Week 3 PBL Flashcards
describe a Hx to evaluate hematuria in a patient
- onset and duration
- trauma
- aggravating and alleviating factors
- initial verus total hematuria
- meds (warfarin, ASA, statins (due to rhabdomyolysis), rifampin)
- clots?
- tissue fragments?
- bleeding elsewhere?
- constitutional symptoms (weight loss, night sweats)
- previous stone disease
- cancer risk factors
what are the most likely causes of painless hematuria?
malignancy or BPH
are stones, UTI, or trauma likely to be asymptomatic
no–usually symptomatic
what condition is initial hematuria associated with?
BPH
what does total hematuria suggest?
bleeding from bladder, ureter or kidney
if there are clots in the urine, what condition is ruled out as a diagnosis?
glomerulonephritis
if there are tissue fragments in the urine, what diagnosis is more likely
bladder tumor
what does bleeding elsewhere, in addition to the hematuria, suggest?
coagulopathy
what do constitutional symptoms like weight loss or night sweats suggest in the context of hematuria?
malignancy
what is the biggest risk factor for TCC
SMOKING
describe a physical exam to evaluate hematuria
- signs of systemic disease (fever, rash, lymphadenopathy)
- signs of medical renal disease (HTN, volume overload)
- genital exam to elicit source of blood (i.e not vagina)
- palpation for bladder/kidney masses, abdominal masses, pelvic masses, costovertebral angle tenderness
- DRE for BPH, prostate masses
- urological exam for prostate, flank mass, urethral disease
what patients presenting with proven hematuria get imaging
everyone
exception is women younger than 40 who’s bleeding could be due to infection or menstruation
gross, painless hematuria in an adults is _____ until proven otherwise
malignancy
what is the most common cause of hematuria in young patients
stones or UTI
what are extra-renal causes of hematuria
malignancy is most important diagnosis
other common non-malignant causes of extrarenal hematuria are infections (cystitis, prostatitis, urethritis)
what are the most common glomerular causes of hematuria
most common = IgA nephropathy
thin basement membrane disease
hereditary nephritis
other mild focal glomuerulonephritis
what are the most common non-glomerular renal causes of hematuria
renal stones
pyelonephritis
polycystic kidney disease
renal cell carcinoma
list a DDX for flank pain
- urolithiasis
- radicular/muscular
- pyelonephritis
- herpes zoster
- renal abscess
- renal vein thrombosis
- renal infarction
- AAA
- retroperitoneal hematoma
symptoms and signs of colic related to ureteric calculi
- pain–most common symptom; location depends on location of the stone and may change as the stone migrates
- hematuria–occurs in most patients with kidney stones
- other symptoms: nausea, vomiting, pain with urination, impacted stone leading to infection, staghorn calculi becoming lodged in renal pelvis
they can be asymptomatic however
where is the pain localized with upper ureter or renal pelvis stones?
flank pain
where is the pain localized for lower ureter stones?
lower abdomen that may radiate to the genitals
what symptoms are particularly suggestive of a kidney stone
hematuria, flank pain, history of acute onset
what imaging test is preferred for stones
CT KUB
what stones cannot be seen on abdominal Xray
uric acid stones and small stones (can be seen on CT KUB tho)
what test is used for pregnant women if stones are suspected
ultrasonography
acute treatment of calculi
- patients require only pain medication and fluids until stone is passed (i.e NSAIDS, narcotics)
- fluids to increase urine flow and facilitate passage of the stone
- ALPHA BLOCKERS may help facilitate passage
- patients able to tolerate the pain and take oral meds can be managed at home
- once the stone is passed, an imaging test is done to ensure passage is complete and no fragments remain
what size stones usually pass spontaneously
smaller than 5mm, though up to 7mm can often pass spontaneously
what are some treatments that can be applied to stones that don’t pass spontaneously
- shockwave lithotipsy (SWL)
- percutaneous nephrolithotomy (PNL)
- ureterorenoscopy
what is shockwave lithotripsy (SWL)
treatment for renal stones
- SWL is the treatment of choice in many patients
- large, hard or complex stones, like staghorn calculi
- xrays or ultrasound are used to pinpoint the location of the stone
- high energy shock wave is directed toward the stone, passing through the skin and bodily tissue and causing a release of energy at the stone surface
- this energy causes the stone to break into fragments that can be more easily passed
what is a percutaneous nephrolithotomy (PNL)
- extremely large or complex stones that are resistant to SWL may require PNL
- small instruments are passed through the skin of the back and into the kidney to access the stone directly
- often used in patients with abnormal kidneys
- rarely, open surgery is used to access and remove complex stones
what is a ureterorenoscopy
- often used to remove stones obstructing the middle and lower portions of the ureter
- very small telescopic instrument is passed up through the urethra and bladder and into the ureter
- the telescope is moved through the ureter until it encounters the obstructing stone which is then removed
- if the stone is too large for intact removal, a HOLMIUM LASER can be applied during the procedure to break the stones into smaller pieces that are easier to extract
what is the only curative therapy for RCC
surgical resection
why cant you use chemotherapy and radiotherapy for RCC
because RCC is highly resistant to both
what immunotherapies are being used for RCC
immunotherapies with interferon-alpha and IL-2 have shown partial response rates of 10-20%
new drugs target the VEGF pathway (sunitinib) or the mTOR pathway
used for people with metastatic RCC
how do you rule out metastatic disease before RCC surgery
abdominal CT chest CT bone scan serum electrolytes liver enzymes and function head CT/MRI if warranted
when can be ipsilateral adrenal gland be spared in RCC surgical treatment
it can be safely preserved if it appears normal on CT scan and the tumor is not immediately adjacent to it
when can do you a partial nephrectomy
- for all renal tumors
in which patients can a nephrectomy be performed prior to systemic therapy
in patients with low volume metastatic RCC
what are the parameters of informed consent
- the patient is informed of treatment options
- the nature of the treatments is taken into account by the patient
- risks versus benefits are fully discussed with the patient
- the choice to undergo treatment is shown by the patient voluntarily
- there is no coercion, manipulation, or duress shown by the physician
what are indications for urological consultation and possible cystoscopy/ureteroscopy
- all cases of urinary tract obstruction and suspected renal malignancies are referred to urologists following initial work up
- referral to urologist is usually made following initial workup including las tests (urine, blood), ultrasound, and CT KUB/CT IVP
- painless hematuria with no US or CT IVP findings indicates C&P or referral to urologist
- urologist can perform cystoscopy and/or ureteroscopy to visualize entire urinary tract up to the kidney
