Urology

Question 1

bladder neoplasms

Answer 1

• In US, urothelial carcinoma is the 2^nd most common malignancy of the GU tract & 2^nd most common cause of all GU tumors
• Estimated 79,000 new cases of bladder cancer per year
• 16,800 deaths from bladder cancer in 2016 in US
• ¾ of bladder cancers are non-muscle invasive
• 20-40% present or progress to high-grade, muscle invasive disease
• Types of bladder cancer: urothelial cell carcinoma (formerly transitional cell), squamous cell, adenocarcinoma, non-urothelial tumors, non-epithelial tumors

Question 2

bladder neoplasm risk factors

Answer 2

• Current or former smoker
• Occupational exposures
• Genetic factors
• Lynch syndrome, also known as hereditary non-polyposis colorectal cancer (HNPCC), is a type of inherited cancer syndrome associated with a genetic predisposition to different cancer types. This means people with Lynch syndrome have a higher risk of certain types of cancer.
• People who have Lynch syndrome have a significantly increased risk of developing colorectal cancer. There is also an increased risk of developing other types of cancers, such as endometrial (uterine), stomach, breast, ovarian, small bowel (intestinal), pancreatic, prostate, urinary tract, liver, kidney, and bile duct cancers.

Question 3

bladder neoplasms presentation

Answer 3

• Hematuria (painless) is the most common presenting symptom
  
  • Macroscopic or microscopic hematuria
• Irritative voiding symptoms
  
  • Urgency, dysuria, frequency, nocturia
  • Sometimes mistaken for bacterial cystitis / UTI symptoms
    
    • May lead to worse prognosis for females with bladder cancer
• Bladder wall thickening / irregularities sometimes incidentally seen on imaging (CT)
• Irritative voiding symptoms more common in carcinoma in situ

Question 4

bladder neoplasms diagnosis

Answer 4

• Urinalysis / Urine culture
• Cystoscopy (lower tract imaging)
• CT urogram (upper tract imaging)
• Urine cytology
  
  • Can detect uroplastic cells in the urine
  • Low-sensitivity for low-grade tumors
• Will ultimately need transurethral resection of bladder tumor (TURBT)

Question 5

bladder neoplasms diagnosis - cytoscopy

Answer 5

• Two technologies are currently available that may increase the effectiveness of TURBT, hexaminolevulinate blue light TUR and narrow band imaging
• HAL cystoscopy requires the intravesical instillation of HAL that stays in the bladder for 1-3 hours prior to cystoscopy.
• When blue light is shone in the bladder, tumors fluoresce a bright pink color that makes their identification easy.
• HAL cystoscopy leads to increased detection of sub-clinical bladder tumors and, when done at the time of TURBT, leads to improved TURBT and a reduction in bladder tumor recurrences of 25%.
• NBI is an optical image enhancement technology that splits typical white light cystoscopy into two short wavelengths of light (blue and green).This process is activated by pressing a button on the endoscope camera and results in an image where vascular and delicate structures are better visualized.

Question 6

bladder neoplasms diagnosis - CT urogram

Answer 6

• Iodine contrast solution injected into a vein
• Dye flows into the kidney, ureters, & bladder à lights these structures up
• Get creatinine checked prior performing to CT urogram
• Alternatives to iodine contrast in patients will allergy or impaired renal function: carbon dioxide, gadolinium, or dilute iodine

Question 7

bladder neoplasms surgery - TURBT

Answer 7

• Transurethral resection of bladder tumor (TURBT)
• Both a diagnostic & therapeutic procedure
• Performed under general anesthesia
• Instruments: cold cup biopsy forceps (small tumors), endoscopic resectoscope (larger tumors)
• Procedure:
  
  • Remove the tumor until it is flush with adjacent bladder wall
  • Deeper resection into the bladder wall to aid in the identification of lamina propria or muscle invasion
  • Send samples separately! (superficial vs. deep resection sites)
  • Intravesicle chemotherapy (IVC)
    
    • Antineoplastic agent: Anthracyclines (epirubicin, doxorubicin, pirarubicin) & mitomycin C most effective
    • Reduce cancer recurrence by 35%
    • Do NOT give IVC in patients with bladder perforations
• TUR or TURP syndrome: Transurethral resection of prostate (TURP) syndrome is a complication characterized by symptoms changing from an asymptomatic hyponatremic state to convulsions, coma and death due to absorption of irrigation fluid during TURP. The syndrome appears to be related to the amount of fluid that enters the circulation via the blood vessels in the resection area.

Question 8

bladder neoplasms intravesicle therapy

Answer 8

• Adjuvant: applied after initial treatment for cancer, especially to suppress secondary tumor formation
• Therapies can be started 2-6 weeks after TURBT
• Used to prevent recurrence & progression of cancer
• Indications:
  
  • NMIBC with high risk of recurrence
  • NMIBC with high risk of progression
  • Carcinoma in situ
  • Residual tumor
• Intravesical therapies can also be applied adjuvantly (usually started 2-6 weeks after TURBT) to prevent the recurrence and progression of bladder cancer. Indications for adjuvant intravesical therapy are: (i) NMIBC with high risk of recurrence (ii) NMIBC with high risk of progression (iii) Carcinoma in situ (iv) Residual tumor (rare indication for small volume tumors, TURBT almost always preferred).
• The AUA guidelines state that in a low-risk patient, a clinician should not administer induction intravesical therapy. In an intermediate-risk patient a clinician should consider administration of a six week course of induction intravesical chemotherapy or immunotherapy. In a high-risk patient with newly diagnosed CIS, high-grade T1, or high-risk Ta urothelial carcinoma, a clinician should administer a six-week induction course of BCG
• Low risk, should not be done, intermediate risk you have to decide, and high risk it should be done
• *NMIBC = non-muscle invasive bladder cancer
• • One treatment weekly for 6 weeks
• Cystoscopy 6 weeks after last treatment
• Retain instillation for 2 hours for peak efficacy
• Patients should not drink 4-6 hours prior to treatment
  
  • Urine will dilute treatment
  • Bladder will become filled making it hard to retain instillation
• Induction series of 6 treatments
  
  • Then series of THREE at 3, 6, 12, 18, 24, 30, & 36 months
• Patients that recur despite BCG should be offered bladder removal but clinical trials and salvage intravesical therapy with a chemotherapy agent are alternative options albeit at a higher risk of recurrence and progression.

