Uro 2020 Flashcards
1
Q
What is the maximum amount of botox that can be given within a 3 month period?
A
400 Units total, no matter what the indication
200U for neurogenic bladder + 200U for limb spasticity = 400, no more can be given for 3 mo
2
Q
What is the max dose of botox approved for neurogenic detrusor overactivity?
A
200 U
3
Q
Initial treatment of renal artery fibroplasia?
A
HCTZ is often first step, if it does not appropriately lower BP then add Lisinopril
Rarely requires surgical intervention
Unlikely to progress to complete occlusion or alter renal functioning and therefore renal fxn scans are not necessary as further workup.
4
Q
Treatment for retrograde ejaculation:
A
Pseudoephedrine
Retrograde ejaculation can be evaluated with a post-ejaculatory urinalysis (will differentiate b/w this and failure of seminal emission)
5
Q
Characteristics of mixed gonadal dysgenesis:
A
Combination of a testis and contralateral streak gonad
Incomplete virilization (bifid scrotum, penoscrotal hypospadias, rudimentary uterus)
2nd most common etiology of ambiguous genitalia
6
Q
Typical chromosomal status of patients with mixed gonadal dysgenesis:
A
Mosaic 45 XO/46 XY
7
Q
Most common etiology of ambiguous genitalia:
A
45 XX DSD – female pseudohermaphroditism, CAH
Does not have testes present
8
Q
Characteristics of pure gonadal dysgenesis:
A
Chromosomal structure – 46 XX or 46 XY
Bilateral streak gonads
9
Q
Characterisitics of hernia uteri inguinale:
A
aka persistent Mullerian syndrome
d/t failure of production of MIS or its receptor
Have normal appearing testes in abdomen w/fallopian tubes and a uterus.
10
Q
Best step to control presacral bleeding 2/2 sacral suture placement during a sacrocolpopexy:
A
Place a sterile tack into the sacrum at the site of the sacral sutures
The presacral bleeding at the venous level is more common when sutures are placed too low in the sacrum (closer to S2/3/4)
11
Q
When is extracorporeal shock wave therapy an option in the treatment of Peyronie’s?
A
For penile pain
Should not be used to reduce curvature or treat calcified penile plaques or hourglass deformity
12
Q
Common features seen in stomal stenosis of an ileal conduit:
A
Dilated ureters, hydronephrosis and an elongated/dilated conduit
13
Q
Gold standard meds for detrusor overactivity:
A
antimuscarinics
14
Q
Most common cause of bladder calculi s/p augmentation cystoplasty:
A
Poor emptying and mucus formation
Risk increases in patients with abdominal wall stomas
Catheterizing per urethra and daily bladder irrigation decrease risk of stone formation
15
Q
Function of genitofemoral n.
A
Runs anterior to psoas muscle
Provides sensation to anterior thigh (femoral br.)
Responsible for cremasteric reflex/innervation of cremasteric mm. and gives sensation to anterior scrotum (all from genital br.)
Ilioinguinal n. also provides sensation to anterior scrotum but not thigh
16
Q
Most likely nerve to be injured in lap. Varicocelectomy:
A
Genitofemoral
17
Q
Function of iliohypogastric n.
A
Innervates internal oblique and tranversalis mm.
Provides sensation to lower abdominal wall
18
Q
Function of posterior femoral cutaneous n.
A
Sensation to posterior scrotum, posterior thigh and perineum
19
Q
What effect does a loop/Turnbull stoma have on complications post-cystectomy w/ileal conduit?
A
Turnbull/loop ileostomies have a decreased incidence of stomal stenosis, but have increased risk of parastomal hernias.
20
Q
What effect does Allopurinol have on stone formation?
A
Increases risk of forming hypoxanthine stones
21
Q
What is often used in patients who form hypoxanthine or uric acid stones?
A
Potassium citrate to alkalinize the urine
These are v. common in Lesch-Nyhan patients, and risk increases with allopurinol which is typically necessary for them to take
22
Q
What should be done for Spina Bifida patients with worsening bladder disease prior to augmentation?
A
MRI of spine – often shows tethered spinal cord, syringomyelia, increased ICP d/t shunt malfunction, or partial herniation.
A corrected tethered cord can sometimes reverse bladder deterioration and prevent the need for augmentation.
MRI should always be sought when there is change on annual UDS in these patients.
23
Q
Drug of choice for collecting duct carcinoma:
A
Cisplatin- or gemcitabine-based therapies
CD carcinoma is v. aggressive and does not respond to the typical txs of other renal cancers (clear cell or papillary) like IL-2, sunitinib, bevacizumab, temsirolimus and sorafenib
24
Q
MoA and contraindications of Fibanserin (Addyi) used to treat hypoactive sexual desire disorder in women:
A
5HT1A agonist and 5HT2A antagonist. Also exerts DA and NE action
EtOH consumption is absolute contraindication (must sign contract to be prescribed) d/t effects on BP.
Only approved for pre-menopausal women, not contraindicated in pregnancy
25
Most common GU sarcomas in adults and histo based on age:
Paratesticular sarcomas are the most common GU sarcomas in adults
Liposarcoma is most common in adults
Embryonal rhabdomyosarcoma is most common in men <30yo
26
What additional therapies should be done for GU sarcomas if metastatic evaluation is normal?
```
Liposarcomas – adjuvant XRT
Other sarcomas (rhabdomyosarcoma, malignant fibrous histiocytoma, angiosarcoma) – RPLND and post-op CXT if RPLNs are involved
```
27
How does syphilis have to be diagnosed before initiating treatment?
