SASP 2013 Flashcards
most common cause of post AUS incontinence 3 yrs out
urethral atrophy
most common cause of post AUS incontinence 3 yrs out - mgmt
(urethral atrophy) downsize cuff, move to more proximal or distal location, add second cuff in tandem
LMWH and spinal anesthesia
risk of spinal hematoma - FDA black box warning.
who is at “increased risk” for DVT - 4
previous DVT, malignancy, immobility, paresis
localized SCC urethral in female - tx
circumfrencial excision including excision of anterior vag wall. Distal urethral tumors usually low stage, 70-90% cure rate
outcome of tx for localized urethral ca
usually low stage, 70-90% cure rate
how much urethra can be excised and maintain continence in female
distal 1/3
when to do groin dissection in female urethral cancer
(+) inguinal/pelvic LN w/o distant mets or if adenopathy develops during surveilance.
when to do anterior pelvic exenteration in female urethral cancer
proximal urethral ca as part of multimodal approach w/ chemoradiation
cisplatin nephrotoxicity due to
direct toxic effect on renal tubular cells.
what predisposes to cisplatin nephrotocity
Azotemia and dehydration
ureteroiliac fistula with no bleeding at the time of angio
do provacative maneuver - stent removal or mechanical friction of ureter (PRG 60% dx, angio 4/14 dx)
osmolarity of proximal tubule fluid reabsorbtion
iso-osmotic
sodium transport in prox tubule
active transport. most chloride and bicarbonate reabsorbed with sodium
renal lymphoma origin, and type
90% are not primary, non-hodgkins is most common
hints at renal lymphoma
multifocal masses, bilateral and regional lymphadenopathy
mgmt of intraoperatively discovered renal lymphoma
finish case - no need for nx. plan for chemo
transverse vaginal septum findings
distended upper vagina and presence of uterus. most common in middle and upper 1/3 vagina.
how does transverse vaginal septum happen
arises from failure in fusion of canalization of UG sinus and Man ducts.
where does transverse vaginal septum occur
most common in middle and upper 1/3 vagina.
vaginal atresia def
ug sinus fails to contribute to formation of distal vagina.
MRKH
partial or complete absence of the vagina and uterine abnormalities. uterus partially or completely abscent. ovaries and fallopian tubes are present and may be normal or hypoplastic.
MRKH type 1
involves Man structures (vagina and uterus)
MRKH type 2
concurrent abnormalities of heart, kidneys, or otologic system
androgen insensitivity syndrome - genital abnormalities
missing uterus, salpinx, upper 2/3 vagina.
how do structures regress in androgen insensitivity syndrome
these regress under influence of MIF secreted from testis
imperforate hymen findings
visible bulging membrane at vaginal introitus
macroscopic vs microscopic penile reimplantation oafter amputation
microscopic has reduced penile skin loss, urethral stricture, loss of penile sensation. equivelant rate of erectile function (50%)
erectile function outcome after penis with micro vs macroscopic repair
50%. repair does not influence outcome.
difference in complications (urethral stricture, penile skin loss, with microvascular vs macroscopic repair of amputated penis
all less with microvascular reapir
bulky penile cancer - mgmt
neoadjuvant chemo may allow for future resection.
Trabulsi EJ, Hoffman-Censits: chemotherapy for penile and urethral ca. urol clin n am. 2010
cisplatin, ifosfamide, paclitaxel in TxN2-3 followed by LND showed objective response rate of 55% and complete pathologic response rate of 10%
kub radiation vs ct
x ray 0.25mSv to stomach, ct = 50x
concordance between retroperitoneal and pulmonary mets path in testicular cancer
75% concordance
why is postchemo thoracotomy with mass resection important in testicular cancer
25% discordant path with retroperitoneum and can be curative if viable tumor
mgmt of lung masses s/p rplnd for active tumor in testicular ca
curative if teratoma, helpful in a subset with viable tumor
when is pet helpful in testicular ca
6 weeks post chemo if > 3 cm postchemo seminoma
where is pet not helpful in testicular ca
NSGCT, and non-abdominal masses (mediastinal, pulmonary) b/c hasnt been studied competely
when to abort ipp placement - 2
urethral injury, significant crural perforation
2 predictors of obstructive azoospermia
96% likelyhood of OA if testis longitudinal axis > 4.6 cm and FSH < 7.6
when does fecundity of female plummet
after 37 yo
what parameter dictates TRUS in infertility w/u
semen volume < 1.5ml. must have nl vas
what is young’s syndrome and assd sx (2)
thick epididymal secretions cause obstructive azoospermia. have assd bronchiectasis, sinusitis
immotile cilia syndrome found in x?
