Recall Diplomate Written 2021 Flashcards
True of RCC
male to female 1.9:1
disease of older adults (55-75)
majority sporadic, 4-6% only sporadic
incidence has been increasing per year
Obesity and RCC
Obesity paradox: increased BMI related with lower stage of RCC
Histology with best prognosis
papillary type 1 or chromophobe>
Familial RCC which observation is an option for <3 cm tumors
HPRC Active surveillance <3cm BHD active surveillance <3cm SDHB surgical PTEN active surveillance <3 cm BAP surgical TSC surveillance surgical MiTF to be determined
Which area of the renal tumor to biopsy best?
Necrosis? Central? Peripheral?
Single most important factor for RCC
Pathologic stage (Sa choice nilagay dun pT1a)
Survival if 3.8 tumor completely excised 5 year survival
Prior experience with “elective” PN for T1a RCC demonstrated
local recurrence rates of 1% to 2%, and overall cancer-free
survival well over 90% (Campbell et al., 2009)
Adrenal which is best to determine lipid content
CT? MRI?
Adjuvant therapy for high risk disease to improve overall survival?
None? Sunitinib? - longer DFS but no diff in OS (STRAC) but no diff in OS (ASSURE) Sorafenib? - Awaiting result Everolimus (not yet complete) Axitinib no diff Pazopanib no benefit table 97.20
Tumor related with aristocholic acid exposure
UTUC
Best sensitivity for evaluation of UTUC
CT urogram
Routine adrenalectomy in RCC
Removal of the ipsilateral adrenal gland
is not routinely necessary in the absence of radiographic adrenal
enlargement or local invasion, unless the malignant lesion extensively
involves the kidney and/or is locally advanced
Routine adrenalectomy in RCC
Today, the
adrenal gland is typically spared when technically possible because removal of the adrenal gland, when not involved by tumor, has
not been shown to improve survival of patients with renal cancer.
Removal of the ipsilateral adrenal gland
is not routinely necessary in the absence of radiographic adrenal enlargement or local invasion, unless the malignant lesion extensively
involves the kidney and/or is locally advanced
Cyst may contain a few hairline thin septa and fine calcifications, or a short segment of slightly thickened calcification may be present in the wall or septa. Uniformly high-attenuation lesions <3 cm (so-called high-density cysts) are well marginated and do
not enhance with intravenous administration of a contrast agent.
What ffup is recommended?
No follow up
Best imaging to visualize bosniak II/IIF cyst?
Although CT and MRI are
comparable in most aspects, MRI can help in the evaluation of hyperdense cysts but at the expense of overestimating cyst wall thickness in smaller cysts (Bosniak, 2012).
Preferred site do insert needle in lap if with severe abdominal adhesions
The Palmer point is the preferred site when
extensive intra-abdominal adhesions are suspected (Palmer, 1974).
Acid-base abnormality in lap?
Animal and human studies have demonstrated that prolonged laparoscopic procedures may result in hypercarbia and respiratory acidosis
(Motew et al., 1973).
Acid-base abnormality in lap?
Animal and human studies have demonstrated that prolonged laparoscopic procedures may result in hypercarbia and respiratory acidosis
(Motew et al., 1973).
Earliest sign of gas embolism?
The diagnosis is usually made by the
anesthesiologist based on an abrupt increase of end-tidal CO2 accompanied by a sudden decline in oxygen saturation and then a marked decrease in end-tidal CO2 (Loris, 1994).
Earliest sign of hypercarbia?
A rise in end-tidal CO2 should prompt the anesthesiologist to adjust the respiratory rate and tidal volume to enhance CO2 elimination. Simultaneously, the surgeon should decrease the insufflation
pressure of CO2 or, if necessary, desufflate the abdomen until the hypercarbia has resolved.
Which hormones increase during lap?
question was which does not increase hay
As in other surgical procedures, several hormones (e.g., β-endorphin, cortisol, prolactin, epinephrine, norepinephrine, dopamine) have been noted to increase during laparoscopic surgery as a response to
tissue manipulation, intraoperative trauma, and postoperative pain (Cooper et al., 1982; Lefebvre et al., 1992; Lehtinen et al., 1987).
Ang sagot ata: T3 (thyroid hormone does not inc in lap_
Principal risk of injury in Hasson technique?
The principal risk with the open access is injury to underlying viscera while traversing the peritoneum.
Which ports should have closure by layers?