Question 9

bladder neoplasms follow up: surveillance

Answer 9

• Bladder cancer has a high risk of recurrence
• Requires life-time surveillance
• Monitored with:
  
  • Cystoscopy
  • Urine cytology
• Cystoscopy is recommended every 3-6 months & then at increasing intervals as appropriate
  
  • No consensus on timing of cystoscopy
  • First cysto 3 months after TURBT
  • Low-risk: at 3 months after TURBT
    
    • If first surveillance cysto negative, repeat cysto 6-9 months later (AUA guideline)
    • Annually thereafter for 5 years
  • High-risk: cysto every 3 months for 2 years, then every 6 months for 2-3 years, then annually
• Surveillance cycle RESTARTS every time a tumor is identified
• • Consider upper tract imaging
• Low-risk NMIBC:
  
  • If asymptomatic, do NOT perform routine surveillance upper tract imaging
• High-risk NMIBC:
  
  • Upper tract imaging every 1-2 years
    
    • CT urogram
    • MR urography
• *NMIBC = non-muscle invasive bladder cancer
• The AUA guidelines state that an asymptomatic patient with a history of low-risk NMIBC, a clinician should not perform routine surveillance upper tract imaging. High-risk patients should get upper tract imaging every 1 to 2 years. CT and MR urography has replaced intravenous pyelography as the main modality due to improved sensitivity and specificity.

Question 10

bladder neoplasms cystectomy: partial cystectomy

Answer 10

• Tumors occurring in a bladder diverticulum should be biopsied BUT extensive resection should be avoided à can lead to bladder perforation as diverticuli are thin-walled
• Partial cystectomy with diverticulectomy is preferred
• Partial cystectomy also indicated for muscle-invasive tumors that are:
  
  • < 3 cm in size
  • Not associated with carcinoma in situ
  • Located in a favorable anatomic location

Question 11

bladder neoplasms cystectomy: radical cystectomy

Answer 11

• Radical cystectomy is not commonly performed for non-muscle invasive bladder cancer (NMIBC)
• Indications for radical cystectomy in NMIBC:
  
  • BCG-refractory, high risk bladder cancer
  • Very large (>10 cm) bladder tumors
    
    • May require multiple TURBTs & leave bladder scarred
  • Variant tumor histology
  • “Bladder cripple”
    
    • Small capacity contracted bladders (from repeated TURBT or intravesical therapy)
    • Neurogenic bladder (often incontinent & miserable)
• Radical cystectomy in NMIBC
  
  • Can cure symptoms
  • Improve quality of life
• NMBIC = non-muscle invasive bladder cancer
• BCG – used as a vaccine for TB in other countries but now used for immunotherapy for bladder cancers

Question 12

bladder neoplasms muscle invasive bladder cancer work up

Answer 12

• Obtain imaging of the chest to rule out metastasis to the lungs
  
  • CT chest
  • AP / lateral chest X-ray
• Obtain imaging of the abdomen
  
  • CT abdomen & pelvis with contrast
  • MRI
• Labs:
  
  • CBC
  • LFTs
  • Creatinine with GFR
  • Alkaline phosphatase
• Hydronephrosis is a strong predictor of upstaging to extravesical disease & an independent predictor of a worse prognosis
• CT abdomen and pelvis, axial view

Question 13

bladder neoplasms muscle invasive bladder cancer surgery

Answer 13

• Gold standard treatment for muscle invasive bladder cancer
  
  • Radical cystectomy with or without neoadjuvant chemotherapy
• Radical cystectomy (male):
  
  • Removal of: bladder, perivesical fat, prostate, seminal vesicles, & prostatic urethra
  • Nerve-sparing surgery as in prostatectomy
  • Total urethrectomy rarely performed concomitantly à negative surgical margin usually achieved
  • If positive margin, can have delayed urethrectomy
• Radical cystectomy (female):
  
  • Includes removal of the bladder &…
  • Anterior pelvic exenteration, which is the removal of uterus, cervix, Fallopian tubes, ovaries, anterior vagina
  • Low stage disease à can consider vaginal-sparing techniques
• In the female patient the reproductive organs are sometimes removed although risk of involvement in female patients who undergo anterior pelvic exenteration for urothelial carcinoma of the bladder is less than 10% with the vagina the most commonly involved site.
• Open vs. laparoscopic approach
  
  • Robotic-assisted laparoscopic radical cystectomy
    
    • Advantages to robotic surgery: decreased blood loss, increased magnification, faster patient recovery time
    • Disadvantages to robotic surgery: lack of tactile feedback, increased technical demands, increased OR time
• Imperative that at time of surgery, meticulous & thorough pelvic lymph node dissection be performed
• Neoadjuvant chemotherapy given prior to cystectomy was associated with a significant improvement in survival
• The value of adjuvant chemotherapy has not been definitively proven
• Neoadjuvant chemo : means given immediately prior to cystectomy. Can use Methotrexate, Vinblastine, Doxorubicin (Adriamycin), and Cisplatin
• Adjuvant chemo: chemotherapy given after radical cystectomy, but prior to disease recurrence

Question 14

bladder neoplasms muscle inasive bladder cancer: surgery - urinary reconstruction

Answer 14

• No randomized data exist regarding the superiority of one type of diversion over the other
• Life-long follow up is necessary with any form of diversion
• Most common form of urinary diversion: ileal conduit
  
  • Incontinent diversion to skin
• Duodendum: The duodenum is the first part of the small intestine. The main role of the duodenum is to complete the first phase of digestion. In this section of the intestine, food from the stomach is mixed with enzymes from the pancreas and bile from the gallbladder. The enzymes and bile help break down food.
• Jejunum: The jejunum is the second part of the small intestine. After food is broken down in the duodenum, it moves into the jejunum, where the inside walls absorb the food’s nutrients. The inside walls of the jejunum have many circular folds, which make its surface area large enough to absorb all of the nutrients that the body needs.
• Ileum: The ileum is the third part of the small intestine. It absorbs bile acids and vitamin B12, which are needed by the body for various functions.
• Ileal conduit is technically “simple”, but complications are often underestimated
• Complications of ileal conduit:
  
  • Upper tract deterioration over the long term
  • Urinary tract infections
  • Stomal or parastomal hernia
  • Peri-stoma skin irritation / infection / ulceration
• Vitamin B12 absorbed in the terminal ileum
  
