Urology for the MRCS part A Flashcards
Enumerate types of renal stones with their percentage of occurrence starting with the most common to the less common
Mnemonic;CC/US/C
(1) Calcium oxalate(85%)
(2) Calcium phosphate stones(10%)
(3) Uric acid stones(5-10%)
(4) Struvite stones(2-20%)
(5) Cystine stones(1%)
Discuss calcium oxalate stones
Percentage =85%
Aetiology
(1)Hypercalciuria
(2)Hyperoxaluria
(3)Hyperuricosuria-may cause uric acid stones to which calcium oxalate binds
(4)Hypocitraturia-increases risk because citrate forms complexes with calcium
making it more soluble
Opacity = Radio-opaque(though less than calcium phosphate stones)
Urine acidity = variable
Urine PH = 6
Enumerate causes of calcium oxalate stones
(1)Hypercalciuria
(2)Hyperoxaluria
(3)Hyperuricosuria-may cause uric acid stones to which calcium oxalate binds
(4)Hypocitraturia-increases risk because citrate forms complexes with calcium
making it more soluble
Comment on opacity of calcium oxalate stones
Radio-opaque(though less than calcium phosphate stones)
Comment on urine acidity of calcium oxalate stones
Variable
What is the urine PH of calcium oxalate stones?
6
Why hyperuricosuria causes calcium oxalate stones?
May cause uric acid stones to which calcium oxalate binds
Why hypocitraturia causes calcium oxalate stones?
Increases risk because citrate forms complexes with calcium making it more soluble
Discuss calcium phosphate stones
Incidence = 10%
Aetiology-the following increases supersaturation of urine with calcium and phosphate causing calcium phosphate stones:-
(1)Renal tubular acidosis types 1 and 3(types 2 and 4 do not)
(2)High urinary PH
Opacity = radio-opaque (composition similar to bone)
Urine acidity = Normal/Alkaline
Urine PH > 5.5
What is the incidence of calcium phosphate stones?
10%
What is the aetiology of calcium phosphate stones ?
the following increases supersaturation of urine with calcium and phosphate causing calcium phosphate stones:-
(1)Renal tubular acidosis types 1 and 3(types 2 and 4 do not)
(2)High urinary PH
What increases supersaturation of urine with calcium and phosphate causing calcium phosphate stones?
(1)Renal tubular acidosis types 1 and 3(types 2 and 4 do not)
(2)High urinary PH
Comment on opacity of calcium phosphate stones
radio-opaque (composition similar to bone)
Comment on urine acidity of calcium phosphate stones
Normal/Alkaline
What is the urine PH of calcium phosphate stones?
> 5.5
How does uric acid form?
A product of purine metabolism
Discuss uric acid stones
Incidence = 5-10%
Aetiology
Mnemonic;TIP
(1)extensive (T)issue breakdown e.g.,malignancy
(2)in children with (I)nborn errors of metabolism
(3)low (P)H-increases uric acid precipitation
(4)Thiazide diuretics
(5)In primary polycythaemia
(6)chemotherapy and cell death can increase uric acid levels.
(7)dehydration
Opacity =radiolucent(unless they have calcium contained within them)
If uric acid stones are unlikely to be coated with calcium therefore will be radiolucent
Urine acidity = acid
Urine PH = 5.5
What is the incidence of uric acid stones?
5-10%
What is the aetiology of uric acid stones?
Mnemonic;TIP
(1)extensive (T)issue breakdown e.g.,malignancy
(2)thiazide diuretics
(3)in children with (I)nborn errors of metabolism
(4)In 1ry polycythaemia
(5)low (P)H-increases uric acid
precipitation
(6)chemotherapy and cell death can increase uric acid levels
(7)Dehydration
Comment on opacity of uric acid stones
Radiolucent (unless they have calcium contained within them)
If uric acid stones are unlikely to be coated with calcium therefore will be radiolucent
Comment on urine acidity in uric acid stones
Acid
What is the urine PH in uric acid stones?
5.5
Discuss struvite stones
Incidence = 2-20%
Aetiology
chronic infections with urease producing bacteria e.g.,proteus mirabilis
Infection with proteus mirabilis accounts for 90% of all proteus infections.
It has a urease producing enzyme.This will tend to favour urinary
Alkalinisation which is a relative prerequisite for the formation of
staghorn calculi.
Composition
(1)Magnesium
(2)Ammonium
(3)Phosphate
(4)Crystals-precipitate under alkaline conditions
Opacity = slightly radio-opaque
Urine acidity = Alkaline
Urine PH = >7.2
What is the incidence of struvite stones?
2-20%
What is the aetiology of struvite stones?
Chronic infection with protease producing bacteria e.g.,proteus mirabilis
Infection with proteus mirabilis accounts for 90% of all proteus infections.
It has a urease producing enzyme.This will tend to favour urinary
Alkalinisation which is a relative prerequisite for the formation of
staghorn calculi.
What is the composition of struvite stones?
(1)Magnesium
(2)Ammonium
(3)Phosphate
(4)Crystals-precipitate under alkaline conditions
Comment on opacity of struvite stones
Slightly radio-opaque
Comment on urine acidity in struvite stones
Alkaline
What is the urine PH in struvite stones?