Non-treponemal test (RPR or VDRL) – if positive then have to get a treponemal test (FTA-Abs) or T. palladium particle agglutination (TP-PA). If both are + can initiate tx
Cannot initiate tx with only a + non-trep test (VDRL/RPR)
28
Most common cause of a false negative diuretic renogram:
Dehydration/inadequate fluid volume and therefore low urine flow at the time of the study
Renograms are dependent on adequate urine production
29
Common causes of false positive diuretic renograms:
Poor renal fxn
Inadeqaute dose of diuretic administered
Full bladder
30
Signs/sxs of lidocaine toxicity:
Metallic taste
Dizziness
Lightheadedness
31
How does citrate inhibit urinary stones?
It binds calcium and prevents formation of calcium oxalate and calcium phosphate crystals
Also inhibits the spontaneous nucleation of calcium oxalate.
32
How does alkalinizing the urine help reduce stone formation?
It decreases uric acid and cystine stone formation
33
How should groin recurrence be treated after partial penectomy for SCCa?
Superficial and deep inguinal lymphadenectomy only on the side with obvious disease.
The contralateral side should be spared
34
Current tx recommendations for b/l WIlm’s tumors in peds patients:
6 weeks of initial cxt w/o renal biopsy in patient’s w/high probability of Wilms
35
Characteristics on 20wk US that are considered prenatal hydronephrosis:
APRPD 4+mm or Calyceal dilatation
36
Most common intervention done in the prenatal period for significant BOO:
Vesicoamniotic shunt – tube similar to JJ stent that drains fetal bladder into amniotic cavity
37
What is the pontine micturition center?
Center for integration and coordination of bladder and urethral activity
Suprasacral spinal cord injuries disrupt communication b/w pons and sacral cord – causes detrusor overactivity and detrusor/external sphincter dyssynergia.
38
Acceptable indications for PCNL in pediatric pts:
Large stone burden >2cm
Staghorn stones
Significant sized cysteine stones
Previously reconstructed LUT precluding retrograde access to UVJ
39
Where is correct placement of an initial nephrostomy puncture in a horseshoe kidney compared to a normal kidney:
Position is more medial and through a posterior calyx
40
Median age of presentation for WIlm’s tumor:
3.5 years
41
Initial treatment of stages I-IV Wilm’s tumors:
Nephrectomy
| Stage V is b/l disease and undergoes cxt first
42
Factor most likely to increase risk of a perirenal hematoma after SWL:
HTN
| Complication is not a/w stone size or location
43
Half life of AFP and tumor its most a/w:
t1/2 is 5-7 days
Elevated in 50-80% of NSGCT
EC and Yolk Sac tumors produce AFP; seminoma and chorio do not.
Decision to treat should not be made on a pt w/AFP <20
44
Half life and tumor a/w bHCG:
t1/2 is 24-36hrs
| bHCG is elevated in embryonal carcinoma, choriocarcinoma and seminoma
45
Half life and tumor a/w LDH:
t1/2 is 24hrs
| LDH is the most common isoenzyme elevated in GCT
46
Primary tumor staging of testicular tumors:
pTis: Intratubular germ cell neoplasia
pT1: Tm limited to testis and epididymis – no LV invasion. May invade tunica albuginea but not tunica vaginalis
- 1a: <3cm
- 1b: 3+ cm
pT2: Tm. limited to testis/epididymis w/LV invasion or involving the tunica vaginalis
pT3: Invades the spermatic cord w/or w/o LV invasion
pT4: Invades the scrotum w/or w/o LV invasion
47
Risk of relapse s/p orchiectomy for a pt. w/Seminoma:
15% risk of developing retroperitoneal relapse w/in first 2 years
48
What type of testicular tumor are patients with Androgen Insensitivity at risk for?
If their testes are left undescended in situ theyre at risk of seminoma development
49
What factors predict high probability of finding only fibrosis/necrosis in post-cxt residual masses/LNs a/w testicular tms?
Absence of teratoma in primary tumor
>90% reduction in retroperitoneal mass post-cxt
Size of post-cxt residual mass
50
What is a common complication causing decreased turgor to the kidney during lap nephrectomy and what should be the first step to correct it?
Renal artery vasospasm can occur during hilar dissection – leads to reduced renal perfusion
1st step is to reduce insufflation pressure – increases renal perfusion.; often don’t need additional therapy after this.
If continued poor perfusion – topical papaverine
51
What drug best reduces the risk of men w/prostate ca from developing bone pathology or having worsening bone pathology when already present?
Denosumab or Bisphosphonate therapy
These prevent osteoporosis and reduce skeletal-related events
They also reduce analgesic use, but they do not improve survival
52
What is the cause of acidic urine in pts w/DM-II who form uric acid stones?
Defective renal ammonia excretion
53
What allows for bladder relaxation during filling?
Stimulation of B-2 and B-3 adrenergic receptors in the detrusor via the hypogastric n.
54
What T1 bladder cancers should undergo radical cystectomy?
Those with the following aggressive features:
Tumor size >3cm
Micropapillary histology
LV invasion
55
How can the ilioinguinal nerve be separated from the cord structures during an inguinal approach to peds hernia?
By entering the cremater – ilioinguinal n. runs in the cremaster layer and can be spared by opening it and separating it from the remained of the cord.
56
What should be used to help prevent stone formation in pts taking topiramate?