  • If terminal ileum utilized in diversion à patient needs vitamin B12 supplementation for life
• Vitamin B12 is a nutrient that helps keep the body’s nerve and blood cells healthy and helps make DNA.
• Vitamin B12 also helps prevent a type of anemia anemia called megaloblastic anemia makes people tired and weak.
• If you do remove the terminal part of the ileum, this is the portion of the intestines that absorbes vitamin B12, so these people need vitamin supplementation for the rest of their live
• Orthotopic: of or relating to the grafting of tissue in natural position; occurring at the normal place
  
  • Orthos = straight
  • Topos = place
• Orthotopic ileal reservoir
  
  • Studer pouch (most common ileal diversion)
    
    • Afferent limb draining into a low pressure reservoir
• Most important intra-operative consideration in Studer pouch is NEGATIVE urethral margin
  
  • A positive urethral margin on frozen-section analysis during a radical cystectomy represents an ABSOLUTE CONTRAINDICATION in female & male patients
• Rate of daytime incontinence in orthotopic diversion: 10-15%
• Nighttime incontinence is generally higher; some form of protection is usually needed at night
• Studer pouch video
• Continent cutaneous reservoir
  
  • Right (ascending) colon is most commonly used as reservoir
  • Indiana pouch
    
    • Reservoir: right (ascending colon)
    • Ileocecal valve is used for outlet à maintains continence
  • Must self catheterize pouch
  • Side note: chemotherapy can be alternative to cystectomy**​
• Indiana pouch: concept developed at University of Indiana
• With any diversion, will have catheter and bilateral stents
• Stents are usually attached to the catheter so caution in catheter removal
• Mention follow up for cystectomy patients:
  
  • Labs
  • Imaging: Urogram
• Ultrasound (hydronephrosis)

Question 15

bladder calculi surgery cystolitholapaxy

Answer 15

• Cystoscope equipped with ultrasonic probe or laser fiber
• Break stones into smaller fragments & remove
• Types of cystolitholapaxy:
  
  • Transurethral
  • Percutaneous suprapubic
    
    • Preferred method in pediatric patients
    • Can also be used in adults with large bladder stones
• Complications: UTI, bleeding, perforation of bowel (percutaneous suprapubic), urethral stricture

Question 16

kidney neoplasms

Answer 16

• Benign renal masses:
  
  • Epithelial tumors
  • Mesenchymal tumors
  • Mixed epithelial & mesenchymal tumors
  • Metanephric tumors
• Malignant renal tumors:
  
  • Renal cell carcinoma (RCC)
  • Urothelial carcinoma of the renal pelvis
  • Sarcomas
  • Wilm’s tumor
• RCC constitutes 80-85% of primary renal neoplasms
• Predominantly occurs in 60-80s
• More common in men
• Risk factors:
  
  • Smoking
  • HTN
  • Obesity
  • Acquired renal cystic disease
  • Occupational exposure (cadmium, asbestos, gasoline)
• Various histologies:
  
  • CLEAR CELL RCC (most aggressive)
  • Papillary RCC
  • Chromophobe RCC
  • Collecting duct carcinoma
  • Renal medullary carcinoma
  • Unclassified RCC
• Clear cell most common histology
• Arises from proximal convoluted tubule
• Clear cell RCC: characterized by malignant epithelial cells with clear cytoplasm and a compact-alveolar (nested) or acinar growth pattern interspersed with intricate, arborizing vasculature.

Question 17

kidney neoplasms presentation

Answer 17

• Classic triad (occurs in ~10% of patients):
  
  • Flank mass
  • Hematuria
  • Pain
• Recent studies show that most renal masses are discovered incidentally
• Incidence of metastatic disease at presentation is 30%
• Other symptoms:
  
  • Fever, chills, weight loss, cachexia
  • Anemia
  • Elevated erythrocyte sedimentation rate, C-reactive protein, alkaline phosphatase, & calcium
  • Polycythemia
• Polycythemia: an abnormally increased concentration of hemoglobin in the blood, through either reduction of plasma volume or increase in red cell numbers. It may be a primary disease of unknown cause, or a secondary condition linked to respiratory or circulatory disorder or cancer.

Question 18

RCC diagnosis and treatment

Answer 18

• Recommend cross sectional imaging
• Labs: CBC, CMP, UA
• Assignment of baseline CKD stage

Question 19

RCC partial nephrectomy

Answer 19

• Partial Nephrectomy (PN):
  
  • Removal of tumor with negative surgical margins
  • Renal reconstruction
  • Approaches: open, laparoscopic, robotic
• PN should be prioritized in patients with:
  
  • Anatomic or functional solitary kidney
  • Bilateral renal tumors
  • Known familial RCC
  • Pre-existing CKD
  • Proteinuria
• Also consider PN in young patients, multifocal masses, or presence of comorbidities that could impact future renal function
• Open PN has long been considered optimal approach but laparoscopic and robotic are increasingly utilized
• Main benefit to PN: preservation of renal function while achieving equivalent oncologic contro
• The primary determinants of long-term renal function after PN are preoperative renal function, warm ischemia duration, comorbidities, and amount of preserved kidney (ie residual functional renal parenchyma).^<a>72</a>
• Warm ischemia time is a modifiable feature predictive of long-term renal function and should ideally be limited to <25 minutes.^{<a>73</a>,<a>74</a>}
• • Open PN long considered optimal approach
    
    • Laparoscopic & robotic approaches increasingly utilized
• Main benefit of PN:
  
  • Preservation of renal function while achieving oncologic control
• Determinants of long-term renal function after PN:
  
  • Pre-op renal function
  • Warm ischemia duration (≤ 25 mins optimal)
  • Comorbidities
  • Amount of preserved kidney

Question 20

RCC radical nephrectomy

Answer 20

• RN is alternate standard of care if:
  
  • PN not technically feasible
  • For larger renal masses limited to the kidney (if normal contralateral 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 (as compared to PN), has lower complication rate:
  
  • Less incidence of hemorrhage
  • Less incidence of urine leak / fistula
  • Less re-operation complications
• RN increases the risk of CKD as compared to PN
• Removal of the adrenal gland during RN is generally not indicated unless there is clinical suspicion for involvement based on preoperative imaging and intraoperative findings. The incidence of ipsilateral adrenal involvement in patients with RCC is less than 10%.
• Risk factors associated with adrenal gland involvement include CT evidence of tumor invasion into the adrenal gland, tumor size >5cm, and upper pole location, although the latter two are not necessarily indications for adrenalectomy.

