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Renal/Skeletal > Urology > Flashcards

Urology Flashcards

1
Q

Ureteritis

A

Inflammation of ureters due to ascending infection from vesicoureteric reflux or descending kidney infections

  • Intrinsic causes: calculi (urolithiasis), intraluminal blood clots, fibroepithelial polyps, inflammatory strictures, amyloidosis, tumors of ureter
  • Extrinsic causes: Tumors (cervical cancer), pregnancy, endometriosis, aberrant renal vessels to lower pole of kidney
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2
Q

Urolithiasis

A

Formation of stones in collecting system of urinary tract

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3
Q

Nephrolithiasis

A

Stones in the collecting system of kidney.

  • Due to urine concentration with precipitation of minerals
  • Most are unilateral, usually in the calyces, renal pelvis, or bladder
  • Presents with severe, abrupt flank pain, groin pain, fever, frequency, pain with urination (dysuria), and blood in the urine (hematuria)

Staghorn Calculi= large stones dilating renal pelvis, calices–> cast formation
(Struvite, cystine, uric acid stones)

Types of Stones:

  1. Calcium stones= most common
    - Calcium oxalate= due to hypercalciuria
    - Acidic urine (low pH)
    - Calcium oxalate stones are hard and dark
    - Urinalysis: calcium oxalate crystals are colorless tetrahedra (envelope shape), oval or dumbbell shapes; polarizable
    * * seen in ethylene glycol poisoning (antifreeze)
  2. Struvite stones= Magnesium ammonium phosphate (15% of stones)
    - Due to urea-splitting bacteria (Proteus, Staphylococcus, Providencia)
    - Alkaline urine (high pH)
    - Triple phosphate crystals in urinalysis are colorless, rectangles or coffin lids shaped
  3. Uric Acid stones= due to hyperuricemia (6% of stones)
    - Radiolucent
    - Acidic urine (low pH)
    - Rhomboid crystals
  4. Cysteine stones= due to genetic defects in cystine transport
    - Autosomal recessive
    - Yellow-brown radiopaque stones
    - acidic urine (low pH)
    - Crystals hexagonal
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4
Q

Hydronephrosis

A

Dilated renal cortex

  • Most commonly caused by congenital obstruction of ureteropelvic junction in children
  • Most common in males, < 6 months
  • Left sided (23-30% bilateral)
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5
Q

Sclerosing retroperitoneal fibrosis

A

Ureteral obstruction due to dense fibrosis of retroperitoneal soft tissues and chronic inflammation

  • Adults age 40-60
  • Associated with drugs, autoimmunity
  • can also be seen with Riedel thyroiditis, liver PSC, mediastinal fibrosis
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6
Q

Bladder exstrophy

A

Absence of anterior bladder wall, anterior abdominal wall

  • May be associated with epispadias
  • 1:3 M:F ratio
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7
Q

Bladder diverticula

A

Pouch-like evaginations of bladder wall

  • Seen in males > 55 years
  • Requires surgery when associated with infections, stones, perforation
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8
Q

Urachus

A

Vestigal structure connecting bladder dome to umbilicus in abdomen
- Can persist in adults, give rise to malignancies

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9
Q

Congenital incompetence of vesicoureteral valve

A

Abnormal junction between ureters, urinary bladder

  • Ureters enter bladder perpendicularly (short intravesical segment–> does not prevent urine backflow during micturation
  • More common in young firls
  • Mostly asymptomatic, but can cause reflux pyelonephritis
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10
Q

Cystitis

A

Inflammation of the bladder.
– Clinically manifest as dysuria (pain or burning with urination), frequent urination including nocturia, urgency, hematuria and lower abdominal pain.

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11
Q

Bacteriuria

A

Bacteria colonization of urine without symptoms

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12
Q

Infectious cystitis

A

Most common UTI
Caused by:
- Fungal cystitis (candida)
- Schistosomiasis
- Viral cystitis: Adenovirus (type 11), HSV (hemorrhagic cystitis)
- Cyclophosphamide (give Mesna to reverse)
- Bacterial: e. coli, staph saprophyticus, klebsiella sp.

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13
Q

Interstitial cystitis

A

Painful bladder syndrome
- Persistent cystitis with pelvic pain and irritative voiding symptoms
• More frequently in females
• Multifactorial
• Cytoscopy: punctate hemorrhage or “Hunner ulcer”
• Diagnosis is of exclusion
• Overactive bladder is characterized by “urgency” of urination, pain is not the key feature but urine leakage
- Mucosal ulceration “Hunner ulcer” covered by fibrin and necrotic debris
• Inflammation, including mast cells, and later, a contracted bladder due to transmural fibrosis.