kartagener’s syndrome
most common karyotypic abnormality in infertile male
kleinfelter’s
definition of primary testicular failure
FSH > 2x nl
abnormalities on TRUS suggesting ejaculatory duct obstruction - 4
- SV > 1.5 cm AP plane, 2. dilated ejaculatory ducts > 2.3 mm diameter, 3. calcifications in ejaculatory duct, 4. midline cystic structure in prostate
what is kallman’s syndrome
most common cause of hypogonadotropic hypogonadism. x linked defect with hypothalamic dysfunction and absent GnRH. anosmia and absent puberty
prader wili syndrome - gu problem and sx
hypogonadotropic hypogonadism. absent GNRH secretion. obesity, small hands/feet, MR, short
laurence moon bardet biedl syndrome
hypogonadotropic hypogonadism. polydactyly, retinitis pigmentosa
prolactinoma most common sx - 2
decreased libido and ED
prolactinoma initial tx
prolactin antagonist - bromocriptine
kleinfelter’s - definition and findings (4)
47 XXY - small firm testis (sclerosis of seminiferous tubules), gynecomastia (elevated [estrogen]), azoospermia, hypogonadism
kleinfelter’s and infertility
azoospermic but viable sperm with nl karyotype can be found on testis biopsy. candidates for ICSI
sertoli cell only syndrome - def
germ cells (sperm and precursors) absent. leydig cells present outside tubules. azoospermia and high FSH
sertoli cell only syndrome and infertility
25-50% can have sperm retrieved –> ICSI
RCC T2a vs T2b
T2a 7-10 cm, T2b > 10 cm
renal us finding most suggestive of renal artery stenosis
increased peak systolic velocity (> 180cm/sec)
what is renal aortic ratio
ratio of renal peak systolic velocity (PSV) to aortic PSV. > 3.5 = > 60% stenosis
what is an abnormal renal aortic ratio
RAR > 3.5 = > 60% stenosis
treatment for kallman’s desiring fertility
first step - HCG and recombinant FSH, if no response then give IV GNRH (expensive and annoying)
how does azoospermia happen in kallman’s
inadequate intratesticular testosterone and natural absence of pituitary hormones
incidence of upper trace deterioration s/p RC/IC
50% with long term followup
how does finasteride supress bph hematuria
intraprostatic supression of VEGF. if hematuria persiste, r/o upper tract source
persistent hematuria in BPH after finasteride and controlling prostate bleeding
if hematuria persistes, r/o upper tract source
prolactinoma associated lab finding
low testosterone
mgmt of mildly elevated prolactin with nl testosterone level
rarely clinically significant. first repeat prolactin
next step in mildly elevated prolactin in any setting
always repeat test because high interassay variability
neurovascular bundle on the prostate travels between what layers of fascia
levator and prostatic fascia
3 layers of fascia covering prostate
levator fascia, denonviers fascia, and prostatic fascia
mgmt of post uretral bulking agent retention
CIC with small catheter (10-14 fr). large or indwelling catheterwill push mucosal blebs apart or cause molding around the catheter
prolonged retention after bulking agent mgmt
SPT preferred
ureterolithiasis and early pregnancy
trial of hydration and analgesia. if fails, stent with us
nl bladder compliance is due to
bladder wall vesicoelasticity
AZFa and/or AZFb deletion + AZFc = x on biopsy
sertoli only phenotype
what does FISH identify
aneuploidy in chr 3,7,17, and homozygous loss of 9p21
positive fish in the setting of previous bladder ca- mgmt and rationale
random bladder biopsies. 2007 yoder - 63% with negative cysto, cytology, and ct had recurrence
upper tract investigation for positive fish and negative cysto , ct, cytology
dont do it, rarely positive
initial eval for luts if nocturia present
h/p, PE, DRE, UA, frequency/volume chart. uds, cysto, cr not part of initial eval
gold std for disseminated orvisceral kaposi sarcoma
doxorubicin
how often does leakage from urinary diversion spontaneously resolve
20-60%.
mgmt of post RC/IC leak
conservative if pt not septic. place foley in conduit. if stomal catheter doesnt decrease abd drain output, place nephrostomies.