When bladed trocars are used, hernias can be avoided by performing a meticulous fascial suture closure of all trocar entry sites 10 mm or larger in all adults. In children, it is advisable to perform fascial closure of any “bladed” port site 5 mm or larger. The fascial layer
is usually closed with an absorbable suture as previously described.
For patients in whom only nonbladed trocars have been used, fascial closure is indicated only of midline ports 10 mm or larger (Kang et al., 2012) or any port site that has been unduly stretched.
male patients with a BMI of 25 or greater
undergoing laparoscopic surgery in the lateral position with the kidney rest elevated and the table completely flexed are at highest risk of developing this complication as a result of flank pressure
rhabdomyolysis
After left-sided retroperitoneal surgery (i.e., left
radical nephrectomy, donor nephrectomy), the patient complains of a distended abdomen. Intervention?
Usually the condition is self-limited and resolves without any intervention.
If tapped, the fluid may reveal elevations in the level of lymphocytes, cholesterol, and triglycerides.
Treatment is usually dietary, with a low-fat, medium-chain triglyceride
diet.
(chylous ascites)
As the ureteric bud divides
and branches, each new ampulla acquires a caplike condensation of mesenchyme that undergoes a mesenchymal-toepithelial
transition (see Fig. 20.45).
Metanephros
Rotation of ureter?
120? 90? does not rotate?
The kidney and renal pelvis normally rotate 90 degrees ventromedially
during ascent.
(no mention of ureters)
VUR and BBD
Spontaneous resolution of reflux is very common and facilitated
by correction of BBD.
Constipation must be recognized and eliminated first to establish optimal conditions for successful spontaneous resolution of reflux. There has been a significant shift in the paradigm for treating children with VUR, ensuring that aggressive treatment of any underlying BBD
is addressed.
VUR and antibiotic prophylaxis
Antibiotic prophylaxis appears to provide little benefit for those with grade II or lower VUR, particularly in the absence of
BBD
6 months with palpable unilateral undescended testis
surgery
non palpable testis should be examined under anesthesia
Imperative (haha ito yung term na ginamit). In short, true
PE is enough to diagnose undescended testis
No imaging needed
Which is better? 1-stage or 2-stage Fowler
2-stage Fowler
Most common site of ectopic testis
Superficial inguinal pouch
Highest risk for Wilms tumor among syndromes?
WAGR, Denys-Drash
both have 50% risk
For Wilms Tumor: Intraop, extracapsular penetration and nothing else, what is the stage and what is the plan?
Stage II
NWTS-3 (1979–1986) demonstrated that stage I and II patients
could be treated with 18 weeks of AMD and VCR without irradiation
(D’Angio et al., 1989).
For Wilms with tumor spillage, management?
Rad nephrectomy + post op radiation
A major achievement of the early trials was identification of prognostic
factors that allowed stratification of patients into high-risk and low-risk treatment groups. Patients with positive lymph nodes
and diffuse tumor spill were found to be at increased risk of abdominal relapse and therefore considered stage III and given
postoperative irradiation. One of the most important findings
was the identification of the unfavorable histologic features that
have a very adverse impact on survival.
Initial management for bilateral Wilms tumor?
Children with
bilateral tumors should not undergo initial radical nephrectomy.
These children should receive preoperative chemotherapy with the
goal of tumor shrinkage and renal-sparing surgery
Threshold for diagnosing urethritis per oil immersion field.
In light of these studies, the
current CDC guidelines recommend using a threshold of greater than or equal to 2 WBCs per oil immersion field for the diagnosis of urethritis (Frieden et al., 2015).
Man with intracellular gram negative diplococci, and allergic to cephalosporin, what can you give instead?
(g- diplococci: N. gonorrhea)
Patients in whom the use of cephalosporins is contraindicated should be
treated with azithromycin 2 g orally in a single dose plus either gemifloxacin 320 mg orally or intramuscular gentamicin 240 mg
(Kirkcaldy et al., 2014, 2016; Workowski, 2015).
Most frequently reported infectious disease in the US?
Chlamydia
Alternative treatment for Chlamydia
The recommended treatment for C. trachomatis is azithromycin 1 g orally in a single dose OR doxycycline 100 mg orally twice
daily for 7 days (Workowski, 2015; Lanjouw et al., 2016).