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14
Q

Malakoplakia

A 
Malakos= Soft
Plax= plaque
- Papule, plaque, ulceration of GU tract
- Accumulation of macrophages
- 5-7th decades, females
- Associated with e.coli infection

Histo: Inflammation with large macrophages, eosinophilic cytoplasm with PAS stain

Michaelis-Gutmann bodies (calcifications)
- Engorged macrophage lysosomes with bacterial fragments (lysosomal defect)–> calcium salt deposition–> Michaelis Gutman bodies

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15
Q

Radiation cystitis

A

4-6 weeks post-radiotherapy

- Edema, chronic cystitis, ulcers, fibrosis

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16
Q

Brunn Buds and Nests

A

Type of benign urothelial lesion; associated with chronic inflammation, caliculi

Buds= Normal invaginations of surface urothelium into lamina propria

Nests= similar to buds, urothelial cells have detached from surface, seen within lamina propria

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17
Q

Cystitis Cystica

A

Type of benign urothelial lesion; associated with chronic inflammation, caliculi

Cystic dilation of Brunn nests (common)

  • See eosinophilic, proteinaceous material in lumen
  • Can also be seen in urethra/ureter
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18
Q

Cytstitis glandularis

A

Type of benign urothelial lesion; associated with chronic inflammation, caliculi

Differs from Cystitis Cystica only in the nature of lining cells–> mucin-secreting columnar epithelial cells

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19
Q

Squamous metaplasia of urothelium

A

transformation of urothelium to squamous mucosa: reaction to chronic injury and inflammation associated with calculi (50% normal adult women, 10% men)

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20
Q

Nephrogenic metaplasia

A

Lesion caused by transformation of urothelium into renal tubules

  • Small tubules clustered in lamina propria–> exophytic nodule
  • Lesions may result form implants of detached renal tubular cells carried downstream
  • Can produced tumor-like protrusions that obstruct the ureters
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21
Q

Hypospadia

A

Urethra opens on underside of penis
- Incomplete closure of urethral folds of urogenital sinus
Non-complicated surgical repair

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22
Q

Epispadia:

A

RARE- Urethra opens on upper side of penis
- Can commonly see entire urethra open along entire shaft
Complicated surgical repair

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23
Q

Phimosis

A

Narrowing of prepuce–> impairs retraction over glans

Paraphimosis: narrow prepuce retracted, can strangulate glans (due to infection, trauma)
- Both cured by cirumcision

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24
Q

Scrotal massas

A

Hydrocele= serous fluid collection in scrotal sac between two layers of tunica vaginalis

  • Congenital: most common cause of scrotal swelling in infants, associated with inguinal hernia
  • Acquired: secondary to infection, tumor, trauma; U/S or transluminate fluid–> can lead to testicular atrophy or fluid can become infected and cause periorchitis

Hematocele: accumulation of blood between tunica vaginalis layers due to trauma, hemorrhage into hydrocele, tumor, infection

Spermatocele: Cyst in efferent ducts (widened) of rete testis or epididymis

  • Ressembles paratesticular nodule or fluid-filled mass
  • Cyst is lined with cuboidal epithelium with spermatozoa in various degenerative stages

Varicocele: Dilation of testicular veins
- Cause infertility, oligospermia (most asymptomatic)

Scrotal inguinal hernia: protrusion of intestines into scrotum through inguinal hernia

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25
Q

Priapism

A

Painful erection unrelated to sexual excitation
- Secondary to blood outflow blockage, hematologic disorders (sickle cell, polycythemia vera, leukemia), brain, spinal cord diseases

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26
Q

STDs causing painful lesions

A

Herpes: Most common STD of the glans; manifestsed as grouped vesicles, ulcerate–> crusts

Chancroid: Haemophilus Ducreyi
- Accompanied by inflammation of inguinal lymph node

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27
Q

STDs causing non-painful lesions

A

Syphillis: Solitary, soft ulcer

Granuloma inguinale: Klebsiella

  • Donovan bodies: rod-shaped bacteria within histiocytes
  • Tropical disease
  • Ulcers enlarge, heal very slowly

Lymphogranuloma Venereum: Chlamydia trachomatis

  • Swollen groin lymph nodes
  • Sinuses drain pus and serosangoinous fluid from nodes

Condylomata Acuminata: HPV genital wart

  • Hyper- and parakeratosis, koilocytes
  • Warts on shaft, small polyps on glans
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28
Q

Inflammatory disorders of Penis

A

Balanitis: Glans, due to poor hygeine

Balanoposthitis: glans and foreskin; bacteria, fungi

Complications: meatal stricture, phimosis, paraphimosis

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29
Q

Balanitis Xerotica Obliterans

A

Chronic inflammatory syndrome of subepithelial connective tissue
Xerotica= fibrosis
Obliterans= sclerosis

Glans= white, indurated
- Can cause strictures, phimosis
Equivalent to lichen sclerosis atrophicus of vulva

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30
Q

Circinate Balanitis

A

Circular, linear, or confluent plaque-like discolorations of glans, superficial ulcerations
Seen in Reiter syndrome

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31
Q

Plasma cell balanitis

A

Zoon balanitis
Chronic disease of unknown origin–> macular discoloration/painless papules on glans
- Infiltration of plasma cells, lymphocytes, epithelial thickening

