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FRCR 2A > Urology > Flashcards

Urology Flashcards

1
Q

Where is tunica albuginea?

A

Fibrous layer that coats the testicle

Disruption of this layer (seen as wrinkling or loss of continuity) is a specific sign of TESTICULAR RUPTURE

This is an indication for surgery!

The tunica albuginea also protects against infertility by guarding spermatozoa

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2
Q

How are peripheral prostate lesions assessed?

A

Peripheral assessed using DIFFUSION RESTRICTION

and CONTRAST ENHANCEMENT (helps assess lesions which have limited diffusion restriction)

ADC is more useful than DWI in assesing. DWI may not be bright but ADC low

A PIRADS 5 lesion will be >1.5cm with marked restriction of diffusion

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3
Q

How are transitional zone prostate lesions assessed?

A

Using T2

Useful in looking for:

  • extracapsular extension
  • bladder base invasion
  • seminal vesicle invasion

The highest grade of suspicion for transitional zone lesions is reserved for moderate T2 lesion which is lenticular or non-circumscribed and moderately T2 hypointense (PIRADS 5 >1.5 cm).

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4
Q

What age group is testicular lymphoma typically seen?

A

Older men

Bilateral hypoechoic masses

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5
Q

What is most aggressive testicular tumour?

A

Embryonal Cell Tumour

  • occur in 30’s
  • visceral mets common
  • 5 year survival 30%
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6
Q

How common is Choriocarcinoma and what age group?

A

This is a rare tumour affecting 20-30-year-olds with rapid metastases to lung, liver, GI tract, brain. Often causes haemorrhage in both primary and metastatic lesions. Causes gynaecomastia in 10% due to raised serum hCG.

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7
Q

How is PSA density calculated?

A

PSA/Volume of prostate

Prostate cancers usually seen in those with PSA Density of >0.1ng/ml/cc

If a radiologist is reviewing a scan for a patient with a PSA density >0.1 and is unable to identify a prostatic malignancy then either they should review the scan more closely, or the PSA value could be repeated following appropriate instructions to the patient regarding cessation of PSA elevating activities prior to the test.

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8
Q

What is an Azzopardi Tumour and how does it arise?

A

Known as Burnt out germ cell tumour

  • a primary germ cell tumour which has outgrown its blood supply and then shrinks
  • appears as small hypoechoic mass in testicle

Assocated with mets to retroperitoneal lymph nodes

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9
Q

Renal Lymphoma Summary

A

Spread to kidneys:

  • Haematogenous
  • Directly from retroperitoneal lymph nodes

There are multiple different patterns:

  1. MULTIPLE Bilateral low attenuation kidney masses with poor enhancement (MOST COMMON)
  2. Solitary mass mimicking a RCC
  3. Perirenal disease (appears as a low attenuation mass beside kidney)
  4. Infiltrative disease (SUBTLE - kidneys can appear enlarged and retain normal shape)
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10
Q

What patterns of washout are seen in Peripheral prostate lesions?

What curve is most concerning and why

A

Post contrast imaging needed to differentiate between PIRADS 3 and 4

Type 1 and 2 curves in prostate imaging can also occur in malignant lesions but type 3 curves are the most concerning.

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11
Q

What are Mullerian Duct cysts?

How to differentiate between Prostatic utricle cyst

A

Ususally seen in men aged 30’s and 40’s

Midline cystic lesion of the prostate which extends superiorly posterior to bladder

DO NOT COMMUNICATE WITH URETHRA

**Both are associated with renal agenesis**

PROSTATIC UTRICLE CYSTS

Seen in young men ages 0-20 years

Pear shaped cysts within prostate and communicate with urethra

Do not extend more superior than the most superior part of prostate

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12
Q

MR Appearances in Prostate Ca

A
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13
Q

What is most common type of cancer in urethra?

A

Squamous carcinoma

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14
Q

What is next step in management in a patient with isolated right sided varicocele??

A

Renal ultrasound

Causes include:

  • right renal mass with tumour thrombus causing varicocele
  • right sided retroperitoneal mass causing mass effect on IVC

No further management needed for left sided varicoceles as they are common and usually due to higher venous pressure on left side

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15
Q

Urethral Injuries Summary

A
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16
Q

What type of stricture does gonococcal infection cause?

A

Long irregular stricture of distal bulbous urethra

  • Trauma (saddle) causes short stricture of bulbous urethra
  • Prolonged catheterisation causes long smooth strictures of membranous urethra
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17
Q

Name the sex cord stromal tumours?

