SASP 2012 2 Flashcards
mech for low urine ph in idiopathic stone formers
insulin resistance. Ammonia production/ excretion results in unbuffered h+ –> acid urine
insulin role in kidney
insulin stimulates amoniagenisis in proximal renal tubule
dent’s disease
x linked recessive nephrolithiasis. Hypercalciuria, nephrocalcinosis, stones, proteinurina, progressive renal failure, +/- rickets
std vs extended LN dissection @ radical cystectomy
standard - bifrucation of common illiac artery. Extended = IMA
enterovesical fistula causes -3
dverticulitis, regional enteritis, sigmoid ca
pneumaturia
60% in diabetics. Get ua/ ucx first
class for temsirolimus
mTOR (involved in growth/ proliferation of cells)
who benefits from temsirolimus
3 or more of poor risk factors: 1. LDH> 1.5x nl, 2. HBG below nl, 3. serum ca >10, 4. dx of rcc to tx > 1 yr, 5. multiple organ mets, 6. karnovsky of 60-70
multiple system atrophy findings
open bladder neck at rest in uds is most telling in a male. MSA often assd w ED. No ED, include parkinsons in ddx
multiple system atrophy eponym
shy-drager
etoposide and platinum long term AE
cardiovascular toxicity and econdary malignancy. Also in radiation
renal bloodlfow is autoregulate by
afferent glomerular artiolar resistance.
distal tubuloglomerular feedback
Changes in rate of fluid flow in the distal tubule elicit changes in afferent glomerular arteriolar resistance. Happens in innervated and denervated kidneys
idiopathic ca oxalate stone formers and randalls plaques
in IDIOPATHIC stone formers - ca phos crystals form in BM of think loop of henle. Plaques progress into interstitum and vasa recta then erode through papillary surface and provide anchored site for ca ox stones. Different mech for other stone types
repeat biopsy of previously negative elevated psa
rebiopsy with anterior apical horn bx - 30-50%. Similar yield to saturation biopsy
what exactly is in sipuleucel-T
autologous peripheral blood mononuclear cells with APC’s activated ex vivo with proteins c/o prostatic acid phosphatase fused to GMCSF
sipuleucel-T premedication
tylenol and benadryl
calcium reabsorbtion induced by PTH and vit D happens in X in kidney
distal tubule. Also happens in prox tubule, but not under hormonal influence
bone scan delayed radiotracer in kidney
get functional imaging to r/o obstruction
Penile cancer Ta, T1a, T1b, T2, T3
Ta - noninvasive veruccous ca, T1a - subepithelial connective tissue, no LVI not poorly differentiated, T1b - invades SECT + LVI or poorly differentiated, T2 - inv corpus vacernosum or spongiosum, T3 - inv urethra
penile ca cN1-3
N0 - no nodes, N1 -mobile unilateral ing LN, N2 - mobile multiple or bilateral ing NL, N3 - fixed in LN or pelvic LN uni or bilateral
idiopathic DO
random episodes of incontenence. CMG fails to ID involuntary bladder contraction in 50% w/ clinical urge incont.
increased stone formation during pregnancy
absorbtive hypercalciuria 2/2 placental production of 1,25-vit D. increased intestinal absorbtion of ca and pth supression. (unrelated) inc citrate and GAG excreation (inhibit stones)–> No change in stone risk
ECOG score
0 - fully active, no restriction, 1 - no strenuous activity (light housework only) ,2 - no work activities, out of bed > 50%, 3 - limited self care and bed> 50%
factors for increased leakage in neobladder
short functional urethral length, non nerve sparing, decreased membranous urethral sensation, increased time after diversion.
persistent hyperoxaluria after low oxalate diet - tx
pyridoxine (b6), cofactor in AGT (glyoxylate –> glycine). Otherwise glyoxalate –> oxalate via LDH
interferon and BCG?
interferon does not help outcome. Give standard RDA vitamins
mcrpc with docetaxel failure - next agent
carbazitaxel. Others with survival benefit - abiraterone, sipuleucel-T
renal insufficiency from atherosclerotic renal artery dz - most important prognostic factor
89% with serum cr < 3 will have improvement.