> 7.2
Discuss cystine stones
Incidence = 1%
Aetiology
Inherited-recessive disorder of transmembrane cystine transport leading to decreased absorption of cystine from intestines and renal tubules
Feature = multiple stones may form
Opacity = because they contain sulphur,they may have the following appearance
(1)radiosense or
(2)semi-opaque
(3)ground glass
Urine acidity = normal
Urine PH = 6.5
Why the urine PH is measured?
What is the incidence of cystine stones?
1%
What is the aetiology of cystine stones?
Inherited-recessive disorder of transmembrane cystine transport leading to decreased absorption of cystine from intestines and renal tubules
What is the feature of cystine stones?
multiple stones may form
Comment on opacity of cystine stones
because they contain sulphur,they may have the following appearance
(1)radiosense or
(2)semi-opaque
(3)ground glass
Comment on urine acidity in cystine stones
Normal
What is the urine PH in cystine stones?
6.5
Summarise types of renal stones for the exam
Classify renal stones
Discuss therapeutic selections for renal stones
How do you manage a ureteric calculi <5mm?
Expectantly
How do you manage a stone burden <2cm?
(1)Lithotripsy or
(2)Ureteroscopy-if pregnant or impacted
How do you manage complex renal calculi?
Percutaneous nephrolithotomy(PCNL)
How do you manage staghorn calculi?
Percutaneous nephrolithotomy(PCNL)
How do you manage stone of any size+obstructed and infected system ?
Urgent decompression(ureteroscopy or nephrostomy)
How do you manage an obstructed stone or a stone causing obstruction?
Urgent decompression(ureteroscopy or nephrostomy)
How do you manage a stone causing infected system?
Urgent decompression(ureteroscopy,nephrostomy)
Discuss staghorn renal calculi
Definition
(1)Involve the renal pelvis hence the stag horn shape
(2)Extend into at least 2 calyces
Aetiology = Recurrent Urinary Tract Infection(UTI)with urea plasma producing bacteria
(1)Ureaplasma urealyticum
(2)Proteus mirabilis
Infection with proteus mirabilis accounts for 90% of all proteus infections.
It has a urease producing enzyme.This will tend to favour urinary
Alkalinisation which is a relative prerequisite for the formation of
staghorn calculi.
(3)Klebsiella
(4)Pseudomonas
(5)Enterobacter
Composition
1st/struvite which is composed of(Mnemonic;MAP/T)
(1)magnesium
(2)ammonium
(3)Phosphate
(4)triple phosphate
2nd/Calcium carbonate appatite
Type of stone
(1)Struvite(magnesium,ammonium,phosphate,triple phosphate) or
(2)Calcium carbonate appatite
Opacity=radio-opaque
Define staghorn renal calculi
(1)Involve the renal pelvis
(2)Extend into at least 2 calyces
What is the aetiology of staghorn renal calculi?
Recurrent Urinary Tract Infection with urea producing bacteria
(1)Ureaplasma urealyticum
(2)Proteus mirabilis
Infection with proteus mirabilis accounts for 90% of all proteus infections.
It has a urease producing enzyme.This will tend to favour urinary
Alkalinisation which is a relative prerequisite for the formation of
staghorn calculi.
(3)Klebseila
(4)Pseudomonas
(5)Enterobacter
What is the composition of staghorn renal calculi?
1st/struvite which is composed of(Mnemonic;MAP/T)
(1)magnesium
(2)ammonium
(3)Phosphate
(4)triple phosphate
2nd/Calcium carbonate appatite
Discuss renal stones appearance on imaging
What is the effect of urinary PH on stone formation?
What is the incidence of urolithiasis?
15%
What are the clinical features of urolithiasis?
Abdominal pain which is
(1)the classic feature in history
(2)loin to groin
(3)sudden onset
(4)almost always associated with haematuria
How to diagnose urolithiasis?
Helical non contrast CT(CT KUB)-the most sensitive and specific diagnostic test
Discuss shock wave lithotripsy
Also known as = extracorporial shock wave lithotripsy(ESWL)
Definition
(1)a shock wave is generated external to the patient
(2)internally,cavitation bubbles and mechanical stress lead to stone fragmentation
Side effects
(1)fragmentation of larger stones results in the development ureteric obstruction
(2)the passage of shock waves results in solid organ injury
(3)the procedure is uncomfortable and requires analgesia during and after the procedure
Indications and contraindications
What is the other name for shock wave lithotripsy?
extracorporial shock wave lithotripsy(ESWL)
Define shock wave lithotripsy
(1)a shock wave is generated external to the patient
(2)internally,cavitation bubbles and mechanical stress lead to stone fragmentation
Draw a schematic diagram illustrating cavitation bubbles in ESWL
Real picture of cavitation bubbles in ESWL
What are the side effects of shock wave lithotripsy(ESWL)
(1)fragmentation of larger stones results in the development ureteric obstruction
(2)the passage of shock waves results in solid organ injury
(3)the procedure is uncomfortable and requires analgesia during and after the procedure
What are the indications and contraindications of shock wave lithotripsy (ESWL)?