A

Tumours of the testes

1. Leydig Tumour - most common type. Associated with gynacomastia

  • most are benign
  • 2 age peaks: 5-10years, 20-30years
    2. Sertoli Tumour - less common and less likely to secrete hormones. assc with Carneys Triad
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18
Q

Common sites of urinary tract malignancy

Which are most and least common?

A

TCC makes up 95% of urinary tract cancers

Most common = Bladder

Renal pelvis

Lower third ureter

Middle third ureter

Least Common = Proximal ureter

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19
Q

What is most common tumour of undescended testis?

A

Seminoma most common

Beta HCG elevated in 90% of cases

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20
Q

What does renal papillary necrosis appear like?

What causes it?

A

Excretory phase urography shows as multiple small collections of contrast in papillary regions peripheral to calyces

-papillary defects can become peripherally calcified

‘tracks and horns apperance’

‘lobster claw sign’

‘ball on a tee sign’

Causes:

  • Diabetes
  • Obstruction
  • Pyelonephritis
  • TB
  • Vasculitis
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21
Q

Types of renal stones

A
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22
Q

What to think of when there is widespread low T2 signal or nodule low T2 signal in prostate?

A

If patient has had intrathecal BCG therapy for bladder cancer - this could be granulomatous prostatisis

Cannot differentiate granulomatous prostatitis and PIRADS 4/5 lesion

Other causes for granulomatous prostatisis:

-TB

  • Sarcoid
  • UTI
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23
Q

Where are regional lymp nodes for bladder cancer?

A

Internal and external iliac lymph nodes are considered regional disease

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24
Q

Anatomy of testis and epididymis

A
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25
Q

Differentials for bilateral testicular masses?

A

Lymphoma most common

Sarcoid

Leukaemia (hard to differentiate from lymphoma on imaging)

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26
Q

Renal cell carcinoma

What are the 4 subtypes?

What are features that make RCC likely?

How do they appear?

A

Most common primary renal malignancy

Features which point towards RCC:

  • enhancement of >15HU
  • -calcifications within a fatty mass*

Types

  1. Clear cell

***Most common in gen population.***

Assc with VHL

  • enhances equal to cortex on arterial (corticomedullary) phase
  • -Aggressive!*
  • -exophytic appearance*

Cystic mass with enhancing components (see picture)

2. Papillary

Second most common.

Less aggressive than clear cell. Less vascular

Most common cancer in POST RENAL TRANSPLANT

-will enhance less than cortex on arterial phase (see photo first page)

3. Medullary

Younger patients

Assc with sickle cell

Highly aggressive and mets are common

4. Chromophobe

Associated with Burt Hogg Dube

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27
Q

What is staging or renal cell carinoma?

What is T3

A

TNM staging

T3 = still contained in Gerotas fascia but potential involvement of:

  • infradiaphragmatic IVC
  • supradiaphragmatic IVC
  • renal veins/renal sinus fat
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28
Q

AMLs

What are atypical features?

A

Normally contain fat

Some can be lipid poor and therefore low T2

IF they have calcification - think RCC!!

They can bleed if they get big enough - think >4cm

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29
Q

Oncocytoma

What are typical features?

A

Has a central scar!!

(Cannot be distinguished from RCC however)

Buzzwords

  • solid renal mass with central scar
  • ‘spoke wheel’ vascularity
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30
Q

Multilocular cystic nephroma

What are appearances?

Classically affects who?

A

Michael Jackson tumour = young boys and middle aged women

  • Non communicating fluid filled locules surounded by thick fibrous capsule*
  • -protrudes into the renal pelvis*
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31
Q

Bosniak cysts

At what point does malignancy become a risk and what is criteria?

A

Becomes malignant risk at Bosniak 2F

  • -hyperdense >3cm*
  • -thin calcifications*

Bengin

Bosniak 2

  • -hyperdens <3cm*
  • -thin calcifications*
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32
Q

ADPKD

vs ARPKD

A

Autosomal dominant (adults)

  1. Cysts in the liver 70% of cases
  2. Seminal vesicle cysts
  3. Berry aneurysms

Autosomal recessive (children)

  1. Hypertension and Renal failure
  2. Abnormal bile ducts and hepatic fibrosis (congenital fibrosis is always present)
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33
Q

Name 2 features of each?