Question 21

RCC ablation

Answer 21

• Thermal ablation is an option for renal masses localized to kidney ≤ 3 cm in diameter
• Can be performed via open, laparoscopic, or percutaneous (most common) approaches
• Commonly involves radiofrequency or cryoablation
• Long-term success of ablation indeterminate
• Considerations:
  
  • Higher risk of local recurrence
  • Potential need for re-intervention
  • Need for long term abdominal imaging
  • Lack of proven parameter for success
  • Potential for difficult surgical salvage
• Renal function after ablation may be superior to PN (absence of renal ischemia from surgical clamping)

Question 22

RCC follow up

Answer 22

• H&P directed at detecting signs & symptoms of metastatic spread or local recurrence
• Labs: BUN, Creatinine, UA, eGFR (possible CBC, LDH, LFTs, alkaline phosphatase (ALP), Calcium)
  
  • If elevated ALP (or if clinical symptoms such as bone pain / bony mets) à bone scan
• If progressive renal insufficiency on follow-up à refer to nephrology
• Majority of relapses occurs within first 3 years following surgery
  
  • More rigorous follow-up in first 3 years post-op
• Imaging (US, CT, or MRI) may be performed yearly for three years in patients with low risk disease following a PN
• Imaging (US, CT or MRI) may be performed in patients with low risk disease following a RN
• Hx of low risk RCC à CXR annually for 3 years (then as clinically indicated)

Question 23

renal calculi

Answer 23

• Stone disease affects 9% of the US population
• Prevention is cornerstone of management
• Presentation
  
  • Flank pain / Abdominal pain / Groin pain (depends on stone location)
    
    • Unilateral pain à kidney stone pain does not pass the midline
  • Hematuria (gross or microscopic)
  • Nausea / Vomiting
  • Dysuria
  • Urinary urgency
  • Flank pain, fever, pyuria à pyelonephritis

Question 24

renal calculi diagnosis

Answer 24

• Renal US
  
  • Less commonly used for surgical planning
  • Provides info on kidney stone burden & collecting system anatomy
  • No risk of radiation exposure
  • Poorly visualizes stones located in ureter & has limited sensitivity for stones < 2-3 mm
• Imaging: plain X-ray, intravenous pyelography (IVP), renal US, CT
• Plain X-ray is:
  
  • Unable to visualize radiolucent stones (uric acid stones)
  • Poorly sensitive for stones overlying the bony pelvis
  • Provides no information on collecting system anatomy
• CT
  
  • Standard imaging modality for patients requiring surgical stone treatment
  • Provides info on stone burden, location, collecting system anatomy, relational anatomy of the kidney & ureter, & perinephric findings (urinary extravasation, stranding, or inflammation)
  • Provides Hounsfield unit (HU) density of stone
  • Provides skin-to-stone distance
  • Primary drawback is radiation exposure
  • “Low dose” CT available
• IVP
  
  • Stones visualized as filling defects within the renal collecting system
  • Administration of IV contrast provides functional data on collecting system dynamics
  • IV contrast associated with risk of allergic reaction, renal toxicity
  • CT favored over IVP
• Stranding (CT):
• HU & skin-to-stone distance are associated with better treatment outcomes with ESWL.
• Vitals:
  
  • Fever greater than 100° F or tachycardia & hypotension à suspect obstructive pyelonephritis
• Labs:
  
  • Complete blood count (CBC)
  • Metabolic panel
    
    • Blood urea nitrogen (BUN) & Creatinine à may influence the decision regarding need for intervention
  • Urinalysis (UA)
  • Urine culture (UC)

Question 25

renal calculi treatment: MET and stent/nephrostomy tube placement

Answer 25

• Medical Expulsive Therapy (MET): 4-6 week trial for spontaneous stone passage
  
  • Normal renal function
  • No signs of infection
  • Well-controlled pain
  • Likelihood of spontaneous stone passage (varying opinions on what stone size is passible)
  • Hydration & Tamsulosin (Flomax) 0.4 mg
    
    • Tamsulosin (Flomax) helps to relax the ureter
    • Considered “off label” use
    • Associated with “intraoperative floppy iris syndrome” à drug should be avoided if cataract surgery is contemplated and/or the patient should notify their ophthalmologist of its use
• Urgent stent placement vs. Nephrostomy tube placement
  
  • Indicated in the setting of obstruction & signs of infection (fever, leukocytosis, hemodynamic instability)
• At present, as both percutaneous nephrostomy and ureteral stent are considered to be appropriate therapies, the decision as to which is the most appropriate for a particular scenario will depend on institutional characteristics.
• Examples of different clinical scenarios would be as follows: is interventional radiology readily available, or is it more expeditious to proceed to the operating room for stent placement; is the patient too unstable for general anesthetic for a stent placement and would be better served with minimal sedation and percutaneous nephrostomy tube placement.

Question 26

renal calculi treatment: SWL/ESWL

Answer 26

• Pregnancy only absolute contraindication in SWL / ESWL
• ESWL performed under sedation
• Consider skin-to-stone distance
• Shock wave lithotripsy (SWL) / Extracorporeal Shockwave Lithotripsy (ESWL)
  
  • Sound waves / Shock waves à repetitively applied creating small fractures in stone à stone fragmentation
  • Stone located with fluoroscopy or ultrasound
  • Cannot target radiolucent stones (uric acid stones) without use of contrast
  • Success depends on location of stone in the kidney
    
    • Stones in lower renal pole not ideal (gravity-dependent)
    • Distal ureteral stones not ideal
• Not ideal when skin–to-stone distance is great
• Routine stent placement not recommended routinely prior to SWL / ESWL
  
  • Consider in stones > 2 cm
• Stone size greatest predictor of success
  
  • As stone size increases, SWL/ ESWL success rates decline
  • < 10 mm are good candidates for SWL / ESWL
  • Risk of “steinstrasse” (German for “stone street”) with large stones treated with SWL / ESWL
• COMPLICATIONS:
  
  • Renal injury
  • Contusion
  • Hemorrhage
  • Steinstrasse
  • Occurs in 10%
  • Hypertension
  • Diabetes mellitus
  • Renal impairment
• CONTRAINDICATED IN:
  