What are the indications of shock wave lithotripsy (ESWL)?
What are the contraindications of shock wave lithotripsy (ESWL)?
Discuss ureteroscopy
Indications
(1)where lithotripsy is contraindicated(e.g.,pregnant)
(2)complex stone disease
(3)stone burden of less than 2cm in pregnants
Technique
(1)passes retrograde
-through the ureter
-into the renal pelvis
(2)left in situ for 4 weeks after the procedure
What are the indications of ureteroscopy?
(1)where lithotripsy is contraindicated(e.g.,pregnant)
(2)complex stone disease
(3)stone burden of less than 2cm in pregnants
What is the technique for ureteroscopy?
(1)passes retrograde
-through the ureter
-into the renal pelvis
(2)left in situ for 4 weeks after the procedure
What do(left in situ) mean for ureteroscopy?
Left in the renal pelvis
For how long the ureteroscopy is left in situ inside the renal pelvis?
4 weeks
Discuss percutaneous nephrolithotomy(PCNL)
Indications
(1)Staghorn stones
(2)Large stones(mostly > 2 cm)-It should be considered 1st line for stones>20mm
(3)Multiple stones
(4)complicated stones(e.g.,upper UTI,obstruction by a stone of whatever the size)
(5)Lower pole calyx or region stones,two options
->1cm do percutaneous nephrolithotomy (PCNL)
-<1cm do flexible ureteroscopy
(6)PCNL is a safe treatment for stones in a transplant kidney but it should be done in a specialist centre
(7)PCNL is often considered in patients with kidney stones that have undergone urinary diversion.
A retrograde approach can also be considered if access to the ureters can be gained
Contraindications
(1)Uncorrected bleeding disorders or coagulopathy
(2)Uncooperative patient
(3)Severe hyperkalemia (>7 mEq/L); this should be corrected with hemodialysis before the procedure
Technique
(1)Access is gained to the renal collecting system
(2)Intracorporial lithotripsy or stone fragmentation is performed
(3)Stone fragments removed
What are the indications of percutaneous nephrolithotomy(PCNL)?
(1)Staghorn stones
(2)Large stones(mostly > 2 cm)-It should be considered 1st line for stones>20mm
(3)Multiple stones
(4)complicated stones(e.g.,upper UTI,obstruction by a stone of whatever the size)
(5)Lower pole calyx or region stones,two options
->1cm do percutaneous nephrolithotomy (PCNL)
-<1cm do flexible ureteroscopy
(6)PCNL is a safe treatment for stones in a transplant kidney but it should be done in a specialist centre
(7)PCNL is often considered in patients with kidney stones that have undergone urinary diversion.
A retrograde approach can also be considered if access to the ureters can be gained
What is the technique used for percutaneous nephrolithotomy(PCNL)?
(1)Access is gained to the renal collecting system
(2)Intracorporial lithotripsy or stone fragmentation is performed
(3)Stone fragments removed
What does radiosense for renal stones mean?
Radio-opaque
What does radio-opaque for renal stones mean?
Radiosense
Discuss nephrostomy
What is the difference between stent(down)and nephrostomy(above)?
Define nephrostomy
Opening in the kidney
What are the indications of nephrostomy?
(1)pyelonephritis
(2)signs of obstruction(especially,distal obstruction)
-RF
-sepsis
-solitary kidney
-continuing obstruction
(3)fever
What is the technique used for renal stents?
Placed from the urethra down so you are not coming from the kidney above
What is the indication of nephrectomy?
If kidney function <15%
Discuss management of renal stones in general
1st/According to the urgency of the case
[I]NON EMERGENCY CASES
#Options
(1)Conservative treatment for 2 weeks
For stones<5mm;90% pass through urine within 4 weeks of symptoms onset
(2)Extracorporial shock wave lithotripsy(ESWL)
(3)Percutaneous nephrolithotomy(PCNL)
(4)Flexible ureteroscopy
(5)Open surgery for selected cases-minimally invasive options are the most popular first line treatment
[II]MORE INTENSIVE AND URGENT TREATMENT
#Indications
(1)Ureteric obstruction
Ureteric obstruction due to stones together
with infection is a surgical emergency and
the system must be decompressed
(2)Renal developmental abnormalities such as horseshoe kidney
(3)Renal transplant
#Options
(1)Nephrostomy tube placement
(2)Ureteric cathetre insertion
(3)Ureteric stent placement
2nd/According to the stone size
What is the management of renal stones according to the urgency of the case?
1st/According to the urgency of the case
[I]NON EMERGENCY CASES
#Options
(1)Conservative treatment for 2 weeks
For stones<5mm;90% pass through urine within 4 weeks of symptoms onset
(2)Extracorporial shock wave lithotripsy(ESWL)
(3)Percutaneous nephrolithotomy(PCNL)
(4)Flexible ureteroscopy
(5)Open surgery for selected cases-minimally invasive options are the most popular first line treatment
[II]MORE INTENSIVE AND URGENT TREATMENT
#Indications
(1)Ureteric obstruction
Ureteric obstruction due to stones together
with infection is a surgical emergency and
the system must be decompressed
(2)Renal developmental abnormalities such as horseshoe kidney
(3)Renal transplant
#Options
(1)Nephrostomy tube placement
(2)Ureteric cathetre insertion
(3)Ureteric stent placement
What are the options of management of renal stones of non emergency cases?
