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Surgery > urology > Flashcards

urology Flashcards

1
Q

2nd MC of malignancy of the GU tract

A

bladder neoplasms

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2
Q

most bladder cancers are invasive or non invasive

A

non-invasive (more favorable outsomes)

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3
Q

MC type of bladder neoplasm

A

urothelial cell carcinoma (formerly transitional cell)

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4
Q

RF for bladder neoplasms

A

current or former smoker

occupational exposure

genetic factors

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5
Q

bladder neoplasm sxs (MC)

A

painless hematuria (macro or micro)

voiding sxs

urgency
frequency
painful urination

can be mistaken for a UTI

sometimes detected on imaging

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6
Q

diagnostic tests for bladder neoplasms

A

urinalyses

urine culture

cystoscopy to look at the upper tract

urine cytology (can detect uroplastic cells in the urine)

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7
Q

what is a TURBT

A

Transuretheral resection of bladder tumor

both diagnostic and therapeutic

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8
Q

CT urogram is necessary because

A

could have a cancer in the upper tract

need CR check prior because need to be able to process dye

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9
Q

when to avoid IVC (intravesicle chemotherapy)

A

NOT wiht bladder perfs

but can reduce cancer reoccurence by 35%

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10
Q

TUR syndrome

A

irrigant used in TURBT can make you hyponatremic

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11
Q

when would chemo be indicated for baldder neoplasm

A

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

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12
Q

what does F/U for bladder enoplasms look like

A

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

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13
Q

when is upper tract imagining needed after TURBT

A

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

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14
Q

hutch diverticula management

A

Partial cystectomy with diverticulectomy is preferred

bladder cancer in diverticula does require cystectomy or partial cystectomy

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15
Q

other than diverticula involved bladder neoplasms whata re some indications for partial cystectomy

A

< 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)

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16
Q

BCG implications for NMIBC tx

A

can be used for immune treatment but if refractory or large may require complete cystecomty

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17
Q

other than refractory to chemo when would a radical cystectomy be implicated

A

very large >10cm

varaitn tumor histology

bladder cripple

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18
Q

what is a “Bladder cripple”

A

Small capacity

contracted bladders (from repeated TURBT or intravesical therapy)

Neurogenic bladder (often incontinent & miserable)

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19
Q

Hydronephrosis is a strong predictor of

A

upstaging to extravesical disease & independent predictor of a worse prognosis

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20
Q

chemo therapy agent most used in the treatment of NMIBC

A

BCG

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21
Q

dx for invasive bladder cancers

A

CT chest
AP lateral

CT abd and pelvis
MRI

CBC
LFTS
Creatinine with GFR

aklaine phos

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22
Q

what is the goldstandard of treatment of MIBC

A

treatment for muscle invasive bladder cancer

Radical cystectomy with or without neoadjuvant chemotherapy

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23
Q

male radical cystectomy for bladder neoplasm usually involves removal of (1)

A

Removal of:

  • bladder
  • perivesical fat
  • prostate
  • seminal vesicles

& prostatic urethra

Nerve-sparing surgery as in prostatectomy

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24
Q

what is not normally performed in a radical cystectomy (male) until positive margin is determined??

A

urethrectomy

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25
Q

what does a radical cystectomy in a female look like

A

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

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26
Q

Muscle Invasive Bladder Cancer: Surgical Complications (top two)

A

gastrointestinal complications and

infection

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27
Q

incontinent types of urinary diversion

A

ileal condut

segment of the intestine is turned into a stoma from the uretors

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28
Q

other than ileal conduit what type of urinary diversions can be performed

A

orthotopic neobladder

continent cutaneous reservoir

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29
Q

important considerations if terminal ilium is utilized in diversion

A

If terminal ileum utilized in diversion –> patient needs vitamin B12 supplementation for life

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30
Q

complications of ileal conduit

A

upper tract deterioration over the long term

UTI

stomal or parastomal hernia

peri-stoma skin irritation/infection/ulceration

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31
Q

orthotopic urinary reconstruction

important consideration for studer pouch

A

of or relating to the grafting of tissue in natural

NEED to have a negative urethral margin

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32
Q

how is the continence maintained in a continent cutaneous reservoir

A

maintained by ileo cecal valve

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33
Q

bladder stones are usually seen in some type of

A

outlit obsturction

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34
Q

Preferred method of cystolitholopaxy in pediatric patients

A

percutaneous suprapubic

NOT

transurethral

but that’s more common

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35
Q

what are come complications of cystolitholapaxy

A

UTI bleeding
perforation of bowel
urethral stricture

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36
Q

RF for kidney neoplasms (RCC)

