39: Urology Flashcards
What are the following characteristics of testicular torsion?
- Risk peaks at which age
- Torsion is usually in which direction
- Treatment
- Risk peaks at which age: Peaks in 15 year olds
- Torsion is usually in which direction: Torsion is usually toward the midline
- Treatment: Bilateral orchiopexy
[UpToDate: Testicular torsion generally presents with the abrupt onset of severe testicular pain. The testis may lie transversely in the scrotum and be retracted, and the cremasteric reflex is typically absent. Doppler ultrasound of the scrotum is a useful adjunct in equivocal cases but should not delay surgical exploration in cases of suspected testicular torsion. Immediate detorsion is required to maintain viability of the testis. In patients suspected with testicular torsion, we recommend immediate surgical exploration rather than manual detorsion (Grade 1B). If surgical treatment is not immediately available, manual detorsion should be performed. Surgical exploration is necessary even after clinically successful manual detorsion because orchiopexy (securing the testicle to the scrotal wall) must be performed to prevent recurrence, and residual torsion may be present that can be further relieved.]
What is the most common urinary tract abnormality and what is the treatment?
- Ureteral duplication
- Treat with reimplantation if obstruction occurs
What are the following characteristics of tumors of the kidney?
- Most common tumor in the kidney
- Treatment for transitional cell carcinoma of renal pelvis
- Syndrome resulting in angiomyolipomas (hamartomas) of the kidney
- Syndrome resulting in multifocal and recurrent renal cell carcinoma, renal cysts, CNS tumors, and pheochromocytomas
- Most common tumor in the kidney: Breast cancer metastasis
- Treatment for transitional cell carcinoma of renal pelvis: Radical nephroureterectomy
- Syndrome resulting in angiomyolipomas (hamartomas) of the kidney: Tuberous sclerosis
- Syndrome resulting in multifocal and recurrent renal cell carcinoma, renal cysts, CNS tumors, and pheochromocytomas: Von-Hippel-Lindau syndrome
What are the following characteristics of kidney stones?
- 4 types of kidney stones
- Most common type of kidney stone
- Type of kidney stone that can result in Staghorn calculi (fill renal pelvis)
- Size above which a kidney stone is unlikely to pass spontaneously
- 4 types of kidney stones: Calcium oxalate, struvite, uric acid, cysteine
- Most common type of kidney stone: Calcium oxalate (75% of kidney stones)
- Type of kidney stone that can result in Staghorn calculi (fill renal pelvis): Struvite stones
- Size above which a kidney stone is unlikely to pass spontaneously: > 6mm is unlikely to pass
What are the following characteristics of a testicular mass?
- Most testicular masses are what (benign or malignant)
- Lab markers that should be obtained
- Percent of testicular masses that are germ cell tumors
- Most likely tumor to occur in the setting of an undescended testicle
- What is the most common overall testicular tumor
- Most testicular masses are what (benign or malignant): Malignant
- Lab markers that should be obtained: LDH (correlates with tumor bulk), B-HCG, AFP
- Percent of testicular masses that are germ cell tumors: 90%
- Most likely tumor to occur in the setting of an undescended testicle: Seminoma
- What is the most common overall testicular tumor: Seminoma
What are the following characteristics of renal cell carcinoma?
- Risk factor
- Fraction that have metastatic disease at the time of diagnosis
- Most common location for metastasis
- Paraneoplastic syndromes of RCC
- Treatment
- Risk factor: Smoking
- Fraction that have metastatic disease at the time of diagnosis: 1/3 (wedge resection of isolated lung or colon metastases can be performed)
- Most common location for metastasis: Lung
- Paraneoplastic syndromes of RCC: Erythropoietin, PTHrp, ACTH, insulin
- Treatment: Radical nephrectomy with regional nodes, XRT, chemotherapy
[UpToDate: Data from the SEER registry covering 2005 through 2011 show the extent of disease at presentation of patients with renal cell carcinoma:
- Localized disease (ie, confined to the kidney) – 65%
- Regional disease (ie, spread to regional lymph nodes) – 16%
- Metastatic disease – 16%
- Unstaged – 3%
In an analysis of over 29,000 cases from the SEER registry, there has been a steady decrease in the size of tumors at presentation. This is likely due to the greater number of incidental tumors detected on abdominal imaging. For example, data from the National Cancer Database showed that the size of stage I tumors decreased from a mean of 4.1 cm in 1993 to 3.6 cm in 2003. Whether all of the asymptomatic RCCs diagnosed through improved imaging are clinically relevant is uncertain.