Tuberous sclerosis and VHL

A
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34
Q

Whats difference in parapelvic vs peripelvic cysts?

A

Parapelvic = look like cortical cysts only in the pelvis. Arise from parenchyma. More rounded.

Peripelvic = can look like hydro. originates in renal sinus. Less rounded.

N.B Hydronephrosis communicated. Cysts dont.

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35
Q

Renal TB

What are features of end stage?

A
  • Calyceal blunting is the earliest sign*
  • -Renal papillary necrosis leading to cavity formation in the papillae*
  • -Renal calcifications are common*
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36
Q

Renal stones

How to identify uric acid stones?

Who do they occur in?

A

Are pH dependent stones

Tend to form in more acidic conditions (diabetics or fat people)

Typically can’t see them on x-ray

Tips for identifying

Tend to have lower attenuation <500HU

No change in HU on dual energy CT

Tx

Uric acid stones can be treated with medical therapy (potassium citrate to alter pH)

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37
Q

What is the main cause of CORTICAL nephrocalcinosis?

What are differentials?

A

Main cause is cortical necrosis after a period of hypotension

DDx = TB or disseminated PCP

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38
Q

What are the 2 main causes of medullar nephrocalcinosis?

A

Hyperparathyroidism

Medullary spone kidney

Diuretics

RTA type 1

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39
Q

What are signs of Renal Vein thrombosis on doppler?

A

Renal vein will be occluded so have to scan ARTERY -Reversed arterial diastolic flow

Renal vein thrombosis post transplant usually occurs in first week

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40
Q

Urologocical complicaitons of transplant

Obstruction - where does usually happen?

Name 3 other urological complications

A

Obstruction

It is normal to have mild hydronephrosis in the transplant kidney

If there is true obstruction - usually at level of ureter implantation to bladder (can kink due to oedema)

Urinoma

Usually in first 2 weeks

Anechoic collection

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41
Q

What are timeframes for acute and chronic rejection?

A

Acute

Week 1-3

Kidney will swell and RIs may go up

How to differentiate between rejection and ATN?

MAG3 flow and uptake will be better in ATN

ATN

Common

Seen in first week

Due to ischaemia from graft harvesting

Cyclosporin Toxicity

Usually around a month

Chronic Rejection

Months after

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42
Q

Renal artery vs hepatic artery thrombosis timeframe?

A

Renal artery thrombosis = minutes to hours usually but definitely within first month

Hepatic artery thrombosis = >1 month post op

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43
Q

Summary of post transplant complications

A
44
Q

Post transplant lymphoproliferative disorder

Which virus is ass with it?

What is treatment used?

A

This is uncommon complication

  • -assc with B cell proliferation*
  • -usually first year*
  • -can be seen as mass encasing the hilum*
  • -easing off immunosuppression helps*

EBV is a risk factor

Treat with Rituximab

45
Q

What to think of when BK virus and renal transplant are mentioned?

A

Urothelial malignancy

46
Q

What is Malakoplakia?

How to differentiate from Leukoplakia?

A

Often seen in immunocompromised women with chronic UTIs

  • Soft tissue nodular plaques in bladder & ureters (more often bladder)*
  • can appear as a mucosal mass and cause obstruction and hydro

Tx

Gets better with ANTIBIOTICS

NOT premaligmant

47
Q

What is Leukoplakia?

A

Squamous metaplasia of the urothelial epithelium

  • Affects bladder, renal pelvis and ureter*
  • Due to chronic UTIs and stones*
  • -Appears as mural filling defects*

Assc with SCC

48
Q

What are most common sites for TCC in order?

A

Think of places where urine stagnates the longest

  1. Bladder
  2. Renal Pelvis
  3. Lower third ureter

(if there is cancer in the ureter, then its probs in bladder too)

49
Q

What is a concerning feature of the urachal remnant of bladder?

A

Any calcification should raise the suspicion of cancer - adenocarcinoma

50
Q

Circumferential bladder thickening

Is this more suggestive of cancer or inflammation/infection?

A

Unlikely to be cancer

More suggestive of inflammatory or infectious aetiology

(if there was asymmetric nodular thickening this may be more suggestive of cancer)

51
Q

Summary of Bladder cancer types

A
52
Q

Psoas Hitch surgery

What is it done for?

A

When theres distal ureteric pathology requiring excision of distal ureter.

Result is short ureter so bladder is pulled up and attached to psoas muscle and ureter then attached to bladder

53
Q

What cancer is female urethral diverticulum assc with?