when is renal biopsy helpful in renal vascular htn
if cr > 4
most accurate way to determine length of graft in urethroplasty
ultrasound identifies length of stricture and scarred spongiosal tissue.
post transplant lymphoproliferative EBV + mass in kidney -tx?
reduce or stop immunosupression
antimuscarinic an DLPP
does not decrease DLPP in NGB
who gets ammonium acid urate stones
chronic diarrhea & history of laxative abuse; or ileal resecion or large colectomy. Pts have low sodium excretion
pH for uric acid stone
<5.5
what helps platelet dysfunction in ESRD
desmopressin, cryoprecipitate, conjugated estrogens, erythropoietin, dialysis
neuroblastoma in children age
50% present < 2 yo.
neuroblastoma feels like and assd sx
large, hard, fixed. Catecholamine release
wilms masses feel like
smooth, not fixed
most common renal tumor in kids < 6 mo
congenital mesoblastic nephroma
cirsoid AV fistula. What is it
congenital, complex fistula.
cirsoid AV fistula tx and who to tx
nephrectomy. Embolization not possible - coil migration. Tx HTN, cardiomegaly, ht failure, hematuria, lesion expansion
SCC of head, neck, or lung and kidney stones
production of PTHRP causes ectopic hyperparathyroidism and absorbtive hypercalciuria.
prostate utricle is analagous to X in females
distal 1/3 of vagina. PU enlarged due to lack of androgen action prox hypospadius
where is cowpers duct cyst confined to
bulbous and prostatic urethra
one kidney one clip - where does htn come from
volume and sodium excess
one kidney one clip - tx
diuretic
2 risk factors for malignancy in pheo
tumor > 5 cm, extra-adrenal tumor
mitotane use
palliation in metastatic adrenal cortical carcinoma
metyrapone and aminogluthamide use
ameliorate hormonal production in metastatic adrenal cortical carcinoma
metastatic pheo chemo agents
cyclophosphamide, vincristine, dacarbazine
why not treat asymptomatic e coli
asymptomatic assd with self agglutinating ecoli that have lost their o-polysaccharide surface antigen. Treatment is followed by new e coli with intact O surface antigen leading to acute sx
spinal shock definition
supression of somatic and autonomic activity below level of injury. Lasts 6-12 wks
spinal shock to T8 - 3 findings
Detrussor overactivity, smooth sphincter synergia (T8 is below sympathetic outflow), absent guarding reflex
initial management of cystinuria
hydration, +/- alkali therapy
Cystine pH for dissolving
> 7.5 (ca phos stones may happen)
cystine stone medications (3)
d-penicillamine (lots of side effects), alpha-mercaptopurine (Thiola). Captopril is last line if cant tolerate other meds
Pediatric postinfectious glomerulonephritis. Timeframe and sx
preceeded by pharyngeal or skin strep 7-21 days earlier. Painless gross hematuria, mild proteinuria, edema, htn.
what is acetohydroxamic acid
urease inhibitor for management of infected stones
post infectious glomerulonephritis tx/prognosis
excellent, supportive
post infectious glomerulonephritis labs
low C3, streptozyme test positive
what is natural cycle artificial insemination
allowing woman to ovulate without meds.
male infertility and natural cycle insemination
no better than timed vaginal intercourse.
when is IUI useful (3)
mechanical problems (hypospadius, retrograde ejaculation, impotence). Preg rate improved with ovulation induction if abn semen parameters.
when is natural cycle IUI useful
pure cervical factor infertility
tubal abnormality best assisted reproductive technique
IVF. (inseminated sperm otherwise need to ascend fallopian tubes)
PUV voiding dysfunction and incontinence mgmt
if high urine output, will see hydro, nocturnal drainage will help. Otherwise try timed voiding before uds test. Don’t give oxybutinin - can cause retention due to kyogenic dysfunction.
geriatric UTI - low CFU
in previously asymptomatic, treat for 7 days with abx
stone in mid-proximal ureter and pain type
flank pain radiationg anteriorly
stone in distal ureter and pain type
irritative voiding sx or pain radiating to penis, scrotum, labia.
first line in kid with urinary frequency
timed voiding, voiding diary
benefit of transurethral incision of prostate
maintain antegrade ejaculation. 1 incision 5%, 2 incisions 15%
retrograde ejacualtion % after turp, laser vaporization
95%. Same for laser
primary source of radiation @ flouro
scatter from patient.