The five-year survival rate of patients with kidney cancer has doubled over the last 50 years, from 34% in 1954 to 62% in 1996, and to 73% from 2005 to 2011. The incidence of RCC has risen threefold higher than the mortality rate. This improved survival and case-fatality rate is mostly due to earlier detection of these tumors at smaller sizes (ie, <4 cm) and curative surgical treatment.
For patients with a resectable stage I, II, or III renal cell carcinoma (RCC), we recommend surgery as the primary treatment approach. Radical nephrectomy has been the most widely used approach and remains the preferred procedure when there is evidence of invasion into the adrenal, renal vein, or perinephric fat. Partial nephrectomy (either open or laparoscopic) is an alternative for smaller tumors and is particularly valuable in patients with bilateral or multiple lesions, those with inherited syndromes in whom there is an increased risk of an additional subsequent primary tumor, and those with impaired renal function. For elderly patients and those with significant comorbid disease, ablative techniques (cryoablation, radiofrequency ablation) are an alternative.
Advanced clear cell renal cell carcinoma - For patients who have a good performance status and intact organ function, we suggest high-dose interleukin-2 (IL-2) rather than antiangiogenic targeted therapy (Grade 2B). For patients who will be treated with a molecularly targeted agent, we prefer either pazopanib or sunitinib.
Advanced non-clear cell RCC - For patients with non-clear cell RCC, we suggest molecularly targeted therapy rather than chemotherapy (Grade 2C). However, some types of non-clear cell RCC are reported to be chemosensitive (including collecting duct, sarcomatoid, and medullary RCC).]
What are the following characteristics of urologic anatomy?
- Name of fascia surrounding the kidney
- Arrangement of renal pelvis, vein, and artery from anterior to posterior
- Position of right renal artery in relation to the IVC
- Position of left renal vein in relation to the aorta
- Position of the ureters in relation to the iliac vessels
- Name of fascia surrounding the kidney: Gerota’s fascia
- Arrangement of renal pelvis, vein, and artery from anterior to posterior: Vein, artery, pelvis
- Position of right renal artery in relation to the IVC: Posterior to IVC
- Position of left renal vein in relation to the aorta: Anterior to aorta
- Position of the ureters in relation to the iliac vessels: Anterior to iliac vessels
What is post-TURP (transurethral resection of the prostate) syndrome?
- Hyponatremia secondary to irrigation with water
- Can precipitate seizures from cerebral edema
- Treat with careful correction of Na with diuresis
[Most patients who have TURP have retrograde ejaculation.]
What are the following characteristics of testicular seminomas?
- Percent that have B-HCG elevation
- Affect on AFP level
- Sensitivity to XRT
- Treatment
- Percent that have B-HCG elevation: 10%
- Affect on AFP level: Should not be elevated
- Sensitivity to XRT: Extremely sensitive
- Treatment: Orchiectomy and retroperitoneal XRT
[Chemo reserved for metastatic disease or bulky retroperitoneal disease (Cisplatin, bleomycin, Etoposide {VP-16}).]
[UpToDate: For patients with stage I seminoma, orchiectomy is usually curative. For patients who are able to comply with follow-up, we suggest active surveillance rather than chemotherapy or adjuvant radiation therapy (RT). Given the excellent prognosis, active surveillance minimizes the risks of treatment-associated morbidity.
For men who refuse active surveillance and for those who want more aggressive treatment despite their excellent prognosis, we suggest one or two cycles of single-agent carboplatin (dosed at an area under the concentration x time curve [AUC] of 7) rather than adjuvant RT. Single-agent carboplatin is well tolerated and as effective as adjuvant RT in preventing relapse. It is also associated with less morbidity, including lower risks of impaired fertility, second malignancy, or late cardiac disease.
For men who refuse active surveillance and are not candidates for chemotherapy, we suggest adjuvant RT.
