization for kidney stones is required when?

A

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
Q

tx for >5mm-2cm proximal kidney stones?

A

Extracorporeal shock wave lithotripsy

52
Q

Extracorporeal shock wave lithotripsy C/I when?

A

Contraindicated w/ pregnancy, tightly impacted stones, cysteine stones, untreatable bleeding d/o’s

53
Q

Extracorporeal shock wave lithotripsy complications?

A

perinephric hematoma and ureteral obstruction

54
Q

tx for >5mm mid and distal ureteral stones?

A

Ureteroscopy

55
Q

Ureteroscopy good for what stones?

A

> 5mm mid and distal ureteral stones

effective for hard stones, cysteine stones, impacted stones

56
Q

Ureterscopy tx for kidney stones requires what?

A

ureteral stent

-keeps ureter open so stone fragments can pass through slowly incase pt has ureteral spasm

57
Q

tx for stones >2cm and in proximal collecting system?

A

Percutaneous nephrostolithotomy

FOR LARGER AND COMPLEX RENAL STONES AND IF FAILURE OF OTHER MODALITIES

58
Q

what are staghorn stones?

A

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
Q

do staghorn stones present with pain?

A

rarely!!!

may just be picked up with imaging

60
Q

how do you treat staghorn stones?

A

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
Q

tx of choice for staghorn stones?

A

Percutaneous nephrostolithotomy (PNL) followed by PNL & Extracorporeal shock wave lithotripsy (ESWL)

62
Q

do pts with FIRST kidney stone (symptomatic or asymptomatic) need metabolic evaluation?

A

NO!!! unless strong family hx then need metabolic evaluation

63
Q

dietary counseling for pts with FIRST kidney stone?

A
  • Reduce dietary sodium
  • Reduce dietary animal protein
  • ***Increase PO fluid intake such that 2L/day urinary output
64
Q

who requires metabolic evaluation for kidney stones?

A

pts with recurrent stones (M/C uric acid, cysteine) or strong fam hx

65
Q

what is key to treating pts with recurrent stones?

A

24hr urinalysis

-can see what is precipitating out and then decide how to treat them

66
Q

what should be initiated for pts with recurrent stones and to prevent them?

A

long-term therapy to prevent recurrence

67
Q

drug therapy for recurrent calcium stones depends on what? what is the tx?

A

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
Q

tx for recurrent uric acid stones?

A

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
Q

tx for recurrent cysteine stones?

A

High fluid intake 3-4L urinary output per day

Urinary alkalinization w/drugs such as penicillamine

70
Q

tx for recurrent Struvite stones?

A

(NEED TO BREAK THESE STONES UP!!!)

  • PNL
  • Ppx abx
  • Acetohydroxamic acid (urease inhibitor)
71
Q

M/C cells for bladder cancer? where can it arise?

A

transitional cell carcinoma

-can arise in places other than bladder

72
Q

bladder cancer is a cancer of who?

A

older patients (>55 y/o)

73
Q

what are the biggest risk factors for bladder cancer?

A

cigarette smoking and occupational exposures (organic chemicals, rubber, paint, dye)

also chronic urinary inflammation from chronic indwelling catheter

74
Q

what are the signs and sx’s of bladder cancer?

A

***painless hematuria (also for renal cell cancer)

urinary voiding sx’s (lower urinary tract sx’s like urgency, frequency, burning)

75
Q

sx’s of advanced bladder cancer?

A

swelling in LE’s, palpable mass

76
Q

dx studies for bladder cancer?

A

Urinalysis - cytology (look for malignant cells TCC)

Cystoscopy w/bx (GOLD STANDARD)

77
Q

what is the gold standard for dx bladder cancer?

A

Cystoscopy w/bx

78
Q

if see malignant cells - signs of TCC on cytology, then do what?

A

do cystoscopy

79
Q

if cytology is negative, but still suspicious of bladder cancer, then do what test?

A

cystoscopy

80
Q

what imaging helps with staging for bladder cancer? what imaging for mets?

A

CT scan w/ contrast, US, and/or MRI

-evaluates upper urinary tract to see how advanced bladder cancer is

bone scan for mets

81
Q

what is T1 stage for bladder cancer?

A

tumor in wedge subepithelial connective tissue

82
Q

what is T2 stage for bladder cancer?

A

tumor in wedge muscle

83
Q

what is T3 stage for bladder cancer?

A

tumor through muscle layer of the bladder and into surrounding adipose

84
Q

what is T4 stage for bladder cancer?