Alternative regimens include erythromycin base 500 mg orally four times daily
for 7 days, erythromycin ethylsuccinate 800 mg orally four times a day for 7 days, levofloxacin 500 mg orally once daily for 7 days, or
ofloxacin 300 mg orally twice a day for 7 days (Workowski, 2015).
Man with description of chancre, allergic to penicillin. What can you give instead?
Primary syphilis is
characterized by the development of an ulcer (chancre) usually
with regional lymphadenopathy. The chancre is usually painless,
single, and indurated with a clean base discharging clear serum
Doxycycline 100 mg PO bid for 14 days
Tetracycline 500 mg PO qid for 14 days
Nongonoccocal urethritis persistent despite azithromycin? What do you give?
Moxifloxacin 400 mg QD + Metronidazole 400 mg tab BID PO x 5 days
Acute pyelonephritis, term should not be used without ________.
Acute pyelonephritis is a clinical syndrome of chills, fever, and flank pain that is accompanied by bacteriuria and pyuria, a combination that is reasonably specific for an acute bacterial
infection of the kidney.
The term should not be used if flank pain is absent.
True of sterile pyuria.
Pyuria without bacteriuria or sterile pyuria, warrants further evaluation
The incidence of bacteriuria ___(increases/decreases)?__ with institutionalization
or hospitalization and concurrent conditions
Increases
True or false: CAUTI is the 3rd most common nosocomial infection?
FALSE.
CAUTIs are the most common nosocomial infection, constituting more than 80% of nosocomial UTIs
True or false:
probability of recurrent UTIs increases with the number of previous infections and decreases in inverse proportion to the elapsed
time between the first and the second infections
TRUE
True or false: The long-term effects of uncomplicated recurrent UTIs are n renal scarring, hypertension, or progressive renal azotemia
FALSE
The long-term effects of
uncomplicated recurrent UTIs are not completely known, but, so far, no association between recurrent infections and renal scarring, hypertension, or progressive renal azotemia has been established
Virulence factor found in strains causing pyelonephritis?
P (Mannose-Resistant) Pili
MOA of uromodulin as defense from UTI
Uromodulin (Tamm-Horsfall protein), saturates all the mannose-binding sites of the type 1 pili, thus potentially blocking bacterial binding to the uroplakin receptors of the urothelium
TRUE or FALSE: Diabetes increase incidence asymptomatic bacteriuria equally for men and women
FALSE
An increased incidence of asymptomatic bacteriuria and symptomatic
UTIs appears to occur in women with diabetes mellitus, but there is no substantial increase among men with diabetes
Of all patients with bacteriuria, no group compares in severity
and morbidity with those who have _______
Spinal cord injury
TRUE OR FALSE
The presence of greater than 10^5 CFU/mL of urine remains the standard for diagnosis in patients
with clinical signs and symptoms of UTI in geriatric patients.
TRUE.
The presence of greater than 105 CFU/mL of urine remains the standard for diagnosis in patients with clinical signs and symptoms of UTI. However, counts of 102
or more bacteria are clinically significant in catheterized specimens
TRUE OR FALSE.
Dizziness and
confusion, in the absence of urinary symptoms, should be attributed to a UTI.
FALSE.
Because new signs or symptoms localized to the GU tract are most important even in the geriatric population, dizziness and
confusion, in the absence of urinary symptoms, should not be attributed to a UTI.
In which groups should asymptomatic bacteriuria be untreated vs treated?
Specifically, it should not be treated in the following populations: premenopausal, non-pregnant women; women with diabetes;
older community dwellers; elderly institutionalized patients; patients with SCI; and patients with indwelling catheters.
On the
contrary, it should always be treated in pregnant women and in patients who are undergoing procedures in which transmucosal
bleeding is anticipated.
“Red-man syndrome”: flushing, fever, chills,
rash, hypotension (histaminic effect)
Vancomycin
According to the McGeer criteria for infections in long-term care facilities, for residents without an indwelling catheter and with fever and leukocytosis, which should the patient have to be diagnosed with UTI?
at least 1 of the following localizing urinary tract subcriteria
i. Acute costovertebral angle pain or tenderness
ii. Suprapubic pain
iii. Gross hematuria
iv. New or marked increase in incontinence, urgency, or frequency
Most reliable indicator of UTI
However, dysuria alone
is the most reliable indicator of UTI; when present it contributes to higher severity and bother scores compared with other typical UTI
symptoms (Dune et al., 2017).
TRUE OR FALSE.