A 
smoking
HTN
male 
occupation exposure
acquired renal cystic disease
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37
Q

Kidney Neoplasms MC and Most agressive

A

CLEAR CELL RCC (most aggressive)

Arises from proximal convoluted tubule

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38
Q

kidney neoplasms -classic triad

A

Flank mass
Hematuria
Pain

occurs in ~10% of patients

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39
Q

other sytmptoms not in the classic triad for RCC

A

Fever, chills, weight loss, cachexia
Anemia
Elevated erythrocyte sedimentation rate,
C-reactive protein, alkaline phosphatase, &calcium
Polycythemia-high hmt and gb

40
Q

labs for RCC

A

CBC, CMP, UA

41
Q

PN should be prioritized in patients with:

A 
Anatomic or functional solitary kidney
Bilateral renal tumors
Known familial RCC
Pre-existing CKD
Proteinuria
42
Q

Determinants of long-term renal function after PN:

A

Pre-op renal function

Warm ischemia duration (≤ 25 mins optimal)

Comorbidities

Amount of preserved kidney

43
Q

RN preferred for higher risk kidney tumors IF following criteria are met

A

High tumor complexity with risk of complications

No existing CKD or proteinuria

Normal contralateral kidney with anticipated post-op GFR > 45

44
Q

RN compared to partial nephrectomy

A

Less incidence of hemorrhage

Less incidence of urine leak / fistula

Less re-operation complications

RN increases the risk of CKD as compared to PN

45
Q

when would you use thermal ablation to treat RCC

A

Thermal ablation is an option for renal masses localized to kidney ≤ 3 cm in diameter

46
Q

labs you need after treating RCC

A

BUN
Creatinine,
UA, eGFR
(possible CBC, LDH, LFTs, alkaline phosphatase (ALP), Calcium)

47
Q

kidney neoplasms

A

Flank mass
Hematuria
Pain

occurs in ~10% of patients

48
Q

other sytmptoms not in the classic triad for RCC

A

Fever, chills, weight loss, cachexia
Anemia
Elevated erythrocyte sedimentation rate,
C-reactive protein, alkaline phosphatase, & calcium
Polycythemia

49
Q

labs for RCC

A

CBC, CMP, UA

50
Q

PN should be prioritized in patients with:

A

Removal of tumor with negative surgical margins
Renal reconstruction
Approaches: open, laparoscopic, robotic

51
Q

Determinants of long-term renal function after PN:

A

Pre-op renal function

Warm ischemia duration (≤ 25 mins optimal)

Comorbidities

Amount of preserved kidney

52
Q

Kidney Neoplasms (RCC)

A

High tumor complexity with risk of complications

No existing CKD or proteinuria

Normal contralateral kidney with anticipated post-op GFR > 45

53
Q

RN compared to partial nephrectomy

A

Less incidence of hemorrhage

Less incidence of urine leak / fistula

Less re-operation complications

RN increases the risk of CKD as compared to PN

54
Q

when would you use thermal ablation to treat RCC

A

Thermal ablation is an option for renal masses localized to kidney ≤ 3 cm in diameter

55
Q

labs you need after treating RCC

A

BUN
Creatinine
UA
eGFR (possible CBC, LDH, LFTs, alkaline phosphatase (ALP), Calcium)

56
Q

majority of relapses in RCC occur when

A

Majority of relapses occurs within first 3 years following surgery
More rigorous follow-up in first 3 years post-op

57
Q

characteristic of kidney stone pain

A

Flank pain
Abdominal pain / Groin pain (depends on stone location)

pain DOES NOT cross midline

58
Q

shortcomings of xray for stones

A

Unable to visualize radiolucent stones (uric acid stones)

Poorly sensitive for stones overlying the
bony pelvis

59
Q

preferred diagnostic test for renal stones

A

CT favored over IVP

“Low dose” CT available

60
Q

cons of uLS for stone dx

A

Poorly visualizes stones located in ureter has limited sensitivity for stones < 2-3 mm

61
Q

SE associated with flomax

A

(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

62
Q

Urgent stent placement vs. Nephrostomy tube placement

when would it be indicated

A

Indicated in the setting of obstruction & signs of infection (fever, leukocytosis, hemodynamic instability)

63
Q

CI and consideration for lithotripsy (SWL) / Extracorporeal Shockwave Lithotripsy (ESWL)

A

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

64
Q

complications of SWL

A

Risk of “steinstrasse” (German for “stone street”) with large stones treated with SWL / ESWL

Renal injury
Contusion
Hemorrhage

Hypertension

Diabetes mellitus

Renal impairment

65
Q

Percutaneous Nephrolithotomy (PCNL) what is it and what is it reserved for

A

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

66
Q

gold standard in the treatment of BPH

A

Electrosurgical-based TURP is the GOLD STANDARD treatment in BPH

67
Q

what does TURP stand for?