how do zolendronic acid and bisphosphonates help in prostate ca
reduce bone resorption by inhibiting osteoclastic activity. ZA reduces skeletal events
bad complication of bisphosphonates
osteonecrosis of mandible. usually associated with dental work or who have poor dentition or chronic dental diseaes. stop if planned dental work
what receptor is used fort cell interaction with dendrytic cells
via MHC 2 receptor
what happens to t cell after activated by dendrytic cell
release TNF, interluken, and other cytokines for augmented cellular/humoral response
what response is provoked by dendritic/APC’s
activation of T cells via interaction of t-cell’s MHC2.
how are b cells stimulated
by dendrytic cell direct stimulationby antigen
what happens to b cell after activated
differentiates into antibody producing plasma cell
when to do laparoscopy for calyceal diverticulum
anterior location and > 2 cm diverticulum
when do ureteroscopy for calyceal diverticulum
anterior and < 2 cm stone
when do pcnl for calyceal diverticulum
posterior diverticulum
what pathologic factor predicts poor response to chemo in bladder cancer
micropapillary does not respond to chemo
what pathologic types respond better to neoadjuvant chemo - 2
small cell and squamous
lesion location for striated sphincter dyssenergia
between pons and sacral spinal cord
lesion above pons and uds
DO with synergistic activity of proximal and distal SC
lithotripsy method best for uncorrected bleeding disorders
urs/ll. ESWL is contraindicated
mgmt of bladder spasms refractory to opioids after reimplant
torodol is effective in reducing bladder spasms after bladder surgery when anticholinergics fail
renal artery aneurysm in F considering pregnancy and why
surgical repair. endovascular stent will require lifelong anticoagulation
first step in alkalinizing urine for uric acid stones
k citrate.
2nd line to alkalinize urine in uric acid stones if k citrate fails
add acetazolamide - increases urinary bicarbonate and h reabsorbtion
when to give allopurinol in uric acid stones
if elevated urinary uric acid level
what not to give in uric acid stones
thiazides increase uric acid level
how to dx and manage benign excessive urinary frequency in children
continence maintained, and frequency does not persist at night. reassure that is assd w emotional stress and will go away in 3-6 mo.
eponym for vesicouterine fistula and triad
youssef syndrome - seen in 20%: menouria, amenorrhis, chronic urinary incontinance
etiologies of vesicouterine fistula - 3
s/p c-section (incorporation of bladder into closure), D&C, vaginal delivery after prior c-section
presentations of vesicouterine fistula
60% intermittent/cyclical gross hematuria (menouria-menustral tissue passed through urine), 20% chronic urinary incontinence (urine passes via incompetent uterine sphincter), 20% youssef syndrome: menouria, amenorrhia, chronic urinary incontinance
mgmt of vesicouterine fistula
< 6 months - conservative with foley and endocrine supression of menustral flow - 50% success. > 6 mo and no desired fertility- do hysterectomy. if desired fertility juxtapose tisue in repair
condyloma lata definition
manifestation of secondary dyphilis. flesh colored or hypopigmented, macerated papules or plaques.
what kind of stones do ketogenic diet and topiramate cause
calcium phosphate
why do ca phos stones form with ketogenic diet and topiramate
they alkalinize urine
autonomic dysreflexia assd w injury above
T5 although can happen w injuries above T6-10
autonomic dysreflexia stimulated by - 4
overfilled bladder, colonic distension, decub ulcer, silent orthopedic fx
tx of autonomic dysreflexia if removal of noxious stimuli doesnt help
1/2 to 1 inch nitropaste, or oral/sublingual nifedipine. can get rebound hypotension (with nitroglycerine - wipe off paste)
POP-Q definition of Aa and Ba
Aa - midline of anterior vaginal wall (AVW), 3 cm proximal to meatus corresponds to urethrovesical junction. +/-3 from hymenal plane. Bamost dependant part of any part of AVW btw Aa and vaginal cuff or anterior vaginal fornix. no prolapse = -3, yes prolapse = distanc btw vaginal apex and hymenal plane
POP-Q definition of C and D
C = most distal (dependent) edge of cervix or leading edge of vaginal cuff, D = only if cervix present - deepest point of posterior fornix. correlates w where uterosacral ligaments attach to posterior cervix
POP-Q definition of Ap and Bp
Ap - midline of posterior vag wall (PVW), 3 cm prox to posterior hymen - +/- 3 cm from hymenal plane. Bp - most distal (dependent) position of any part of upper PVW btw Ap and vaginal cuff/ posterior fornix. no prolapse = -3, + value beyond hymen
POP-Q definition of gh and pb
gh - anterior posterior measurement from muddle of meatus to posterior midline hymen. pb - measured from posterior margin of genital hiatus to mid anal opening
POP-Q TVL definition
measured by reducing point C or D to its most superior position
POPQ - Stage 0 - II
0 - no prolapse. all points - 3 and D or C = TVL; I - most distal portion of prolapse is >1 distal to hymen (ie -1); II - prolapse is -1 to +1 to hymenal plane
POP-Q Stage III and IV
III - max prolapse is > 1 cm outside hymenal plane, but 2 cm less than max possible protrusion (aka TVL); IV - eversion of total vagina. extends beyond TVL - 2 (stage III)
ureterocalycostomy is reserved for - 4
failure of less invasive tx, intrarenal pelvis, dilated lower calyces, lengthy proximal ureteral stricture
acute viral cystitis - def
sudden onset gross hemturia, bladder wall thickening, urgency/frequency.
