urology Flashcards
2nd MC of malignancy of the GU tract
bladder neoplasms
most bladder cancers are invasive or non invasive
non-invasive (more favorable outsomes)
MC type of bladder neoplasm
urothelial cell carcinoma (formerly transitional cell)
RF for bladder neoplasms
current or former smoker
occupational exposure
genetic factors
bladder neoplasm sxs (MC)
painless hematuria (macro or micro)
voiding sxs
urgency
frequency
painful urination
can be mistaken for a UTI
sometimes detected on imaging
diagnostic tests for bladder neoplasms
urinalyses
urine culture
cystoscopy to look at the upper tract
urine cytology (can detect uroplastic cells in the urine)
what is a TURBT
Transuretheral resection of bladder tumor
both diagnostic and therapeutic
CT urogram is necessary because
could have a cancer in the upper tract
need CR check prior because need to be able to process dye
when to avoid IVC (intravesicle chemotherapy)
NOT wiht bladder perfs
but can reduce cancer reoccurence by 35%
TUR syndrome
irrigant used in TURBT can make you hyponatremic
when would chemo be indicated for baldder neoplasm
Chemo started 2-6 weeks after turbt
NMIBC with high risk of recurrence
]NMIBC with high risk of progression
Carcinoma in situ
Residual tumor
High and intermediate risk of reoccurrence
what does F/U for bladder enoplasms look like
lifetime surveillance because high rates of reoccurrence
should have a cystoscopy every 3-6 months fora year
if they do find a tumor after the administration of chemotherapy cycles then bladder surveillance starts again
high risk stay at 3 months
if low risk can drop down to 6/9 months and then annually for 5 years
when is upper tract imagining needed after TURBT
Low risk NMIBC (non-muscle invasive bladder cancer)
If asymptomatic, do NOT perform routine surveillance upper tract imaging
high risk will require CT urogram every 1-2 years
or mR urograph
hutch diverticula management
Partial cystectomy with diverticulectomy is preferred
bladder cancer in diverticula does require cystectomy or partial cystectomy
other than diverticula involved bladder neoplasms whata re some indications for partial cystectomy
< 3 cm in size
Not associated with carcinoma in situ
Located in a favorable anatomic location ( not in the urethral orifices)
Radical cystectomy is not commonly performed for non-muscle invasive bladder cancer (NMIBC)
BCG implications for NMIBC tx
can be used for immune treatment but if refractory or large may require complete cystecomty
other than refractory to chemo when would a radical cystectomy be implicated
very large >10cm
varaitn tumor histology
bladder cripple
what is a “Bladder cripple”
Small capacity
contracted bladders (from repeated TURBT or intravesical therapy)
Neurogenic bladder (often incontinent & miserable)
Hydronephrosis is a strong predictor of
upstaging to extravesical disease & independent predictor of a worse prognosis
chemo therapy agent most used in the treatment of NMIBC
BCG
dx for invasive bladder cancers
CT chest
AP lateral
CT abd and pelvis
MRI
CBC
LFTS
Creatinine with GFR
aklaine phos
what is the goldstandard of treatment of MIBC
treatment for muscle invasive bladder cancer
Radical cystectomy with or without neoadjuvant chemotherapy
male radical cystectomy for bladder neoplasm usually involves removal of (1)
Removal of:
- bladder
- perivesical fat
- prostate
- seminal vesicles
& prostatic urethra
Nerve-sparing surgery as in prostatectomy
what is not normally performed in a radical cystectomy (male) until positive margin is determined??
urethrectomy
what does a radical cystectomy in a female look like
removal of the bladder and
the enterior pelvic exenteration which the uterus cervix fallopian tubes ovaries anterior vagina
if in a low stage can consider bladder sparing techniques
Muscle Invasive Bladder Cancer: Surgical Complications (top two)
gastrointestinal complications and
infection
incontinent types of urinary diversion
ileal condut
segment of the intestine is turned into a stoma from the uretors
other than ileal conduit what type of urinary diversions can be performed
orthotopic neobladder
continent cutaneous reservoir
important considerations if terminal ilium is utilized in diversion
If terminal ileum utilized in diversion –> patient needs vitamin B12 supplementation for life
complications of ileal conduit
upper tract deterioration over the long term
UTI
stomal or parastomal hernia
peri-stoma skin irritation/infection/ulceration
orthotopic urinary reconstruction
important consideration for studer pouch
of or relating to the grafting of tissue in natural
NEED to have a negative urethral margin
how is the continence maintained in a continent cutaneous reservoir
maintained by ileo cecal valve
bladder stones are usually seen in some type of
outlit obsturction
Preferred method of cystolitholopaxy in pediatric patients
percutaneous suprapubic
NOT
transurethral
but that’s more common
what are come complications of cystolitholapaxy