2 ways to minimize radition exposure during flouro
maximize distance form patient, primary beam under patient
2 known defects in primary enuresis
- reduced functional bladder capacity, 2. mild OAB, 3. elevated arousal threshold while sleeping
how to use nocturnal enuresis alarm. Timeframe, % success
parent has to make sure kid gets up. Takes 3-4 months. 80% success
DESD implies location of lesion where
between pons and lower spinal cord
skin graft of choice for large volume scrotal skin loss and pro/con
split thickness. Pro’s: high success rate, can cover large area, mimmic rugated appearance of scrotum. Cons: lack of hair, may retract.
how to minimize split thickeness skin graft
avoid expansion of graft - 2:1 or 3:1. do not place in acute injury site (bacteria)
thigh pouch and scortal injury
temporizing, except in debilitated patients.
why are child kidneys more suseptible to trauma than adult - 4
more pliable thoracic cage, weaker abdominal muscles, less perirenal fat, lower position in abdomen
when to image suspected renal injury in adults/kids
- significant deceleration or high velocity injury (fall > 15 ft, hi speed MVC, significant abdominal blow), 2. trauma resulting in fx rib cage or spine, 3. gross hematuria, 4. micro hematuria assd w shock (SBP <90))
what sacral foramen does interstim lead go to
S3.
sign of correct interstim lead placement
bellows reflex (contraction of perineal area) and plantar flexion of ipsilateral great tow
sign of interstim placed 1 foramen too high
S2. plantar flexion and rotation of foor with sensation in buttock
postobstructive diuresis and persistent elevated cr- mgmt?
renal us to r/o upper tract obstruction
hemihypertrophy in kid - genetic abnormality and mgmt
WTR1 or WTR2. renal us q 3 mo
time to sperm after vasoepididymostomy
3-15 months, mean 6.
ultimate sperm count after VE and timing
sperm count and motility similar if sperm @ 6 mo or delayed
deciding factor for doing VE
presence of sperm in epididymal fluid
test to identify ectopic ureter
T2 MRI as good as MRU for fluid filled structures
testiclular lymphoma - age, types, us presentation
possible multiple lesions on us, most common testis tumor > 50 yo, all lymphoma types possible but diffuse hystiocytic most common.
penoscrotal hypospadius, nonpalpable testis - test
first - r/o CAH with 17 oh progesterone level. Tx dehydration/salt loss if CAH ASAP
reason for OCP and decreased libido
decreased testosterone
OCP effects
increased SHBG by liver, this lowers testosterone (irreversible binding). Estrogen may decrease and progesterone may increase (no effect on libido)
rb mutation in bladder cancer correlated with
found in 30%. Sddociated with higher stage at dx and decreased patient survival.
chromosomal analysis and bladder cnacer outcome
low grade are diploid, triploid and tetraploid have poorer prognosis.