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32
Q

Peyronie disease

A

Fibrous induration of penis with asymmetric fibrosis of penile shaft, induration and normal overlying skin

  • “Penile strabismus”–> lost penile curvature, pain in erection
  • Seen in young, middle-aged men (1% over 40)
  • Dense fibrosis with chronic inflammation
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33
Q

Urethritis

A

Nonspecific infectious urethrits: e.coli, pseudomonas

  • Associated with cystitis
  • Seen in hospitalized patients (indwelling catheters)–> urgency, burning on urination, rare discharge

Urethral caruncles= polypoid inflammatory lesions of femal urethral meatus–> pain and bleeding

  • Could be caused by prolapse of urethral mucosa, inflammation
  • Seen in post-menopausal women (exophytic, ulcerated mass 1-2 cm in diameter)
  • Treat with surgical excision

Reiter syndrome= urethritis, conjunctivitis, arthritis in weight-bearing joints

  • can also see circinate balantitis, cervicitis, skin eruptions
  • Effects adults with HLA-B27 haplotype
  • Symptoms after chlamydia, Shigella, Salmonella, Campylobacter
  • Inappropriate immune reaction- spontaneously resolves
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34
Q

Cryptorchidism

A

Bilateral in 30% of cases
Seen in 1% of infants: most common urologic condition requiring surgery
- Increases infertility, germ cell neoplasia
- Orchiopexy= surgery at age 6-12 months to correct; does not reduce neoplastic risk but improves fertility

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35
Q

Infertility (Male)

A

Klinefelter’s syndrome:

  • Hyalinzed seminiferous tubules
  • Prominent Leydig cells
  • Results in infterility

Immature seminiferous tubules

Decreased spermatogenesis (hypospermatogenesis)

Idiopathic Germ cell maturation arrest

Germ cell aplasia (“Sertoli cells only” syndrome)

Peritubular and tubular fibrosis

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36
Q

Epididymitis

A

Clinical features: Intrascrotal pain with or without fever, and infertility

Bacterial epididymitis: young men with gonorrhea or Chlamydia and in older men and children with E. coli

Tuberculous epididymitis

Spermatic granulomas

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37
Q

Orchitis

A

Gram-negative bacterial orchitis is the most common form, often secondary to urinary tract infection

Syphilitic orchitis

Mumps orchitis unilateral

Granulomatous orchitis type IV (cell-mediated) hypersensitivity reaction and tuberculosis

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38
Q

Prostatitis:

A

Cause: coliform uropathogens, but often cannot be determined
** May cause elevated serum prostate-specific antigen (PSA)

Types of Prostatits:

  • Acute Prostatitis
  • Chronic Bacterial Prostatitis
  • Nonbacterial Prostatitis
  • Granulomatous Prostatitis
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39
Q

Benign Prostatic Hyperplasia

A 
Enlargement of the prostate and urinary outflow tract obstruction:
– decreased vigor of the urinary stream 
– increasing frequency 
– post urinary dripping 
– hydroureter, hydronephrosis
– ultimately renal failure 
Higher among blacks than among whites 
Peaks in the 7th decade 
10% has incidental adenocarcinoma

Treatment: Transurethral resection, suprapubic enucleation

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40
Q

Prostate Carcinoma

A
  • The most frequently diagnosed cancer in men the United States: 220,000 new cases
  • The second cause of death in men after lung cancer
  • Elderly men
  • American blacks exhibit a rate over twice as high as white Americans and have the highest prostate carcinoma death rates in the world
  • Geographic variation: highest being in the United States and the Scandinavian
  • Unknown etiology: “Androgen” and PIN.
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41
Q

Tumors of the Testis

A 
Germ Cell Tumors (90-95%)
- Germ Cells within Seminiferous Tubules
Sex Cord-Gonadal Stromal Tumors (5%):
- Leydig cell 
- Sertoli cell
Metastasis to the Testis (5%) 
- Lymphoma
- Carcinoma
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42
Q

Epidemiology of Renal cell carcinoma

A
  • RCC 2–3% of all adult cancer
  • Seventh most common cancer in men, ninth in women.
  • Incidence approx 209,000/year and 102,000 deaths per year.
  • Incidence of all stages has increased, contributing to a steadily increasing mortality rate
43
Q

Risk factors of Renal cell carcinoma

A
  • Cigarette smoking established risk factor - relative risk of about 2–3
  • Obesity (BMI) is also a known risk factor
  • ESRD
  • Acquired renal cystic disease
  • Hypertension
44
Q

Presentation of renal cell carcinoma

A

Frequency 2:1 male:female
Usually in sixth to seventh decade of life
More presenting asymptomatic
Hematuria, flank pain, palpable mass – poor
Vena caval / atrial involvement (5-10%)
- can produce ascites, hepatic dysfunction, PE
Local extension (liver, pancreas, colon)
- Brain, ipsilateral adrenal, contralat kidney, bone, lung, pancreas

Types:

  • 70-80% clear cell
  • 10-15% papillary
  • 3-5% chromophobe
45
Q

Management of RCC by Bosniak Criteria

A

Category I and II:
- Further evaluation not required

Category III: Indeterminant cystic masses
- Low risk of metastatic malignancy

Category IV: Malignant cystic lesions with soft-tissue components
- High risk of metastatic malignancy

46
Q

Risk of malignancy of renal mass

A

Rises with lesion size:

< 3 cm has rare metastases

47
Q

Surgical management of RCC

A

Stage I – partial or radical nephrectomy
- Three years after surgery, partial vs radical nephrectomy - significantly lower risk of GFR below 45 mL/min (5 vs 36 percent)

Patients with hereditary cancer syndromes:
- Loss of renal function associated with increased risk of cardiac death and a decrease in overall survival (5yr overall survival 78 versus 85 percent for patients treated with radical and partial nephrectomy, respectively).

Stages II and III – radical nephrectomy

Radical Nephrectomy : Ligation of renal artery and vein, removal of kidney, Gerota’s fascia, and ipsilateral adrenal gland)

Laparascopic = open in experienced hands, 4 cm) upper pole lesions, non-organ confined tumor stage (T3 or greater), or solitary ipsilateral adrenal metastases identified by preoperative imaging studies

Cavoatrial invasion in 5 to 10 percent of cases – concern for thrombus migration and embolization

48
Q

RCC metastases: predictors of poor prognosis

A

LDH > 1.5 ULN
Hemoglobin < LLN
Corrected calcium >10
Interval 2 sites of organ metastasis

Low risk= 0 : overall survival 30 months
Intermediate= 1-2 : overall 15 months
High risk= 3-5 : overall 5 months

Sites of metastases:

  • Lung, Bone Brain
  • Contralateral Kidney
  • GI including pancreas
49
Q

Cytoreductive nephrectomy (RCC)

A
  • for resectable tumors
  • patients with good performance status
  • palliation of local symptoms
  • oligometastatic or lung only disease
  • survival benefit in surgery followed by interferon vs interferon alone
  • improvement in paraneoplastic syndrome symptoms
50
Q

Targeted systemic therapy for RCC

A

In selected groups of patients, still use IL-2 (low burden disease patients)

2 main pathways targeted:

  • HIF: hypoxia inducible factor
  • mTOR

First line:

  1. TKIs: Sunitinib, Sorafenib
    - Side effects= HTN (marker of efficacy of treatment), thyroid dysfunction, renal insufficiency, thromboembolic events, decline in ejection fraction, hand/foot syndrome, hepatotoxicity, GI toxicity/taste, cytopenias
  2. VEG-F: Bevacizumab
    - Side effects: HTN, thromboembolic events, proteinuria, GI performation, RPLS (reversible posterior leukencephalopathy syndrome)

Second line: tesmirolimus (mTOR-inhibitor)
- Side effects: rash, hyperglycemia, hypertriglyceridemia, pneumonitis, anemia/cytopenias

51
Q

Bladder cancer: epidemiology

A
  • 70,980 new diagnoses in 2009, 14,330 deaths
  • 4th most common cancer
  • 3:1 M:F
  • Rare <40
  • Median age 65 - medical comorbidities
  • Often multifocal
  • Can involve the urothelium from the renal pelvis to the urethra

Cytogenic abnormalities:
- Deletion of chromosome 9 (9p- or 9q-), 11p, 13p, 14q, or 17p

Risk factors:

  • Cigarettes
  • Arsenic exposure
  • Bladder caliculi, infections, TB, schistosoma
  • Radiation therapy
  • Cyclophosphamide, analgesics
  • Occupational exposure to aromatic amines, β-naphthylamine, phenacetin, dye and others
  • Infection with Schistosoma haematobium is a risk factor for squamous cell carcinoma of the bladder
52
Q

Categories of bladder cancer

A
  1. Non-Invasive: most common (90%)
    - prevent recurrence and progression
  2. Invasive
    - preserve bladder or prevent progression
  3. Metastatic
    - maintain quality and prolong life
53
Q

Signs and symptoms of bladder cancer

A
  1. Gross or microscopic hematuria
  2. Irritative symptoms (Dysuria, frequency, urge incontinence, urgency)
  3. Obstructive symptoms
  4. Advanced: abdominal, pelvic pain, anorexia, edema
54
Q

Treatment of non-invasive bladder cancer

A

TURBT: transurethral resection of bladder tumor;

  • Low risk: observe
  • Intermediate: chemo, BCG/maintenance
  • High risk: BCG/maintenance
  • Recurrence–> radical cystectomy

Chemo: Cisplatin

Surgery:

  • urinary diversion: ileum connected to ureters
  • Neobladder/continent diversion: patients may have to self-catheterize
55
Q

Epidemiology of testicular cancer

A
  • 2-3 new cases per 100,000 US males per year
  • Marked variation in incidence among different countries/races
  • 90-95% are germ cell
  • Most common solid tumor in males ages 15-35
56
Q