Potassium citrate
Topiramate causes a chronic intracellular acidosis – high urine pH, low urinary citrate and hypercalciuria. K-citrate will help to prevent stone formation
57
Why do endemic bladder stones form?
Aka primary idiopathic calculi
| Form d/t high urinary excretion of ammonia
58
How to achieve adequate alpha blockade pre-op in pts w/Pheochromocytoma:
Phenoxybenzamine
| If this does not achieve BP control can add Metyrosine
59
What is typically the dose-limiting toxicity associate with Abiraterone?
Hepatotoxicity
| Need LFT monitoring biweekly for first 3 months
60
What artery most reliably supplies the omentum?
R gastroepiploic
61
Where does PTH/VitD induced Ca absorption primarily occur?
Distal tubule
62
What is the minimum volume accepted for interpretability during Uroflow in UDS?
125cc
63
How is detrusor pressure determined?
It is the difference between intravesical and abdominal pressures
64
What aspect of UDS is classically associated with intrinsic sphincter deficiency?
Low ALPP (abdominal leak point P) – <60 defines ISD
65
Characteristics of BOO on UDS:
Elevated voiding pressures and diminished uroflow
BOO cannot be ruled out when there is diminished pressure and low flow, but these are ore classically detrusor underactivity
66
Normal detrusor voiding pressures in adult males and females:
Males: 40-60
Females: much lower pressures – often have undetectable voiding pressures
67
What are girls with turner syndrome Karyotype 45XO/46XY at risk of?
Dysgerminoma and gonadoblastome – require gonadectomy
68
What male organs are affected in Kallman syndrome?
Prostate, seminal vesicle, and testicular size are all often decreased.
69
What is a common way to evaluate for ejaculatory duct obstruction?
TRUS
70
What is the most accurate measure of renal function in patients with intestinal diversions?
Fractional excretion of sodium
Intestinal conduits absorb many other urine components such as creatinine, urea, and alkalizing substances so these are all going to be affected and inaccurate in urine samples.
Proteinuria and the ability to concentrate the urine will also be affected.
71
Syndromes at high risk for developing Wilms’ tumor and their features:
1. Denys-Drash: male pseudohermaphroditism (proximal hypospadias, cryptorchidism), membranoproliferative glomerulonephritis, and nephroblastoma
2. Beckwith-Wiedemann: macroglossia, nephromegaly, hepatomegaly
3. WAGR: Wilms’ tm, aniridia, gonadoblastoma, intellectual disability
72
What is the only aspect of renal function preserved in chronic unilateral ureteral obstruction?
Urinary dilution
| Urinary concentration, ammonia excretion, K and Na reabsorption are all impaired
73
How to diagnose and treat a confirmed UTI in a male with suspicion of chronic bacterial prostatitis:
First treat the UTI and sterilize the urine – get a midstream urine sample and tx w/Macrobid
Once urine is documented as sterile get localization testing – initial voided, midstream, expressed prostatic secretions and post-prostatic massage urinary specimens.
Once bacterial prostatitis has been confirmed tx E.coli w/4-6 weeks quinolone. Alternative is 3 months TMP-SMX
If patients fail initial quinolone therapy, switch to another quinolone
74
What stone composition is most resistant to fragmentation by SWL?
Brushite
Cystine and Ca-Ox monohydrate are also extremely resistant.
Uric acid is not very resistant and Struvite is the most fragile
75
When is the cutoff for orchiectomy in the setting of cryptorchidism?
Males >50yrs or those with anesthesia-related mortality risks outweighing surgical benefits should be observed and not undergo orchiectomy
12-50 = orchiectomy
<12 = pexy; >50 = observation
76
Sxs that merit tx of UTI in patients who do CIC:
Fever, flank/abdominal discomfort, increased leakage between CIC, increased spasticity, sxs of autonomic dysreflexia and malaise/lethargy.
Asymptomatic bacteriuria in these patients does not require tx as most are colonized
77
What should be done first in the workup/treatment of suspected adrenal malignancy?
First do endocrine testing and CT chest for staging
| May need bx if theres mass in chest to determine which is primary – chest and adrenal met to each other
78
Most common causes of Autonomic dysreflexia:
#1 is bladder distention, #2 is fecal impaction.
79
Role of clomiphene citrate in male infertility:
It will increase the intratesticular testosterone levels in a patient w/low serum testosterone – will optimize the intratesticular environment for spermatogenesis
80
If the IMA is ligated how will the L colon maintain blood supply?
```
Middle colic (br. of SMA) will supply proximal L colon, and middle/inferior hemorrhoidal aa. will supply distal L colon.
The marginal a. of Drummond will connect the 2 blood supplies to the L colon
```
81
Recommended treatment of symptomatic submucosal ureteral stones:
These are often iatrogenically displaced fragments of stones.
Best treatment is laser excision and stent placement
If this fails, next step is resection of affected segment of ureter with repair.
82
What is sphincter bradykinesia associated with?
Parkinson disease
83
What is commonly seen in patients with MS and suprasacral spinal cord injuries?
Detrusor overactivity with detrusor external sphincter dyssynergia
84
What is the optimal way to administer mitomycin C?
Eliminate residual urine
Overnight fasting (dehydration)
Oral sodium bicarb (alkalinize the urine – reduces drug degradation)
Increase drug concentration to 40mg/20mL
85
What is a Martius flap composed of and where do you get it’s blood supply?
Composed of fibrofatty labial tissue
Blood supply comes from the posterior labial vessels inferiorly, external pudendal a. superiorly and obturator a. laterally
Typically used for distal fistulae involving bladder neck, trigone and urethra
86
What should be used as a flap for apical vesivovaginal fistulas using a transvaginal approach?