CAUTI Is a UTI after placement
of an indwelling urinary catheter for more than 2 days
TRUE
To diagnose CAUTI, patient must have 1 symptom of UTI and ____
a urine culture with a single
organism more than 100,000 CFU/mL.
_____ has been
shown to decrease lower urinary tract complications by maintaining
low intravesical pressure and by reducing the incidence of
stones
CIC
TRUE OR FALSE.
There is no current consensus on the role of antibiotics in renal transplant patients with asymptomatic bacteriuria
TRUE
Treatment duration of UTI, particularly in the early post-transplantation
period (6 months), is usually ____ days for uncomplicated UTIs and
_____ for complicated UTIs
uncomplicated: 14d
complicated 21-28 days
Patient will undergo TURP but allergic to cephalosporins, what is the antibiotic of choice?
TMP SMX, Single dose
Antimicrobial prophylaxis for laparoscopic adrenalectomy?
Cefazolin single dose
For those patients who will undergo urodynamic testing, what should be done prior?
The statement recommends that all patients be
screened for symptoms of UTI and undergo dipstick urinalysis
Which patients who will undergo ESWL have to be given pre-op antibiotics?
a history of a recent UTI or of infection stones
should warrant a full treatment course of antimicrobial agents
before shock-wave lithotripsy
53 yo male with description of epididymitis, what is the most common organism
the most common was Escherichia (56%).
Most common site if GUTB
Eighty percent of GU TB occurs in the kidney
Which hormone is mostly associated with spermatogenesis?
Because spermatogenesis is highly dependent on intratesticular
testosterone synthesis, it is unsurprising that hypoandrogenism is
associated with male infertility
Male with azoospermia with bilaterally small testes and elevated gonadotropin levels
Klinefelter syndrome (47XXX)
>most common genetic cause of male infertility
> testis biopsy is not indicated
ICSI facts
> Subsequent studies confirmed these initial observations and
demonstrated that ICSI was equally effective with sperm from either
testicular or epididymal origin
Low testosterone, small testes, high FSH
hypergonadotropic hypogonadism
_______remains the gold standard for testis biopsy because it provides an optimal
amount of tissue for accurate diagnosis and retrieval of sperm for IVF
open testis biopsy
priapism from trauma
Nonischemic priapism is a persistent erection caused by unregulated
cavernous arterial inflow. Typically, the corpora are tumescent
but not rigid and the penis is not painful. A history of blunt
trauma to the perineum or an iatrogenic needle injury is common.
Hours of persistent erection to diagnose priapism
Once an erection persists beyond 4 hours and is not relieved by
orgasm or pharmacologic reversal, the pathophysiologic phenomena
of ischemic priapism have begun.
Major risk factor for ischemic priapism
Sickle cell disease
Hematologic dyscrasias are a major risk factor for ischemic
priapism (Box 70.1). Priapism has been described as a complication
of SCD, thalassemia, hereditary spherocytosis, paroxysmal
nocturnal hemoglobinuria, glucose-6-phosphate dehydrogenase
deficiency, glucose-6-phosphate isomerase deficiency, and congenital
dyserythropoietic anemia
Antihypertensives that cause priapism
Hydralazine, guanethidine, propranolol
TRUE OR FALSE relative
risk for GCT falls to 2 to 3 if orchidopexy is performed before puberty
TRUE
TRUE OR FALSE
Only cryptorchid testis is at risk for GCT.
FALSE
metaanalysis
of cryptorchidism studies reported that the contralateral
descended testis is also at slightly increased risk
Which tumors arise from GCNIS, which do not?
Any post pubertal invasive GCT arise from GCNIS except spermatocytic tumor
Which tumors arise from GCNIS, which do not?
Any post pubertal invasive GCT arise from GCNIS except spermatocytic tumor
If histopath is seminoma but has increased AFP in markers
Patients with pure seminoma in the primary tumor with an elevated serum AFP are considered
to have NSGCT.
If histopath is seminoma but has increased AFP in markers
Patients with pure seminoma in the primary tumor with an elevated serum AFP are considered
to have NSGCT.
Left sided testicular tumor drains to ____
Paraaortic LN
Quadrivalent vaccine for HPV
the quadrivalent HPV 16/18/6/11 vaccine
Gardasil
in penile Ca what structure acts as a temporary natural barrier to local extension
of the tumor, protecting the corporeal bodies from invasion.