A

Adenocarcinoma

54
Q

Bladder Cancer Summary

A
55
Q

Urethral cancer summary

A
56
Q

Renal Cancer summary

A
57
Q

What encompasses the trigone of the bladder?

A

Formed by 2 ureteral orfices and urethra

Located within the fundus

58
Q

Mullerian duct vs prostatic urethra

A
59
Q

Testicular tumours summary

A
60
Q

Filling defects in Ureters

Name 4 differentials?

A
61
Q

What is most common tumour of undescended testes?

A

Seminoma

62
Q

What tumour is most associated with gynaecomastia?

A

Leydig cell tumour which is a sex cord stromal tumour

If that isnt an option = next best is Germ cell tumour

63
Q

Where is regional lymph node drainage in testicular tumours?

A

Regional drainage is to the para-aortic lymph nodes

Non-regional = internal, external and common iliac lymph nodes

64
Q

Are inguinal and external iliac lymph nodes considered regional?

In what case?

A

They are normally NON regional

But if there is a history of previous scrotal or inguinal surgery - these are then considered regional

65
Q

Which testicular tumour is most commonly associated with Gynaecomastia?

A

Sex cord Leydig cell tumour is most common (30%) however these tumours in general are rare.

Germ cell tumours can also present with gynaecomastia but less so (5%) and these are more common to occur that leydig in first place - read Q carefully to determine

Leydig Tumour

Two peaks

5 - 10 years

20 - 30 years

66
Q

What gives a false low reading for PSA?

A

Aspirin

NSAIDS

67
Q

What is an Azzopardi tumour?

A

Burnt out germ cell tumour

It is a primary germ cell tumour of the testis which has outgrown its blood supply

It metastasizes to the retroperitoneal lymph nodes which become LARGE

After it outgrows blood supply it ‘burns out’ and you are left with small cystic lesion in testicle (can also be hyeprechoic or calcified)

68
Q

What scoring system is used in the followup of prostate cancers?

A

PRECISE

PC Radiological Estimation of Change in Sequential Evaluation

-it is an MRI followup tool

_PERCIST_- scoring system for the followup of lesions using PET

69
Q

Which of the prostate cancers tends to be more organ confined - transitional or peripheral?

A

Transitional usually organ confined due to cushioning from peripheral zone

70
Q

Which MRI feature gives highest degree of suspicion of cancer in peripheral zone lesions?

A

Highest grade of suspicion is high B value with low ADC

71
Q

What is highest grade of suspicion in transitional zone? MRI features

A

Non-circumscribed or Lenticular shaped moderate T2 lesion which is moderately T2 hypointense

72
Q

What is most common tumour to metastasize to the testicles?

A
  1. Prostate
  2. Lung
  3. Melanoma
73
Q

Which sequence in MRI is best for assessing bladder wall involvement in cancer?

A

T2 best for bladder wall muscle involvement

  • -T1 is best for bones and lymph nodes*
  • -T1 also best for assessing extravesical extension into the perivesical fat*
74
Q

Testicular tumour summary

A
75
Q

Name 3 areas ureteric stones are likely to get stuck?

A
  1. PUJ
  2. As ureter cross bifurcation of common iliac arteries
  3. VUJ where it enters bladder obliquely
76
Q

What are the appearances of a tunica albuginea cyst?

A

Mutliseptate cystic mass with thin echogenic running around the testicle (representing tunica albuginea)

  • can be unilocular or multilocular
  • most commonly in anterosuperior or superolateral aspect of testicle
77
Q

How does Rete testes ectasia appear?

A

Will appear as ‘tubular, branching anechoic structures in the testes’

  • -Usually appear in over 60’s due distal part getting stenosed then there is buildup of fluid*
  • -Rete testes carry spermatozoa to the extra-testicular ducts*
78
Q

Which lobe of prostate is enlarged in BPH?

A

Median lobe

-located between ejaculatory ducts and urethra

79
Q

How is contrast enhancement used in peripheral prostate lesions?

A

If lesion demonstrates only SOME diffusion restriction then contrast is used to determine whether it is a PIRADS 4 lesions

  • If a lesion with some restriction diffusion demosntrates contrast enhancement with type 3 curve = PIRADS 4*
  • Otherwise if there is marked diffusion restriction = automatically a PIRADS 4*
  • PIRADS 5 is >1.5cm*
80
Q

What is most common presentation of renal lymphoma?