Peritoneum
| Greater omentum can be used as flaps in this location during a transabdominal approach but not transvaginal.
87
What are the exceptions to non-operative mgmt. of extraperitoneal bladder injuries?
Extraperitoneal injuries can be managed non-op w/catheter drainage
If the patient has bladder neck injury, rectal injury, or clot retention.
All intraperitoneal injuries should be repaired
88
What spinal level must injuries be below to have preserved psychogenic erections?
T9 and above have no psychogenic or reflex erections
| Injuries below T9 have no reflex erections but have preserved psychogenic erections
89
Mgmt of lymphadenopathy in Verrucous carcinoma:
Observation – LAD is likely reactive in these cases.
| Verrucous carcinoma has v. low likelihood of mets.
90
What is the best way to detect persistent/recurrent CIS on follow up cystoscopy after treatment?
Blue-light fluorescent imaging
91
What drug should be prescribed to patients who have recurrent calcium oxalate stones w/hyperuricosuria and normal urinary calcium?
Allopurinol
92
When should a low sodium diet be advised to a patient with recurrent ca-ox stones?
If they have hypercalciuria
93
Periop antibiotic recommendations for radical cystectomy:
2nd or 3rd gen cephalosporin 30min to an hr prior to incision and continued for 24hrs post-op
94
What prostatic enzyme is also found in the small intestine and salivary glands?
Prostate specific membrane antigen (PSMA)
95
Types of testicular tumors:
```
Germ cell tms (90-95%): Seminoma and Non-Seminoma
Stromal tms (5-10%): Leydig cell, Sertoli cell, and Granulosa cell tms
Others: Gonadoblastoma (rare – but most commonly found in intersex pts.)
```
96
What is the most common b/l testis tumor?
Malignant lymphoma
97
Most common tm in an undescended testis?
Typical/classic seminoma
98
Most common testis tm in men >50yo:
Malignant lymphoma
99
Most common testis tm in infants/children:
Yolk sac tumor
100
Which side is cryptorchidism more common on?
The right – therefore testis tms are more common on the R.
101
Risk factors for testis cancer:
1. Cryptorchidism – biggest risk factor
2. HIV
3. Gonadal dysgenesis w/Y chromosome
4. Testicular feminization >30yo
5. Intratubular germ cell neoplasia/CIS (pTis)
6. FHx – 1st degree relative
7. Personal hx
8. Infertility
9. Klinefelter’s syndrome – risk of extra-gonadal/mediastinal germ cell cancer
102
Most common side effect of Alprostadil for ED:
Penile pain – can include scrotum and extremities. NTD, just reassure patient
103
What is a thiazide challenge often used for?
To unmask subtle primary hyperparathyroidism – will increase proximal tubular resorption of calcium and cause significant rise in serum calcium.
These patients should undergo parathyroidectomy to decrease stone formation.
If they have symptomatic or obstructive stones at time of diagnosis these should be treated prior to parathyroidectomy.
104
What test compares means of 2 groups?
T-test
ANOVA compares means of >2 groups
Chi square compares proportions of 2 groups
105
What is normal LPP?
>60cm H2O
| <60 indicates dysfunctional urethra/intrinsic sphincter deficiency
106
What are indications for an autologous sling placement?
Severely dysfunctional urethra (low LPP 0-60)
Loss of urethral tissue (s/p synthetic mesh erosion into urethra, urethral diverticulectomy or urethrovaginal fistula repair)
Multiple previous anti-incontinence procedures
107
What is an option for female patients with recurrent pyocystitis and supravesical diversions?
Vesicovaginostomy in – drains bladder and relieves sxs
| Cystectomy can also be performed but not the best option in poor surgical candidates
108
What organisms are likely to cause wound infections w/in the firs 24hrs post-op?
Strep and Clostridium
Both are characteristically invasive, painful and occur w/in 24hrs
Strep – thin, watery purulent discharge w/o frank abscess formation or foul smell
Clostridium – gray/reddish brown and foul smelling discharge. a/w wound crepitus and necrosis. Often have intra-op fecal contamination.
Staph infections occur >24hrs and have indurated areas of cellulitis, a/w abscess formation and thick yellow/cream colored pus
109
What is the finding on a high-dose dexamethasone suppression test that establishes the diagnosis of Cushing’s Disease (xs pituitary ACTH secretion)?
Suppression of urinary 17-hydroxycorticosteroids
110
What parameter on prenatal US early in pregnancy is most predictive of poor renal outcome?
Oligohydramnios
111
What are the major effects of insufflation pressures >20?
1 – Tachycardia 2/2 decreased venous return and cardiac output
2 – Decreased GFR and oliguria 2/2 increased pressure on the renal parenchyma
3 – Hypercarbia/Resp Acidosis 2/2 expanded abd P resulting in decreased diaphragmatic movement and decreased pulmonary insufflation
112
What effect does ejaculatory duct obstruction have on semen pH?
Causes it to be acidic – <7.0-7.2
| bc seminal vesicles add alkaline fluid
113
Preferred modality to assess urethral integrity in females?
Cystoscopy + vaginoscopy under anesthesia
| RUG is preferred in males
114
Cavernosal blood gas values in ischemic priapism:
PO2 <30
PCO2 >60
pH <7.25
115
HTN in Cushing’s syndrome is primarily related to what?
Retention of water and salt
116
Where does DDAVP exert its effects?