Buck fascia
Penetration of Buck fascia and the tunica albuginea permits invasion
of the vascular corpora and establishes the potential for vascular
dissemination.
In ILND, which are superficial and which are pelvic nodes?
The superficial nodes drain to the deep inguinal
nodes (those deep to the fascia lata).
From there, drainage is to the pelvic nodes (external iliac, internal iliac, and obturator
Most sensitive and specific in penile ca to assess corporal invasion.
Palpation
The respective positive predictive value, sensitivity, and
specificity for the study were as follows—physical examination: 100%,
86%, 100%; ultrasound examination: 67%, 57%, 91%; and MRI:
75%, 100%, 91%.
Most sensitive and specific in penile ca to assess corporal invasion.
Palpation
The respective positive predictive value, sensitivity, and
specificity for the study were as follows—physical examination: 100%,
86%, 100%; ultrasound examination: 67%, 57%, 91%; and MRI:
75%, 100%, 91%.
Penile ca with No palpable, nodes, what is the best imaging
On the basis of these data the authors concluded that CT
and lymphangiography offer no useful additional information
over physical examination, especially in patients with no palpable
adenopathy.
Examples of organ preservation techniques in penile ca
Such approaches include topical treatments (5-fluorouracil
or imiquimod cream for Tis only), radiation therapy, Mohs surgery,
limited excision strategies, and laser ablation
Signs of urine leak in imaging
urine leak can be
evident as a fluid leak from the wound, wound dehiscence, scrotal
swelling, and/or pelvic or abdominal pain. US or non-enhanced CT
scan can establish the diagnosis of fluid collection.
Post transplant patient with hydronephrosis of transpanted kidney
The priority in the management of ureteral obstruction is to
decompress the collecting system and allow the allograft to recover.
Nephrostomy, nephroureteral stent, antegrade stent, or retrograde
stent placement can be used.
Post transplant patient with hydronephrosis of transpanted kidney
The priority in the management of ureteral obstruction is to
decompress the collecting system and allow the allograft to recover.
Nephrostomy, nephroureteral stent, antegrade stent, or retrograde stent placement can be used.
When to repeat imaging after grade III injury non-operative management?
No need to repeat without symptoms
Signs of major renal injury on CT
Findings on CT that raise suspicion for major injury are (1) medial hematoma, suggesting vascular injury;
(2) medial urinary extravasation, suggesting renal pelvis or ureteropelvic junction avulsion injury;
(3) global lack of contrast enhancement of the parenchyma, suggesting renal artery occlusion; and
(4) the combination of two or more of the following: large hematoma greater than 3.5 cm, medial renal laceration, and vascular contrast
extravasation (suggesting brisk active bleeding), which constitute an AAST grade IVb injury
Large hematomas may extend over the aorta and obscure the landmarks for the planned initial retroperitoneal incision, what is the appropriate incision?
By making the retroperitoneal incision just medial to the inferior mesenteric vein and dissecting through the hematoma, the anterior surface of the aorta can be
identified and followed superiorly to the crossing left renal vein.
Most common cause of penetrating ureteral injury?
In addition, penetrating stab and gunshot wounds and external injury from highspeed blunt mechanisms contribute to the overall incidence; 95%
are penetrating and 5% are blunt injuries.
BUT ang choices are:
gunshot, stab, colorectal surgery, vascular surgery
Most commonly associated with hematuria?
ESWL URS etcz?
Common cause of ureteroscsopic injury?
One factor associated with ureteral injury during ureteroscopy was continued stone basket attempts after recognition of a ureteral tear.
Doing URS, intraop for an impacted stone, suddenly cannot visualize what do u do?
Current recommendations are to stop the procedure and place a ureteral stent when ureteral perforations are identified
Post renal transplant, thermal injury to 3 cm from the UPJ which is the best way to repair the ureter
Ureteral avulsion from the renal pelvis, or even very proximal ureter, can be managed by reimplantation of the ureter directly into the renal pelvis
Post renal transplant, you ligated 5 cm from the UVJ which is best to repair the ureter?
Ureteroneocystostomy is used to repair distal
ureteral injuries that occur so close to the bladder that the bladder does not need to be brought up to the ureteral stump with a psoas hitch or Boari procedure.
Principles of ureter repair
- Mobilize the injured ureter carefully, sparing the adventitia widely, so as not to devascularize the ureter further.