acute viral cystitis - tx
supportive. antimuscarinics for sx. ribavirin if highly symptomatic or immunosupressed
aleep apnea and enuresis
causes nocturnal diuresis by: hypoxioa @ sleep –> increased R atrial pressure –> increased atrial naturetic peptide (elevated intrathoracic pressure sue to diaphragmatic contration against closed airway) –> increased nocturnal UOP.
2 cm ureteral stricture in transplanted kidney mgmt
pyeloureterostomy to native ureter. stents are difficult to place in transplant. nephrostomy = infection. balloon dilation fails in transplant and nl kidneys. pyelovesicostomy = reflux and infection
new onset incontinence in SCI and detrussor areflexia - why
due to abnormal detrussor compliance. suggested by DLPP > 15 @ 200 cc
how to tx deteriorated detrussor compliance in SCI
start with antimuscarinics
mgmt of elevated DLPP in SCI
antimuscarinic
DESD tx in SCI
dantrolene. relaxes skeletal muscle
ephedrine effect in SCI bladder
increases sphincter tone and DLPP
what is double dye test for fistula
rx pyridium several days before visit. methylene blue via urethra. 3 gauze placed in vagina - upper near vag cuff, mid in vag and above bladder neck, lower below bladder neck and urethra (external)
how to reduce need for revision of mitrofanoff when initial difficulty passing catheter
leave catheter through superficial stoma nightly. dont place full time due to risk of plugging with mucous and introduction of bacteria.
L stent - what is it?
knot tied 1-2 inches from tip of catheter. insert upto knot nightly to stent cutaneous portion of stoma and tape in place. Mickelson. J urol, 2009
severe burn to penis and scrotum - initial tx
remove foley within 72 hrs, place spt. remove foley early to prevent urethral slough/ fistula formation
when to skin graft penoscrotal burn
split or full thickeness once granulation tissue present and all necrotic tissue removed
first step in assessing new onset hydro in transplant
foley and cystogram to r/o reflux.
if cr does not decrease after foley placement for hydro in txp, whats next?
r/o ureteral stricture. nephrostomy drains kidney and allows for study of ureter if cr > 2 (false positive mag 3)
most common cause for complication of ureter in txp
most comm related to vascular viability of ureter causing leakage or ureteral stenosis.
RF for ureteral complication in txp - 4
advanced donor age, delayed graft function, severe graft rejection, > 2 arteries
large length ureteral avulsion during urs - mgmt
nephrostomy preserves function and minimizes urine extravisation - discuss mgmt w pt. not UU or reimplant
VUR suspected on antenatal us when x
degree of hydro varies with serial us.
metabolism of viagra may be inhibited by 4 meds
ritonavir, ketoconazole, itraconazole and protease inhibitors by blocking CYP3A4
high fat meals and PDE inhibitors
inhibit absorbtion of sildenafil and vardenafil, not tadalafil (cialis). does not affect metabolism
idiopathic oligospermia - when is clomiphine not effective
elevated FSH
when to consider anti-sperm antibody testing - 3
low motility with nl concentration, sperm agglutination, abnormal post coital test (with shaking sperm)
risks for anti-sperm ab’s - 3
genital duct obstruction, hx genital infection, trauma/surgery
anti-sperm ab types
IgG and IgA, not IgM. ab’s are significant if found bound to sperm
where does ureteric bud arise
off the mesonephric duct
ectopic ureteral insertion into vagina is due to
ureteral bud arising or interacting PROXIMALLY on the mesonephric duct
wolffian/mesonephric remnants in males - 3
appendix epididymis, paradidymis (organ of giraldes) (tubules btw effecent ducts and vas), vas aberrans of haller
where does proximal ureteric bud on mesonephric duct end up in male - 4
epididymis, vas, SV, prostate
where does proximal ureteric bud on mesonephric duct end up in female - 3
epoophoron, oophoron, gartner’s duct. ureter ruptures into fallopian tube, uterus, upper vag, or vestibule
wolffian/mesonephric remnants in females- 4
appendix vesiculosa, epoophoron (tubules in broad ligament), paroophoron of waldeyer (persistent tubules in broad ligament near uterus, gartner’s duct (persistent duct in broad ligament, along lateral uterus, or vag wall)
mullerian/ paramesonephric remnant in M - 2
appendix testis, prostatic utricle
mullerian/ paramesonephric remnant in F
morgagni’s hydatid
standard definition for significant bacteriuria and exception
> 105 CFU/ml in urine.
