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.