  • Pregnancy*
  • Coagulopathies
  • Presence of cardiac arrhythmia / pacemaker
  • Aortic aneurysm & Renal artery aneurysm
  • UTI

Question 27

Renal calculi treatment: percutaneous nephrolithotomy (PCNL)

Answer 27

• PCNL reserved for:
  
  • Large (>2 cm) stones
  • Complex stones
  • Staghorn calculi
  • Lower pole stones > 1 cm
  • Complex renal anatomy
  • Anatomy that precludes ureteroscopy or makes stone fragment passage difficult
• Avoid PCNL in:
  
  • Pregnancy
  • Uncorrected coagulopathies
  • UTI
  • Body habitus that precludes safe positioning & access to kidney
• Requires percutaneous access
  
  • Usually obtained by interventional radiology with use of contrast & fluoroscopy
• 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)
• COMPLICATIONS:
  
  • Urosepsis
  • Hemorrhage
  • Injury to surrounding organs
  • Injury to collecting system
• A 21 or 18-gauge Chiba needle or an 18-gauge diamond tip needle is used to puncture the selected calyx. Entry into the collecting system is confirmed by aspiration of urine. A soft, atraumatic guidewire such as a hydrophilic guidewire is negotiated down the ureter, if possible, then later exchanged for a stiffer working wire. A second guidewire is placed as a safety wire. Dilation of the tract with either sequential fascial dilators (Amplatz dilators) or a dilating balloon allows placement of a working sheath to facilitate entry and exit of the nephroscope and to promote egress of fluid, thereby maintaining low intrarenal pressure. Most working sheaths are 30F but can be obtained in smaller sizes down to 18F.

Question 28

Renal calculi treatment: ureteroscopy (URS)

Answer 28

• Ureteroscope used for visualization
  
  • Flexible & Semi-rigid ureteroscopes available
    
    • Flexible: stones at or proximal to the iliac vessels
    • Semi-rigid: stones below the level of the iliac vessels
• Guidewire placed
• Saline used as irrigant
• Stones are removed intact if they are no larger than the smallest caliber of the ureter or…
• Stones can also be fragmented with the holmium laser or pneumatic lithotripter
• Stent placement is optional but should be used if there is significant ureteral edema, incomplete stone fragmentation, or suspicion of ureteral injury
• COMPLICATIONS:
  
  • Ureteral perforation
  • Stent for 2-6 weeks
  • Ureteral avulsion
  • Infection / Sepsis
  • Ureteral stricture
  • Risk factors: impacted stone > 2 months and/or ureteral injury

Question 29

Benigh prostatic hyperplasia (BPH)

Answer 29

• Increase in the number of stromal & epithelial cells à formation of large, discrete nodules in the prostate
• If nodules large enough, can result in benign prostate enlargement (BPE) à causes urethral compression & bladder obstruction
• Symptoms:
  
  • Lower urinary tract symptoms (LUTS)
  • Obstruction of the bladder can lead to detrusor overactivity (DO)
• BPH influenced by:
  
  • Androgen levels
  • Estrogen levels
  • Paracrine factors in prostatic stroma & epithelium
  • Growth factors
  • Cytokines
  • Sympathetic nerve signaling
  • Genetic inheritance
• increase in the number of prostatic stromal and epithelial cells, resulting in the formation of large, discrete nodules in the transition zone of the prostate
• Diagnosis and evaluation:
  
  • Incidence of BPH & LUTS increases with age
  • Diagnosis:
    
    • Medical history
    • Physical exam / Digital rectal exam (DRE)
    • Urinalysis: screen for hematuria, UTI
    • PSA
      
      • Appropriate for patients with lifespan of 10 or more years
      • Screening between the ages of 50-69 y.o.
    • Post-void residual (PVR) by ultrasound or catheterization
    • Uroflow / Flow rate
    • Cystoscopy
    • +/- Urodynamics: can help assess the degree of bladder outlet obstruction (BOO) & assess for detrusor overactivity (DO)

Question 30

BPH surgery: transurethral reseciton of the prostate (TURP)

Answer 30

• Monopolar TURP (mTURP) or Bipolar TURP (bTURP)
• Electrosurgical-based TURP is the GOLD STANDARD treatment in BPH
• Absolute 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
• • Bipolar TURP is performed in similar fashion to mTURP with the major difference in the operative electrode configuration. In bTURP, both electrodes are contained within the operative device, which not only allows for the use of isotonic saline but also decreases the risk of thermal burns.
• • In mTURP, one of the electrodes is in the instrument itself and the other is typically on the exterior of the patient in the form of a grounding electrode. Because of the distance between electrodes in mTURP, a non-conductive solution such as glycine is necessary to ensure that the current does not dissipate; this is not necessary in bTURP since the electrodes are close to one another. bTURP may represent the next generation “gold standard” for benign prostatic obstruction.
• Goal of TURP, no matter which ablative energy used (bTURP vs. mTURP), is to resect adenomatous tissue present in the transitional zone of the prostate.
• Equipment: 24 or 26-french resectoscope, an Iglesias working element with a thin-loop wire electrode, & a 30 or 12-degree lens
• Each lobe is resected in its entirety prior to proceeding to the next one à typically middle (median) lobe, followed by lateral lobes
• Prostate “chips” are evacuated
• Final survey of the bladder should show no persistent chips & no injury to the ureteral orifices
• A large 22 to 24 French three-way hematuria catheter is usually placed & continuous bladder irrigation is performed with normal saline
• Most patients report immediate improvement in voiding symptoms after TURP
• Some may have delayed improvement, particularly those that presented in urinary retention or those with a significant component of bladder dysfunction (detrusor underactivity or acontractility)
• Complications
  
  • Dilutional hyponatremia (TUR Syndrome, occurring in 1-2% of patients)
    
    • Clinical picture of TUR syndrome can vary widely ranging from confusion to coma
    • TUR syndrome less common in bTURP
  • Delayed complications:
    
    • 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%)
  • Dilutional hyponatremia (TUR Syndrome), occurring in 1-2% of patients. Delayed complications include urinary tract infections, urethral stricture (up to 10%), urinary incontinence (up to 10%, usually mild and self-limiting), retrograde ejaculation (60-90%), and the need for re-operation (3-8%).