(1)Conservative treatment for 2 weeks
For stones<5mm;90% pass through urine within 4 weeks of symptoms onset
(2)Extracorporial shock wave lithotripsy(ESWL)
(3)Percutaneous nephrolithotomy(PCNL)
(4)Flexible ureteroscopy
(5)Open surgery for selected cases-minimally invasive options are the most popular first line treatment
What are the indications of more intensive and urgent treatment for renal stones?
(1)Ureteric obstruction
Ureteric obstruction due to stones together
with infection is a surgical emergency and
the system must be decompressed
(2)Renal developmental abnormalities such as horseshoe kidney
(3)Renal transplant
What are the options of more intensive and urgent treatment for renal stones?
(1)Nephrostomy tube placement
(2)Ureteric cathetre insertion
(3)Ureteric stent placement
What is the treatment of renal stones according to the stone size?
What is the treatment of renal stones according to the symptoms ?
What is the complication of instrumentation of renal tract and what is the treatment?
What is the complication of instrumentation of renal tract?
What are the organisms causing sepsis during instrumentation of renal tract as part of management of renal stones?
Gm(-)ve sepsis caused by organisms such as
(1)E.coli
(2)Bacteroides
What is the treatment of the organisms causing sepsis during instrumentation of renal tract as part of management of renal stones?
What is the indication of conservative management of renal stones?
(1)Conservative treatment for 2 weeks for stones<5mm
(Salah stated < 0.5cm in MRCS but in reality<1 cm)
without obstruction features ;
90% pass through urine within 4 weeks
of symptoms onset
(2)Conservative treatment is not for patients with solitary kidney and a chance of obstructing this kidney
What is the treatment of renal stones <5mm size?
Conservative treatment for 2 weeks for stones<5mm;90% pass through urine within 4 weeks of symptoms onset
For how long the conservative treatment of renal stones lasts?
2 weeks
How long do renal stones need to pass out if treated conservatively?
4 weeks
What is the percentage of renal stones passing through the urine if treated conservatively?
90%
What is the way through which renal stone pass out if treated conservatively?
Urine
What is the treatment of renal stones > 5mm?
What are the features of obstruction of renal tract by stones?
(1)RF
(2)Sepsis
(3)Solitary kidney
(4)Continuing obstruction
What is the treatment of renal stones > 5mm with obstruction features?
Nephrostomy
If no nephrostomy option in answer key,then ureteric stent option
What is the treatment of renal stones > 5mm with obstruction features and no nephrostomy in answer key?
ureteric stent option
What is the treatment of renal stones > 5mm with no obstruction features?
What is the treatment of renal stones > 5mm in the renal pelvis with no obstruction features?
(1)Extracorporial shock wave lithotripsy(ESWL)1st line treatment
(2)Percutaneous nephrolithotomyPCNL) if staghorn or large stone > 2cm
What is the treatment of simple renal stones > 5mm with no obstruction features?
Extracorporial shock wave lithotripsy(ESWL) 1st line treatment
What is the treatment of staghorn renal stones with no obstruction features?
Percutaneous nephrolithotomy (PCNL)
What is the treatment of large renal stones > 2cm with no obstruction features?
Percutaneous nephrolithotomy (PCNL)
What is the treatment of renal stones > 5 mm and ≤ 2cm in the upper pole calyx with no obstruction features?
Extracorporial shock wave lithotripsy (ESWL)
What is the treatment of renal stones > 1cm in the lower pole calyx with no obstruction features?
Percutaneous nephrolithotomy (PCNL) if > 1cm otherwise ESWL
What is the treatment of renal stones > 5 mm in the upper 1/3rd ureter with no obstruction features?
Push-Bang or ESWL in situ
What is the treatment of renal stones > 5 mm in the middle 1/3rd ureter with no obstruction features?
Mnemonic;PULLL
(1)Push-Bang 1st line treatment or
(2)USG or
(3)Laser or
(4)Lithoclast or
(5)Lithotripsy(if not considering surgery)
What is the treatment of renal stones > 5 mm in the lower 1/3rd ureter with no obstruction features?
Mnemonic;DJU
(1)Dormia Basket &
(2)JJ stent(Ureteroscopic removal if mild obstruction)
What is the treatment of renal stone <2cm with no obstruction features?
What is the treatment of small stone at the collecting system?
Flexible ureter-Renoscopy+Laser+Lithotripsy but never ESWL
What is the treatment bladder stone ?
Lithoclast fragmentation but required surgery if >5cm
What is the treatment of cystine calculi?
Dissolves by alkaline diuresis
What is the management of stones according to the symptoms?
What are the symptoms of bladder instability?
H/o
(1)urgency
(2)frequency
(3)nocturia
(4)uroflowmetry flow rate>15ml
What is the treatment of bladder instability?
