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Surgery > Urology P1 > Flashcards

Urology P1 Flashcards

1
Q

Causes of unilateral hydronephrosis:

A
  • pelvic ureteric obstruction
  • aberrant renal vessels
  • calculi
  • tumours of renal pelvis
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2
Q

Causes of bilateral hydronephrosis:

A
  • stenosis of urethra
  • urethral valve
  • prostatic enlargement
  • extensive bladder tumour
  • retro-peritoneal fibrosis
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3
Q

1st line and other investigations for hydronephrosis:

A

US

-other: IVU (assess position of obstruction), integrate or retrograde pyelography, suspected renal colic - CT scan

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4
Q

Management of hydronephrosis:

A
  • remove obstruction and drain urine
  • acute UUTI obstruction: nephrostomy
  • chronic: ureteric stent or pyeloplasty
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5
Q

Histology of renal cell cancer:

A
  • hypernephroma
  • 86% primary neoplasm
  • from proximal renal tubular epithelium
  • most common subtype clear cell
  • 20% multifocal, 20% calcified, 20% cystic component or wholly cystic
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6
Q

Associations of RCC:

A
  • middle aged men
  • smoking
  • Von Hippel Lindau
  • tuberous sclerosis
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7
Q

Features of RCC:

A
  • triad: haematuria, loin pain, abdominal mass
  • pyrexia
  • left varicocele (occlusion left testicular vein)
  • endocrine effects: polycythaemia, hypercalcaemia, renin, ACTH
  • paraneoplastic hepatic dysfunction syndrome (Stauffer syndrome): cholestasis/hepatosplenomegaly, secondary to increased IL-6
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8
Q

Management of RCC:

A
  • confined disease: partial or total nephrectomy depending on size
  • alpha IF and IL-2 to reduce size and treat metastatic disease
  • receptor tyrosine kinase inhibitors e.g. sorafenib, sunitinib superior to IF alpha
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9
Q

All types of renal stones:

A
  • calcium oxalate
  • cystine
  • uric acid
  • calcium phosphate
  • struvite
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10
Q

Features of calcium oxalate stones and appearance:

A
  • 85%
  • hypercalciuria increases risk
  • hyperoxaluria increases risk
  • hypocitraturia increases risk because forms complexes with calcium - more soluble
  • radio-opaque (less than calcium phosphate)
  • hyperuricosuria can cause uric acid stones to which calcium oxalate binds
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11
Q

Features of cystine stones and appearance:

A
  • 1%
  • inherited recessive disorder of transmembrane cystine transport - reduce absorption from intestine and renal tubules
  • multiple may form
  • radiodense (contain sulphur)
  • semi-opaque ‘ground glass’
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12
Q

Features of uric acid stones and appearance:

A
  • 5-10%
  • product of purine metabolism
  • precipiate when urinary pH low
  • diseases with extensive breakdown e.g. malignancy
  • more common in children with metabolism issues
  • radiolucent
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13
Q

Features of calcium phosphate stones and appearance:

A
  • 10%
  • in renal tubular acidosis
  • high urinary pH supersaturates urine with calcium and phosphate
  • RTA 1 and 3 increases risk
  • radio-opaque stones
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14
Q

Features of struvite stones and appearance:

A
  • 2-20%
  • magnesium, ammonium and phosphate
  • urease producing bacteria
  • under alkaline conditions produced, crystals can precipitate
  • slightly radio-opaque
  • staghorn calculus
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15
Q

What is the appearance of xanthine stones?

A

-radio-lucent

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16
Q

What infection does stag horn calculi increase risk of?

A

proteus mirabilis

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17
Q

What does periureteric fat stranding indicate?