exception for standard definition for bactiuria CFU count
pyuria/dysuria syndrome
kids with renal dysplasia and surgical procedures - renal consideration
at increased risk of reversible ARF.
ARF in kid with CKD and metabolic acidosis correction with sodium bicard - what to watch out for?
monitor ionized calcium - can drop precipitously
signs of hypocalcemia - 3
cramping, tetany, prolonged QT on EKG
sign of resolved spinal shock
return of DTR’s
clostridium perfrigens infection findings - 4
suspect when colon injury, toxic appearance, bronze discoloration of skin. crepitus may be absent.
clostridium perfrigens gram stain and shape
anaerobic G+, club shaped
clostridium perfrigens tx
double coverage with PCN + clinda or flagyl
turp gluid absorbion rate
20ml/min
TUR syndrome - when do pts become symptomatic
na <125 mEq/ml
TUR syndrome - sx
confusion, nausea, vomiting, hypertension, bradycardia, visual disturbances
sorbitol as TURP irrigant
inert sugar - doesnt result in hyperglycemia
2009 AUA guideline for initial eval of femal SUI beyond hx, physical
PVR, UA/ ucx, objective demonstration of SUI
earliest sign of sepsis
respiratory alkalosis from sepsis induced tachypnea
long term use of NSAID results in x
acute interstitial nephritis w/ proteinuria, WBC casts w/o eosinophiluria (eosinophiluria found when due to methicillin).
acute interstitial nephritis in lupus tx
observation
UA finding in lupus nephritis
RBC casts
what is procidentia
complete uterine prolapse
GU eval of advanced uterine prolapse
upper tract imaging
complete uterine prolapse - gu considerations and mgmt
can cause bilateral ureteral obstruction. initial mgmt = vaginal pessary followed by hysterectomy
failed proximal hypospadius x 2 mgmt
resection of scarred urthral plate with 2 stage BMG
aldosterone levels primarily regulated by - 2
angiotensin II via RAS, and serum potassium levels. produced in zona glomerulosa
paratesticular rabdomyosarcoma with neg CT scan mgmt
< 10 yo = chemo alone. > 10 yo = ipsilateral RPLND as 50% will have microscopic disease not seen w CT
positive LN on RPLND for paratesticular rhabdomyosarcoma
retroperitoneal radiation + chemo
threshold for IPP in priapism
> 36 hrs. although morbid, it preserves penile length and makes ipp placement easier.
mgmt of BCG cystitis
r/o bacterial infection and give antimuscarinic if neg.
lowering BCG dose in BCG cystitis
dont do it as decreases theraputic efficacy
cipro for bcg cystitis
negative effect on bcg as partially tuberculocidal
most important parameter indicative of postnatal renal outcome when prenatal hydro present
presence of oligohydramnios and renal cortical cysts
prenatal renal us with renal echogenicity
unreliable as marker for renal function UNLESS renal cortical cysts are present
2 tests for rhabdo
serum CPK and spot urine for myoglobin
RF for rhabdo during surgery
BMI> 25, male, prolonged OR time, full table flexion, prolonged use of kidney rest
most common problem after hypothermia and circulatory arrest
coagulopathy and hemorrhage due to platelet and clotting factor dysfunction.
what hampers K replacement for hypokalemia
serum potassium rise with replacement in the setting of hypokalemia is blunted b/c 80% of K goes into intraellular space
pathognomonic for neurofibromatosis
cafe-au-lait spots
VHL phys exam findings - 4
hemangioblastomas of cerebellum, RCC, cystadenomas of epididymis, retinal angioma
what syndrome has AML’s
tuberous sclerosis
substitution of carboplatin for cisplatin in bladder ca…
decreases response rate by 3x. improved renal safety profile. galsky. ann oncol 2012
initial eval when suspecting pituitary adenoma
ophtho to eval visual field defects and mri of the pituitary.