Stage II seminoma — Following orchiectomy, the optimal treatment for stage II disease depends upon the extent of lymph node involvement.
Stage IIA – For men with stage IIA disease (ie, diameter of involved nodes ≤2 cm), we suggest adjuvant RT rather than chemotherapy. However, cisplatin-based combination chemotherapy is a reasonable alternative.
Stage IIB or IIC – For men with more extensive retroperitoneal adenopathy (ie, diameter of involved nodes >2 cm), we recommend cisplatin-based chemotherapy.
Elevated beta-hCG – Although uncommon, men with pure seminoma may have associated elevations in serum beta-human chorionic gonadotropin (beta-hCG; >50 international units/L). While its clinical significance is controversial, we suggest treatment using cisplatin-based chemotherapy.
The optimal chemotherapy regimen has not been definitively established. The author’s preference is for three courses of bleomycin, etoposide, and cisplatin (BEP), but four courses of etoposide and cisplatin (EP) is an alternative. A choice between them should be based on institutional practice and the predicted ability of the patient to tolerate bleomycin.]
A left sided varicocele is worrisome for what?
Renal cell cancer of the left kidney
[Left gonadal vein inserts into the left renal vein. Obstruction by a renal tumor causes a varicocele. This could also be caused by another retroperitoneal malignancy.]
What are the treatments for the following urologic diseases?
- Ureteropelvic obstruction
- Vesicoureteral reflux
- Ureterocele
- Hypospadias
- Horseshoe kidney
- Ureteropelvic obstruction: Pyeloplasty
- Vesicoureteral reflux: Reimplantation with long bladder portion
- Ureterocele: Resect and reimplant if symptomatic
- Hypospadias: Repair at 6 months with penile skin
- Horseshoe kidney: May need pyeloplasty
[UpToDate: Pyeloplasty is performed for ureteropelvic junction obstruction. It consists of resecting the atretic or stenotic segment, and reattaching the normal ureter to the renal pelvis, thereby relieving the obstruction. If the obstruction is due to an aberrant renal blood vessel, the UPJ is repositioned anatomically above the blood vessel preventing further obstruction.]
What is the #1 cause of cancer-related death in men aged 25-35 years old?
Testicular cancer
[UpToDate: Testicular cancer is the most common solid malignancy affecting males between the ages of 15 and 35, although it accounts for only 1%of all cancers in men. Germ cell tumors (GCTs) account for 95% of testicular cancers. They may consist of one predominant histologic pattern or represent a mix of multiple histologic types. For treatment purposes, two broad categories of testis tumors are recognized: pure seminoma (no nonseminomatous elements present), and all others, which together are termed nonseminomatous germ cell tumors (NSGCTs). In most series, the ratio of seminoma to NSGCT is about one.
Testicular cancer has become one of the most curable of solid neoplasms because of remarkable treatment advances beginning in the late 1970s. Prior to that time, testicular cancer accounted for 11% of all cancer deaths in men between the ages of 25 to 34, and the five-year survival rate was 64%. In 2017, approximately 400 deaths from testicular cancer are expected in the United States, with a five-year survival rate over 95%.]
What is involved in treating ureteral trauma that can be repaired primarily end-to-end?
- Spatulate ends
- Use absorbable suture to avoid stone formation
- Stent the ureter to prevent stenosis
- Place drains to idenify and potentially treat a leak
- Avoid stripping the soft tissue on the ureter as it will compromise the blood supply
Nerve injury at what level of the spinal cord will result in neurogenic obstructive uropathy?
Below T12
[Characterized by incomplete emptying. Treatment is intermittent catheterization.]
Which renal disorders are associated with the following?
- WBC casts
- RBC casts
- Fever, rash, arthralgias, and urine eosinophils
- WBC casts: Pyelonephritis and glomerulonephritis
- RBC casts: Glomerulonephritis
- Fever, rash, arthralgias, and urine eosinophils: Interstitial nephritis
What are the following characteristics of benign prostatic hypertrophy (BPH)?