Question 31

BPH laser TURP

Answer 31

• Benefits: reduction or absence of complications
  
  • Intraoperative fluid absorption
  • Bleeding
  • Retrograde ejaculation
  • Erectile dysfunction
  • Incontinence
• Tissue is heated rapidly after absorbing laser energy
• At about the boiling point of water (100 °C) à vaporization occurs
• Temperatures above 150 °C result in tissue carbonization (charring of prostatic tissue)
• For laser TURP, vaporization is the goal, as target tissue is completely removed from the operative field
• Laser types: Holmium, Thulium, Greenlight
• No randomized control trials between laser treatments
• Outcomes similar to TURPs
• Holmium laser had less hospital time and less catheterization time
• Holmium laser (particular type) is size independent so may be new gold standard for large prostates
• Laser has steeper learning curve for surgeons
• The Holmium:Yttrium Aluminum Garnet (Ho:YAG) laser (2140nm) was originally used in treating stones but has since been adapted to BPH therapy. Laser energy is absorbed by aqueous irrigant in close proximity to the laser fiber tip, resulting in a vaporization bubble, leading to “micro-explosions”. This results in tissue destruction, although its ability to vaporize is inefficient as minimal energy reaches the tissue surface. Holmium laser ablation of the prostate (HoLAP) utilizing a side-firing fiber is an example of the ablative use of this laser
• The thulium laser has wavelengths that can be tuned from 1750nm to 2200nm in both pulsed and continuous modes. The physical effect is similar to the holmium laser, but a more continuous beam may result in more rapid tissue ablation and improved hemostasis.^<a>31</a>
• In contrast to the holmium and thulium lasers, the 532nm Greenlight™ laser possesses a low absorption coefficient for water but high for hemoglobin, leading to selective absorption by the oxyhemoglobin chromophore. Depending on the system, laser energy is created through a potassium titanyl phosphate (KTP) crystal addition to an Nd:YAG laser (KTP laser) or a lithium triborate crystal (LiB₃O₅ or LBO) added to a diode pumped Nd:YAG laser. Latter generations of the system are able to generate up to 180W.^<a>32</a> The use of the Greenlight™ laser has been particularly well-studied in patients on systemic anti-coagulants.

Question 32

BPH surgery: urolift

Answer 32

• Prostatic urethral lift (Urolift^®)
• Involves implantation of tissue retracting elements inserted under cystoscopic guidance using the Urolift^® delivery system
• Appropriate patient selection based on prostate anatomy is critical for the success of this operation
• For patients 45 y.o. or older
• ~ 4-6 implants are placed
• Should not be performed if:
  
  • Prostate volume of >80 cc
  • Urinary tract infection
  • Urethra conditions that may prevent insertion of delivery system into bladder
  • Urinary incontinence due to incompetent sphincter
  • Gross hematuria
  • Known allergy to nickel, titanium, or stainless steel
• Further studies needed to define role of Urolift^® in BPH
• Benefits of Urolift:
• -Does not cause new onset, sustained erectile or ejaculatory dysfunction
• -Minimally invasive
• -Minimal downtime
• -Durable results
• -Rapid symptom relief and recovery
• -Significant improvement in quality of life
• The first multicenter, prospective randomized controlled study known as the L.I.F.T study randomly assigned 206 patients in a 2:1 fashion to either Urolift^® or sham control. Statistically significant improvements in AUA symptoms score as well as Qmax were noted at 12 month follow up. No benefits were observed in regards to post- void residual and no differences were noted in regards to ejaculatory or erectile dysfunction. Adverse effects were few including dysuria and hematuria and resolved spontaneously.^<a>67</a> In regards to durability Roehrborn et all found an improvement of IPSS at 4 and 5 year follow up when compared to sham procedure. IPSS improvement after Urolift^® was 88% greater than that of sham at 3 months. Improvement in IPSS, QOL, BPHII, and Qmax were durable through 5 years with improvements of 36%, 50%, 52%, and 44% respectively. The surgical retreatment was 13.6% over 5 years. Adverse events were mild to moderate. Sexual function was stable over 5 years with no de novo, sustained erectile or ejaculatory dysfunction.^<a>68</a> Overall, most studies conducted are small without adequate randomization or control. Further studies are needed to define the role Urolift^® will play in the treatment of BPH

Question 33

BPH surgery: Rezum

Answer 33

• Transurethral water vapor therapy (Rezum^® system)
• Delivers targeted & controlled doses of thermal energy directly into the prostate by using sterile water vapor relying on convective energy.
• Procedure:
  
  • A narrow sheath, similar in size & shape to a cystoscope, is inserted via the urethra
  • A thin needle is deployed through the urethra into the prostate
  • Water vapor is delivered rapidly into the hyperplastic tissues
  • When the water vapor comes into contact with the prostatic tissue, it condenses into its liquid state & releases stored thermal energy
• Early results for Rezum are promising however robust randomized & controlled data as well as follow up data is currently limited

Question 34

BPH surgery: simple prostatectomy

Answer 34

• Consider simple prostatectomy over TURP in the following:
• Large prostates à 80 g or larger
  
  • “Normal” prostate 30 g = walnut-sized
• Patients who need additional procedures (diverticulectomy, bladder stone removal)
• Involves enucleation (removal) of prostate gland within the capsule
  
  • Capsule remains intact
• Open surgery, Laparoscopic, Robotic-assisted
• Complications:
  
  • Blood loss requiring transfusion
  • Bladder neck contractures
  • Urethral strictures
  • Longer hospital stay than TURP
  • Complications reduced with use of minimally invasive techniques (laparoscopy, robotic-assisted)
  • Typically patients stay overnight in hospital for observation
  • Have foley catheter with continuous bladder irrigation (CBI)
  • Have JP drain

Question 35

prostate cancer

Answer 35

• Most commonly diagnosed cancer in men (adenocarcinoma of the prostate)
• 240,000 prostate cancer diagnoses annually
• 80% of prostate cancers diagnosed are localized disease
• 1 in 7 men will be diagnosed with prostate cancer in their lifetime
• 2.8% of men will die from the disease
• Mean age at diagnosis is 67 y.o.
• Presentation:
  
  • Early stage à usually no symptoms
  • 80% of men diagnosed with prostate cancer (via prostate biopsy) due to elevated PSA
  • 20% of cases have an abnormal digital rectal exam (DRE) that prompts prostate biopsy
    
    • Asymmetry
    • Areas of induration
    • Nodules
  • Lower urinary tract symptoms (LUTS):
    