Risk factors for testicular cancer

A

Cryptorchidism: 7-10% of patients with testicular cancer have a history of cryptorchidism

  • Abnormal germ cell morphology
  • Elevated temperature
  • Interference with normal blood supply

5-10% of patients with testicular cancer and a history of cryptorchidism develop cancer in the contralateral testis

Orchidopexy does not prevent development of cancer – just allows for detection

Gonadal Dysgenesis 
- 20-30% develop cancer (gonadoblastoma) 
Trauma ??
- prompts evaluation
Hormones
- DES/OCP probably do not increase risk
Atrophy (nonspecific vs. mumps orchitis)
- Speculative
57
Q

Symptoms of testicular cancer

A

Painless swelling / mass
30-40% dull / aching sensation
10% present with metastatic symptoms

Gynecomastia:

  • 5% germ cell
  • 30-50% Sertoli/Leydig

1-2% have bilateral disease at diagnosis
More common on the right

58
Q

Workup for testicular cancer

A

Exam
U/S
CXR +/- Chest CT

Abdominal CT

  • Can identify small nodal deposits <2 cm
  • MRI and PET scan no advantage over CT

Serum markers: AFP, BHCG and LDH

  • Elevation after orchiectomy represents metastatic disease
  • Conversely normalization does not rule out metastatic disease

** Fertility preservation – Sperm Bank

59
Q

Risk stratification

A

Seminoma: good/moderate risk

Non-seminoma: good/moderate or poor risk
Poor risk seminoma:
- May have metastases, mediastinal primary tumor
- AFP > 10,000, HCG> 50,000, LDH > 10x upper limit of normal

60
Q

Isochromosome 12p

A

Patients with testicular cancer (80-90%) will gain short arm of chromosome 12p
- Not 100% specific, but highly diagnostic

61
Q

Alpha-Fetoprotein

A

Expressed by the early embryo (also liver and GI tract)

  • Half-life: 5-7 days
  • Produced by pure embryonal, teratocarcinoma, yolk sac, mixed tumors (NOT pure choriocarcinoma or seminoma)
  • Falsely elevated in liver dysfunction, viral hepatitis and ETOH
    • Presence of AFP in what’s thought to be pure seminoma suggests a mixed tumor
62
Q

Human chorionic gonadotropin

A

Secretory product of the placenta
Alpha unit (LDH,FSH,TSH) and beta unit
Half-life: 24-36 hours

Produced by syncytiotrophoblastic tissue

All choriocarcinomas, 40-60% embryonal, 5-10% seminoma

Falsely elevated in hypogonadism and marijuana use

63
Q

Lactate dehydrogenase

A
  • Presents normally in smooth, cardiac and skeletal muscle, liver and brain
  • Most useful in advanced seminoma or tumors where other markers are not elevated
  • Many false positives

LDH correlates to tumor burden

64
Q

Radical orchiectomy

A

Inguinal approach

  • Avoid seeding the scrotum and disrupting lymphatics
  • Wait 5 half lives before rechecking markers
  • Biopsy not recommended due to the risk of tumor spread
65
Q

Treatment of seminoma

A

Stage I: carboplatin

Stage II: Radiotherapy, chemotherapy (bleomycin)
- Marker positive: chemotherapy

Stage IIC, III:

  • Cisplatin based chemo (4 cycles of EP or 3 cycles of BEP)
  • 90% will have a complete response
  • Residual retroperitoneal masses are usually fibrosis
  • RPLND warranted if >3cm and well circumscribed
66
Q

RPLND: retroperitoneal lymph node dissection

A

Stage and remove lymph nodes that drain lymph nodes

- Can cause ejaculatory dysfunction (hence sperm-banking beforehand important)

67
Q

Risk factors for prostate cancer

A

Increased risk with first degree relative: 2.5 odds ratio)

  • 2-3 first degree relatives: 2-10 fold increase
  • Also increased risk with familial breast cancer history

Hereditary prostate cancer (HPC) meet at least one criteria:

  1. Family including prostate cancer in >3 first-degree relatives
  2. Family with prostate cancer in three successive generations of the maternal or paternal lineages
  3. Family with two first-degree relatives affected at age ≤ 55 years
68
Q

Screening for Prostate cancer

A
  1. Digital rectal exam:
    Various organizations recommend annual testing (digital rectal exam)
    - Age varies from 35 to 50 based on risk
    - Screen with 10 year life expectancy
    Some are more cautious; more discussion with patient
    - No uniform guidelines; testing controversial
  2. PSA: Biggest concerns:
    - Over diagnosis of clinically unimportant cancers leading to over-treatment
    - PSA may not detect all cancers

**Starting at age 30, men have 1/3 chance of having cancerous foci in prostate

69
Q

Interpreting PSA

A

Increased PSA: Prostatitis, BPH, cancer, prostatic trauma, ejaculation (rarely), NOT routine rectal exam

Decreased PSA: Antibiotics with infection, Tx prostate cancer , meds (finasteride/dutasteride)

