Week 3 PBL

Question 1

describe a Hx to evaluate hematuria in a patient

Answer 1

1. onset and duration
2. trauma
3. aggravating and alleviating factors
4. initial verus total hematuria
5. meds (warfarin, ASA, statins (due to rhabdomyolysis), rifampin)
6. clots?
7. tissue fragments?
8. bleeding elsewhere?
9. constitutional symptoms (weight loss, night sweats)
10. previous stone disease
11. cancer risk factors

Question 2

what are the most likely causes of painless hematuria?

Answer 2

malignancy or BPH

Question 3

are stones, UTI, or trauma likely to be asymptomatic

Answer 3

no–usually symptomatic

Question 4

what condition is initial hematuria associated with?

Answer 4

BPH

Question 5

what does total hematuria suggest?

Answer 5

bleeding from bladder, ureter or kidney

Question 6

if there are clots in the urine, what condition is ruled out as a diagnosis?

Answer 6

glomerulonephritis

Question 7

if there are tissue fragments in the urine, what diagnosis is more likely

Answer 7

bladder tumor

Question 8

what does bleeding elsewhere, in addition to the hematuria, suggest?

Answer 8

coagulopathy

Question 9

what do constitutional symptoms like weight loss or night sweats suggest in the context of hematuria?

Answer 9

malignancy

Question 10

what is the biggest risk factor for TCC

Answer 10

SMOKING

Question 11

describe a physical exam to evaluate hematuria

Answer 11

1. signs of systemic disease (fever, rash, lymphadenopathy)
2. signs of medical renal disease (HTN, volume overload)
3. genital exam to elicit source of blood (i.e not vagina)
4. palpation for bladder/kidney masses, abdominal masses, pelvic masses, costovertebral angle tenderness
5. DRE for BPH, prostate masses
6. urological exam for prostate, flank mass, urethral disease

Question 12

what patients presenting with proven hematuria get imaging

Answer 12

everyone

exception is women younger than 40 who’s bleeding could be due to infection or menstruation

Question 13

gross, painless hematuria in an adults is _____ until proven otherwise

Answer 13

malignancy

Question 14

what is the most common cause of hematuria in young patients

Answer 14

stones or UTI

Question 15

what are extra-renal causes of hematuria

Answer 15

malignancy is most important diagnosis

other common non-malignant causes of extrarenal hematuria are infections (cystitis, prostatitis, urethritis)

Question 16

what are the most common glomerular causes of hematuria

Answer 16

most common = IgA nephropathy

thin basement membrane disease

hereditary nephritis

other mild focal glomuerulonephritis

Question 17

what are the most common non-glomerular renal causes of hematuria

Answer 17

renal stones

pyelonephritis

polycystic kidney disease

renal cell carcinoma

Question 18

list a DDX for flank pain

Answer 18

1. urolithiasis
2. radicular/muscular
3. pyelonephritis
4. herpes zoster
5. renal abscess
6. renal vein thrombosis
7. renal infarction
8. AAA
9. retroperitoneal hematoma

Question 19

symptoms and signs of colic related to ureteric calculi

Answer 19

1. pain–most common symptom; location depends on location of the stone and may change as the stone migrates
2. hematuria–occurs in most patients with kidney stones
3. other symptoms: nausea, vomiting, pain with urination, impacted stone leading to infection, staghorn calculi becoming lodged in renal pelvis

they can be asymptomatic however

Question 20

where is the pain localized with upper ureter or renal pelvis stones?

Answer 20

flank pain

Question 21

where is the pain localized for lower ureter stones?

Answer 21

lower abdomen that may radiate to the genitals

Question 22

what symptoms are particularly suggestive of a kidney stone

Answer 22

hematuria, flank pain, history of acute onset

Question 23

what imaging test is preferred for stones

Answer 23

CT KUB

Question 24

what stones cannot be seen on abdominal Xray

Answer 24

uric acid stones and small stones (can be seen on CT KUB tho)

Question 25

what test is used for pregnant women if stones are suspected

Answer 25

ultrasonography

Question 26

acute treatment of calculi

Answer 26

1. patients require only pain medication and fluids until stone is passed (i.e NSAIDS, narcotics) 2. fluids to increase urine flow and facilitate passage of the stone 3. ALPHA BLOCKERS may help facilitate passage 4. patients able to tolerate the pain and take oral meds can be managed at home 5. once the stone is passed, an imaging test is done to ensure passage is complete and no fragments remain

Question 27

what size stones usually pass spontaneously

Answer 27

smaller than 5mm, though up to 7mm can often pass spontaneously

Question 28

what are some treatments that can be applied to stones that don't pass spontaneously

Answer 28

1. shockwave lithotipsy (SWL) 2. percutaneous nephrolithotomy (PNL) 3. ureterorenoscopy

Question 29

what is shockwave lithotripsy (SWL)

Answer 29

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

Question 30

what is a percutaneous nephrolithotomy (PNL)

Answer 30

- 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

Question 31

what is a ureterorenoscopy

Answer 31

- 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

Question 32

what is the only curative therapy for RCC

Answer 32

surgical resection

Question 33

why cant you use chemotherapy and radiotherapy for RCC

Answer 33

because RCC is highly resistant to both

Question 34

what immunotherapies are being used for RCC

Answer 34

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

Question 35

how do you rule out metastatic disease before RCC surgery

Answer 35

``` abdominal CT chest CT bone scan serum electrolytes liver enzymes and function head CT/MRI if warranted ```

Question 36

when can be ipsilateral adrenal gland be spared in RCC surgical treatment

Answer 36

it can be safely preserved if it appears normal on CT scan and the tumor is not immediately adjacent to it

Question 37

when can do you a partial nephrectomy

Answer 37

1. for all renal tumors

Question 38

in which patients can a nephrectomy be performed prior to systemic therapy

Answer 38

in patients with low volume metastatic RCC

Question 39

what are the parameters of informed consent

Answer 39

1. the patient is informed of treatment options 2. the nature of the treatments is taken into account by the patient 3. risks versus benefits are fully discussed with the patient 4. the choice to undergo treatment is shown by the patient voluntarily 5. there is no coercion, manipulation, or duress shown by the physician

Question 40

what are indications for urological consultation and possible cystoscopy/ureteroscopy

Answer 40

1. all cases of urinary tract obstruction and suspected renal malignancies are referred to urologists following initial work up 2. referral to urologist is usually made following initial workup including las tests (urine, blood), ultrasound, and CT KUB/CT IVP 3. painless hematuria with no US or CT IVP findings indicates C&P or referral to urologist 4. urologist can perform cystoscopy and/or ureteroscopy to visualize entire urinary tract up to the kidney