    • Urinary frequency, Urinary urgency, Nocturia, Urinary hesitancy
  • Hematuria (uncommon)
  • Hematospermia (uncommon)
  • Bone pain (can be presenting symptom in metastatic disease)

Question 36

prostate cancer diagnosis

Answer 36

• PSA screening guidelines (per American Urological Association):
  
  • Not recommended in men < 40 y.o.
  • Screening in men between 40-54 y.o. who are at average risk is not recommended
  • Men 55-69 y.o. à weigh risks & benefits of screening with patient à shared decision making between patient & provider
  • Consider screening every 1-2 years
  • Routine PSA screening not recommend in men over 70 y.o. or men with a life expectancy of less than 10-15 years
• PSA (PSA vs. PSA free & total) screening & DRE
• Prostate biopsy when prostate cancer is suspected
• If biopsy negative but PSA continues to rise à consider multiparametric MRI
• If lesions present on MRI à MRI-targeted biopsy may be performed
• Once diagnosis is made, risk assessment becomes paramount in guiding treatment decisions & for counseling patients accurately about expected oncologic & functional outcomes
• Using well established clinical variables, men are commonly characterized into low, intermediate, or high risk prostate cancer categories
• Risk stratification systems are primarily based on PSA level, Gleason score, & clinical stage
• For men ages 55 to 69 years, the decision to undergo PSA screening involves weighing the benefits of preventing prostate cancer mortality in 1 man for every 1,000 men screened over a decade against the known potential harms associated with screening and treatment. For this reason, shared decision-making is recommended for men age 55 to 69 years that are considering PSA screening, and proceeding based on patients’ values and preferences.
• Explain PSA vs PSA free and total
• MULTIPARAMETRIC MRI:
• -T2 weighted MRI (T2 MRI) gives a 3D map of prostate zone anatomy.
• A suspicious-looking area is called a region of interest or ROI.
• T2 MRI is called the workhorse of prostate MRI, but more information is needed to determine if the ROI is prostate cancer or a benign (noncancerous) condition.
• Diffusion weighted imaging (DWI MRI) shows the movement of water molecules in tissue.
• Cancer cells restricts the motion more than other cells do, which shows up in DWI MRI.
• Dynamic contrast enhanced imaging (DCE MRI) reveals a tumor’s blood flow.
• A contrast agent is injected into a vein.
• Prostate cancer tumors develop their own blood vessels, which look abnormal.
• When injected, the contrast agent is quickly taken up by the tumor blood vessels, then washes out and is later excreted in urine.
• During the uptake and washout phase, the contrast agent shows the cancer’s blood flow.
• Also, the pace of the uptake/washout tells about the nature of the tumor.
• Spectroscopy (MRI-S) may be added as a fourth parameter.
• If prostate cancer is present, it maintains its life by certain chemical processes (metabolism) that are distinct from normal cell metabolism.
• MRI-S gives metabolic information that confirms prostate cancer.

Question 37

prostate cancer treatment

Answer 37

• Active surveillance
• Radiation therapy
• Radical prostatectomy

Question 38

RALP

Answer 38

• RALP involves:
  
  • Removal of prostate
  • Removal of seminal vesicles
  • Urethrovesical anastomosis
  • Pelvic lymph node dissection
  • (possible depending on prostate cancer risk category)
  • May be difficult in patients with very large prostates, presence of median lobe (makes dissection more difficult)
• 2010: 67%-85% of all prostatectomies in the US are performed robotically.
• Space of Retzius / Retropubic space: the extraperitoneal space between the pubic symphysis and the urinary bladder.

Question 39

open retropubic radical prostatectomy

Answer 39

• Midline incision from umbilicus to pubic region
• Incision retracted & prevesical space is developed
• Bladder mucosa cut à bladder retracted to expose the prostate region
• Anterior & posterior urethra are cut
• Prostate, seminal vesicles, & portion of vas deferens are removed
• Urethra & bladder neck are sutured & incision closed
• Perineal prostatectomy: less post-op pain, less bleeding, unable to perform LND, unable to perform nerve sparing, may be difficult to remove all of prostate tissue leading to positive surgical margins

Question 40

Radical Prostatectomy

Answer 40

• Curative treatment option for localized prostate cancer
• Gold standard of definitive therapy in patients that are surgical candidates
• RP also allows for accurate pathologic grading & staging
• Surgical approaches:
  
  • Robotic-assisted *
  • Open retropubic *
  • Laparoscopic
  • Open perineal
• Robotic surgeries à better oncologic outcomes, less blood loss, quicker convalescence
• * = most commonly performed
• Complications:
  
  • Intraoperative complications:
    
    • Hemorrhage
    • Rectal / Bowel injury
    • Bladder/ Ureteral injury
    • Obturator nerve injury
    • Venous thromboembolic events
  • Postoperative complications:
    
    • Venous thromboembolic events
    • Incontinence
    • Erectile dysfunction
    • Urethrovesical anastomotic leak
    • Lymphocele
    • Bladder neck contracture
    • Hernia (incisional or inguinal)
    • Neurapraxia

Question 41

RALP vs open retropubic radical prostatectomy

Answer 41

• RALP:
  
  • Decreased blood loss & decreased length of hospital stay
  • Reduction in cardiac & respiratory events
  • Marginal advantage in continence rates in RALP over open retropubic approach
    
    • 12 month urinary incontinence rates
      
      • RALP: 7.5%
      • Open retropubic: 11.3%
    • Better erectile function outcomes with RALP
• RALP more costly than open retropubic approach

Question 42

prostate cancer follow up

Answer 42

• 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
• PSA in 3 months; will continue to track PSA
• Men can lose length and girth from this surgery

Question 43

testicular cancer

Answer 43

• Testicular neoplasms are uncommon
• Types of testicular neoplasms:
• Germ cell tumors (95%)
  
  • Seminoma: localized seminoma most common presentation (50% of cases)
  • Non-seminoma germ cell tumors (NSGCT)
• Remaining are predominately sex cord / stromal tumors (mainly Leydig cell & Sertoli cell tumors)
• Most common malignancy in men aged 20-40 y.o.
• Incidence in U.S. à 5/100,000 men
• Incidence highest among non-Hispanic whites
• Germ cell tumors are further designated as seminoma or non-seminoma germ cell tumors (NSGCT)
• Risk factors:
  
  • Cryptorchidism (undescended testicle)
  • Intra-tubular germ cell neoplasia (ITGCN)
  • Family or personal history of testicular cancer
  • Cryptorchidism: a condition in which one or both testicles fail to move from the abdomen, where they develop before birth, into the scrotum.
  • Intratubular germ cell neoplasia (ITGCN) is the precursor lesion for invasive testicular germ cell tumors (TGCTs) of adolescents and young adults.
• Presentation
  
  • Painless testicular mass
  • Other symptoms (may be related to metastatic disease):
    
    • 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)
  • Most common site of mets is abdominal lymph nodes.