Antimuscarinic drug like Tolterodine
What is the 1st line analgesia for renal colic?
NSAID
What is the 2nd line treatment for renal colic?
Strong opiates
Discuss diabetic nephropathy very briefly?
How is the diabetic nephropathy detected early?
By Micro-albuminaemia
What are the histological features of diabetic nephropathy?
Diffuse and nodular glomeruloscelerosis
What do we mean by antegrade and retrograde?
Discuss ureteric colic
Discuss rate of stones passage
Discuss over active bladder
Define the following terms
Urinary urgency,urge incontinence,urinary frequency and nocturia
Define urinary urgency
Inability to defer voiding
Define urge incontinence
Urgency causing non-voluntary urinary incontinence
Define urinary frequency
8 or more voids per 24hrs
Define nocturia
Awakening to void >1 instance per night
Discuss indinavir stones
What type of renal stones produced by indinavir could be seen on imaging?
Radiolucent stones
Discuss risk factors for stone disease
What is the effect of corticosteroids on stones formation?
Are urine cultures necessary in stone disease?
How to briefly manage urosepsis according to Pastest?
What are the sites of narrowing in the renal tract and what is its importance?
The following are the sites where the renal stones dislodge:
(1)Ureteropelvic junction(UPJ) or pelviureteric junction(PUJ)
(2)Ureteral crossing of the iliac vessels
(3)Ureterovesical junction(UVJ) or vesicoureteric junction(VUJ)
What is the duration required for complete renal obstruction to cause permanent renal dysfunction?
28 days
Enumerate causes of hydronephrosis
Enumerate causes of bilateral hydronephrosis
Enumerate causes of unilateral hydronephrosis
What is the sequele of pelvic ureteric junction obstruction?
Dietl’s crisis
Discuss Dietl’s crisis
Definition
Intermittent hydronephrosis
Aetiology
Pelvis Ureteral junction (PUJ) obstruction
Clinical features
Swelling in the loin
(1)appears after an attack of acute renal colic
(2)disappears after passage of urine
Define Dietl’s crisis
Intermittent hydronephrosis
What is the clinical feature of Dietl’s crisis?
Swelling in the loin
(1)appears after an attack of acute renal colic
(2)disappears after passage of urine
What is the aetiology of Dietl’s crisis?
Pelvic ureter junction(PUJ) obstruction
What are the investigations of hydronephrosis?
What is the role of USS in hydronephrosis?
(1)Identifies hydronephrosis
(2)Assess kidneys
What is the role of IVU in hydronephrosis?
Assess the position of the obstruction
What is the role of Antegrade and retrograde pyelography in hydronephrosis?
Allows treatment
What is the role of CT scan in hydronephrosis?
CT scan is done if suspect renal colic as the majority of stones are detected this way
What is the management or treatment of hydronephrosis?
Mnemonic;CAR
What is the treatment of acute urinary tract obstruction as part of management of hydronephrosis?
Nephrostomy tube placement
What is the treatment of chronic urinary tract obstruction as part of management of hydronephrosis?
(1)Ureteric stent placement or
(2)Pyeloplasty
What is the importance of proteus mirabilis infection in the renal stones formation?
Infection with proteus mirabilis accounts for 90% of all proteus infections.
It has a urease producing enzyme.This will tend to favour urinary alkalinisation which is a relative prerequisite for the formation of staghorn calculi.
What is the clinical picture of pelvic ureteric junction(PUJ)obstruction?
What is the cardinal feature of pelvic ureteric junction(PUJ)obstruction?
Back and flank pain correlates with periods of increased fluids intake and food ingestion with diuretics properties
What is the other name for ureteropelvic junction(UPJ)?
Pelviureteric junction
What is the other name for ureterovesical junction?
Vesicoureteric junction(VUJ)
What is the other name for renal cell carcinoma?
(1)Renal cell carcinoma of the renal cortex
(2)Renal adenocarcinoma
(3)Adenocarcinoma of the kidney
(4)Hypernephroma
(5)Grawtis tumour
(6)Clear cell carcinoma
What are the other names for renal cell carcinoma?
(1)Renal cell carcinoma of the renal cortex
(2)Renal adenocarcinoma
(3)Adenocarcinoma of the kidney
(4)Hypernephroma
(5)Grawit’s tumour
(6)Clear cell carcinoma
Discuss the incidence of the renal cell carcinoma
What is the general incidence of renal cell carcinoma?
Renal cell carcinoma are the most common renal tumour comprising 75-85% of all renal malignancies
What is the sex incidence of renal cell carcinoma?
M>F
What is the age incidence of renal cell carcinoma?
Sporadic tumours affect patients in their 6th decade.
Discuss manifestations of renal cell carcinoma
Discuss the asymptomatic presentation of the renal cell carcinoma
-Incidence:50%
-most commonly present as asymptomatic unilateral tumour in adults not in children
What is the percentage of asymptomatic presentation of renal cell carcinoma?
