Urology Flashcards
1
Q
Pain related to kidney disease: Evaluation
A
- Hx, PE (+DRE)
- Usg: differentiate solid vs cystic; rule out dilatation. Stones in kidney/bladder
- urine test: bactus, microscopy (rbc, wbc, casts=nephritic), urine cytology(tumors)
- FBC (anemia type, polycythemia, leukocytosis)
- CRP (infection)
- urea, electrolytes, eGFR,
- PSA: metastatic ca, bph, acute urinary retention, UTI, prostatic biopsy
- ALP: bony metastasis
- Ca2+, phosphate, PTH - stone eval.
- IV urography
- CT urography / CT
- Ascending ureterography (uretric tumors; goblet sign)
- radionucleotide scanning (bone metastasis?)
- Chest CT: r/o metastasis
2
Q
Indications for emergency hospitalization of urologic patient:
A
- Acute kidney failure
- Acute urinary retention
- Acute prostatitis
- Stone disease (obstructed flow, (infection after urinary stasis -> pyelonephritis), severe pain, solitary kidney.)
- Severe UTI
- Trauma (parenchymal hematoma, kidney parenchyma disruption, vascular pedicle injury, injury to ureters, bladder, urethra)
- Priapism
- Scrotal gangrene
- Testicular torsion
- Penile fracture (tunica albuginea)
- Scrotal trauma
3
Q
Tx of adenoma of prostate:
A
- *Drugs:
- Finasteride/dutasteride (5-alpha reductase inhibitors: prevent testo converted into DHT)
- Alpha adrenergic agonist (symptomatic; =tamsulosin, alfuzosin, prazosin)
- *Transurethral resection of prostate(TUR-P)
- Lower post mortality and morbidity, and shorter hospital stay than open retropubic prostatectomy. Remove the bulk of the prostate but leave the compressed but normal peripheral tissue; protects the sub capsular venous plexus. Great care is taken to preserve the sphincter mechanism immediately distal to the very montanum.
- Other:
- Holmium laser enucleation of prostate; equivalent result to TUR-P, w/ reduced blood loss. Preferred for patients on warfarin
- Retropubic prostatectomy - gland too large for TUR-P or w/ accompanying bladder diverticula or huge stones.
- Long term catheterization or stunting: for severely demented, debilitated, or immobile patients
4
Q
Pain related to kidney disease - etiology
A
Etiology:
- renal inflammation and stretching of the capsule
- Renal stones, tumors or polycystic disease
- Acute infections: Pyelonephritis, cystitis; assoc. systemic symp & uti-symp
- Obstruction
5
Q
Hematuria - etiology:
Gross or microscopic hematuria. Also clots may be present.
A
- Tumors –> Painless hematuria (Micro & macro); must be suspected even if other cause is found
- Infection –> Painful hematuria; +/- dysuria
- If urethra obstructed by prostatic enlargement –> Straining may lead to disruption of dilated veins at the bladder neck
- Trauma to a normal kidney –> hematuria
- Renal parenchymal inflammation: Glomerulonephritis or arteritis
- Microemboli in the kidneys
- Increased revelation of underlying abnormalities in patients on anticoagulant Tx.
6
Q
Hematuria - Evaluation:
A
- *Stage at which bleeding occur, tells you something:
- Kidneys/ureters/bladder –> Completely mixed into urine
- Urethral bleeding –> may leak out independently of micturition, or only seen at the beginning of the stream
- Blood arising form the bladder neck or posterior urethra may sometimes present as terminal hematuria
- *Hematuria @ dipstick, should be confirmed by microscopy.
- *Cystoscopy or ureteroscopy
- *US
- *CT - useful for staging of cancer
- *IV urography (outlines the upper urinary tract, and a filling defect in the collecting system or ureters is suspicious for urothelial tumors
- *In lower urinary tract - TUR-P can provide tissue samples for histological examination
- *In upper urinary tract: A nephroscope can be used for visualization passed percutaneously
7
Q
Hematuria - Management: RCC
A
- *RCC:
- In most cases: Nephrectomy
- Most surgeons prefer anterior transperitoneal approach (allow staging; control of IVC; and access to renal AA and VV).