- Debride the ureter minimally but judiciously until edges bleed, especially in high-velocity gunshot wounds.
- Repair ureters with spatulated, tension-free, stented watertight anastomosis, using fine absorbable sutures and
retroperitoneal drainage afterward. - Retroperitonealize the ureteral repair by closing peritoneum over it if possible.
- Do not tunnel ureteroneocystostomies but rather create a widely
spatulated nontunneled anastomosis. - With severely injured ureters, blast effect, concomitant vascular surgery, and other complex cases, consider omental interposition
to isolate the repair when possible. - If immediate repair is not possible, or the patient hemodynamically
unstable, one management option is to ligate the ureter with long silk or polypropylene suture, and plan to repair it later, or place a nephrostomy tube after ICU resuscitation (damage control).
The other option is a temporary cutaneous ureterostomy over a
single-J stent or pediatric feeding tube with a suture tied around the ureter proximal to the injury site, in order to secure the stent in place, and to prevent urinary leakage.
Factor important in uric acid and calcium formation
At low urine pH (<5.5), the undissociated form of uric acid predominates, leading to uric acid and/or calcium stone formation; Urine pH is a critical factor in determining uric acid solubility;
Metabolic problems in distal RTA
The most common stone composition associated with distal RTA is calcium phosphate as a result of hypercalciuria, hypocitraturia, and increased urinary pH
Main determinants of uric acid formation
The three main determinants of uric acid stone formation are low pH, low urine volume, and hyperuricosuria
The most important pathogenetic factor is low urine pH because most
patients with uric acid stones have normal uric acid excretion but invariably demonstrate persistent low urine pH
Stones due to a metabolic disorder
Xanthine and Dihydroxyadenine Stones
Radiolucent stone
Xanthine and DHA stones are highly insoluble and
completely radiolucent, often resulting in them being mistaken for
uric acid stones.
Stone in laxative abuse
Ammonium urate stones are radiolucent and occur in patients with chronic diarrhea, inflammatory bowel disease, ileostomy bowel diversions, laxative abuse, recurrent urinary tract infection, and recurrent uric acid stone formation
Best diagnostic imaging for stones
Noncontrast computed tomography (CT) imaging is the gold
standard in terms of diagnostic accuracy for stones, with a reported
sensitivity of 98% and a specificity of 97%
Hexagonal stones
Cystine
2 step question
Coffin-lid stone,
what is the tx?
MAP (struvite)
AHA
Best practice after stone before metabolic evaluation
Stone analysis may improve the accuracy of further
evaluation.
perhaps the most important risk factor for kidney stone formation.
Low urine volume
Antihypertensive used for prevention of urinary lithiasis
Captopril
table 92.5
Drug of choice in cystinuria (described scenario with hexagonal crystals)
α-mercaptopropionylglycine (Tiopronin) is possibly more effective than D-penicillamine and is associated with fewer adverse effects, making it the thiol drug of choice in patients with cystinuria
Stone most likely to cause ESRD
choices: calcium oxalate, brushite, cystine
Can’t find the answer yet
Procedure that is mostly associated with hematuria?
ESWL? URS?
Treatment of choice for 1.5 cm stone in horseshoe kidney kid
In general, stones smaller
than 15 mm and not situated in the lower pole can be approached with SWL or URS. Stones that fail treatment with SWL or URS and stones larger than 15 mm should be considered for PCNL. Based on numerous reports, stone clearance and complications
in horseshoe kidneys appear to be no different than for PCNL on orthotopic kidneys.
Asymptomatic stone in solitary kidney
Because only one kidney exists or is functioning, a single, obstructing stone leads to total urinary obstruction and demands urgent attention. It is for this reason that proactive
treatment of asymptomatic stones, which may otherwise be observed when two functioning kidneys exist, is recommended
in solitary kidneys.
In URS what is the modality of choice
For patients with imperative indications to remain on antiplatelet therapy (e.g., recent coronary artery stenting) or anticoagulant
agents (e.g., high-risk atrial fibrillation, venous
thromboembolic disease, or mechanical cardiac valves), URS withholmium:yttrium-aluminum-garnet (Ho:YAG) laser lithotripsy is the treatment modality of choice
Most common stone in urinary diversion (ileum and colon)
CaPO4, MAP
both in choices?