50%
Fill the blanks:
Renal cell carcinoma most commonly present as———,———-,in ———- not in ———
Renal cell carcinoma most commonly present as ASYMPTOMATIC,BILATERAL TUMOUR,in ADULTS not in CHILDREN
Discuss the unilateral presentation of renal cell carcinoma
-most commonly present as asymptomatic,unilateral tumour in adult not in children
-sometimes bilateral multicentric but not often
Discuss the triad of renal cell carcinoma
Incidence
10%
Presentation
(1)Haematuria(50%)
1)Microscopic-most commonly discovered during diagnostic work up
2)Macroscopic-the patient may develop frank haematuria and have episodes
of clot colic
(2)Renal colic(40%)
sometimes;it would be painless
(3)Renal mass(30%)
-RCCs typically affect the renal parenchyma
-Benign renal tumours are rare,so renal masses should be investigated with
multisliced CT scanning.
Some units will add an arterial or venous phase to the scan to demonstrate
1.vascularity
2.evidence of caval growth
What is the incidence of renal cell carcinoma triad?
10%
Discuss Haematuria in renal cell carcinoma
Incidence
50%
Presentation
1)Microscopic-most commonly discovered during diagnostic work up
2)Macroscopic(frank)-the patient may develop frank haematuria and have episodes of
clot colic
Discuss presentation of renal cell carcinoma triad
(1)Haematuria(50%)
1)Microscopic-most commonly discovered during diagnostic work up
2)Macroscopic-the patient may develop frank haematuria and have episodes
of clot colic
(2)Renal colic(40%)
sometimes;it would be painless
(3)Renal mass(30%)
-RCCs typically affect the renal parenchyma
-Benign renal tumours are rare,so renal masses should be investigated with
multisliced CT scanning.
Some units will add an arterial or venous phase to the scan to demonstrate
1.vascularity
2.evidence of caval growth
Discuss renal colic as a presentation of renal cell carcinoma triad
Incidence
40%
Presentation
sometimes;it would be painless
What is the incidence of renal colic as a presentation of renal cell carcinoma?
40%
What is the presentation of renal colic as part of the renal cell carcinoma triad?
Sometimes,it would be painless
Discuss renal mass as part of the renal cell carcinoma triad
Incidence
30%
Presentation
-RCCs typically affect the renal parenchyma
-Benign renal tumours are rare,so renal masses should be investigated with
multisliced CT scanning.
Some units will add an arterial or venous phase to the scan to demonstrate
1.vascularity
2.evidence of caval growth
What is the incidence of renal mass as part of renal cell carcinoma triad?
30%
What is the presentation of renal mass as part of renal cell carcinoma triad?
-RCCs typically affect the renal parenchyma
-Benign renal tumours are rare,so renal masses should be investigated with
multisliced CT scanning.
Some units will add an arterial or venous phase to the scan to demonstrate
1.vascularity
2.evidence of caval growth
Discuss left varicocle as part of the presentation of renal cell carcinoma
Due to compression of the left testicular vein as it joins the renal vein
What is the cause of left varicocele in renal cell carcinoma?
Due to compression of the left testicular vein as it joins the renal vein
What is the site of left testicular vein drainage?
Left renal vein
Why should we do an U/S to left vericocle in renal cell carcinoma
Discuss paraneoplastic syndrome as part of presentation of renal cell carcinoma
Aetiology in renal cell carcinoma
Paraneoplastic syndromes are due to ectopic secretion of hormones by the RCCs
Presentation
What is the aetiology of paraneoplastic syndromes as part of presentation of renal cell carcinoma?
Paraneoplastic syndromes are due to ectopic secretion of hormones by the RCCs
What are the paraneoplastic syndromes as part of presentation of renal cell carcinoma?
What is the most common paraneoplastic syndromes in general?
Endocrinopathies
What is the most common endocrinopathies in paraneoplastic syndromes?
Cushing syndrome(50%)
What is the most common paraneoplastic syndromes in general?
Cushing syndrome
What is the most common paraneoplastic syndromes in renal cell carcinoma?
Hypercalcaemia(20%)
What is the cause of hypercalcaemia in renal cell carcinoma?
(1)Parathyroid hormone
It leads to increased bone resorption and decreased
renal clearance of calcium
(2)TGF-alpha
(3)TNF
(4)IL-1
What is the incidence of hypercalcaemia in renal cell carcinoma?
20%
What is the presentation of hypercalcaemia in renal cell carcinoma?
(1)Depression
(2)Lethargy
(3)Constipation
(4)Abdominal pain
(5)Vomiting
What is the effect of parathyroid hormone in hypercalcaemia as a presentation of renal cell carcinoma?
(1)Increased bone resorption
(2)Decreased renal clearance of calcium
What is the importance of hyponatraemia in renal cell carcinoma?
Although not caused by renal cell carcinoma,it may be considered as poor prognostic indicator
What is the importance of hypocalcaemia in renal cell carcinoma?
Not seen in renal cell carcinoma
What is the most common malignancy associated with hypercalcaemia?
Squamous cell carcinoma of the lung
What is the importance of lymphopaenia in renal cell carcinoma?
What is the importance of polycythaemia in renal cell carcinoma?