- Posterolateral thoraco-abdominal approach - for early access to the IVC and renal arteries (in case of large tumor).
- Whenever possible: radical resection (kidney, perinephric fat and lymph nodes taken en bloc)
- Immunotherapy w/ IL or IFNalfa may help; but not chemoradiotherapy.
- Increasingly radical nephrectomies are done laparoscopically.
- RCC are unusual in that surgical removal of isolated lung or cerebral metastases may result in cure
- For palliation of multiple metastases, chemo- or radio-tx is sometimes used but tx is generally ineffective.
8
Q
Hematuria - management: Bladder tumors
A
- *Bladder tumors
- In situ carcinoma –> BCG
- Up to T2 –> Cystoscopic transurethral resection
- Intravesical chemo has been showed to reduce the recurrence after TURBT of T1
- T1 lesions are notoriously recurrent and if they recur repeatedly, weekly courses of intravesical chemo or BCG therapy is the Tx of choice
- Radiotherapy is reserved for patients who are unfit, or for those with relapse after initial cystectomy or initial chemotherapy
- After cystectomy –> Need ileal conduit
- T4 tumors are incurable. Radiotherapy offers palliation.
9
Q
Hematuria - management: Transitional cell tumors of the upper tract (Rare)
A
- Transitional cell tumors of the upper tract:
- Excision of the whole upper tract including kidney, ureter and a cuff of bladder wall surrounding the distal ureter
- Some small, isolated renal pelvic tumors can be dealt with endoscopically via a nephroscope or by laser ablation via a fibreooptic flexible ureteroscope (low-grade, low-stage tumors)
- NB! 60% of UTUC are invasive at diagnosis –> Aggressive approach
- 17% of UTUC have concurrent bladder cancer –> Check bladder!
- Follow-up w/ cystoscopy every 6 mo-1yr; and cytology every 3 mo.
10
Q
Hematuria - management: Urethral tumors
A
Occasionally involve the urethra by direct spread
Very rarely a primary lesion
Management is by urethroscopic coagulation
Usually early spread
11
Q
Hematuria - management: Tx of nephrolithiasis
A
Urinary colic Tx:
- FLUIDS!
- Bed rest
- Strong analgesics (NSAIDs > morphine; due to longer duration, and no provocation of ureteric spasm and pain)
DOC = diclophenac
- If complete obstruction or infection above the stone –> urgent intervention needed (prevent renal damage). E.g. 1) percutaneous nephrostomy tube or 2) stent beside the stone; also 3) endoscopic stone removal.
Methods of stone removal
- Cystoscopic method - lower third of ureters & bladder
- Open surgery
- Percutaneous techniques (renal pelvis)
- Extracorporeal shock wave lithotripsy (Shatter stone)
12
Q
Tumors of the urinary system
A
Renal cell carcinom
Transitional cell carcinoma
13
Q
S&Sx: RCC
A
- ASYMPTOMATIC! Often Dx incidentally or late
- Hematuria (micro or macro)
- Loin pain
- Lumbar mass (Virchovs triad - rarely found all together)
- Iron deficiency anemia (bleeding)
- Polycythemia (increased EPO)
- HTN (Increased Rennin)
- Hypercalcemia due to PTH-like protein prod.
- Pyrexia of unknown origin
- Elevation of ESR
- Secondary lesions (e.g., cannonball lesion on x-ray, pathological fractures)
- Paraneoplastic syndromes!
14
Q
S&Sx: Transitional cell carcinoma
A
- Painless hematuria
- Urinary colic in upper tract lesions (clot colic after bleeding or clot retention)
- Hydronephrosis
- Uremia (If bilateral obstruction)
- UTI
- Incontinence (tumor invasion near the bladder neck)
15
Q
Tumors of the testis - S&Sx:
A
- Painless; progressively enlarging lump
- Secondary hydrocele, if the capsule becomes involved
- Enlarged inguinal lymph nodes
- Pain or dullness in lower abdomen, scrotum and back
- Heaviness in scrotum
- Gynecomastia (elevated hCG)