best prdictor of post turbt recurrence in well-moderate differentiated
post turbt cysto @ 3 mo - if negative have an 80% chance of no further recurrence
urinary concentration results from x in kidney
hypertonic medullary interstitial fluid - causes water to diffuse out of collecting ducts then to medullary blood vessels. High adh levels - more concentrated, low adh - more dilute
3 ct findings suggestive of vesicoenteric fistula
- bladder wall thickening, 2. air in the bladder, 3. colonic diverticula
rate of definitive dx for VE fistula on cysto
35-46%
conervative management of poor risk patient with VE fistula
long term abx
AFP elevated in seminoma means
indicative of nonseminomatous tumor
nonseminomatiou tumor with retroperitoneal LN tx
3 cycles cysplatin based chemo - BEP
4 yo w nonacute phymosis - tx
seroid cream -90% success
4 yo w phymosis - who gets circ
severe blanitis, obstructive voiding sx
PDE5I and alpha blocker - precautions (2)
start PDE5 or alpha -x at lowest recommended dose. Don’t take at the same time
nelson’s syndrome - what Is it
10-20% s/p bilateral adrenalectomy for cyshings develop pituitary chromophobe adenoma
nelsons synd - sx
hyperpigmentation, headaches. Visual disturbances (growing tumor)
how to avid vesicostomy prolapse
place stoma at bladder dome- this immobilizes posterior wall of bladder
hypercoagulability seen in what type of ESRD and why
nephrotic. Loss of antithrombin 3, protein c and protein s
general cause of hypercoagulability in esrd
hyperhomocysteinemia
2 most common complication of intravesical mitomycin c
contact dermatitis rash (9%), chemical cystitis 6-41%
ddavp@ surg for outpatinet hypospadius - fluids and postop
ns, drink thirst postop
testosterone replacement in postprostatectomy w undetectable psa
after “prudent interval.” informed consent with patient. “close followup”
old, decrepid with 6 mm HG ureteral tumor mgmt
urs/ ablation. Avoid major abd surgery
stepwise diagnosis of SUI - 3?
- cough with pelvic exam, 2. full bladder supine stress test, 3. uds to deliniate leakage.
post ebrt neobladder - considerations
ok if ureter, urethra, bowel not affected by RT. higher risk of incontinance
primary hyper pth - how to finalize diagnosis if equivocal
thiazide challenge differentiates renal hypercalciuria (s ca and pth should remain nl and urinary ca returns to nl) from primary hyper pth (become overtly hypercalcemic and s pth become elevated without change in u ca
resorbtive hypercalciuria aka
primary hyperparathyroidism
primary hyperparathyroidism - s ca, PTH, fasting urinary ca, intestinal ca absorbtion, tx
s ca HI, PTH HI, fasting urinary ca HI, intestinal ca absorbtion HI, tx parathyroidectomy
renal hypercalciuria - s ca, PTH, fasting urinary ca, intestinal ca absorbtion, tx
s ca NL, PTH HI, fasting urinary ca HI, intestinal ca absorbtion HI, tx thiazide, low sodium diet, K citrate
traumatic renal injury - predictors of persistent bleeding - 4
Grade 3 or 4 injuries - medial hematoma, hematoma > 3.5 cm thick, presence of vascular contrast blush - increased risk of intervention.
treatment options for persistent bleedingin gr 3-4 renal inj
IR - angio w/ selective embolization
orthostatic proteinuria def
elevated protein excretion in kids while uprisht and nl protein excretion while supine. causes - left RV entapment, subtle glomerular abnormality, exaggerated hemodynamic response to upright position, nl variant. excellent prognosis. no tx
orthostatic proteinuria - dx
any kid w >1+ proteinuria - UA and first morning spot protein : cr ratio. void before sleep, remain supine, if AM r:cr <0.2 (normal) dx orthostatic proteinuria
% with y chromosome microdeletion and finding
7%. assd w azoospermia or severe oligospermia and elevation in FSH
where do y chromosome microdeletions happen and most common type
long arm of Y - borken down in to AZFa (prox), b(mid), c (distal)
y chromosome microdeletion with sperm
75% with AZFc have sperm on testicular biopsy. no sperm with AZF a or b.
absence of vas and FSH
have obstructive azoospermia picture with normal FSH
nonobstructive azoospermia and FSH
elevated FSH
bone loss in ADT and pathologic fx risks (%’s)
bone loss (6.5-17.3%) in ADT and pathologic fx (4% at 5 yrs and 20% at 10 yrs) risks (%’s)
initial tx for osteoporosis
weight bearing exercise, calcium and vitamin D
time to correct creatinine in newborn
reflect’s child’s cr at 7-10 D
long term renal fxn in PUV determined by
nadir cr at 1 yo. <0.8 is good prognosis
when is renal development completed
34 wks GA
ureteral peristalsis originate from?