UTI bleeding
perforation of bowel
urethral stricture
RF for kidney neoplasms (RCC)
smoking HTN male occupation exposure acquired renal cystic disease
Kidney Neoplasms MC and Most agressive
CLEAR CELL RCC (most aggressive)
Arises from proximal convoluted tubule
kidney neoplasms -classic triad
Flank mass
Hematuria
Pain
occurs in ~10% of patients
other sytmptoms not in the classic triad for RCC
Fever, chills, weight loss, cachexia
Anemia
Elevated erythrocyte sedimentation rate,
C-reactive protein, alkaline phosphatase, &calcium
Polycythemia-high hmt and gb
labs for RCC
CBC, CMP, UA
PN should be prioritized in patients with:
Anatomic or functional solitary kidney Bilateral renal tumors Known familial RCC Pre-existing CKD Proteinuria
Determinants of long-term renal function after PN:
Pre-op renal function
Warm ischemia duration (≤ 25 mins optimal)
Comorbidities
Amount of preserved kidney
RN preferred for higher risk kidney tumors IF following criteria are met
High tumor complexity with risk of complications
No existing CKD or proteinuria
Normal contralateral kidney with anticipated post-op GFR > 45
RN compared to partial nephrectomy
Less incidence of hemorrhage
Less incidence of urine leak / fistula
Less re-operation complications
RN increases the risk of CKD as compared to PN
when would you use thermal ablation to treat RCC
Thermal ablation is an option for renal masses localized to kidney ≤ 3 cm in diameter
labs you need after treating RCC
BUN
Creatinine,
UA, eGFR
(possible CBC, LDH, LFTs, alkaline phosphatase (ALP), Calcium)
kidney neoplasms
Flank mass
Hematuria
Pain
occurs in ~10% of patients
other sytmptoms not in the classic triad for RCC
Fever, chills, weight loss, cachexia
Anemia
Elevated erythrocyte sedimentation rate,
C-reactive protein, alkaline phosphatase, & calcium
Polycythemia
labs for RCC
CBC, CMP, UA
PN should be prioritized in patients with:
Removal of tumor with negative surgical margins
Renal reconstruction
Approaches: open, laparoscopic, robotic
Determinants of long-term renal function after PN:
Pre-op renal function
Warm ischemia duration (≤ 25 mins optimal)
Comorbidities
Amount of preserved kidney
Kidney Neoplasms (RCC)
High tumor complexity with risk of complications
No existing CKD or proteinuria
Normal contralateral kidney with anticipated post-op GFR > 45
RN compared to partial nephrectomy
Less incidence of hemorrhage
Less incidence of urine leak / fistula
Less re-operation complications
RN increases the risk of CKD as compared to PN
when would you use thermal ablation to treat RCC
Thermal ablation is an option for renal masses localized to kidney ≤ 3 cm in diameter
labs you need after treating RCC
BUN
Creatinine
UA
eGFR (possible CBC, LDH, LFTs, alkaline phosphatase (ALP), Calcium)
majority of relapses in RCC occur when
Majority of relapses occurs within first 3 years following surgery
More rigorous follow-up in first 3 years post-op
characteristic of kidney stone pain
Flank pain
Abdominal pain / Groin pain (depends on stone location)
pain DOES NOT cross midline
shortcomings of xray for stones
Unable to visualize radiolucent stones (uric acid stones)
Poorly sensitive for stones overlying the
bony pelvis
preferred diagnostic test for renal stones
CT favored over IVP
“Low dose” CT available
cons of uLS for stone dx
Poorly visualizes stones located in ureter has limited sensitivity for stones < 2-3 mm
SE associated with flomax
(tamsulosin) flomax is used in conjunction with hydration and medical expulsion therapy (spontaneous stone passage)
floppy iris
if a pt has cataract surgery schedule with stones don’t use flomax
Urgent stent placement vs. Nephrostomy tube placement
when would it be indicated
Indicated in the setting of obstruction & signs of infection (fever, leukocytosis, hemodynamic instability)
CI and consideration for lithotripsy (SWL) / Extracorporeal Shockwave Lithotripsy (ESWL)
Stone located with fluoroscopy or ultrasound
Cannot target radiolucent stones (uric acid stones) without use of contrast
not ideal for stones low in the kidney or pelvic or uric acid stones
Pregnancy*
Coagulopathies
Presence of cardiac arrhythmia / pacemaker
Aortic aneurysm & Renal artery aneurysm
UTI
complications of SWL
Risk of “steinstrasse” (German for “stone street”) with large stones treated with SWL / ESWL
Renal injury
Contusion
Hemorrhage
Hypertension
Diabetes mellitus
Renal impairment
Percutaneous Nephrolithotomy (PCNL) what is it and what is it reserved for
Stone extraction with rigid or flexible nephroscope
Nephroscope can be used in conjunction with laser
Likely will require stent placement
Nephrostomy tube
Overnight stay in hospital at minimum (usually 1-2 days)
Percutaneous Nephrolithotomy (PCNL)
Large (>2 cm) stones
Complex stones
Staghorn calculi
Lower pole stones > 1 cm
Complex renal anatomy
gold standard in the treatment of BPH
Electrosurgical-based TURP is the GOLD STANDARD treatment in BPH
what does TURP stand for?
