Urology Flashcards
Right renal artery
Crosses posterior to IVC
Left renal vein
The left gonadal vein drains into the left renal vein; the left renal vein crosses anterior to the aorta and receives branches from: left adrenal, left gonadal, left lumbar
Ureters
Pass over iliac vessels
Calcium oxalate stones
Most common stones, radiopaque
Magnesium ammonium phosphate stones
Struvite stones, associated with infections, urea splitting, proteus. Staghorn calculi. Radiopaque
Uric acid stones
Radiolucent. Risk factors include ileostomy, gout, short gut.
Cysteine stones
Radiolucent. Prevent with tiopronin
Stone size for spontaneous passage
> 6 mm stone will not pass spontaneously
Testicular cancer
1 male killer 25-35
Majority of testicular masses = malignant
Any mass in testicle = orchiectomy through inguinal incision
More common on right, so is cryptochordism
Avoid scrotal approach and open testicular biopsy: can cause metastatic spread to both retroperitoneal and inguinal node
Primary metatstatic site:
-Left: para-aortic nodes
-Right: interaortocaval nodes
-Lymphoma involving both testis is more common cause of bilateral testicular masses in men over 50
Testicular mass in congenital adrenal hyperplasia
Is a hyperplastic nodule, treatment is glucocorticoid
Diagnosis of testicular cancer
Need US first
Staging for testicular cancer
CT abdomen/chest to look for retroperitoneum and chest metastasis
Labs needed before orchiectomy
LDH, B-HCG, AFP
Percentage of germ cell tumors
90% are Germ cell - Seminoma or non-seminoma
Seminoma most common histology in primary testis tumors
Undescended testes
Increased risk of seminoma; if corrected, increased risk of non-seminoma
MC seminoma characteristics
10% have B-HCG elevation, NEVER has AFP elevation. If AFP high = non-seminoma
Seminoma treatment
-Extremely sensitive to XRT. Spread to retroperitoneum.
- Tx:
o Start radical inguinal orchiectomy
o Stage I – no tumor outside of testicle Close follow up
o Stage II spread to retroperitoneum lymph nodes
o If LN involved now need chemo vs XRT
o If LN < 2 cm XRT
o If LN > 2 cm, any mets or if BGCG elevated: chemo
- Chemo (cisplatin, bleomycin, etoposide)
- Then need surgical resection of any residual disease after above
Non-seminoma types
Embryonal, teratoma, choriocarcinoma, yolk sac.
Spreads to retroperitoneum and hematogenously to lungs.
High AFP and BHCG
Non-seminoma treatment
o Start radical inguinal orchiectomy
o Stage I – no tumor outside of testicle Close follow up
o Stage II spread to retroperitoneum lymph nodes
o If LN involved now need chemo vs retroperitoneum lymph node dissection
o If LN < 2 cm retroperitoneum lymph node dissection
o If LN > 2 cm, any mets chemo
- Tx: all stages get radical inguinal orchiectomy and retroperitoneal LN dissection
- Stage II or greater (beyond testicle) – also get chemo (cisplatin, bleomycin, etoposide)
- Surgical resection for residual disease after above
5-year survival for seminoma
90%, better than non-seminoma
MC location for primary germ cell tumor
Mediastinum
Prostate cancer concern
If alk phos high, worry about metastasis
Diagnosis of prostate cancer
TRUS biopsy. Most common in posterior lobe
Stage I prostate cancer
Found on TURP; do nothing
Stage I or stage II, intracapsular T1 or T2 with no metastatic disease options:
- XRT
- Radical prostatectomy + pelvic LN dissection (if life span > 10 years)
- Nothing (age > 75, short life expectancy)
Extracapsular (Stage III or IV) prostate cancer
Extends through capsule or metastatic disease.
-Tx: XRT and androgen ablation -> (leuprolide (GnRH analogue, decreases FSH and LH), flutamide (testosterone receptor blocker) or bilateral orchiectomy)
MC kidney tumor
Metastasis from breast cancer
Renal cell carcinoma diagnosis
CT scan is sufficient for diagnosis. Never biopsy kidney lesions.