A

spread beyond the adipose and into nearby organs or structures

85
Q

tx for non-muscle invasive bladder cancer?

A

Ta, T1

surgery (Endoscopic TURBT) followed by BCG tx

86
Q

when is radical cystectomy done for non-muscle invasive bladder cancer?

A

failure of intravesical therapy, bulk tumor too large to endoscopically resect, prostatic urethra involved

87
Q

what is immunotherapy and chemotherapy tx for non-muscle invasive bladder cancer?

A

intravesicle instillation (w/ urethral catheter) or BCG vaccine

88
Q

when is intravesicle instillation (w/ urethral catheter) or BCG vaccine given for non-muscle

A

2-4 weeks following endoscopic resection or biopsy

weekly BCG for 6-12 weeks

89
Q

if fail BCG or intravesicular chemo, then?

A

Mitomycin, valirubicin, doxorubicin

90
Q

tx for muscle-invasive bladder cancer?

A

T2 and greater

neoadjuvant chemotherapy before radical cystectomy (also take out lymph nodes)

91
Q

what is the neoadjuvant chemotherapy for muscle-invasive bladder cancer?

A

MVAC

  • methotrexate
  • vincristine
  • adriamycin
  • cisplatin
92
Q

what is the tx modality of choice for muscle-invasive bladder cancer?

A

radical cystectomy w/LN dissection

urinary diversion required with this tx (get urostomy)

93
Q

who is radiation therapy for bladder cancer?

A

pts that aren’t surgical candidates

94
Q

what is the tissue of origin for renal cell carcinoma (RCC)?

A

proximal renal tubular epithelium

95
Q

what decades does RCC most commonly occur?

A

5th to 6th decade

96
Q

risk factors for RCC?

A

smoking

s/p renal transplant/dialysis if develop cystic renal disease

97
Q

signs and sx’s for RCC?

A

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
Q

RCC has a frequent occurrence with what syndromes?

A

paraneoplastic syndromes

  • hypercalcemia (tumor makes PTHrP)
  • non-metastatic liver dysfunction
  • HTN
  • erythrocytosis
99
Q

RCC labs for dx?

A

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
Q

is cytology helpful for dx of RCC?

A

o Cytology not helpful with RCC unless cancer itself is in the renal pelvis and cells are being spilled off into the urine

101
Q

what is the dx imaging of choice for RCC?

A

CT w/ contrast

-it’s definitive

102
Q

when is MRI used for RCC?

A

good for staging, but superior w/assessing IVC involvement

103
Q

stage 1 of RCC?

A

tumor <7cm and tumor is confined w/in kidney parenchyma

104
Q

stage 2 of RCC?

A

tumor >7cm

-involves perinephric fat, but confined w/in fascia

105
Q

stage 3A of RCC?

A

involves main renal vein or IVC

106
Q

stage 3B of RCC?

A

involves LN

107
Q

stage 4A of RCC?

A

involves adjacent organs other than the adrenal like colon, pancreas

108
Q

stage 4B of RCC?

A

distant mets

109
Q

what is RCC resistant to?

A

chemo and radiation

110
Q

tx for localized RCC (w/in kidney)

A

T1a <4cm -> partial nephrectomy (wedge resection)

T1b-T2 -> radical nephrectomy w/regional LNectomy

111
Q

unique feature of growth of locally advanced RCC?

A

venous tumor thrombus -> IVC thrombus

112
Q

findings suspicious for IVC thrombus from RCC?

A

ANYTHING THAT MAKES YOU SUSPICIOUS FOR IVC CONGESTION

  • LE edema
  • dilated superficial abd veins
  • PE
  • right atrial mass
113
Q

tx for locally advanced RCC?

A

Radial nephrectomy, LN dissection and IVC thrombectomy (doesn’t invade wall of IVC)

114
Q

tx for locally invasive RCC?

A

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
Q

what meds are the future of disseminated (Stage 4) RCC tx?

A

Multikinase-inhibitor, VEGF (vascular endothelial growth factor) inhibitor treatment

  • Sorafenib
  • Sunitinib
  • Temsirolimus
116
Q

IL-2 tx for disseminated RCC tx is for who?

A

pts with minimal tumor burden (i.e., primary kidney tumor removed), lung or nodal metastases only, and an excellent performance status

117
Q

when do you use VEGF inhibitor tx for disseminated RCC tx?

A

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

Clin Med 3 (21 decks)

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