Transurethral Resection of the Prostate (TURP)
Electrosurgical-based TURP is the GOLD STANDARD treatment in BPH
indications for TURP
Acute urinary retention
Bladder calculi
Azotemia: elevation of blood urea nitrogen (BUN) & serum creatinine levels; abnormally high levels of nitrogen-containing compounds in the blood
Recurrent UTI
Recurrent hematuria
Worsening LUTS refractory to medical therapy
complications of TURP
Dilutional hyponatremia (TUR Syndrome, occurring in 1-2% of patients
ALSO
Urinary tract infections Urethral stricture (up to 10%) Urinary incontinence (up to 10%, usually mild & self-limiting) Retrograde ejaculation (60-90%) Need for re-operation (3-8%)
what is a urolift
Involves implantation of tissue retracting elements inserted under cystoscopic guidance using the Urolift® delivery system
Consider simple prostatectomy over TURP in the following:
Large prostates –> 80 g or larger
Patients who need additional procedures (diverticulectomy, bladder stone removal)
screening for prostate cancer
Screening in men between 40-54 y.o.
who are at average risk is not recommended
Men 55-69 y.o.
weigh risks & benefits of screening with patient
shared decision making between patient & provider
Consider screening every 1-2 years
PSA testing not recommended in
Routine PSA screening not recommend in men over 70 y.o. or men with a life expectancy of less than 10-15 years
how would you normally diagnose prostate cancer
Prostate biopsy when prostate cancer is suspected
If biopsy negative but PSA continues to rise
consider multiparametric MRI
Gold standard of definitive therapy in patients that are surgical candidates
for prostate cancer
Radical Prostatectomy (RP) Robotic-assisted * msot common but there is also
Open retropubic *
Laparoscopic
Open perineal
(RALP)
Robotic-Assisted Laparoscopic Prostatectomy (
follow up for RALP
Post-op:
JP drain
Discharged with foley for 10-14 days
Anastomosis needs to heal
Kegels
Erectile dysfunction counseling
Medication (for penile rehabilitation)
Vacuum erection device (VED) training
screening after s/p prostatectomy for cancer
PSA in 3 months; will continue to track PSA
most common type of testicular tumor
and most common presentation
Germ cell tumors (95%)
Seminoma: localized seminoma most common presentation (50% of cases)
Non-seminoma germ cell tumors (NSGCT
3 RF for testicular cancer
Cryptorchidism (undescended testicle)
Intra-tubular germ cell neoplasia (ITGCN)
Family or personal history of testicular cancer
other than a mass what other sxs might you expect to see with a testicular cancer
Abdominal mass (retroduodenal mets)
Anorexia, Nausea, Vomiting, GI hemorrhage
Back pain (retroperitoneal disease)
Bone pain (skeletal mets)
Central or peripheral nervous system symptoms (cerebral, spinal cord, or peripheral root involvement)
Supraclavicular mass (lymph node mets)
Cough, Hemoptysis, Shortness of breath (pulmonary mets)
workup for testicular cancer (think tumor markers and imaging)
Alpha-fetoprotein (AFP)
Beta-human chorionic gonadotropin (bHCG),
lactate dehydrogenase (LDH)
Also, consider CT or MRI to assess for lymph node involvement
screening most testicular resection
Men with stage I cancer &; no risk factors for relapse
Surveillance for 5-10 years following orchiectomy
CXR, CT, MRI
Serum tumor markers (AFP, bHCG, LDH) at scheduled intervals
Adjuvant chemotherapy
Radiation chemotherapy
Annual H&P (including testicular examination, lymph node & skin cancer survey)
most common renal tumor of childhood
Wilm’s Tumor
Accounts for 6-7% of all childhood cancers
Median age is 3.5 years at presentation
Classic pathologic finding (triphasic pattern containing 3 cell types):
Blastemal, Stromal, Epithelial
how does wilm’s tumor arise
Embryonal tumor developing from the remnants of the immature kidney
Most commonly occurs sporadically but 10% of children with WT have a congenital malformation syndrome
treatment of wilm’s will depend on
High propensity for tumor rupture
Intra-op tumor spillage results in UPSTAGING & requires abdominal RADIATION
“unfavorable histology” with wilm’s tumor
Tumors with ANAPLASIA (large nuclei, abnormal mitotic figures, & hyperchromasia) = “unfavorable histology”
Patients with above features have higher risk for relapse or death
SXS wil Wilm’s
wagger
Aniridia
hemihypertrophy
Abdominal pain, hematuria,
HTN also possible symptoms
Aniridia
absence of the iris
hemihypertrophy
overgrowth of one side of the body as compared to the other
biopsies with Wilm’s tumor
Pre-op & Intra-op biopsies are usually CONTRAINDICATED
Chemotherapy utilized pre-operatively with wilm’s in
Bilateral WT
Predisposition syndromes
Solitary kidney
definitve treatment of stones
Ureteroscopy (URS)
definitve treatment of stones
Ureteroscopy (URS)