A

recent stone passage

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18
Q

Risk factors for renal stones:

A
  • dehydration
  • hypercalciuria, hyperparathyroidism, hypercalcaemia
  • cystinuria
  • high dietary oxalate
  • RTA
  • medullary sponge kidney, polycystic kidney disease
  • beryllium or cadmium exposure
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19
Q

Risk factors urate stones:

A
  • gout

- ileostomy: loss of bicarbonate and fluid results in acidic urine

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20
Q

Drug causes of renal stones:

A
  • promoting calcium stones: loop diuretics, steroids, acetazolamide, theophylline
  • prevents calcium stones: thiazides (increases distal calcium resorption)
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21
Q

Investigations for renal stones:

A
  • urine dipstick and culture
  • serum creatinine and electrolytes
  • calcium/urate
  • CTKUB within 14 hours
  • fever, solitary kidney or when uncertain - immediate CTKUB
  • CTKU sensitivity 97% and specificity 95%
  • US not first line
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22
Q

Initial management renal colic caused by stones:

A
  • NSAID analgesia
  • diclofenac IM (increased risk CV events) for rapid relief
  • alpha blockers for larger stones?
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23
Q

What to do if stones are <5mm?

A
  • pass spontaneously within 4 weeks

- lithotripsy and nephrolithotomy for severe cases

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24
Q

Treatment for stones causing ureteric obstruction:

A
  • decompress with nephrostomy tube replacement, insertion catheters and ureteric stent
  • non emergency: lithotripsy, percutaneous nephrolithotomy, uterosopy, open surgery
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25
Q

Treatment for stone burden of less than 2 cm in aggregate:

A

lithotripsy

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26
Q

Treatment for stone burden of less than 2 cm in pregnant females:

A

ureteroscopy

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27
Q

Treatment for complex renal calculi and stag horn calculi:

A

percutaneous nephrolithotomy

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28
Q

Treatment for ureteric calculi less than 5mm:

A

manage expectantly

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29
Q

How does a percutaneous nephrolithotomy work?

A
  • access to renal collecting system
  • intra corporeal lithotripsy or stone fragmentation performed
  • stone fragments removed
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30
Q

How does shock wave lithotripsy work?

A
  • internal cavitation bubbles and mechanical stress - stone fragmentation
  • can cause solid organ injury or ureteric obstruction
  • uncomfortable
31
Q

How does ureteroscopy work?

A
  • passed retrograde through ureter and into renal pelvis
  • indicated where lithotripsy contra and complex stone disease
  • stent left in situ for 4 weeks after
32
Q

Prevention of renal stones:

A 
hypercalciuria:
-fluid intake
-low animal protein, low salt
-thiazide diuretics
oxalate stones:
-cholestyramine
-pyridoxine
uric acid stones;
-allopurinol and urinary alkalisation e.g. oral bicarbonate
33
Q

What is the most common cause of AKI?

A

ATN

34
Q

2 main causes of ATN:

A
  • ischaemia

- nephrotoxins: ahminoglycosides, myoglobin secondary to rhabdo, radio contrast agents, lead

35
Q

Features of ATN:

A
  • AKI: increased urea, potassium, creatinine

- muddy brown casts in urine

36
Q

Histopathology of ATN:

A
  • tubular epithelium necrosis: loss of nuclei and detachment of tubular cells from BM
  • dilation of tubules
  • necrotic cells obstruct tubule lumen
37
Q

Phases of ATN:

A
  • oliguric
  • polyuric
  • recovery
38
Q

What is nephroblastoma also known as?

A

Wilm’s tumour

39
Q

When does nephroblastoma happen and what are the features?

A
  • first 4 years of life
  • haematuria
  • pyrexia
  • often metastasis early to lungs
  • younger children better prognosis
  • HTN
  • US and CT
40
Q

Treatment nephroblastoma:

A

nephrectomy + chemotherapy (cinvristine, actinomycin D, doxorubicin)

41
Q

Paraneoplastic features of RCC:

A
  • HTN

- polycythaemia

42
Q

How does RCC commonly metastasise:

A

haematogenously

43
Q

What is a neuroblastoma?