- Zone of prostate from which it arises
- Initial therapy
- Surgical treatment
- Zone of prostate from which it arises: Transitional zone
- Initial therapy: Alpha blockers (Terazosin and Doxazosin) to relax smooth muscle, 5-alpha-reductase inhibitors (Finasteride) to inhibit the conversion of testosterone to dihydrotestosterone (DHT causes hypertrophy)
- Surgical treatment: Transurethral resection of the prostate (TURP)
What are the following characteristics of bladder cancer?
- Most common type
- Presentation
- Risk factors
- Diagnosis
- Infection associated with squamous cell carcinoma of the bladder
- Most common type: Transitional cell cancer
- Presentation: Painless hematuria
- Risk factors: Smoking, aniline dyes, and cyclophosphamide
- Diagnosis: Cystoscopy
- Infection associated with squamous cell carcinoma of the bladder: Schistosomiasis infection
[UpToDate: Patients with bladder cancer classically present with painless hematuria (grossly visible or microscopic), although irritative voiding symptoms (frequency, urgency, dysuria) can be the initial manifestation. The diagnosis is often delayed due to the similarity of these symptoms to those of benign disorders (urinary tract infection, interstitial cystitis, prostatitis, passage of renal calculi), and delays can lead to a worsened prognosis due to more advanced stage at diagnosis. There is evidence to suggest that delayed diagnosis accounts for the poorer survival in women diagnosed with bladder cancer compared with men. Furthermore, symptoms are often intermittent. In some patients, metastases will cause the initial symptoms. Incidental bladder cancer is rare at autopsy, suggesting that most cancers eventually become symptomatic.
Cystoscopy is the initial procedure for both the diagnosis and management of urothelial malignancy. Cystoscopy is used to establish the diagnosis, assess whether or not muscle invasion is present, and provide initial therapy for non-muscle-invasive lesions.
Urine cytology is widely used in combination with cystoscopy to assess for the presence of carcinoma in situ and to evaluate for the presence of upper urinary tract lesions. Computed tomography is the preferred imaging procedure to assess the local extent of disease and to further examine the renal pelvis and ureters.
Stage is the most important independent prognostic variable for assessing the probability of progression and survival. The standard approach is the tumor, node, metastasis (TNM) staging system, which requires cystectomy. For patients who will undergo neoadjuvant therapy, clinical staging is appropriate.]
What is the treatment for bladder cancer?
T1 (no muscle invasion): Intravesical BCG or transurethral resection
T2 and greater (muscle invasion): Cystectomy with ileal conduit, chemotherapy and XRT
Metastatic disease: Chemotherapy
[Chemotherapy regimen with MVAC: Methotrexate, vinblastine, doxorubicin, and cisplatin]
[UpToDate: The presence of otherwise unexplained hematuria frequently denotes urinary tract cancer in individuals over the age of 40 until proven otherwise. Flexible cystoscopy and urine cytology are the initial steps in making the diagnosis. Transurethral resection of the bladder tumor (TURBT), along with examination under anesthesia, is required in order to determine histology, depth of invasion, and potential involvement beyond the bladder. Bladder biopsies of normal-appearing mucosa are required in patients with an otherwise unexplained positive urine cytology.
Primary tumors without muscle invasion (Ta and T1 lesions) are generally managed initially with TURBT. Patients at significant risk of recurrence and/or progression may also require intravesical therapy. All patients are at risk for recurrence both in the bladder and elsewhere in the urothelium, and long-term surveillance is required following initial therapy.
For patients with low-risk disease, a single intravesical instillation of chemotherapy is usually sufficient as adjuvant therapy and no further therapy is indicated. For patients with intermediate-risk disease, we recommend an induction course of either intravesical chemotherapy or bacillus Calmette-Guerin (BCG). Following this, maintenance therapy should be continued for one year. For patients with high-risk disease, we recommend an induction course of BCG, and maintenance therapy should be given and continued for three years.
Radical cystectomy with urinary diversion is the treatment of choice for patients with muscle-invasive disease.
- Neoadjuvant cisplatin-based chemotherapy improves overall survival and should be considered for appropriate patients.
- Although the benefit of adjuvant chemotherapy has not been established in randomized clinical trials, adjuvant chemotherapy may have a role following cystectomy in patients with high-risk invasive urothelial carcinoma who are otherwise candidates for chemotherapy, although this view remains controversial in view of the published randomized clinical trials.