imaging for pituitary adenoma
MRI, ct isnt sensitive enough
how high does prolactin get in renal failure/ stress
< 50 nd/ml
how to give formalin
start at 1%, then 5%, then 10%. do cystogram first to r/o VUR. if present, occlude UO’s w/ fogarty and place patient head up. very painful and needs general anesthesia.
what is formaldehyde solution
37% solution of formaldehyde gas dissolved in water. do not use intravesically
what is formalin solution
1-10% formaldehyde diluted in nl saline
recurrent SUI 10 yrs after initial sling mgmt
repeat retropubic mid urethral sling or autologous fascial sling.
what kind of sling placement is more successful in redo sling
retropubic>transobturator likely more successful due to higher rate of intrinsic sphincter dysfunction in pts requiring repeat surgery.
where can nephrogenic adenoma happen
any urothelial surface, even transplanted urotheial graft
nephrogenic adenoma sx
hematuria/ irratitive voiding sx
nephrogenic adenoma histology
subepithelial tubular structures similar to loops of henle
nephrogenic adenoma mgmt
TUR and antibiotic prophylaxis x 1 yr (UTI is associated causative factor). dont do surveilance cysto due to risk of further urothelial trauma
multicystic dysplastic kidneys and assd findings
25% have contralateral VUR
when to do circ in baby with VUR
if breakthrough infection while on abx
genitofemoral nerve entrapment can be seen after what 2 procedures
transplantation or psoas hitch
genitofemoral nerve anatomy
arises from L1-2, pierces anterior psoas at L3-4, descends past ureter and splits to genital and femoral branches near ingiunal ligament.
genitofemoral nerve supplies
cremaster muscle, spermaticord, scrotum, thigh
lateral cutaneous nerve injury presents as
anterior and lateral thigh paresthesia sx of burning/tingling that increase with standing, walking, hip extension
most important single prognostic marker for outcome in RCC
tumor stage
persistent hydronephrosis after PUV resection
hydro and VUR resolve in 50% s/p ablation. re-eval in 12-18 months
SIADH in RCC mets to brain - tx for symptomatic?
hypertonic saline to raise serum na no more than 2 mEw/l/hr or 25 mEw/l/24 hrs and fluid restriction
SIADH in RCC mets to brain - tx for asymptomatic?
fluid restriction if asymptomatic +/- lithium or demeclocycline
myelomeningocele with new incontinence - next step
uds to eval etiology of incontinence.
myelomeningocele with new incontinence - when to get MRI - 3
if uds shows new abnormal findings, or onset of LE weakness or other neuro exam abn
RF for renal vein thrombosis in infant
umbilical artery catheter
renal vein thrombosis in infant - 3 sx
abdominal mass, hematuria, THROMBOCYTOPENIA
renal artery thrombosis in infant cause and sx
prolonged umbilical artery catheter and mass and hematuria
henoch schonlein purpura - sx
systemic vasculitis presenting at 4-6 yo w/ palpable purpuritic rash, abd pain w GI bleed, and arthritis
calciphylaxis - what is it & significance
dry gangrene. ESRD patinets - mortality within 6 months of ESRD
calciphylaxis - what does it look like?
microscopic calcification in arterioles and capillaries leading to dry necrosis
calciphylaxis - mgmt
leave it alone - doesnt heal well - poor blood supply
stepwise mgmt of chylous ascites
medium chain fatty acids, then TPN + NPO, then IV/SQ somatostatin
how does somatostatin work in chylous ascites
decreases absorbtion of fat, inhibiting gastric, intestinal, pancreatic secretions, and inhibiting motor activity of intestines –> reduced flow in major lymphatic channels and reduced leakage
continent urinary diversion and elevated ammonium level
urinary ammonium reabsorbed by intestine and converted to urea via urea cycle.
continent urinary diversion and liver effects of sepsis
endotoxin release from sepsis can cause hepatic dysfunction disrupting normal ammonium –> urea leading to elevated ammonium and coma. urea splitting organisms also cause this
continent urinary diversion and liver dysfunction - mgmt - 2
give lactulose or neomycin
what is pca3
detects mrna from DD3 gene (specific to prostate ca)
REDUCE trial and PCA3
PCA3 measured in 1000 ppl with negative prior bx and results correlated with second biopsy.