On the collecting ducts
117
What is the main disadvantage of bladder autoaugmentation?
Limited increase in bladder capacity
118
What is Fowler’s syndrome?
A cause of urinary retention in young women – a/w abnormally increased EMG activity resulting in impaired external sphincter relaxation.
It is often highly responsive to neuromodulation
119
What drug has the most rapid onset of action in treating BCG sepsis?
Cycloserine – inhibits BCG growth w/in 24hrs
120
What anti-androgen is most associated with painful gynecomastia?
Bicalutamide
121
What is the most common cause of Hypokalemia in patients with HTN?
Diuretic treatment
122
What should be considered in a child w/stranguria and gross hematuria with a normal US?
Urethral abnormality – congenital urethral polyp, stricture, etc.
Should evaluate with VCUG
123
When should cystectomy, ileal conduit patients receive tx for asx bacteriuria?
If the culture grows mainly proteus or pseudomonas – these increase risk of deterioration to the upper tracts and increase risk of stone formation.
124
Mean time to diagnosis of bowel leak post-diversion:
12d post-op
Some may occur as late as 30+ days
Risk factors: ischemia, local infection, drain placement onto the anastomosis, anastomosis of radiated bowel
125
Primary mgmt. of urine leak post-diversion:
Maximal urinary drainage – place b/l stents if not placed intra-op + stomal catheter
If these fail, b/l PCN tubes can be placed
Surgical intervention only if all the above fail
126
Lumbar plexus terminal branches and their roots:
Iliohypogastric (T12, L1) – iliac br, and hypogastric br
Ilioinguinal (L1) – sensory to upper scortum and base of penis/mons pubis and labia majora; motor to internal oblique and transversus mm.
Genitofemoral n. (L1, L2) – genital br: motor to cremaster m., sensation to ant. scrotum; femoral br sensation to ant. thigh
Lateral femoral cutaneous n. (L2, L3)
Femoral n. (L2,3,4) – flexion at hip, leg extension at knee; sensation to majority of medial LE
Obturator n. (L2,3,4) – adducts thigh; sensory to tiny portion of posteromedial thigh
127
What roots give off to sciatic n.?
L4-S3
| Provides sensory and motor innervation to back of thigh, leg and foot
128
What houndsfield units are characteristic of an adrenal adenoma?
<10U
129
What abx are required to tx pyelonephritis in patients w/PCKD and why?
Lipid soluble abx are required in order to penetrate the cysts.
Lipid-soluble abx include: Cipro, Levaquin, TMP, tetracycline, doxy, chloramphenicol
**Aminoglycosides, cephalosporins, macrobid and ampicillin are all not lipid soluble and therefore not appropriate to tx these pts**
130
What should be the initial step in treating recurrent UTIs in a patient post-diversion?
Start with a program of mechanical pouch irrigation – can help decrease infections (though asx colonization may not decrease) and will help clear xs mucus that is produced in the early post-op period.
Ppx abx and urine acidification can be used in pts who fail initial steps
131
What should be done when an incidental subcapsular renal hematoma is found on imaging?
Assess for the presence of a tumor – subcapsular hematomas can occur in the absence of malignancy but there should always be high suspicion when these are found
Repeat CT should be performed 3mo after initial to eval for tm once hematoma has been absorbed
132
What is the common pathway to tx hemorrhagic cystitis?
Start with fulguration/clot evac/CBI
If these fail begin irrigations – Silver nitrate and 1% alum is often first, then move to Formalin, start with 1-2%, then 5%, then 10% if absolutely necessary (must assess for reflux first as formalin is toxic to the upper tracts)
If irrigations fail – internal iliac a. embolization
Last choice is diversion
**Formaldehyde should not be used solely as the irrigant**
133
First step to restore BP after it drops once the adrenal v. is ligated during adrenalectomy for Pheo:
Saline bolus – restore intravascular volume
| a-agonists may also be required
134
Intra-op mgmt. of HTN spikes during adrenalectomy for Pheo:
Nitroprusside, nicardipine, nitrogylceride, or phentolamine
| **tachyarrhythmias can be controlled with lidocaine or esmolol**
135
Safest CXT agent to use in pts w/extensive prior bone marrow radiation:
Bleomycin – primary toxicity is pulmonary fibrosis, only has mild BMS effects at high doses
Cisplatin main toxicity is renal but can also have significant BMS effects
MTX, vinblastine and Adriamycin are all poor choices and have high BMS effects
136
What is the superior hemorrhoidal a. a branch of?
Inferior mesenteric a.
| middle and inferior hemorrhoidals are brs of internal iliac
137
How do calcium stones appear on MRI?
As poorly visualized images – MRI does not visualize calcium and therefore doesn’t reliably identify urinary calculi.
Stones are noted as filling defects overlying the high signal intensity of urine on a T2 weighted image.
Stones are not visualized on T1 weighted images
138
Tx of Stage 4S neuroblastoma:
Stage 4-S can include mets to the skin, liver and BM, but without bone mets on skeletal survey
Tx in children <1yr – observation, the mets will likely regress spontaneously
Children >1yr or those who mets don’t regress chemo is used
139
What is the only indication to use ADT + docetaxel together for prostate ca?
Metastatic, hormone-sensitive prostate ca.
| Currently no role in non-met disease
140
Best tx option for locally advanced non-metastatic prostate ca?
XRT + ADT (2-3yrs)
141
What is brushite?