A

Transurethral Resection of the Prostate (TURP)

Electrosurgical-based TURP is the GOLD STANDARD treatment in BPH

68
Q

indications for TURP

A

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

69
Q

complications of TURP

A

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 &amp; self-limiting)
Retrograde ejaculation (60-90%)
Need for re-operation (3-8%)
70
Q

what is a urolift

A

Involves implantation of tissue retracting elements inserted under cystoscopic guidance using the Urolift® delivery system

71
Q

Consider simple prostatectomy over TURP in the following:

A

Large prostates –> 80 g or larger

Patients who need additional procedures (diverticulectomy, bladder stone removal)

72
Q

screening for prostate cancer

A

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

73
Q

PSA testing not recommended in

A

Routine PSA screening not recommend in men over 70 y.o. or men with a life expectancy of less than 10-15 years

74
Q

how would you normally diagnose prostate cancer

A

Prostate biopsy when prostate cancer is suspected

If biopsy negative but PSA continues to rise
consider multiparametric MRI

75
Q

Gold standard of definitive therapy in patients that are surgical candidates
for prostate cancer

A 
Radical Prostatectomy (RP)
Robotic-assisted * msot common but there is also

Open retropubic *
Laparoscopic
Open perineal

76
Q

(RALP)

A

Robotic-Assisted Laparoscopic Prostatectomy (

77
Q

follow up for RALP

A

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

78
Q

screening after s/p prostatectomy for cancer

A

PSA in 3 months; will continue to track PSA

79
Q

most common type of testicular tumor

and most common presentation

A

Germ cell tumors (95%)

Seminoma: localized seminoma most common presentation (50% of cases)

Non-seminoma germ cell tumors (NSGCT

80
Q

3 RF for testicular cancer

A

Cryptorchidism (undescended testicle)

Intra-tubular germ cell neoplasia (ITGCN)

Family or personal history of testicular cancer

81
Q

other than a mass what other sxs might you expect to see with a testicular cancer

A

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)

82
Q

workup for testicular cancer (think tumor markers and imaging)

A

Alpha-fetoprotein (AFP)

Beta-human chorionic gonadotropin (bHCG),

lactate dehydrogenase (LDH)

Also, consider CT or MRI to assess for lymph node involvement

83
Q

screening most testicular resection

Men with stage I cancer &; no risk factors for relapse

A

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)

84
Q

most common renal tumor of childhood

A

Wilm’s Tumor

Accounts for 6-7% of all childhood cancers
Median age is 3.5 years at presentation

85
Q

Classic pathologic finding (triphasic pattern containing 3 cell types):

A

Blastemal, Stromal, Epithelial

86
Q

how does wilm’s tumor arise

A

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

87
Q

treatment of wilm’s will depend on

A

High propensity for tumor rupture

Intra-op tumor spillage results in UPSTAGING & requires abdominal RADIATION

88
Q

“unfavorable histology” with wilm’s tumor

A

Tumors with ANAPLASIA (large nuclei, abnormal mitotic figures, & hyperchromasia) = “unfavorable histology”

Patients with above features have higher risk for relapse or death

89
Q

SXS wil Wilm’s

A

wagger

Aniridia

hemihypertrophy

Abdominal pain, hematuria,

HTN also possible symptoms

90
Q

Aniridia

A

absence of the iris

91
Q

hemihypertrophy

A

overgrowth of one side of the body as compared to the other

92
Q

biopsies with Wilm’s tumor

A

Pre-op & Intra-op biopsies are usually CONTRAINDICATED

93
Q

Chemotherapy utilized pre-operatively with wilm’s in

A

Bilateral WT
Predisposition syndromes
Solitary kidney

94
Q

definitve treatment of stones

A

Ureteroscopy (URS)

95
Q

definitve treatment of stones

A

Ureteroscopy (URS)

Surgery (18 decks)

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