Question 44

testicular cancer diagnosis and tx

Answer 44

• Diagnosis
  
  • Scrotal US in men with testicular mass or suspected testicular mass
  • Tumor markers: Alpha-fetoprotein (AFP), Beta-human chorionic gonadotropin (bHCG), lactate dehydrogenase (LDH)
  • Once testicular cancer diagnosed à need CT chest/abdomen/pelvis with oral & IV contrast; can consider CXR as initial staging in low risk patients
  • Also, consider CT or MRI to assess for lymph node involvement
• tx
  
  • Radical inguinal orchiectomy
    
    • Involves removal of testicle & spermatic cord to the level of the internal inguinal ring
  • Performed via inguinal incision
  • Can consider testis sparing surgery in following situations:
    
    • Small tumor in one testicle
    • Small bilateral tumors
    • Increased suspicion of benign tumor
  • Can elect to have prosthetic implant
  • Can consider sperm banking prior to treatment, but this is rare (< 30% bank sperm and < 10% use banked sperm).
  • Can consider retroperitoneal lymph node dissection (RPLND) but most men (70%) who have RPLND are node negative so they do no benefit from RPLND.
  • Spermatic cord contents:
  • Papers Don’t Contribute To A Good Specialist Level
  • P: pampiniformplexus
  • D: ductus deferens
  • C: cremastericartery
  • T: testicular artery
  • A: artery of the ductus deferens (deferential artery)
  • G: genital branch of the genitofemoral nerve
  • S: sympathetic nerve fibers
  • L: lymphatic vessels

Question 45

testicular cancer follow up

Answer 45

• Active surveillance
  
  • 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)
• NOTE: survivors at risk for solid tumors (lung, colon, bladder, pancreas, stomach), non-melanoma skin cancers, leukemias, contralateral testicular cancer (rare)
• More than 80 percent of patients with stage I seminoma are cured with orchiectomy alone
• For men with stage I NSGCTs approximately 70% will be cured with radical orchiectomy alone
• Risk factors for recurrence: vascular or lymphatic invasion, embryonal carcinoma >40% total tumor volume, absence of yolk sac elements, elevated serum tumor markers that do not decrease within the expected half life
• Most relapses occur in the first 5 yrs following orchiectomy
• Testicular caners survivors are at increased risk for solid tumors, non-melanoma skin cancers, & leukemias

Question 46

wilm’s tumor

Answer 46

• Wilm’s tumor (WT) or Nephroblastoma is the most common renal tumor of childhood
• Embryonal tumor developing from the remnants of the immature kidney
• Classic pathologic finding (triphasic pattern containing 3 cell types):
  
  • Blastemal, Stromal, Epithelial
• Treatment: Surgery, Chemotherapy, Radiation (or combination)
• Accounts for 6-7% of all childhood cancers
• 7.6 cases per 1 million children under 15 years
• Median age is 3.5 years at presentation
• Equal distribution between males & females
• Most commonly occurs sporadically but 10% of children with WT have a congenital malformation syndrome
• Histopathology of tumor is important predictor of outcome
  
  • Tumors with anaplasia (large nuclei, abnormal mitotic figures, & hyperchromasia) = “unfavorable histology”
• Patients with above features have higher risk for relapse or death
• • Anaplasia is found in ~10% of patients and is the single most important histologic predictor of response and survival in patients with WT

Question 47

wilm’s tumor diagnosis

Answer 47

• Most common presentation: asymptomatic abdominal mass noted by parents / caregivers
• Abdominal pain, hematuria, HTN also possible symptoms
• Physical Exam:
  
  • Palpable mass in flank is typical finding
  • Assess for syndromic features:
    
    • Aniridia: absence of the iris
    • Hemihypertophy: overgrowth of one side of the body as compared to the other
    • GU abnormalities
• Labs: CBC, LFTs, Renal function panel, UA
• Imaging, US, CT, or MRI
  
  • Cross-sectional imaging needed to define location, size, local extension of tumor, evaluate contralateral kidney, & assess for presence of mets (lungs most common site)
• HTN related to high plasma renin levels
• Renin: an enzyme secreted by and stored in the kidneys that promotes the production of the protein angiotensin.
• High renin levels can be caused by condition that decreased blood flow to the kidney, decreases BP, or lower sodium levels
• Aniridia photo: also with corneal scar and cataract

Question 48

wilm’s tumor tx

Answer 48

• Unilateral lesions à nephrectomy with renal hilar lymph node sampling
• High propensity for tumor rupture
  
  • Intra-op tumor spillage results in UPSTAGING** & requires abdominal **RADIATION
• Biopsies, if taken, are also considered “tumor spill”
  
  • Pre-op & Intra-op biopsies are usually CONTRAINDICATED
• Chemotherapy utilized pre-operatively in:
  
  • Bilateral WT
  • Predisposition syndromes
  • Solitary kidney
• Chemo utilized pre-operatively in attempt to reduce tumor burden & facilitate partial nephrectomy
• Chemotherapy prior to nephrectomy is standard of care outside of US
• Incision: transverse abdominal or thoracoabdominal
  
  • Large incision decreases risk of inta-op tumor rupture, facilitates intra-op inspection
• Adrenal gland can be left in place unless:
  
  • Upper pole WT
  • Abutting tumor
• In radical nephrectomy à ureter should be
• taken as low as possible
• Biopsies in WT are only performed in unique circumstances
• Since patients with bilateral WT, predisposition syndromes, and solitary kidneys are at higher risk for long-term renal dysfunction, they are treated with upfront chemotherapy in an attempt to reduce tumor burden and facilitate partial nephrectomy.
• Follow up:
  
  • Late effects seen in WT survivors include:
    
    • Musculoskeletal effects related to radiation
    • Cardiotoxicity associated with chemotherapy
    • Reproductive health problems
    • Renal dysfunction
    • Secondary malignancies