What is the incidence of symptoms of metastasis in renal cell carcinoma?
25%
What are the symptoms of metastasis in renal cell carcinoma?
What are the routes of spread of renal cell carcinoma?
Discuss the direct route of spread to the metastasis of renal cell carcinoma
What is the most common route of spread to the metastasis of renal cell carcinoma?
Heamatogenous spread
Discuss the haematogenous route of spread to the metastasis of renal cell carcinoma
What are the organs to which the renal cell carcinoma directly metastasise?
What are the organs to which the renal cell carcinoma haematogenously metastasise?
Discuss the histological features of renal cell carcinoma
What is the origin of renal cell carcinoma?
Proximal convoluted tubules(PCT)
Discuss role of 20% in renal cell carcinoma
What is the appearance of renal cell carcinoma
What are the investigations of renal cell carcinoma?
What is the reason for which multisliced CT scan is done for renal cell carcinoma?
Benign tumours are rare,so renal masses should be investigated with multisliced CT scanning.
Some units will add an arterial or venous phase to demonstrate
(1)Vascularity
(2)Evidence of caval growth
What is the reason for which CT scan of the chest and abdomen is done for renal cell carcinoma?
To detect distant disease
What is the reason for which routine bone scan is done for renal cell carcinoma?
Not indicated in the absence of symptoms
What is the reason for which biopsy is done for renal cell carcinoma?
What is the indication of renal biopsy in renal cell carcinoma?
Before any ablative therapies
What are the contraindications of renal biopsy in renal carcinoma?
Post nephrectomy
What is the reason for which renal biopsy is contraindicated post nephrectomy?
Most cases of malignancy can be accurately classified on imaging
What multisliced CT scan show in renal cell carcinoma?
A mass with small cystic centre
What is the differential diagnosis of renal cell carcinoma?
What is the importance of oncocytoma as a differential diagnosis of renal cell carcinoma?
Discuss TNM staging and grading of renal cell carcinoma
What is the importance of renal cell carcinoma staging and grading?
Prognosis
Describe primary tumour (T) category of renal cell carcinoma staging?
Describe regional lymph nodes (N) category of renal cell carcinoma staging?
Describe distant metastasis (M) category of renal cell carcinoma staging?
Describe prognostic stage groups of renal cell carcinoma staging?
What is Tx stage of renal cell carcinoma mean?
Primary tumour can not be assessed
What is T0 stage of renal cell carcinoma mean?
No evidence of primary tumour
What is T1 stage of renal cell carcinoma mean?
What is T1a stage of renal cell carcinoma mean?
Tumour ≤4 cm in greatest dimension,limited to the kidney
What is T1b stage of renal cell carcinoma mean?
Tumor >4 cm but ≤7 cm in greatest dimension, limited to the kidney
What is T2 stage of renal cell carcinoma mean?
What T2a means in staging of renal cell carcinoma?
Tumor >7 cm but <10 cm in greatest dimension, limited to the kidney
What T2b means in staging of renal cell carcinoma?
Tumor >10 cm, limited to the kidney
What T3 means in staging of renal cell carcinoma?
Tumor extends into major veins or perinephric tissues, but not into the ipsilateral adrenal gland and not beyond Gerota’s fascia
What T3a means in staging of renal cell carcinoma?
What T3b means in staging of renal cell carcinoma?
Tumor extends into the vena cava below the diaphragm
What T3c means in staging of renal cell carcinoma?
Tumor extends into the vena cava above the diaphragm or invades the wall of the vena cava
What T4 means in staging of renal cell carcinoma?
Tumor invades beyond Gerota’s fascia (including contiguous extension into the ipsilateral adrenal gland)
What Nx means in staging of renal cell carcinoma?
Regional lymph nodes cannot be assessed
What N0 means in staging of renal cell carcinoma?
No regional lymph node metastasis
What N1 means in staging of renal cell carcinoma?
Metastasis in regional lymph node(s)=1 node
What N2 means in staging of renal cell carcinoma?
Metastasis in regional lymph node(s)=2 nodes
What M0 means in staging of renal cell carcinoma?
No distant metastasis
What M1 means in staging of renal cell carcinoma?
Distant metastasis
What stage I means in the grading of renal cell carcinoma?
T1N0M0
What stage II means in the grading of renal cell carcinoma?
T2N0M0
What stage III means in the grading of renal cell carcinoma?
(1)T1N1M0
(2)T2N1M0
(3)T3NxM0
(4)T3N0M0
(5)T3N1M0
What stage IV means in the grading of renal cell carcinoma?
(1)T4,any N,M0
(2)Any T,any N,M1
Discuss management of renal cell carcinoma
Discuss management of T1 stage of renal cell carcinoma
What is the main procedure to treat T1 stage in renal cell carcinoma?
Partial nephrectomy
What is the indication of partial nephrectomy in the treatment of T1 stage in renal cell carcinoma?
Inadequate reserve in the remaining kidney
What is the advantage of partial nephrectomy in the treatment of T1 stage in renal cell carcinoma?