  • 20% assay variability
  • No lower PSA limit eliminates cancer risk
  • As a rule of thumb PSA level of 2.5 ng/dL can be considered abnormal
  • Changes in PSA (velocity) better than absolute level
  • With cancer, PSA > 20 ng/dL more likely mets** (high risk)
70
Q

Diagnosis of Prostate cancer

A

ONLY through biopsy

  • Trans-rectal ultrasound with local anaesthesia
  • 10-12 core biopsy as lesions rarely seen on ultrasound/CT
71
Q

Staging prostate cancer

A

T1= inapparent tumor (not palpable, visible by imaging)- detected with PSA
T2- confined to prostate (most diagnoses here)
T3- outside prostate (through capsule)
T4- invading local structures (bladder wall)

72
Q

Gleason scoring

A

Histopathologic tumor architecture score

Gleason 1: normal glands
Gleason 2: Smaller, more numerous glands
Gleason 3: tight glands with lumen still present
Gleason 4: glands within glands
Gleason 5: Halo around nuclei, sheets of cells

Gleason > 5 = addition of primary and secondary architectural pattern

Gleason 8, 9, 10= high risk

73
Q

Prostate cancer NCCN Risk Categories

A
  1. Low risk
    - T1-2a, Gleason Score ≤ 6, and PSA < 10 ng/mL
  2. Intermediate risk
    - T2b-2c and/or Gleason Score 7, and/or PSA 10-20 ng/mL
  3. High risk
    - T3a or Gleason Score 8-10, or PSA > 20 ng/mL
74
Q

Management of low risk prostate cancer

A
  1. Active surveillance:
    - PSA, digital rectal, regular biopsies
    - Die “with” rather than from prostate cancer
  2. Radical prostatectomy
    - remove prostate through 5” incision
    - Nerve sparing preserves potency
    - PSA should be 0 afterwards
    - No rectal issues
    - Cons: operation, urethral narrowing, ED, incontinence
  3. External beam radiation therapy
    - Intensity modulated radiation therapy
    - Can dose to rectum, bladder
    - Grade dosage to prevent radiation to external structures
  4. Prostate brachytherapy
    - Insert probe in rectum, implant radioactive seeds around prostate (spare urethra)
75
Q

Treatment of Metastatic prostate cancer

A

Androgen deprivation therapy: ADT

  1. GnRH analogs: Lower LH–> decrease testosterone therapy
  2. Anti-androgen therapy: block testosterone production
  3. Surgical orchiectomy

Side effects of androgen deprivation therapy:

  • Fatigue
  • CV morbidity
  • Loss of libido
  • Cognitive decline
  • Altered body composition
  • Arterial stiffness
  • Osteoporosis/ Skeletal fractures
  • Metabolic syndrome
76
Q

Clinical presentation of urolithiasis (stones)

A

Asymptomatic

  • Many times found Incidentally
  • Non-obstructing stones usually cause no pain

Symptomatic (Renal Colic)

  • Symptoms are secondary to obstruction
  • Intermittent flank pain, nausea, vomiting
  • Hematuria
  • Groin pain, lower urinary tract symptoms
    • Read Cope’s Early Diagnosis of the acute abdomen
77
Q

Ureteral stone emergencies

A

Obstructing Ureteral Stones
- May cause sepsis (fever, hypotension, tachycardia, mental status changes)

Obstructed Solitary Kidney
- s/p nephrectomy or atrophic / natural history
Bilateral Obstruction
- Simultaneous obstructing ureteral stones
*** ANURIA, fluid overload, hyperkalemia, metabolic acidosis (MAY REQUIRE EMERGENT DIALYSIS)

Treatment:

  1. Ureteral stent (go up urethra)
  2. Percutaneous nephrostomy: Go through back into kidney collecting system to drain kidney
  3. Extracorporal shock-wave lithotrypsy (ESWL)
  4. Ureteroscopy with laser lithotripsy
  5. Surgical excision
  6. Medical treatment
  7. Observation
78
Q

ESWL= extracorporal shock-wave lithotripsy

A

Localize stone with fluoroscopy or U/S

  • Popular with patients & urologists
  • 60 – 90% success rate
  • Time for fragment passage varies.

Contraindications:

  • Anticoagulation
  • Pregnancy
  • AAA
  • Distal obstruction, infection

Side effects:

  • Hematoma (1 in 500)
  • Steinstrasse= stone street: column of stone dust accumulating in distal ureter
79
Q

Ureteroscopy with lase lithotripsy

A

Long, thin, flexible

  • Dual deflection
  • Holmium laser
  • Nitinol baskets allows for active stone removal
  • Usually requires stent
  • Safe in pregnancy, anticoagulation

Complications:

  • Ureteral stricture
  • Stent encrustation (if patient doesn’t have stent removed in timely manner)
80
Q

PCNL: percutaneous nephrolithiasis

A

Used for renal staghorn calices (large stones)

