Nephrolithiasis, bladder cancer, renal cell carcinoma Flashcards
What is Kidney stone Etiology?
- Stone formation occurs when normally soluble material (Ca, PO4, uric acid) supersaturates the urine and begins the process of crystal formation.
- It is not clear how crystals formed in the tubules become a stone, rather than being washed away by the high rate of urine flow.
- It is presumed that crystal aggregates become large enough to be anchored ( usually at the end of the collecting ducts), and then slowly increase in size over time.
What are types of Nephrolithiasis?
-60-80% calcium stones (Ca oxalate > Ca phosphate) -15% struvite (magnesium ammonium phosphate) -5% uric acid (radiolucent stones) -1-3% cystine -The same patient may have more than one type of stone concurrently (e.g.. calcium and uric acid).
What is the Epidemiology of Nephrolithiasis?
- Prevalence 2-3% in general population
- Estimated lifetime risk about 12% for men 5% for women
- Approximately 50% of patient with previous urinary calculi have recurrence within 10 years.
- The rate of urolithiasis increases with age, is higher in men compared to women, and caucasians compared to other races
- It has been estimated that 7-10 of every 1,000 hospital admission are due to stones.
What are the Risk Factors of calcium stones?
- History of prior calcium urolithiasis
- Family history of urolithiasis
- Diet
- Medications
- Hyperparathyroidism
- Hypercalcemia of malignancy
- Sarcoidosis
- Medullary sponge kidney
What are the Risk Factors of Nephrolithiasis?
- Uric acid lithiasis = radiolucent
- Struvite stones
- Cystine stones
Clinical presentation of Nephrolithiasis?
- Renal colic begins suddenly
- Severe unilateral flank pain– radiating to groin/testicle/labia (T10-S4 dermatome)
- Pacing, Rocking, Writhing, Constant movement unable to find position of comfort (contrast to peritonitis)
- Frequently with nausea, vomiting, diaphoresis
- Tachycardia, Hypertension
- Gross hematuria and dysuria/frequency/urgency
- May have CVAT but abdomen is unremarkable
- Testicles are not tender or swollen
What is the diagnosis of Ureteral colic?
-Focused history with RF assessment (family history of calculi, duration and evaluation of symptoms)
-Clinical presentation w/ Physical Exam
-Urinalysis
-CBC
-BMP
-Radiologic tests
(KUB, IVP, US, NCCT scan)
What is an ultrasound?
- Sensitivity19%, specificity 97%
- Accessible
- Good for diagnosis of hydronephrosis and renal stones
- Poor visualization of ureteral stone unless at UPJ or UVJ
- Detects indirect signs of obstruction: collecting system dilatation (hydroureter), a loss of a ureteric jet
- Difficulty in measuring the size of a stone
- Procedure of choice for patients who should avoid radiation, including children, pregnant women and woman in childbearing age.
What is KUB?
- Sensitivity 45-59% Specificity 71-77%
- Accessible and inexpensive.
- May be sufficient to document the size and location of radiopaque (59%) urinary calculi ( Ca oxalate, Ca phosphate), but radiolucent stones such as pure Uric acid, pure Cystine, Indinavir, pure matrix
- Unfortunately stones are frequently obscured by stool or bowel gas, ureteral stones overlying the bony pelvis or transverse processes of vertebrae .
- Furthermore, non-urologic radio-opacities, such as calcified mesenteric lymph nodes, gallstones, stool and phleboliths may be misinterpreted as stones.
What is Ivp study?
- Sensitivity 64-87% Specificity 92-94%
- Relatively safe despite the need for contrast (If CT is unavailable)
- Provides information about the stone (size, location, radiodensity) and degree of obstruction.
- Serum Cr must be measured before the test
- Nephrotoxic effect is minimized by adequate hydration, minimum amount of contrast material used.
- Poor visualization of non-genitourinary structures
What is Noncontrast helical ct?
