23 - Urologic Diseases I Flashcards Preview

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Flashcards in 23 - Urologic Diseases I Deck (38)
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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?

- Urolithiasis
- Pyelonephritis
- 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)
- Prostatitis
- Urothelial/Transitional cell carcinoma
- Spurious (false) hematuria (e.g. menses, vaginal atrophy)
- Instrumentation


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)
- Cystoscopy
- 10-20% of patients evaluated will be diagnosed with a urologic malignancy


What is a urinary calculi

A stone

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)

Very common
- 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

Alpha blockers
Calcium channel blockers


Describe oral stone dissolution therapy

Uric acid stones only
Urinary alkalinization
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



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?

- 2.5-3 L/day)

Dietary modifications
- 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?

- Benign
- Malignant


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?

Selective embolization
Partial nephrectomy
Radical nephrectomy


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)