  • Percutaneous Access via peripheral calyx
  • Ultrasonic lithotripter breaks and suctions out stone
  • Most efficient
  • Most invasive
Risk:
Hemorrhage:
- Acute (10% transfusino rate)
- Delayed (pseudoaneurysm, AV malformation)
Infection
Renocutaneous fistula
Damage to surrounding organs
Intrarenal scarring
Renal loss
81
Q

Surgical excision

A
  • Open surgery rarely used today
  • Laparoscopy and robotics have renewed interest
  • Look for old incisions: may indicate strictures
82
Q

Medical treatment: dissolution therapy

A
  • Pure uric acid stones will dissolve with urinary alkalinization.
  • Urine pH (6.5 – 7.0)
  • Potassium Citrate
  • Na Bicarbonate
  • Calcium stones cannot be dissolved.
83
Q

Observation of stones: when to observe vs intervene

A

Ureteral Calculi:

  • <5mm can have trial of passage
  • Larger ureteral stones require treatment

Renal Calculi
- May be observed if not obstructing

Staghorn Calculi

  • Require treatment
  • Natural history: Infection, abscess, atrophy, potential for emergent nephrectomy
84
Q

Prevention of kidney stones

A

50% of stone patients will get recurrent stone within 5 yrs

Surgery alone does not prevent future stone formation

Identifiable abnormalities which predispose to stone formation found in over 90% of stone formers

20% of new stone formers demonstrate systemic disorder predisposing to stone formation

Correction of abnormalities may reduce recurrence rates

85
Q

Metabolic evaluation in nephrolithiasis

A

Serum testing:
- SMA-7, Ca, Mg, PO4, PTH, uric acid (urate)

Urine testing

  • 24 hr urine electrolyte testing
  • UA and urine culture

Chemical stone analysis

86
Q

Identifiable abnormalities in nephrolithiasis

A

Hypercalcuria (> 200 mg calcium excreted in 24 hrs) due to:

  1. Increased intestinal absorption (normal serum PTH, serum Ca but elevated urine Ca)
  2. Renal hypercalcuria: slight elevation in serum PTH (can develop osteoporosis over time), normal serum calcium, elevated urine calcium
  3. Primary hyperparathyroidism: elevated PTH, elevated serum calcium, elevated urine ca

Hyperoxaluria

  1. Enteric hyperoxaluria: super-absorbers of oxalate thru gut due to:
    - Inflammatory bowel disease (Crohn, UC) or surgical resection of bowel
    - -> intestinal fat malabsorption
    - -> saponification
    - -> Ca moves out with fat, Oxalate crystals get reabsorbed

Hyperuricosuria (> 600 mg uric acid excreted in 24 hrs)

Hypocitraturia: Lack of citrate (natural stone inhibitor)

87
Q

Conservative managment of calcium stones

A

Consider before medical managment
Empiric diet and lifestyle modifications
1. Hydration: urine output > 2500 cc/day
2. Limit sodium: 2300-3300 mg/day
3. Normal calcium: 800-1200 mg/day
4. Limit oxalate (plants, plant byproducts)
5. Limit red meat (no more than 6-8 oz/day)

88
Q

Thiazides for calcium stones

A
  1. Augments Ca reabsorption in distal tubule
  2. Reduces urinary saturation of Ca
  3. Retained calcium accreted in bone
  4. Eventual attenuation of effect in absorptive hypercalciuria

Side effects:

  1. Wastes K: check labs, consider adding K-citrate)
  2. Limited effectiveness with persistant high dietary Na
  3. Rash, pancreatitis, elevated LDH, impotence (contraindicated with high serum calcium)
89
Q

Potassium citrate for calcium stones

A

Citrate= natural stone inhibitor (forms soluble complex with calcium)

Side effects:

  1. Dyspepsia (contraindicated in peptic ulcer disease
  2. Hyperkalemia (caution with K-sparing meds, ACE-I; renal insufficiency)
90
Q

Urine pH and stone formation

A

Alkalinze patient’s urine–> prevent uric acid precipitation

- Also lower uric acid levels in patient’s blood to prevent stones

91
Q

Insulin resistance and increased urine acidity

A

Higher incidence of uric acid stone formation in type 2 DM stone formers than non-diabetic stone forming pts (34% vs 6%).

Prevalence of DM or impaired glucose tolerance over 50% in uric acid stone formers.

