Flashcards in 23 - Urologic Diseases I Deck (38):
What should you focus on for these lectures?
- Diagnosis and treatment
- Don't worry about pathology as much
What is hematuria?
- Gross hematuria: visible blood in urine
- Microscopic hematuria: > 3 red blood cells per high powered field (RBCs/HPF) on two of three urine specimens
- May originate from anywhere along the urinary tract
What is nephrologic/glomerular hematuria?
- Significant proteinuria is also present with hematuria (>1 gm/24 hours)
- Dysmorphic red blood cells
- Red cell casts (means nephrologic origin)
- Warrants nephrology evaluation
What are common causes of non-glomerular hematuria when it is from the UPPER urinary tract?
- Renal cell cancer
- Urothelial/Transitional cell carcinoma
- Urinary obstruction
What are common causes of non-glomerular hematuria when it is from the LOWER urinary tract?
- Bacterial cystitis (UTI)
- Urothelial/Transitional cell carcinoma
- Spurious (false) hematuria (e.g. menses, vaginal atrophy)
What will you do in a hematuria evaluation?
- UA with microscopic analysis
- Urine culture (if indicated)
- Urine cytology/tumor markers
- Upper urinary tract imaging (renal US, intravenous urogram, or CT urogram)
- 10-20% of patients evaluated will be diagnosed with a urologic malignancy
What is a urinary calculi
Stones are formed because solutes in urine precipitate and aggregate.
What can stones be composed of?
- calcium oxalate (monohydrate or dihydrate)
- uric acid
- struvite (magnesium ammonium phosphate)
- calcium phosphate
- cystine (uncommon)
Describe the clinical presentation of a patient with a urinary calculi (stone)
- Acute onset, colicky flank pain radiating to the groin or scrotum due to ureteral obstruction causing renal capsular and ureteral distention
- Renal and ureteral colic are often considered among the most severe pain experienced by patients
- Lower quadrant pain, urinary urgency, frequency, and dysuria as the stone approaches the ureterovesical junction,
- Distressed patient, often writhing, while trying to find a comfortable position
- Costovertebral angle or lower quadrant tenderness may be present
- Nausea and vomiting
How do you diagnose a urinary calculi (stone)?
******* THIS IS IMPORTANT *******
- Gross or microscopic hematuria is present in approximately 90%
*** Gold standard: Computed tomography (CT) scan of the abdomen and pelvis WITHOUT oral or intravenous contrast ***
KNOW CT, do NOT use contrast ***
- KUB Xray
What are the four indications for urgent intervention with urinary stones?
******* THIS IS IMPORTANT *******
- Obstructed upper tract with infection
- Impending renal deterioration
- Pain refractory to analgesics
- Intractable nausea/vomiting
**** KNOW THESE ****
What are three management options for urinary stones?
- Strain urine for stone passage
- Medical expulsion therapy
- Oral stone dissolution
Describe medical expulsion therapy
Calcium channel blockers
Describe oral stone dissolution therapy
Uric acid stones only
Potassium citrate, sodium bicarbonate
What is the chance of passing a ureteral stone?
*****KNOW THIS ******
- 2/3 of ureteral stones will pass within 4 weeks of the onset of symptoms
- Complete obstruction is rare so risk of renal deterioration from observation is presumed low
- If stone has not passed within 4 weeks, intervention is usually needed
KNOW 4 WEEKS ***
How can you use the size of the stone in order to determine the likelihood you will need intervention?
*******KNOW THIS *******
- Stone 6 mm (80% will need intervention)
What are the three surgical stone intervention options?
- Extracorporeal Shock Wave Lithotripsy (ESWL)
- Ureteroscopy +/- laser lithotripsy
- Percutaneous nephrolithotomy (PCNL)
Describe Extracorporeal Shock Wave Lithotripsy (ESWL)
Extracorporeal Shock Wave Lithotripsy (ESWL)
- 4-15 mm stones in kidney or proximal ureter
- Stone must be radio-opaque
Describe ureteroscopy +/- laser lithotripsy
All stones amendable but large renal stone treatment is tedious
Describe percutaneous nephrolithotomy (PCNL)
- Renal calculi >15-20 mm
- Most invasive treatment
How can you prevent stones?