Calcium phosphate stones with pH <6.6
| Apatite stones are calcium phosphate with pH >6.6
142
What should be suspected in a patient with recurrent Brushite stones?
Primary hyperparathyroidism – resorptive hypercalciuria
143
What is xs meat consumption associated with?
Hyperuricosuria
144
What is phosphate renal leak hypercalciuria associated with?
Elevated vitamin D levels – causes ca-ox or mixed ca-ox and ca-phos calculi
145
Tx for ureteral obstruction post-reconstructive vascular surgery:
Most are caused by localized retroperitoneal fibrosis and can be treated w/4wk course of steroids
146
What is the predicted bladder capacity of a child?
Average bladder capacity = [(age in yrs + 2) x 30]
So for a 3 year old, = (3+2) x 30 = 150
To determine fill rate for UDS divide avg. bladder capacity by 10 (150/10 = 15ml/min or less)
147
Urethral lymph drain in women:
Distal urethra and labia drain to superficial and then deep inguinals
Proximal urethra drains primarily to external iliac and then secondarily to hypogastric and obturator LNs
148
Most common metabolic disturbance in a patient w/ileal conduit:
Hypokalemic, hyperchloremic metabolic acidosis
149
What metabolic disturbances occur with jejunal diversions?
Hyponatremic, hypochloremic, hyperkalemic metabolic acidosis
150
What metabolic disturbances occur with stomach diversions?
Hypochloremic, hypokalemic, metabolic alkalosis
151
Characteristics of renovascular HTN likely to respond to angiographic or surgical intervention:
Elevation of ipsilateral renal v. renin by at least 50% over peripheral and contralateral renal v. renin
152
What is the tx of acute, uncomplicated cystitis in women?
3d of antibiotics – TMP-SMX is the recommended choice
Macrobid may be used but requires 5d to be equivalent to other abx
Fosfomycin may be used as a single dose therapy
153
First step in diagnosing a vesicovaginal fistula:
VCUG
154
How should enterococci UTIs be treated?
Most are sensitive to: Amoxicillin, Extended-spectrum pen derivatives (piperacillin), macrobid, and fosfomycin
Fluoroquinolones, clinda, aminoglycosides and cephalosporins don’t have adequate coverage
155
Where are neurological lesions located when detrusor-external sphincter dyssynergia is seen on UDS?
Between the pons and sacral spinal cord
156
How would the location of a lesion effect detrusor activity?
Lesions at or distal to the sacral spinal cord would likely result in detrusor areflexia
Lesions above the pons result in detrusor overactivity w/synergistic activity of the proximal and distal sphincter mechanisms
Lesions between the pons and sacral cord result in detrusor external sphincter dyssynergia
157
Characteristics of RCC in VHL:
Has both solid renal masses and renal cysts that contain either frank cancer or a lining of abnormal clear cells that represent incipient carcinoma
Therefore surgical tx of RCC in VHL requires excision of all solid and cystic lesions
Partial nephrectomy should be delayed until renal masses are >3cm
158
What are typical UDS findings in a patient with a functional neobladder?
Increased Pabd and Pves with decreased Purethra
159
What is the treatment of a phimotic ring?
Phimotic rings are pathologic causes of phimosis – occur d/t chronic inflammation causing a dense fibrotic ring to form.
Tx w/topical steroid ointment
160
When should revascularization be recommended in renal a. stenosis?
When there’s >75% occlusion either b/l or in a solitary kidney
Revascularization is unlikely to help when there is severe renal loss (Cr >4)
161
What drugs should be avoided in combo w/PDE5 inhibitors as they increase serum levels?
P450 (CYP3A4) inhibitors like the Protease inhibitors (idinavir, and ritonavir), ketoconazole and macrolide abx
If taken together doses of PDE5 inhibitors should be lowered
162
What does the presence of nitrites on UA suggest?
G- nitrate splitting bacteria (E. coli, proteus, serratia, klebsiella)
G+ and pseudomonas do not cause +nitrite and should be considered for coverage in a +UA w/-nitrite
163
What are the most common bacteria a/w Struvite stone formation?
Proteus and S. aureus – both are urease producing
164
When should Sipuleucel-T be used in castration-resistant prostate ca?
In men with asymptomatic or minimally symptomatic mets
165
What is the most common source of bleeding after division of the renal hilum on the left?
Lumbar vein
166
How do checkpoint inhibitors work?
Through the PD-1 and PD-L1 receptor/ligand complex which normally function to inhibit T-cell response.
167
What do mutations in SLC7A9 or SLC3A1 cause?
Cystinuria
168
Tx pathway of cystinuria:
Start with hydration and alkalinization of urine – increased potassium citrate
Next is chelation therapy with a-mercaptoproprionylglycine (tiopronin) or d-penicillamine
169
If fluids need to be given for pathologic diuresis in a post-obstructive patient what should be given?
0.45% NS
LR and NS should not be given
Most patients don’t need fluids and can just take PO liquids
170
How are scrotal dog bites best managed?
They’re managed as penetrating trauma
Explore, irrigate, debride and primary repair/closure of any injured structures
US is not indicated unless there is evidence of testicular injury on exam
**human bites are managed similarly but w/o primary closure**
171
What is renal blood flow primarily autoregulated by?
Afferent arteriolar tone
| Autoregulation is present in both innervated and denervated kidneys
172
How will pheochromocytomas appear on T2 MRIs?
As a bright “light bulb” – this is not pathognomonic as adrenocortical ca. may also appear like this as well as mets
Pheos will not have high T1 signal on MRI
173
How will adrenocortical carcinomas appear on imaging?