MECHANISM: Insulin resistance at level of PCT leads to defective ammonia production and excessive urine acidity due to unbuffered H+

92
Q

Uric acid stone prevention and dissolution

A

Dietary Modification:

  1. Increase fluids (generate 2- 3 Liters urine per day)
  2. Limit purine intake ( 6- 8 oz meat per day)
  3. Limit sodium (2300 – 3300 mg per day)

Medication

  1. Increase uric acid solubility
    - Potassium citrate 20 – 60 meq / day
    - Sodium bicarbonate 1.3 – 2.6 grams / day
    - Stones dissolve 1 cm per month (depends on compliance)
    - pH range 6.5 – 7.0
  2. Reduce uric acid concentration
    - Allopurinol 100 – 300 mg /day (Inhibits enzyme xanthine oxidase)
    - Use only if UUA still elevated after urine alkalinized
93
Q

Struvite stone treatment

A

Formed due to Proteus infection (urease-producing bacteria)

  1. Surgical removal of all stone burden
  2. Correction of anatomic abnormality if possible
  3. Culture specific antibiotics
  4. IRRIGATE, IRRIGATE, IRRIGATE (if applicable)
  5. Long term culture specific antibiotic suppression
    - Pen VK 250 mg po daily for 6 mos
  6. Acetohydroxamic Acid (urease inhibitor)
    - 80% stone growth arrest (vs 40% placebo)
    - Multitude of complications: Palpitations, Edema, rash, Nausea, vomit, diarrhea, Headache, loss of taste, hallucination
94
Q

Cystine nephrolithiasis

A

Rare stone type (1 – 3%)
Autosomal recessive inherited disorder with defective renal transport of dibasic amino acids
- Cystine
- Ornithine
- Lysine
- Argenine
* Cystine poorly soluble in urine (250 mg/ Liter)
See Hexagonal crystals, positive Nitroprusside Test

95
Q

Treatment for cystine stones

A
  1. Surgical considerations: very dense (ESWL resistant)
  2. Increase fluids
  3. Low methionine diet (meat, eggs; precursor to cystine)
  4. Limit sodium (increases renal cystine excretion)
  5. Alkalinization (limited role)
  6. Chelating Agents
    - Captopril
    - D-penicillamine (Add pyridoxine to prevent Vit B6 Deficiency)
    - Thiola
96
Q

BPH: pathophysiology

A
  1. Mechanical Component
    - Glandular proliferation
  2. Dynamic Component
    - Baseline tonicity of smooth muscle (activated by alpha receptors)

** Prostate enlargement in BPH driven by androgens= dihydrotestosterone (DHT)

97
Q

BPH: clinical presentation

A

Obstructive symptoms:

  • Decreased force of stream
  • Feeling of incomplete emptying
  • Intermittency (double voiding)
  • Hesitancy (delay of onset of voiding)
  • Need to strain to empty bladder

Irritative:

  • Frequency of urination
  • Urgency (strong desire to void)
  • Nocturia (waking to urinate)
  • Dysuria (pain during urination)
  • Hematuria (blood in urine)
98
Q

BPH: evaluation

A
  1. Assess symptoms: AUA symptom score:
    - 7 questions: Incomplete emptying, frequency, intermittency, urgency, weak stream, straining, nocturia
    - Each question has severity (1-5)
    - Mild= 0-7; moderate= 8-19; severe= 20-35
  2. Labs: serum creatinine, PSA, urinalysis, urine culture
  3. Check PVR (post-void residual)
    - Remaining volume after micturation
    - Transabdominal U/S or catheterization
  4. Renal ultrasound:
    - Check for hydronephrosis, cortical thinning
99
Q

BPH: treatment

A
  1. Observation
  2. Medical management
    - Alpha blockers
    - 5-alpha reductase inhibitors
  3. Surgery
    - Various methods of clearing bladder outlet (TURP, etc)

Indications for surgery:

  • Refractory urinary retention (may require catheters.
  • Recurrent UTI
  • Renal Insufficiency
  • Bladder calculi
  • Recurrent gross hematuria from prostate

Risks:

  • bleeding, bladder neck contracture
  • Retrograde ejaculation (30-97%)- usually indicator of treatment effectiveness
  • Tranurethral syndrome: absorption of hypotonic solution used in TURP procedure (hyponatremia)
100
Q

Coude catheter

A

Foley catheter with 35 degree bent angle

Practical for catheterizing BPH patients

101
Q

Stress urinary incontinence

A 
More common in women
Risk factors
- Obesity
- Parity
- Route of delivery (vaginal delivery vs C-Section)
Leakage with increase in intra-abdominal pressure (cough, sneeze, laugh)
ALPP (Abdominal leak point pressure)
- Normal ALPP is infinity
- Severe SUI has low ALPP

Treatment

  • Slings
  • Collagen Injection
102
Q

Urge incontinence

A

Involuntary loss of urine associated with strong sudden desire to void
Hyperactive detrusor muscle

Treatment

  • Medical (anticholinergics)
  • Surgery (botox injections, neurostimulator)
  • Lifestyle modifications
103
Q

Continuous incontinence

A

Continual leakage of urine
Fistulas
- Vesicovaginal (3rd world country with prolonged labor)
- Ureterovaginal (radiation, pelvic surgery)

Ectopic ureter
- Usually presents in pediatric population

104
Q

Transient incontinence

A

Reversible, transient loss of urine
* Usually associated with mental status changes in geriatric population

D.I.A.P.P.E.R.S.
Delirium
infection
atrophic vaginitis
pharmaceuticals
psychological problems
excess urine output
Restricted mobility
Stool impaction

Renal/Skeletal (11 decks)

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