DRINK WATER *****
- 2.5-3 L/day)
- Low animal protein, low sodium, low oxalate diets
- NORMAL dietary calcium intake
- Citrate therapy
If this doesn't help patient...
- Full metabolic evaluation
What are the two type of renal cysts we have?
Describe a benign renal cyst
- Present in 50% of people age > 50
- Fluid filled epithelial lined cavity in renal parenchyma
- Typically asymptomatic
- No treatment required unless very large and causing pain
What is an angiomyolipoma?
Benign solid renal tumor
Contains three components:
- Proliferation of blood vessels
- Smooth muscle
- Adipose tissue
Frequently associated with Tuberous sclerosis
What is the presentation of a patient with angiomyolipoma?
- Typically an incidental finding on imaging study
- Spontaneous bleed occurs in 10%
What property of the angiomyolipoma determines your treatment method?
Larger than 4 cm ***
- Treatment needed
Smaller than 4 cm ***
- Don't treat unless patient has symptoms that interfere with their life
- If there is an atypical appearance, consider treating
KNOW 4 cm ****
What are the treatment options?
What do you NEED to know about diagnosing angiomyolipomas?
****** KNOW THIS *****
The presence of even a small amount of fat within a renal lesion on CT scan virtually excludes the diagnosis of renal cell carcinoma and is considered diagnostic of AML
If there is ANY fat, it is BENIGN (angiomyolipomas)****
Not 100% positive, so still observe the angiomyolipomas, but don't do a biopsy
What is an oncocytoma?
- Benign tumor derived from distal tubules
- Most renal oncocytomas cannot be differentiated from malignant renal cell carcinoma by clinical or radiographic measures
- Biopsy also is often indeterminate
- Need to treat aggressively as if malignant ****
This is one that you DO TREAT because you cannot tell if it is malignant or not *****
Describe the epidemiology of renal cell carcinoma
- Most lethal of all GU cancers
- 5 year survival rates following nephrectomy/partial nephrectomy
- Localized disease 60-95% depending on stage
- Metastatic disease has VERY poor prognosis 0-15%
- Tobacco is ONLY risk factor
- Majority of cases are sporadic/idiopathic
- Family history in 2-4% of cases (Von Hippel Lindau Disease)
What are the three renal cell carcinoma tumor histotypes?
- Clear cell (80%)
- Papillary (15%)
- Chromophobe (5%)
This was not emphasized since it was covered in previous lectures
What is the patient presentation of renal cell carcinoma?
>50% detected incidentally on imaging performed for unrelated purpose
Physical exam has a limited role except in advanced disease—abdominal mass, lymphadenopathy, or bilateral lower extremity edema
What is a HIGHLY EMPHASIZED concept related to renal cell carcinoma?
Metastatic disease is common
- Approximately 1/3 have metastatic disease at presentation
What are the sites of metastasis for renal cell carcinoma?
Sites of metastasis
- Retroperitoneal lymph nodes
What is the treatment for localized renal cell carcinoma?
- Only in those contraindicated for surgery
- If you wouldn't survive a surgery
- Typical course of action
Partial nephrectomy/Nephron sparing surgery
- If carcinoma is
What are the treatment options for advanced or metastatic renal cell carcinoma?
- Generally resistant to radiation and traditional chemotherapy
- Systemic immunotherapy: Interleukin-2
- Targeted antiangiogenic agents
- Nephrectomy (cytoreductive) may improve survival over immunotherapy/chemotherapy alone
What is the downfall of Systemic immunotherapy: Interleukin-2
- Overall response rates low
- Very toxic therapy and requires hospitalization