Typically >4cm w/heterogenous appearance often w/calcifications and necrosis.
HU on non-con CT typically >25HU
<50% washout demonstrated at 10min post-contrast imaging
**Adrenal mets also have similar features on CT and must be distinguished by hx**
174
What are common features of a JG cell tumor?
Often in teens and young adults (<20yo)
Cause increased renin and secondary hyperaldosteronism – cuases HA, polydipsia, polyuria and hypokalemia (from increased aldosterone)
Tx w/surgical excision
**differentiate from aldosteronomas that cause hypokalemia, but suppress renin secretion**
175
What is the first renal function impaired by ureteral obstruction?
Water reabsorption – causes concentrating defect
| Thought to be 2/2 defects of aquaporin water channels in the CD
176
How would ureteral necrosis present post-kidney transplant?
Presents 1-2 weeks post-op (unlike faulty ureteroneocystostomy which presents immediately)
Ureteral necrosis will cause leakage of urine, increased serum creatinine, increased drain output and increased wound drainage.
May also cause mild hydro of transplant
Initial mgmt. is endourological, but open repair may be necessary to decrease risks of infection
177
What is the first choice drug to give someone whose cortisol levels don’t drop post-adrenalectomy?
As long as there is no evidence of ACTH dependent disease and it is thought to be adrenal in nature Metyrapone is the DoC – will block conversion of 11-deoxycortisol to cortisone
178
What is the most common pattern of voiding dysfxn in a patient with expected pelvic plexus injury?
Failure of bladder contraction/decreased compliance (areflexia)
Fixed striated sphincter tone – continually increases outlet resistance
Bladder neck incompetence
179
Why won’t patients with h/o PUV respond to DDAVP for nocturnal enuresis?
Bc they often develop Nephrogenic DI 2/2 early obstruction and develop concentrating defects
They will be resistant/unresponsive to increased levels of ADH and DDAVP
180
What ischemia time periods are typically acceptable for phallus re-implantation?
6hours warm ischemia time
| 16hours cold ischemia time
181
Deletions/mutations on Chromosome 3 are most common in which subtype of RCC?
Clear cell – most common type of RCC a/w VHL
182
What intravesical therapy should be used in pts on steroids?
Mitomycin C
BCG and interferon are less efficacious in an immunosuppressed pt. as they require mounting of an immune response to work
183
Normal washout time on a MAG-3 scan:
<20min
184
What is globozoospermia and how should it be treated?
Condition where the sperm heads are missing their acrosome and therefore unable to penetrate the oocyte
Sperm will have round/spherically shaped heads on evaluation
The only method that will result in pregnancy is ICSI – placing the sperm directly into the oocyte
If a varicocele is present in these men, varicocelectomy will not result in resolution of the problem
185
What is the dominant pattern of bladder dysfxn in prepubertal boys w/persistent incontinence post-PUV resection?
Detrusor overactivity
186
What are the 3 patterns of bladder dysfunction in boys post-resection of PUV?
Myogenic failure – typically presents post-puberty
Detrusor overactivity – typically presents pre-pubertal w/persistent incontinence
Decreased compliance w/a small bladder
187
What is normal micturition initiated by?
Originates in the pons and is under voluntary control – complete relaxation of striated external sphincter comes first
Then detrusor pressure rises followed by the opening of the vesical neck and urethra
188
How should direct injury to the penile urethra be managed?
Primary surgical repair.
189
What are non-malignant causes of persistently elevated B-hCG post-orchiectomy?
Hypogonadism (can be 2/2 alcoholism or chronic opioids)
| Marijuana use
190
What are non-malignant causes of persistently elevated AFP post-orchiectomy?
Liver damage – often 2/2 drugs, hepatitis and alcohol abuse
191
What is the mgmt. of renal a. aneurysms in women of childbearing age?
Surgical resection – if they rupture during pregnancy results are catastrophic
All renal a. aneurysms >1.5cm should be surgically resected, <1.5 can be treated conservatively
192
What is the most common solid renal tumor in infants?
Congenital mesoblastic nephroma – mean age of 3.5mos
| Require radical nephrectomy, excellent outcomes once removed
193
Following CXT what size must all LNs be under to avoid needing a RPLND?
All LNs must be <1cm – otherwise RPLND is indicated
194
What tumor marker indicates NSGCT parts in a tumor that is histologically pure seminoma?
AFP – limited to cells of cytotrophoblast and indicates that there is presence of yolk sac elements (NSGCT)
195
When is RPLND indicated in patients w/NSGCT?
If there is residual mass/LNs >1cm following CXT
196
What imaging should be done in a patient suspected to have an ectopic ureter?
MRI urogram
197
What is the embryology that explains the pathology of an ectopic ureter?
Cephalad origin of the ureteral bud on the mesonephric duct
198
What is the most frequent UDS finding in patients with tethered cord?
Detrusor overactivity
199
What will be seen on bx of eosinophilic cystitis and how is it treated?
Diffuse inflammatory cells and eosinophils throughout the entire bladder wall
Tx: Oral abx, steroids and antihistamines
In asx children, observation is appropriate
200
What effect does male obesity have on sex hormone binding globulin (SHBG)?
It decreases SHBG – also increases estradiol and decreases testosterone
201
What other organ should be evaluated when a man is found to have bilateral absence of vas deferens?
Kidneys – renal agenesis is found in 11% of men with congenital bilateral absence of vasa.
202
What effect does age have on sex hormone-binding globulin?