For patients unable or unwilling to undergo radical cystectomy with urinary diversion for muscle invasive urothelial bladder cancer, complete TURBT combined with radiation therapy plus chemotherapy may offer an alternative bladder-sparing approach.
Combination chemotherapy (using platinum-based regimens such as methotrexate, vinblastine, doxorubicin, and cisplatin [MVAC] or gemcitabine plus cisplatin [GC]) may prolong survival and often provides palliation of symptomatic disease. Checkpoint inhibition immunotherapy has substantial clinical activity in postchemotherapy patients, and ongoing trials are further defining its role.]
What is the treatment for priapism?
Aspiration of the corpus cavernosum with dilute epinephrine or phenylephrine
[May need to create a communication through the glans with scalpel.]
[UpToDate: In patients with ischemic priapism, we recommend intracavernosal injection with a sympathomimetic agent (Grade 1B). We prefer phenylephrine (100 to 500 mcg/mL with 1 mL injection) to other agents based on fewer adverse effects. In addition to sympathomimetic injection, we suggest cavernosal blood aspiration (Grade 2C).]
What are the following characteristics of nonseminomatous testicular cancer?
- 4 types
- Elevated markers
- Treatment
- 4 types: Embryonal, teratoma, choriocarcinoma, yolk sac
- Elevated markers: Alpha fetoprotein and B-HCG
- Treatment: Orchiectomy and retroperitoneal node dissection
[Stage II or greater also should receive chemotherapy with cisplatin, bleomycin and etoposide (VP-16)]
[UpToDate: The staging of patients with NSGCT is based on tumor markers following radical orchiectomy, as well as on clinical staging. For those patients whose treatment includes retroperitoneal lymph node dissection (RPLND), pathologic staging may result in further changes in treatment.
Stage IA and IB NSGCT — For men with stage IA and IB NSGCTs, management depends on whether factors associated with an increased risk of relapse are present. These include:
- Lymphovascular invasion
- Predominance of an embryonal carcinoma component
- A T3 or T4 primary tumor
Using these risk factors, our approach to stage I NSGCTs is as follows:
- Low risk – For men who do not have any risk factors present, we suggest active surveillance.
- High risk – For men with one or more risk factors, active surveillance, chemotherapy, and RPLND are all options. If technical expertise is available, RPLND is an appropriate treatment option. However, chemotherapy (one or two cycles of BEP) is a reasonable alternative. For men who prefer not to undergo further treatment, active surveillance is a reasonable alternative. However, these men should understand that their risk of relapse, and thus the need for subsequent treatment at a later date, approaches 40%.
Stage IS — Patients with NSGCT limited to the testis on clinical staging but who have persistent elevation of tumor markers following orchiectomy are classified as stage IS. Persistently elevated markers generally indicate the presence of metastatic disease. These patient should be treated with chemotherapy similarly to those with good-risk stage III disease.
Stage II NSGCT — For patients with stage II NSGCTs, treatment depends upon whether disease is documented clinically or pathologically.
Clinical stage IIA NSGCT – For men with radiographically abnormal nodal involvement ≤2 cm and normal serum tumor markers, we suggest RPLND. Further treatment will be based upon the pathologic stage.
Clinical stage IIB and IIC NSGCT – For men with radiographically detected nodal disease ≥2 cm and/or elevated serum tumor markers following orchiectomy, we suggest primary cisplatin-based combination chemotherapy. BEP for three cycles and EP for four cycles are acceptable regimens.
Pathologic stage II NSGCT – Men with NSGCTs with confirmed pathological node involvement following RPLND have pathologic stage II NSGCTs. Treatment following RPLND is based on the extent of nodal:
- For men with lymph node metastases ≤2 cm in greatest diameter, we suggest surveillance. While adjuvant chemotherapy dramatically reduces the relapse rate, treatment has no significant effect on survival because patients who relapse are treated with chemotherapy for curative intent.
- For men with nodal involvement >2 cm, we suggest two cycles of adjuvant cisplatin-based combination chemotherapy because the relapse risk is relatively higher.]