A

Multiple bilateral poorly enhancing masses. Seen as low attenuation

-can also appear as large solitary mass mimicking RCC

81
Q

Of what type do cystic testicular masses usually represent?

A

These are usually non-seminomatous

  • -Yolk sac*
  • -Embryonal*
  • -Teratoma*
  • Choriocarcinoma
82
Q

Workup for staging prostate cancer based on gleason score?

A
83
Q

At what denisty are stones visible on AXR?

A

Usually above 700HU

(some can be seen at 500HU)

84
Q

How to calculate absolute and relative washout of adrenal lesions?

A

Diagnostic of adrenal adenoma:

  • At least 60% absolute washout
  • At least 40% relative washout
  • <18 HU (100% specific)
  • <37 HU on a delayed scan
  • India ink effect on GE MRI
  • Chemical shift on GE and SE MRI
85
Q

What is crossed fused renal ectopia?

A

When both kidneys ascend on ONE SIDE of the body during embryological development

Both kidney fuse together with development of intercondylar notch where kidneys fuse together

On imaging = enlarged kidney with intercondylar notch (absent kidney on other side)

Prone to infections and stones

86
Q

What is horseshoe kidney?

A

When kidneys fuse at the poles and fail to ascend

They meet resistance at the IMA

The ureters course anteriorly over the fused portion and are prone to reflux

87
Q

Most common neonatal lesion of the adrenal gland?

A

Non-traumatic adrenal haemorrhage

Infants who are large for gestational age and those of diabetic mothers are of increased risk

88
Q

Microscopic fat vs macro

A

Microscopic fat is affected mainly by chemical shift

(Myeolipomas have mature fat within them)

89
Q

In adrenal glands dod suspicious lesions wash out quick or slow?

A

Malignant = Slow washout

Benign = Rapid washout

90
Q

Diagnostic criteria for VHL?

A
  1. More than one CNS hemangioblastoma
  2. Once CNS hemangioblastoma + any visceral manifestations
  3. Any manifestation and family history VHS disease
91
Q

Most common soft tissue tumour in adults over 50 years?

A

Malignant fibrous histiocytoma

Can occur in retroperitoneum in 15%

92
Q

Most common type of bladder injury associated with penetrating trauma?

A

Extraperitoneal - Anterolateral base of bladder

Is most common type of bladder injury

93
Q

Where does intraperitoneal bladder rupture happen?

A

Occurs at the dome with blunt trauma to a distended bladder

Needs surgery

94
Q

What does prostate cancer look like?

A

DARK on T2

Dark on ADC

Enhances

95
Q

Typical appearance of BPH nodules on MRI?

Location?

A
  • In transitional zone (central gland)
  • T2 heterogenous
  • Can restrict diffusion
  • May enhance and washout
96
Q

What is bell clapper deformity?

A

Abnormally high insertion of the tunica vaginalis

Results in increased mobility and predisposes to torsion

Usually bilateral

97
Q

High vascularity in a testicle

Orchitis vs detorsion?

A

Orchitis will be painfull

Detorsion wont

98
Q

Most common location for epididymitis?

A

Tail most common as usually starts here

Spreads tail - body - head

Epididymo orchitis is usually due to infection first in epi that spreads to testes

99
Q

Young patient with isolated orchitis

A

Mumps is main cause of isolated orchitis

100
Q

Testicular tumour summary

A
101
Q

Staging of prostate cancer

What warrants MRI Prostate, CT CAP and Bone scan?

A
102
Q

Extraperitoneal bladder rupture

Where does contrast go?

What is it associated with?

A

Contrast leaks anteriorly. Fills prevesical space of Rezius

Associated with pelvic fracture

Can be managed medically*****

103
Q

Intraperitoneal bladder rupture

What is usual history?

Where is contrast seen?

A

Direct blow to a full bladder

Usually at bladder dome (weakest part)

Contrast outlines the bowel. Also seen in paracolic gutters

104
Q

Summary of urethral trauma

A
105
Q

Delayed nephrogram on IVU which becomes more apparent on delayed imaging

What is classic apperance caused by?

A

Renal vein thrombosis

‘Increasing delayed nephrogram’

106
Q

What are the signs of extracapsular extension in prostate Ca?

A
  1. Irregular capsular bulge
  2. Obliteration of rectoprostatic angle
  3. Asymmetry of neurovascular bundle
  4. Focal capsular thickening or retraction

FRCR 2A (25 decks)

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