-All kidney tumors need some sort of resection for official diagnosis
MC subtype of renal cell carcinoma
Clear cell carcinoma
MC site of metastasis for renal cell carcinoma
Lung
Paraneoplastic syndrome associated with renal cell carcinoma
Stauffer syndrome - increased LFT, improved with resection
Renal cell carcinoma treatment
Radical nephrectomy (don’t take adrenal unless involved) with regional nodes, followed by postoperative chemo-radiation
Renal artery ligation during nephrectomy
Vital to ligate the renal artery before the renal vein to prevent congestion of the kidney
Partial nephrectomy indication
Only if resection would lead to dialysis, BL renal lesion or mass <4 cm and Cr >2.5
Transitional cell carcinoma of renal pelvis
Requires radical nephroureterectomy
Metastatic renal cell carcinoma treatment
Non-curable; treatment is immunotherapy with sunitinib or pazopanib (tyrosine kinase inhibitors)
Bladder cancer treatment for T1a and T1b
T1a (mucosa) T1b (submucosa) (no muscle involvement) do trans-urethral resection and a single dose of Intravesical mitomycin or BCG
Muscle wall invasion in bladder cancer (T2 or higher)
Need cystectomy with ileal conduit, BL pelvic node dissection, then chemo-XRT (MVAC- Methotrexate, vinblastine, Adriamycin, cisplatin)
Men include prostatectomy
Women include TAH-BSO and anterior vaginal wall
Testicular torsion most accurate sign
Loss of cremasteric reflex (rubbing inner thigh does not elevate scrotum)
Testicular torsion presentation
High riding testicle, testicle lies horizontally
Torsion direction
Usually towards midline (like closing a book)
Prehn sign in testicular torsion
Negative; elevating the scrotum does not alleviate pain. Found in epididymitis
Diagnosis of testicular torsion
Clinically diagnosed; no imaging needed if highly suspected
Testicular torsion treatment
All need bilateral orchidopexy +/- orchiectomy
Priapism cause
Caused by decreased venous outflow from corpora cavernosa
corpora cavernosa involved, not corpus spongiosum
Priapism treatment
Tx: 1st corporal cavernosa aspiration and irrigation with epinephrine, can try injecting phenylephrine into corpora too
2nd cavernoglandular shunt procedure
BPH treatment
– transitional zone.
-Finasteride
-TURP only for recurrent UTI, gross hematuria, stones, renal damage, failure of medical management.
TURP side effects
Retrograde ejaculation
Varicocele location
Most common on left, on posterior surface of testicle
Exam: “bag of worms”
Treatment: Most do not require treatment. But if symptomatic, causing infertility ligate spermatic vein
New onset left varicocele in adult
Means IVC obstruction; MCC renal cancer, get CT abdomen
Varicocele effects on fertility
Causes reduced fertility; improve fertility with high spermatic vein ligation
Nutcracker syndrome
Compression of left renal vein between aorta and SMA
Left gonadal vein empties in left renal: can cause testicular pain and VARICOCELES
Nutcracker syndrome symptoms
Left flank pain, abdominal pain, and hematuria
Spermatocele
MC cystic structure of scrotum. cyst superior and separate from testis along epididymis. Tx: Leave alone if asymptomatic. surgical removal if symptoms.
Spermatocele and hydrocele do not affect fertility
Hydrocele in pediatrics
Hydrocele: - most disappear by 1 year in pediatrics. Formed by tunica vaginalis.
Can have connection to peritoneum processus vaginalis, communicating hydrocele or non-communicating
Adult hydrocele acute onset
If acute and new onset, rule out cancer
Hydrocele diagnosis
Will transilluminate
Hydrocele treatment indication
Only indicated if symptomatic; otherwise leave alone
Hydrocele treatment if symptomatic
Excision of hydrocele sac; don’t aspirate
In adult males these are all non-communicating!!!! They don’t connect to peritoneal cavity
- Lump that goes into the internal ring = hernia – differentiates from hydrocele
- Non-Communicating will resolve
- Failure to resolve indicates persistent processus vaginalis = communicating hydrocele
- CAN BE IN INGUINAL CANAL OR SCROTUM
- Dx: US will transilluminate if in scrotum
- If < 1 year old and non-communicating. Wait until 1 year old and resect if still there
- If thought to be communicating (size waxes and wanes), then resect hydrocele even if < 1 year old
- Resect hydrocele and ligate processus vaginalis inguinal approach
Ureteropelvic junction obstruction treatment
Pyeloplasty
Ureteral duplication
Most common urinary tract abnormality. Treatment: reimplantation if obstruction occurs
Ureterocele location
Most common at junction of ureter and bladder. Symptoms: UTI, retention. Resect and reimplant if symptomatic
Patent urachus
Connection between bladder and umbilicus (wet umbilicus). Diagnosis: voiding cystourethrogram. Treatment: resect cyst and close bladder
Epididymitis cause
Most common cause of scrotal pain in adults. Need to rule out torsion with US: shows increased blood flow to epididymis. Most common cause is chlamydia
Neurogenic bladder
Neurogenic bladder = SPASTIC bladder
Most commonly 2/2 to spinal injury
Patient urinates all the time
Nerve injury above T12
Tx: surgery to improve bladder resistance
Neurogenic obstructive uropathy
Incomplete emptying
Nerve injury below T12, can occur with APR
Tx: Intermittent cath
Stress incontinence
Stress incontinence (cough sneeze)
Due to Pelvic floor weakness Causes hypermobile urethra or loss of sphincter mechanism
MC Women
Tx: Kegel exercises, alpha agonist, surgery for urethral suspension or pubovaginal sling (Best)
Overflow incontinence
Incomplete emptying of enlarged bladder
MC men
BPH leads to this
Tx: Flomax, TURP
Urge incontinence treatment
Antimuscarinics, oxybutynin, tolterodine
Peyronie’s disease
Thick plaque in tunica albuginea. Treatment: conservative management for 1 year (colchicine, vitamin E). If that fails, need Nesbit operation (tissue on opposite side of plaque is shortened). PLAQUE IS NOT EXCISED
Infundibular ligament
Carries ovarian vessels
Broad ligament
Carries uterine vessels. Medial to this is the ureter
Cardinal ligament
At the base of broad ligament contains uterine vessels