SHBG concentration increases with age and results in a decreased level of bioavailable testosterone
203
What is the threshold of sperm concentration considered to be fertile in a man?
>48 million sperm is considered to be fertile
13.5M – 48M is considered to be appropriate for IUI
<13 needs IVF/ICSI
204
What is brown colored sperm often associated with?
Spinal cord injury
205
What are the common differentials of seminal hypovolemia?
Retrograde ejaculation
Ejaculatory ductal obstruction
Accessory sex gland hypoplasia
206
What is the first step in workup of seminal hypovolemia?
Postejaculatory urinalysis – can exclude or diagnose retrograde ejaculation and is the least invasive first step of workup
207
What assays can be used to directly assess sperm DNA fragmentation?
The TUNEL assay – terminal deoxynucleotidyl transferase dUTP nick end labeling assay
and the comet assay at neutral pH (not acidic or alkaline)
208
What is the expected endocrine evaluation of a patient with Kallman Syndrome?
Low testosterone
Low LH
Low FSH
Patients have soft, small testicles bilaterally and azoospermia.
209
What is the expected endocrine profile in a patient with androgen receptor insensitivity?
Significantly elevated testosterone
Mildly elevated LH
Elevated Estradiol
Normal FSH
210
What is the innervation of the adrenal medulla?
Preganglionic sympathetic nerve fibers (thoracic splanchnic nerves) from lower T spine and L spinal cord travel through the sympathetic chain to reach a nerve plexus at the adrenal capsule. The nerves then traverse through the cortex to reach the medulla
211
What are adrenal rests?
Ectopic adrenal tissue – can be derived from either cortex or medulla.
Typically found in the vicinity of the adrenals in proximity of the celiac axis, but can be found along the path of gonadal descent.
In patients with CAH adrenal rests can present as testes masses
212
What part of the adrenal is aldosterone synthesized in?
In the zona glomerulosa of the adrenal cortex
| It is synthesized in the smooth ER and mitochondria in the cells of the ZG
213
What type of cells are chromaffin cells?
They are postganglionic sympathetic neurons that have lost their axons and dendrites
214
What is the HU of a normal adrenal gland?
Normal adrenal tissue has a density of 10HU or less on non-con CT
215
What is the only region of the adrenal cortex that does not atrophy with pituitary failure?
Zona glomerulosa – ACTH does not have much regulation on this region as compared to the ZF and ZR
216
What amino acid are catecholamines produced from?
Tyrosine – produces Epi, Norepi and Dopamine
217
What are the biggest promoters of ACTH release?
CRH is number one, but oxytocin and vasopressin (ADH) also play a role
218
What is the most important variable in modulating the HPA axis?
Stress – psychologic or physiologic
219
When is the highest level of cortisol detected in healthy patients?
In the morning – around 8AM/after waking
| Nadir is reached around 11pm
220
Syndromes associated with an increased incidence of ACC:
```
Li-Fraumeni
Beckwith-Wiedemann
Lynch Syndrome
Carney complex
MEN-1
Neurofibromatosis type I
FAP
McCune-Albright syndrome
```
221
What are two suggested factors to be associated with tumorigenesis of sporadic ACC?
Loss of TP53 function and increased expression of IGF
222
What is the most common hormone secreted by ACC?
Cortisol – typically results in Cushing Syndrome
| Androgens are the second most common
223
What is the mean attenuation of ACC on non-con CT?
About 39HU
224
What are the criteria to classify prostate cancer as “very low risk”?
```
Clinical T1c
PSA 10 or less
PSA density <0.15
Gleason score 6(3+3)/GG1
Up to 3 +biopsy cores with no core >50% involvement
```
225
What are the criteria to classify prostate cancer as Low Risk?
PSA <20
| GG1/Clinical stage T1-T2a
226
What are the criteria to classify prostate cancer as Intermediate Risk?
PSA 10-20 OR GG2-3 OR clinical stage T2b-c
Favorable: GG1 w/PSA 10-19 OR GG2 w/PSA <10
Unfavorable: GG2 w/PSA 10-19 or stage T2b-c OR GG3 w/PSA <20
227
What are the criteria to classify prostate cancer as High Risk?
PSA >20 OR GG4-5 OR Clinical stage T3+
228
What are neurons in Onuf’s nucleus responsible for?
Onuf’s nucleus resides in anterior horn of S2-S4 regions of the sacral spinal cord.
It contains the pudendal motor neurons that innervate the external striated urethral sphincter
229
What is responsible for bladder sensation and contraction?
Bladder sensation – involves parasympathetics in the dorsal sacral spinal cord
Bladder contraction – involves parasympathetics in the ventral sacral spinal cord
Bladder relaxation does not involve parasympathetics – it is sympathetics
230
What are the current guidelines for surveillance of patients at moderate to high risk for RCC recurrence?
Moderate to high risk patients are those with pT2-4 disease and any N+ patients
Surveillance guidelines: abdominal CT and CXR every 6mo for 3 years and then annually until year 5.
231
What is first line therapy in patients with dRTA?
Potassium citrate
232
How to calculate FeNa?
FeNa = (Plasma Cr x Urine Na) / (Plasma Na x Urine Cr)
233
What is “spinning-top urethra” often associated with?
External sphincter overactivity – can be seen on VCUG
234
What should be the next step in a patient with verrucous carcinoma of the penis and palpable inguinal LN?
Observation – verrucous ca has v. low likelihood of mets and therefore LNs should be observed for a period as many are reactive