- Fast, accurate, and readily identifies all stone types in all location (pure matrix stones and Indinavir stones not seen)
- Sensitivity 95-100% , Specificity 94-96%
- Expensive
- CT should not be used as a first line test with pregnant/child/suspicion of gynecologic etiology
- Findings consistent with calculi on CT
What is >5mm management?
- Open nephrostomy
- Percutaneous nephrostolithotomy
- Ureteroscopy
- Extracorporeal shock wave lithotripsy
What is Staghorn calculi?
Upper urinary tract stones involve the renal pelvis and extend into at least 2 calyces
What is the Work up for recurrent stones?
- calcium stones
- Uric acid
- Cystine
- Struvite
What is the Pathology of Bladder cancer?
Transitional cell carcinoma
What is the Epidemiology of Bladder cancer?
- 90% >55yo
- Men have more incidence of bladder cancer than women
- Cancers are more common in caucasian – 2:1.
What is the Risk factors
of Bladder cancer?
Occupational exposures**
Signs and symptoms of Bladder cancer?
- Painless Hematuria (80-90%)
- Urinary voiding symptoms(LUTS)(20-30%)
- Symptoms of advanced disease
What is the Work up of Bladder cancer?
-Urinalysis
-Cystoscopy
(Diagnostic standard w/ bx)
-CT scan w/ contrast, U/S and/or MRI
What is the Tnm staging?
- T1 Tumor in wedge subepithelial connective tissue
- T2 Tumor in wedge muscle
- T3: through the muscle layer of the bladder and into surrounding adipose
- T4: spread beyond the adipose and into nearby organs or structures
What is the Prognosis of bladder cancer?
- Overall 10 yr survival is 70%
- Lesions up to T1, especially TA, have 95% survival rate
- Muscle invasive carcinoma 5-year survival rates are 70%
- Regional lymph node involvement 5-year survival rate is 35% and distant mets 5%
What is Treatment for bladder cancer?
-Muscle invasive versus non-muscle invasive treatment modalities
-Non-muscle invasive disease
-Surgery (Endoscopic TURBT, Radical cystectomy)
-Immunotherapy and chemotherapy
(Intravesicle instillation)
What is Renal cell carcinoma?
- the proximal renal tubular epithelium
- 90-95% of all renal cancers
What are the Signs and symptoms of Renal cell carcinoma?
- Hematuria
- CLASSIC TRIAD flank pain, hematuria, flank mass
- Frequent occurrence w/ paraneoplastic syndromes
What’s the diagnosis of of Renal cell carcinoma?
-Labs
(Anemia/Erythrocytosis, CMP, Hematuria. Elevated ESR
-Imaging
(Ultrasound, CT w/ contrast. MRI. Bone scan, PET Scan)
What is the Rcc staging?
-Stage I:—Tumor is confined within the kidney parenchyma (no involvement of perinephric fat, renal vein, or regional lymph nodes).
Ia: <4cm
Ib: 4-7cm
-Stage II:—Tumor (>7cm) involves the perinephric fat but is confined within Gerota’s fascia (including the adrenal).
-Stage IIIA:—Tumor involves the main renal vein or inferior vena cava
-Stage IIIB:—Tumor involves regional lymph nodes
-Stage IIIC:—Tumor involves both local vessels and regional lymph nodes.
-Stage IVA:—Tumor involves adjacent organs other than the adrenal (colon, pancreas, etc).
-Stage IVB:—Distant metastases
What’s Rcc prognosis?
-Tumor size (>10cm 0% @5yr, 5-10cm 50%, <5cm 84%) -Multiple lymph node involvement dire prognostic sign -Overall stage survival (1 yr vs 5 yr) Stage 1 : 91-100% (81%) Stage 2 : 74-96% (74%) Stage 3 : 59-70% (53%) Stage 4 : 16-32% (8%)
Whats Rcc treatment?
-Localized disease(w/in kidney) (T1a <4cm partial nephrectomy, T1b-T2 radical nephrectomy) -Locally invasive RCC -Disseminated Disease -Locally advanced disease