Gives equivalent oncological results to total radical nephrectomy
Discuss treatment of T2 stage or above of renal cell carcinoma
Discuss total radical nephrectomy as an option for treatment of T1 stage or above of renal cell carcinoma
What is the standard practice for treatment of T1 stage or above of renal cell carcinoma
Total radical nephrectomy
What is the technique for total radical nephrectomy as an option for treatment of T1 stage or above of renal cell carcinoma
What is the technique for total radical nephrectomy as an option for treatment of T1 stage or above of renal cell carcinoma if performed via the open approach?
What is the reason that early venous control is mandatory during surgery of total radical nephrectomy for treatment of T1 stage or above of renal cell carcinoma?
To avoid shedding of tumour cells into the circulation
What is not indicated in total radical nephrectomy for treatment of T1 stage or above of renal cell carcinoma?
What is the treatment of stages 1-4 of renal cell carcinoma?
Discuss adjuvant therapy as an option for treatment of T2 stage or above of renal cell carcinoma
What is the treatment of stage 1 renal cell carcinoma?
Partial nephrectomy
What is the treatment of stage 2,3 and 4 of renal cell carcinoma?
Total radical nephrectomy
What is the other name for Wilm’s tumour?
(1)Wilm’s nephroblastoma
(2)Nephroblastoma
Discuss incidence of Wilm’s tumour
(1)Rare childhood tumour
(2)It accounts for 80% of all genitourinary malignancies in
pre-school children <15 years
(3)They are the commonest intra-abdominal tumours in
children under 10 years of age
(4)Occurs in children <5 years of life
(5)Usually presents in the first 4 years of life
What are the manifestations of Wilm’s tumour?
What is the chance of a patient with Wilm’s tumour to have a renal mass?
90%
Discuss renal mass in a patient with Wilm’s tumour?
What is the chance of a patient with Wilm’s tumour to have bilateral or multi-centric renal mass?
10%
What is the chance of a patient with Wilm’s tumour to have haematuria ?
Renal mass in Wilm’s tumour is rarely associated with haematuria(1/3rd of the patients)
What is the number of patients with Wilm’s tumour to have haematuria?
1/3rd of the patients
What is the chance of a patient with Wilm’s tumour to have fever?
50%
What is the chance of a patient with Wilm’s tumour to have hypertension?
50%
At which side the varicocele usually presents in patients with Wilm’s tumour?
Left side
Discuss WAGR syndrome in patients with Wilm’s tumour?
(1)Wilm’s tumour
(2)Aniridia
(3)Genitourinary
(4)Mental Retardation
What are the symptoms of metastasis in patients with Wilm’s tumour?
What is the characteristic feature of children with Wilm’s tumour?
Failure to thrive
What are the investigations of Wilm’s tumour?
What does XRs show in Wilm’s tumour?
Non calcified lesion
What does CT show in Wilm’s tumour?
Non calcified lesion
Discuss differential diagnosis of Wilm’s tumour
What is the difference between Wilm’s tumour and neuroblastoma?
What is the histological feature of Wilm’s tumour?
Undifferentiated embryonic tumour
What is the management of Wilm’s tumour?
What is the VAD regime for the management of Wilm’s tumour?
It is a chemotherapy regime combined with nephrectomy and includes
What is the prognosis of Wilm’s tumour?
Define neuroblastoma
What is the origin of neuroblastoma?
What is the incidence of neuroblastoma?
What are the manifestations of neuroblastoma?
What is the name of the syndrome associated with neuroblastoma?
Opsoclonus-myoclonus syndrome
What are the investigations of neuroblastoma?
What are the catecholamines secreted by neuroblastoma?
(1)Vanillylmandelic acid
(2)Homovanillic acid
What does the urine test for in neuroblastoma?
Catecholamines
What is the diagnostic test of neuroblastoma and what does it show?
Meta-Iodophor-Benzyl-Guanidine(MIBG) is diagnostic and shows calcified tumour
What does Meta-Iodo-Benzyl-Guanidine(MIBG) show in neuroblastoma?
Calcified tumour
What is the reason for doing a CT scan in neuroblastoma?
For staging
What is the management of neuroblastoma?
Discuss pathology of Wilm’s tumour
Discuss complications and ways of spread of Wilm’s tumour
What is the difference between Wilm’s tumour and Hypernephroma(renal cell carcinoma)?
What is the other name for renal transitional cell carcinoma?
Transitional cell carcinoma of the kidney
What is the incidence of renal transitional cell carcinoma?
What is the incidence of renal transitional cell carcinoma for or compared to the upper urinary tract tumours?
90%
What is the incidence of renal transitional cell carcinoma for or compared to all renal tumours?
Rare,approximately 7-10% of all renal tumours
What is the sex incidence of renal transitional cell carcinoma?
M 3x > F
What is the incidence of renal transitional cell carcinoma in males?
M 3x > F
What is the incidence of renal transitional cell carcinoma in females?
M 3x > F
What are the risk factors for renal transitional cell carcinoma?
What is the significance of smoking in renal transitional cell carcinoma?
What is the significance of smoking in urology ?
Renal transitional cell carcinoma
What is the significance of the occupation in renal?