Most common composition of urethral calculi
First, the composition of these migratory calculi
has been predominantly calcium oxalate (85%–90%), which is akin to those found in the upper tracts
Purpose of ramping up
benefit of “ramping up”
the energy of the lithotripter by not only improving stone fragmentation
but also decreasing renal injury effects
Intraop during shockwave, you encounter sinus arrhythmia, what do you do next?
Early clinical studies noted that shock waves could induce a cardiac arrhythmia, an observation that led to electrocardiographic
synchronization with R-wave triggering on the Dornier HM3 device. However, later clinical studies with non–water bath lithotripters have concluded that SWL is safe to the
electrophysiology of the heart and gating to the cardiac rhythm is unnecessary.
Choices were:
Continue ESWL
Decrease frequency and observe
Terminate procedure
These smaller diameter access procedures in PCNL have been reported to be associated with
longer operative times
blood loss and transfusion rates with mini-PCNL are lower compared with those with standard PCNL
Best time to do elective URS in pregnancy
A pregnant patient should never be denied indicated surgery,
regardless of trimester.
Elective surgery should be postponed until after delivery.
If possible, nonurgent surgery should be performed in the
second trimester when preterm contractions and spontaneous abortion are least likely.
Contraindications for PCNL
identify patients with an absolute contraindication to PCNL, such as uncorrected coagulopathy, as
well as those with an active, untreated urinary tract infection
Proximal, non invasive low grade UTUC < 1 cm in a patient with urinary diversion, management
Tumors of the upper urinary tract can be approached in a
retrograde or antegrade fashion. The approach chosen depends
largely on the tumor location and size. In general, a retrograde ureteroscopic approach is used for low-volume ureteral and renal tumors.
An antegrade percutaneous approach is preferred for larger tumors of the upper ureter or kidney and for those that cannot be adequately manipulated in a retrograde approach because of location (e.g., lower pole calyx) or previous urinary diversion.
Muscarinic receptor involved in detrusor contraction
Although ligand receptor
binding studies revealed that M2 receptors predominate, M3 receptors mediate cholinergic contractions
1st reaction of detrusor in BOO
BOO, such as that in patients often produces detrusor hypertrophy and DO
(choices were: hypertrophy, hyperplasia)
Spinal cord injury in pons what is the expected neurogenic dysfunction
The PMC is involved in suprapsinal coordination of
micturition and is located in the pons. In another study of 39 patients the primary
complaints were nocturnal frequency and voiding difficulty in 6, urinary retention in 8, and urinary incontinence in 3.
Detrusor overactivity was found in 8 of the 11 symptomatic patients who underwent urodynamic evaluation, and
low compliance was found in 1 patient
CVA patient pattern of voiding
Detrusor overactivity, normal compliance, smooth and striated sphincter synergy
CVA patient pattern of voiding
Detrusor overactivity, normal compliance, smooth and striated sphincter synergy
PFMT effect (what was asked was early effect)
In women, it is postulated that a PFM contraction may raise
the urethra and press it toward the symphysis pubis, prevent urethral descent, and improve structural support of the pelvic organs (Berghmans et al., 1998).
PFMT may result in hypertrophy of the striated muscles, thus increasing the external mechanical pressure on the urethra. Intensive PFMT is also hypothesized to
reinforce structural support of the bladder neck in women, limiting its downward movement during increases in abdominal pressure
(Bø, 1995, 2004).
Which is recommended as part of initial management of women with incontinence?
The ICS recommends
both a 3-day bladder diary and pad weight test as proper measures for symptom quantification in incontinence research.
The 5th ICI Committee on initial assessment did not recommend pad tests as part of the initial evaluation in the incontinent patient
Best way to assess PVR
This simple test, which can be performed via in-and-out catheterization or using noninvasive transabdominal
ultrasonography, evaluates the bladder’s emptying ability and can be helpful in the diagnosis of overflow incontinence.
Procedure of choice for surgical correction of female SUI
Suburethral slings are currently considered the procedure of choice
for the surgical correction of female stress urinary incontinence (SUI).
Effect of adding bladder training to antimuscarinics in treatment of incontinence
They also found insufficient
evidence to draw conclusions on the comparative effectiveness
of BT and current drug therapy, or for their combined effectiveness
for women with detrusor overactivity or urgency UI.
Effect of adding bladder training to antimuscarinics in treatment of incontinence
They also found insufficient
evidence to draw conclusions on the comparative effectiveness
of BT and current drug therapy, or for their combined effectiveness
for women with detrusor overactivity or urgency UI.