A
  • most common extra cranial tumour of childhood
  • under 4 years usually
  • tumour of neural crest origin
  • 50% adrenal gland
  • calcified tumour and diagnosed using MIBG scanning
  • staging with CT
44
Q

Treatment neuroblastoma:

A
  • surgical resection

- radio and chemotherapy

45
Q

What is transitional cell carcinoma?

A
  • 90% of lower urinary tract tumours
  • males 3x
  • occupational exposure to industrial dyes and rubber chemicals increase risk
  • 80% painless haematuria
  • diagnosis and staging with CT IVU
46
Q

Treatment transitional cell carcinoma:

A

radical nephroureterectomy

47
Q

What is an angiomyolipoma?

A
  • 80% of hamartoma type lesions occur sporadically
  • rest tuberous sclerosis
  • composed of blood vessels, smooth and muscle and fat
  • massive bleeding 10%
48
Q

Treatment angiomyolipoma:

A

> 4cm will have symptoms and require surgical resection

49
Q

General investigations for renal tumours:

A
  • multislice CT
  • CT chest and abdomen
  • no routine bone scanning
  • no biopsy when nephrectomy planned
  • assess contralateral kidney function
50
Q

Management T1 lesion or inadequate reserve remaining kidney:

A

partial nephrectomy

51
Q

Management T2 lesions:

A

radical nephrectomy or early venous control to avoid tumour cell shedding in circulation

52
Q

How much does smoking increased the risk of bladder cancer?

A

2-5 fold increase

53
Q

Benign bladder tumours:

A
  • inverted urothelial papilloma

- nephrogenic adenoma

54
Q

Bladder malignancies:

A
  • transitional cell carcinoma
  • squamous cell carcinoma
  • adenocarcinoma
55
Q

T0

A

no evidence of tumour

56
Q

Ta

A

non invasive papillary carcinoma (urothelium)

57
Q

T1

A

tumour invades sub epithelial connective tissue (lamina propria)

58
Q

T2a

A

tumour invades superficial muscular propria (inner half of detrusor muscle)

59
Q

T2b

A

tumour invades deep muscular propria (outer hand of detrusor muscle)

60
Q

T3

A

tumour extends to perivesical fat

61
Q

T4

A

tumour invades: prostatic stroma, seminal vesicles, uterus, vagina (local structures)

62
Q

T4a

A

invasion of uterus, prostate or bowel

63
Q

T4b

A

invasion of pelvic sidewall or abdominal wall

64
Q

N0

A

no nodal disease

65
Q

N1

A

single regional lymph node metastasis in true pelvis (hypogastric, obturator, external iliac, or presacral lymph node)

66
Q

N2

A

multiple regional lymph node metastasis in true pelvis (hypogastric, obturator, external iliac, presacral lymph nodes)

67
Q

N3

A

lymph node metastasis to common iliac lymph nodes

68
Q

M0

A

no distant metastasis

69
Q

M1

A

distant disease

70
Q

Investigations bladder cancer:

A
  • cystoscopy and biopsies or TURBT
  • pelvic MRI and CT - loco regional spread and distant
  • nodes uncertain - PET CT
71
Q

Presentation bladder cancer:

A
  • 85% painless macroscopic haematuria

- incidental microscopic haematuria - 10% females >50yo - malignancy

72
Q

Treatment bladder cancer:

A
  • superficial lesions - TURBT
  • recurrences or high grade on histology - intravesical chemotherapy
  • T2 disease - surgery (radical cystectomy and ill conduit) or radical radiotherapy
  • neobladder increased risk of adenocarcinoma
73
Q

Risk factors bladder cancer:

A
  • transitional cell carcinoma: smoking, aniline dyes in printing and textile e.g. 2-naphthylamine and benzidine, rubber manufacture, cyclophosphamide
  • squamous cell carcinoma: schistosomiasis, smoking

Surgery (10 decks)

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