intrinsic smooth muscle pacemaker sites in the minor calyces. denervated or transplanted kidneys maintain peristalsis
renal innervation - 2
preganglionic sympathetic input - T8 to L1. postganglionic sympathetic fibers from celiac and aorticorenal ganglia. parasympathetic from vagus nerve. no role in ureter
significance of ductal carcinoma of prostate
associated with high grade disease and recurrence
ductal carcinoma pathologic features
automatically graded as 4+4 as it shares cribiform pattern and is associated with hi grade dz/recurrece.
what zone does prostate ca arise from
peripheral zone
triad of leydig tumor in children and tx
precocious puberty, testis mass, elevated 17-ketosteroid. tetis sparing therapy - usually benign
leydig tumor may present similar to X and mgmt
hyperplastic nodule of CAH when steroid replacement is inadequate. also has elevated 17-ketosteroid. glucocorticoid tx will cause regression of hyperplastic nodule
CAH with 21-hydroxylase deficiency and urine finding
elevated 17-ketosteroid AND elevated urinary pregnanetriol
sterilization vs high level disinfectant - specific risk
sterilization kills everything. HLD cant kill large numbers of bacterial spores unless exposed for promonged time
acute adrenal insufficiency sx
fever, nausea/vomiting, abdominal pain, hypotension, abdominal distension, lethargy, hyponatremia, hypokalemia
preop sunitinib can contribute to x syndrome postop
acute adrenal insufficiency
test to confirm adrenal insufficency
ACTH stim test to confirm adrenal insufficiencyi
most reliable test to confirm renal function in ileal conduit
FENA - sodium handling is not affected in ileal segments. BUN, cr, alkalinizing agents, and ostmotic content affected
what cancer is more common in kleinfelters and its features
breast cancer, 80% estrogen receptor positive (anything increasing estrogen is contraindicated)
hypogonadal man with hx breast cancer - mgmt
give aromatase inhibitor - decreases conversion of testoserone to estrogen, increasing [T]. dont give exogenous T as some will be converted to estrogen
isolated node metastasis on final prostatectomy path - mgmt
lifelong lhrh agonist. ECOG 3807. LN+ at higher risk of systemic recurrence
what type of bacteria convert nitrate to nitrite
gram negative, except pseudomonas - lacks enzyme. G+ dont make nitrite. G - examples - e coli, serratia marcescens, klebsiella oxytoca, proteus mirabilis
no muscle in tubt specimen- % with residual tumor
20-40%
turners syndrome chromosomes
45XO
GU abnormality in turners syndrome
horseshoe kidney
turner syndrome findings
short stature, webbed neck, shield chest
mosiac turners syndrome and specific abnormality
dysgerminoma and gonadoblastoma - need orchiectomy
one treatment for stones due to chronic diarrhea
K citrate corrects acidosis. can give liquid if pills seen in stool
what was PLCO
ransomization of 75K men to PSA (6 yrs) DRE 4 {yrs). screening increased detectino of prostate cancer. survival same in screened and control, same number of advanced cancer in both groups
hemolytic uremic syndrome triad
hemolytic microangiopathic anemia, thrombocytopenia, renal insufficiency
henoch-schonlein purpura - what is it
systemic vasculitis. purpuritic rash, abdominal pain, GI bleed, arthritis. presents at 4-6 yo
membranous glomerulonehritis - what is it
most common cause of nephritis, less common in kids. glomerular subepithelial immune deposits on electron microscopy
what is alports syndrome
inherited d/o of glomerular basement membrane due to type 4 collagen associated with hearing loss. glomerular vasculature abnormality on biopsy
how to follow patients with IgA nephropathy
24 hr urine cr and protein. biopsy if severe disease.
clinical sx iga npehropathy - 2
painess gross hematuria, RBC on UA without casts
IgA nephropathy biopsy findings
glomerulonephritis with immunoglobulin deposits on mesangial areas
benefits of daily dosing of aminoglycosides
reduced nephrotoxicity, more cost effective administration (nursing and serum levels), maximizes bacterial killing by optimizing peak concentration to MIC.