PCA3 use
evaluate risk of prostate cancer in history of prior negative biopsy, (< 35 = low risk)
PCA3 affected by infection, prostate vol, 5-ARI - T/F
FALSE
SGBH and estrogen/progesterone
estrogen increases, progesterone decreases
infertility and thyroid disease
HYPERthyroidism and thyrotoxicosis elevate SGBH, decrease testosterone. hypothyroidism has opposite effect
what lowers SGBH - 5
insulin administration, glucocorticoid stress, liver disease, nephrotic syndrome, progesterone
purpose of detubularization of bowel
reduce intraluminal pressure (upper tract deterioration) by increaseing radius of reservoir (laplace’s law), and eliminating peristalsis
horseshoe kidney assd w 2 renal issues
UPJO and wilms tumor
ADPKD assd w/ x?
berry aneurysm, higher likelyhood of bleeding due to assd HTN
ARPKD assd w x
liver failure
colchicine and acute peyrones
colchicine helps with acute phase penile pain but has bad GI side effects
when is penile plication useful in peyrones?
if curvature < 60 deg. lots of shortening if > 60
haugnes JCO 2010
mediastainal and subdiaphragmatic radiation has HR for 2nd malig/CV disease of 3.7. chemo HR 1.9, smoking HR 1.7
sperm drainage in testicle (6 steps)
seminiferous tubules (200-300) –> tubuli recti (20-30) –> rete testis (in testicular mediastinum) –> ductuli efferentes –> caput epididymis –> cauda epididymis
UU of distal ureter?
never indicated
presentation of pouchitis in continent diversion
abdominal pain, explosive leakage from stoma due to hypercontractility of bowel. tx w > 10 days abx
spermicide use in women
increases risk for UTI by disrupting nl vag floura
3 common misconceptions re UTI in adult women
does not reduce risk: wiping front to back, urinating after intercourse, increasing fluid intake
post-adrenalectomy mgmt for pheo
repeat metabolic testing (plasma free metanephrines) after adrenalectomy to document normalization of chromaffin cell fxn. only do MIBG if abnormal serum test. can have residual/unidentified tumor
% pheo malignant or multifocal
10-20%
rectal blood supply - 4
superior rectal (hemorrhoidal), IMA, middle hemorrhoidal, and inferior rectal artery
if IMA ligated, where does rectal blood supply come from
middle hemorrhoidal (from posterior hypogastric a.), and inferior rectal (from internal pudendal)
groin pain with tenderness over symphisis pubis in athelte and mgmt
osteitis pubis. anti-inflammatory
corpora amylacea?
calcifications between transition zone and peripheral zone seen on TRUS in large adenomas
indications for removal of multicystic dysplastic kidney - 4
HTN, solid mass, respiratory or GI distress
acetohydrozamic acid - what does it do/ not do
decreases rate of stone growth in pts with struvite stone, does not impact rate of stone recurrence
mgmt of ureteroenteric stx for conduit
open surgical revision. low longterm success with endoscopic tx.
hyponatremia in vomiting
vomiting= loss of salt and fluid. kidneys reabsorb all sodium. results in hypovolemia and hyponatremia and low urine [sodium].
how do renal disease, addisons, and excess diuretics cause hyponatremia
excess excretion of sodium
when is extra sedation needed in eswl - 5
if stone is overlying a rib, female, young, hx anxiety/depression, prior ESWL
active surveilance protocol - PSA and biopsy (ref)
PSA q 3 mo x 2 yrs then q 6 mo, bx at 1 yr, then q 3-5 yrs until age 80.
which preemies are at risk for stones - 2
severe ventilatory problems and bronchopulmonary dysplasia due to need for lasix (increased 10x u ca excretion) to control ht failure.
preemies and lasix - long term outcome (2) and mgmt
eventually can cause hyper PTH and bone changes. switch to thiazide
urethroplasty injury causing difficulty w ejaculation
bulbocavernosus muscle - rythmic contractions responsible for antegrade ejaculation
weiss criteria for adrenal masses? 9
distinguish benign from malignant adrenal lesions. need >/= 3: mitotic rate > 5/HPF, atypical mitosis, venous invasion, high nuclear grade, absence of cells w clear cytoplasm ( 1/3 tumor), necrosis, sinusoidal invasion, capsular invasion.
hx hip prosthesis and stone surgery abx
single dose oral FQ or IV amp/gent
lab to follow while on sunitinib
T4, TSH.
