True Learn- Urology Flashcards
Repair of distal ureteral trauma
Injuries to the ureter can be approached by dividing the ureter into thirds. Lower ureter injuries are commonly managed with reimplantation of the proximal ureter into the bladder. If the ureter has been ligated without transection, repair can be attempted with primary ureteroureterostomy over a stent. There are two other procedures that can aid in reimplantation of the ureter into the bladder, ie, psoas hitch and Boari flap
Repair of upper and middle ureteral trauma
Injuries to the upper and mid-portion of the ureter are commonly treated with the formation of a ureteroureterostomy (ie, primary anastomosis of the two ends of the injured ureter segment) over a double J stent or a transureteroureterostomy (ie, connected the injured ureter to the adjacent ureter)
Phimosis vs Paraphimosis
Phimosis: abnormal constriction of the opening in the foreskin that makes it unable to retract over the glans penis, usually results from chronic inflammation, infection (balanitis), and/or edema of the prepuce.
The first step in retracting the foreskin is to inspect the glans for any foreign body. Swelling, if present, can be reduced with ice or compression. Often, gentle dilation can be performed after the patient is sedated using a Kelly clamp. If this is not effective, a dorsal slit circumcision should be performed. This involves a dorsal skin incision about 1–2 cm over the foreskin. After the foreskin is reduced, 4-0 chromic sutures are placed longitudinally to close the incision without constriction. Definitive treatment is a complete circumcision, which may be performed under elective circumstances.
If an individual forcibly retracts the prepuce or incompletely retracts the foreskin, paraphimosis can occur. Paraphimosis is a urological emergency and results when the foreskin is retracted and is subsequently unable to be returned to its normal anatomic position. The constricting band will limit the venous and lymphatic outflow while allowing continued arterial inflow. An emergent reduction of the paraphimosis is required in all circumstances.
Solid testicular mass next step
Solid testicular masses are malignant germ cell tumors until proven otherwise. Tissue diagnosis is obtained by radical orchiectomy (removal of the testicle and spermatic cord en bloc) through an inguinal incision. Transscrotal biopsy and orchiectomy are avoided- violation of these tissue planes alters lymphatic drainage of the testicle and may affect future treatment. After radical inguinal orchiectomy confirms a diagnosis of malignancy, the patient should undergo disease staging, including cross-sectional imaging of the chest, abdomen, and pelvis.
Renal blood supply
Arterial blood supply to the kidney comes from the renal artery. The right and left renal arteries come off the aorta just inferior of the takeoff of the superior mesenteric artery at the level of the second lumbar vertebra. The right renal artery usually courses underneath and posterior to the inferior vena cava on its way to the right kidney. The renal veins are anterior to the renal arteries and drain into the inferior vena cava.
The order of structures that compose the renal hilum from anterior to posterior are: renal vein, renal artery, and renal pelvis. The initials ‘V-A-P’ can be used to help recall the order: V-vein, A-artery, and P-pelvis. Of anatomical significance the left renal vein is longer than the right; it runs anterior to the aorta and posterior to the superior mesenteric artery.
Chronic indwelling urinary catheter with evidence of urethral erosion
Urethral damage occurs primarily in men because the urethral catheter can interfere with seminal secretion drainage and is associated with epididymitis, orchitis, scrotal abscess, prostatitis, and prostate abscesses. However, it may happen in women as well.
In those with chronic indwelling urinary catheters, there is a high risk of erosion (or tearing) of the urethra, particularly in males. The erosion is caused by catheter tension on the distal urethra at the orifice. Proper securing of the catheter to avoid tension can reduce this risk.
Because this patient has a loop of small intestine interposed between her bladder wall and her anterior abdominal wall, percutaneous suprapubic catheter placement is relatively contraindicated due to the lack of percutaneous safe access to the bladder percutaneously. For this reason, open surgical suprapubic catheter placement (or cystostomy) would be preferred over percutaneous suprapubic catheterization.
Renal cell carcinoma with thrombus extending into the inferior vena cava. Next step?
Renal cell carcinoma is optimally treated with a radical nephrectomy. If there is an associated IVC thrombus, radical nephrectomy with simultaneous IVC thrombectomy is the preferred management. This is best done by utilizing an open approach and mobilizing the retrohepatic and infrarenal IVC in order to gain vascular control prior to open thrombectomy.
RCC vs simple renal cyst.
80-85% of kidney cancers originate in the parenchyma (ie, within the renal cortex), the second most common location is the renal pelvis (which are transitional cell carcinomas accounting for 8%), and the remaining primary renal cell carcinomas (RCCs) are various epithelial tumors and sarcomas.
The majority of patients (approximately 85%) with RCC present with localized disease. Those with localized disease present with a wide array of symptoms and/or laboratory abnormalities. However, the majority of these tumors are diagnosed incidentally during an imaging procedure that is performed for another issue. These lesions are then worked up to make a definitive diagnosis in order to guide appropriate management. The mass is first determined to be cystic or solid in nature. Then it is further classified as a benign lesion versus a malignant lesion.
Note the contrast enhancement associated with the RCC, as well as the hy
