23 - Urologic Diseases I Flashcards Preview

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Flashcards in 23 - Urologic Diseases I Deck (38):
1

What should you focus on for these lectures?

- Diagnosis and treatment
- Don't worry about pathology as much

2

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

3

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

4

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

5

What are common causes of non-glomerular hematuria when it is from the LOWER urinary tract?

- Bacterial cystitis (UTI)
- BPH
- Prostatitis
- Urothelial/Transitional cell carcinoma
- Spurious (false) hematuria (e.g. menses, vaginal atrophy)
- Instrumentation

6

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

7

What is a urinary calculi

A stone

Stones are formed because solutes in urine precipitate and aggregate.

8

What can stones be composed of?

- calcium oxalate (monohydrate or dihydrate)
- uric acid
- struvite (magnesium ammonium phosphate)
- calcium phosphate
- cystine (uncommon)

9

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

10

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 ***

Others
- KUB Xray
- IVP

11

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 ****

12

What are three management options for urinary stones?

- Strain urine for stone passage
- Medical expulsion therapy
- Oral stone dissolution

13

Describe medical expulsion therapy

Alpha blockers
Calcium channel blockers
NSAIDS

14

Describe oral stone dissolution therapy

Uric acid stones only
Urinary alkalinization
Potassium citrate, sodium bicarbonate

15

What is the chance of passing a ureteral stone?


*****KNOW THIS ******

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 ***

16

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)

KNOW THIS

17

What are the three surgical stone intervention options?

- Extracorporeal Shock Wave Lithotripsy (ESWL)
- Ureteroscopy +/- laser lithotripsy
- Percutaneous nephrolithotomy (PCNL)

18

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

19

Describe ureteroscopy +/- laser lithotripsy

All stones amendable but large renal stone treatment is tedious

20

Describe percutaneous nephrolithotomy (PCNL)

- Renal calculi >15-20 mm
- Most invasive treatment

21

How can you prevent stones?

DRINK WATER *****
- 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

22

What are the two type of renal cysts we have?

- Benign
- Malignant

23

Describe a benign renal cyst

Benign
- 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

24

What is an angiomyolipoma?

Benign solid renal tumor

Contains three components:
- Proliferation of blood vessels
- Smooth muscle
- Adipose tissue

Frequently associated with Tuberous sclerosis

25

What is the presentation of a patient with angiomyolipoma?

- Typically an incidental finding on imaging study
- Spontaneous bleed occurs in 10%

26

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 ****

27

What are the treatment options?

Selective embolization
Partial nephrectomy
Radical nephrectomy

28

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

29

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 *****

30

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)

31

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

32

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

33

What is a HIGHLY EMPHASIZED concept related to renal cell carcinoma?

Metastatic disease is common
- Approximately 1/3 have metastatic disease at presentation

34

What are the sites of metastasis for renal cell carcinoma?

Sites of metastasis
- Retroperitoneal lymph nodes
- Lung
- Liver
- Bone
- Brain

35

What is the treatment for localized renal cell carcinoma?

Active surveillance
- Only in those contraindicated for surgery
- If you wouldn't survive a surgery

Radical nephrectomy
- Typical course of action

Partial nephrectomy/Nephron sparing surgery
- If carcinoma is

36

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

37

What is the downfall of Systemic immunotherapy: Interleukin-2

- Overall response rates low
- Very toxic therapy and requires hospitalization

38

Describe targeted antiangiogenic agents

Very expensive and out of pocket
- Delay progression but not cure
- Much less toxic
- "Pay for more time"