why follow TSH in pts on sunitinib and mgmt
upto 85% develop hypothyroidism within 12-50 wks and risk increases with duration of tx. reversible once stopped. get baseline thyroid tests and check frequently. start synthroid
most common cause of daytime incontinence in 7 yo
infrequent voididng
daytime incontinence in 7 yo - mgmt
timed voididng, voiding diary. can take months to reverse.
causes of anatomic bladder outlet obstruction in women - 4
cystocele (bladder prolapse), bladder neck sling, external striated sphincter dyssenergia, bladder neck obstruction
bladder neck does not relax in female voiding mgmt
can tx with alpha blocker
when is biofeedback useful in female LUTS
pelvic floor spasticity
how to remember intestinal segs
phuck cl (ph, k, cl). ph starts elevated (other 2 low) with gastric, jejunum, ileum/colon
jejunal diversion metabolic abnormalities - 4
hyponatremia, hypochloremia, hyperkalemia, acidosis
ileocolic poich metabilic abn
hyperchloremic metabolic acidosis with mild hypokalemia
ureterosigmoidostomy electrolite abnormality
metabolic acidosis with profound hypokalemia
infant with diabetes insipidus - mgmt
overnight fluid restriction until 3% body weight lost or urine osmolality is > 600. if no improvement restrict for a second day and give desmopressin
DI with response to desmopressin - mgmt
central DI should be investigated - head CT
low urine pH and stone type
uric acid and CaOx
highest renal acid load food
cheese
foods with negative potential renal acid load
fluits and vegetables - encourage these
dairy and stones
dairy intake encouraged. cheese has high potential renal acid load (predisposes to uric acid/ caox stones), milk and yogurt have minimal PRAL
who gets endoscopic mgmt of UTUC
solitary kidney, bilateral disease, renal dysfunction, decrepid or small, lowgrade, noninvasive.
roscigno, shariat j urol 2009
UTUC - T2-4 N0 have no improved CSS vs Nx. node dissection does not help in UTUC
most comon causes of iatrogenic injuries to neonate bladder - 4
umbilical vessel catheterization, forceful expression of over distended bladder, cysto, inguinal hernia repair. can cause forniceal rupture if VUR present
credoiding and spina bifida neonate
dont start until uds to make sure they dont have reactive external sphincter.
credaneuver and sphincter
stimulates reflex response to external sphincter increasing urethral resistance
sports drink and urine
increase urinary citrate. do not cause hypernatruria. lots of calories
what are clinical T1 lesions in prostate cancer
clinically inapparent tumor - not seen on imaging or on exam
clinical T1c prostate ca def
PSA disgnosed lesion with nl DRE and us
what is clinical T2 prostate cancer
nodule palpable on exam - either unilateral or bilateral
clinical T2a vs t2b prostate ca def
T2a - < 1/2 of one lobe, T2b > 1/2 of one lobe on DRE or nodule on TRUS
clinical T2c prostate ca def
bilateral nodule on DRE
GU abnormalities associated with imperforate anus - 6
VUR (40%), renal agenisis (25%), renal ectopy (25%), rectourethral/vaginal fistula (20-30%), neurogenic bladder (15-25%), tethered cord (2-8%).
GU abnormalities associated with HIGH/SUPRA LEVATOR imperforate anus
rectourethral fistula, neurogenic bladder, tethered cord
non obstructive azoospermia hints - 2
FSH > 7.6 and testis axis < 4.8 cm - 90% chance of NOA
mgmt of nonobstructive azoospermia
testicular sperm extraction for ICSI
omental blood supply for vesicovaginal fistula
mobilize off the left of stomach, preserving right gastroepiploic (larger and originate more caudal vs left - shorter course to pelvis)
indication for sperm motility testing
motility < 5%
what usually causes sperm motility< 5%
flagellar defects. most nonmotile sperm are viable
kallman’s syndtome and infertility
hypogonadotropic hypogonadism and azoospermia
eosinophilic granulomatous cystitis - what is it
mass like lesion with irritative sx and hematuria. bx - intense inflammation, granulomatous rxn, and eosinophilic infiltrate. benign and self limiting
eosinophilic granulomatous cystitis - mgmt
if minimal sx, observation or TUR/laser ablation. diffuse lesion - antihistamines and steroids
antisperm ab’s and motility
low motility, but non-motile sperm are dead :-x
benefits of zolendronic acid
decrease bone pain from cap mets and skeletal related events. No survival advantage
what is denosumab
rank ligand inhibitor and decreases skeletal related events and helps prevent SRE due to osteoporosis