how do aminoglycosides kill bacteria
concentration and time dependent killing. once dialy dosing maximizes these
aminoglycoside ideal dosing
7mg/kg/dose gent, 5-7 mg/kg tobramycin.
adjustment of aminoglycoside dose too high
space out medication to maximize concentration dependent killing
ditinguish essential htn from pheo
oral clonidine test - essential htn will get significant drop in plasma catecholamine
cowpers gland duct cyst - radiographic finding vs prostatic utricle
CGC - diverticulum of bulbous urethra, PU - enters prostatic urethra
cowpers duct gland anatomy and %
ducts open into urethra in the bulb and travel to the glands located in UG membrane adjacent to membranous urethra. cysts in 2.3% autopsied males
2 fx that are independent predictors of urethral injury
medial inferior ramus and pubic diastesis
independent molecular predictors of RCC prognosis -3
high carbonic anhjydrase IX, absent vimentin, absent p53
complete duplication association with upper and lower pole
upper pole ectopic and obstructed. lower pole reflux
in complete duplication why does reflux happen into upper pole alone
insertion into bladder neck or urethra - lack of trigonal support with inadequate submucosal tunnel
most predictive factor of fibrosis on postchemo rplnd for GCT
normal post chemo CT scan with no NL > 8 mm asss with 90% chance of fibrosis at RPLND
% with germ cell tumor or teratoma on postchemo RPLND
if tumor markers negative, 10-20% with viable tumor, 30% with teratoma
age for classic testicular tumors - 0-10, 20-30, 25-35, 30-40, >50
0-10 yolk sac, 20-30 Choriocarcinoma, 25-35 embryonal/teratoma, 30-40 classic seminoma, >50 malignant lymphoma
Half life HCG, AFP, LDH
HCG 1-3, AFP 5-7, LDH 4
HCG is always elevated for x
choriocarcinoma
AFP is never elevated in
pure choriocarcinoma or pure seminoma
2 reasons for false HCG elevation
elevated LH (bilateral orchiectomy…), weed
pathognomonic path finding in leydig tumor
reinke crystals
2 testosterone producing tumors
leydic cell tumors, sertoli cell tumors
yolk sac tumor pathognomonic path finding
schiller-duvall bodies
granulosa cell tumor
75% present within one month of birth, orchiectomy is curative
classic seminoma relapse rate and risk factors
0-1 RF 15%, 32% > 1 RF. risk factors: tumor > 4 cm, rete testis invasion
relapse for seminoma after chemo vs radiation
chemo - retroperitoneum, radiation - pelvis
post chemo followup for seminoma
pet scan 6 weeks post chemo. if no pet scan, observe masses < 3 cm, biopsy lesions > 3 cm
nonseminoma risk factors for relapse
LVI (most important), >/= pT2, embryonal cell predominance, absence of yolk sac.
ideal fluid replacement for hypernatremic child
1/4 ns @ 1.5-2x maint
factor in gsw with most impace on tissue damage
velocity
ureteral contusion post gsw mgmt
cysto, stent
timeframe for leiomyosarcoma of cord
1st 2 decades of life
post resection of leiomyosarcoma of cord mgmt
high risk of local recurrence even if negative margin. do ingional orchiectomy with high ligation of cord with resection of scar. chemoradiation if microscopic diesase on resection path.
what is medial umbilical ligament
obliterated hypogastric artery. in fetus carries de oxygenated blood to umbilical artery and placenta. after birth, hypogastric artery distal to superior vesical artery is coverted to fibrous cord
CBAVD next step
CFTR testing - often have mutation of 5T polymorphism of CFTR gene. ideally test both partners if considering sperm retrieval and ICSI. if both positive, child has 50% chance of clinical CF
followup schedule for low risk patient with NSGCT
chest/abdomen at 3 and 12 months (JCO 2007)
who is at risk for retrorenal colon
pts with NGB
mgmt of colonic perforation with nephrostomy
withdraw tube into colon, low residue diet, broad spectrum abx. remove nephrostomy @ 7 -10 days if no evidence of extravisation or fistula formation. explore if peritonitis, intraperitoneal perf, sepsis
