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1

fascia around the kidney

gerota's fascia

2

how does the vasculature lie in the kidney?

anterior to posterior: renal vein, renal artery, and renal pelvis

3

how does the right renal artery lie in relation to the IVC?

right renal artery crosses posterior to the IVC

4

what vessels do the ureters cross?

ureters cross over iliac vessels

5

renal vein: right vs left ligation at the IVC

left renal: can be ligated from SVC secondary to increased collaterals

right renal vein lacks collaterals

6

collaterals of left renal vein

left adrenal vein
left gonadal vein
left ascending lumbar vein

7

how is the left renal vein associated with the aorta?

left renal vein usually crosses anterior aorta

8

connects to vas deferens

epididymis

9

most common cause of acute renal insufficiency following surgery

hypotension

10

symptoms: severe colicky pain, restlessness

kidney stones
- UA: blood or stones

11

kidney stones: abdominal CT

can demonstrate stones and associated hydronephrosis

12

MC stone (75%); radiopaque

calcium oxalate

13

why are calcium oxalate stones increased in patients with terminal ileum resection?

due to increased oxalate absorption in colon

14

- magnesium ammonium phosphate
- radiopaque
- occur with infections (proteus mirabilis) that are urease producing; cause stag horn calculi (fill renal pelvis)

struvite stones

15

what are struvite stones composed of?

magnesium ammonium phosphate

16

- radiolucent stones
- increased in patients with ileostomies, gout, and myelproliferative disorders

uric acid stones

17

- radiolucent stones
- associated with congenital disorders in the reabsorption of cysteine

cysteine stones

18

surgical indications for kidney stones

intractable pain or infection
progressive obstruction
progressive renal damage
solitary kidney

19

size of stone not likely to pass

> 6 mm

20

% of kidney stones that are radiopaque

90%

21

tx: kidney stones

ESWL (extra-corporeal shock wave lithotripsy); other options: stereoscopy with stone extraction or placement of stent past obstruction, percutaneous nephrostomy tube, open nephrolithotomy

22

4 types of kidney stones

- calcium oxalate (radiopaque)
- struvite (radiopaque)
- uric acid (radiolucent)
- cysteine (radiolucent)

23

#1 cancer killer in men 25-35

testicular cancer

24

symptoms: painless hard testicular mass

testicular cancer

25

management: testicular mass

patient needs an orchiectomy through an inguinal incision (not a trans-scrotal incision -> do not want to disrupt the lymphatics)
- the testicle and attached mass constitute the biopsy specimen

26

are most testicular masses benign or malignant?

malignant

27

how can you diagnose testicular cancer?

- ultrasound can help with diagnosis
- chest and abdominal CT - to check for retroperitoneal and chest metastases

28

testicular cancer: lab value correlating with tumor bulk

LDH correlates with tumor bulk; also check B-HCG and AFP level

29

percent of testicular cancers that are germ cell

90% are germ cell - summon and nonseminoma

30

are undescended testicles (cryptorchidism) a problem?

increased risk of testicular cancer
- most likely to get seminoma

31

#1 testicular tumor

seminoma

32

- 10% have beta-hcg elevation
- should not have AFP elevation
- extremely sensitive to XRT

seminoma

33

tx: seminoma

all stages get orchiectomy and retroperitoneal XRT
- chemo reserved for mets or bulky retroperitoneal disease (cisplatin, bleomycin, VP-16)
- surgical resection of residual disease after above

34

chemo regimen: seminoma

cisplatin
bleomycin
VP-16

35

types of nonseminomatous testicular cancer

embryonal
teratoma
choriocarcinoma
yolk sac

36

90% have these markers in nonseminomatous testicular CA

alpha fetoprotein
beta-hcg

37

nonseminomatous testicular CA: classically this type of tumor are more likely to metastasize to the retroperitoneum

classically, tumors with increased teratoma components are more likely to metastasize to the retroperitoneum

38

tx: nonseminomatous testicular ca

all stages get orchiectomy and retroperitoneal node dissection
- stage 2 or greater: also give chemo (cisplatin, bleomycin, BP-16)
- surgical resection of residual disease after above

39

what part of the prostate is most common for cancer?

posterior lobe

40

prostate CA: most common site of metastases

bone

41

prostate mets to bone: XR

osteoblastic; xr demonstrates hyperdense areas

42

potential complication after prostate resection

many patients become impotent after resection; can get incontinence
- can also get urethral strictures

43

dx: prostate CA

- transrectal BX
- chest/ab/pelvic CT
- PSA
- alkaline phosphatase
- possible bone scan

44

options for tx: prostate CA - intracapsular tumors and no metastases (T1 and T2)

- XRT or
- Radical prostatectomy + pelvic LN dissection (if life span > 10 years) - or -
- nothing (depending on age and health)

45

tx: prostate CA - extracapsular invasion or metastatic disease

XRT and androgen ablation (leuprolide [LH-RH blocker], flutamide [testosterone blocker], or bilateral orchiectomy

46

tx: prostate CA - stage 1a disease found with TURP

Nothing

47

how does PSA trend with prostatectomy?

with prostatectomy, PSA should go to 0 after 3 weeks -> if not, get bone scan to check for metastases

48

what is a normal PSA?

49

what can increase PSA?

prostatitis, BPH, chronic catheterization

50

increased alkaline phosphatase in a patient with prostate CA?

worrisome for metastases or extra capsular disease

51

#1 primary tumor of kidney (15% calcified)

renal cell carcinoma (RCC, hypernephroma)

52

risk factor: renal cell carcinoma

smoking

53

abdominal pain, mass, hematuria

renal cell carcinoma

54

how does renal cell carcinoma present?

1/3 have metastatic disease at the time of diagnosis -> can perform wedge resection of isolated lung or colon metastases

55

most common location for RCC metastases

lung

56

what causes erythrocytosis in renal cell carcinoma?

secondary to increased erythropoietin (HTN)

57

tx: renal cell carcinoma

radical nephrectomy with regional nodes; XRT; chemotherapy

58

what composes radical nephrectomy?

takes kidney, adrenal, fat, Gerona's basic, and regional nodes

59

where does renal cell carcinoma like to grow?

predilection for growth in the IVC; can still resect even if going up IVC -> call pull the tumor thrombus out of the IVC

60

when should you consider partial nephrectomy in management of renal cell carcinoma?

partial nephrectomies should be considered only for patients who would require dialysis after nephrectomy

61

most common tumor in kidney

metastasis from the breast CA

62

Renal cell carcinoma paraneoplastic syndromes

erythropoietin, PTHrp, ACTH, insulin

63

tx: transitional cell CA of renal pelvis

Radical nephroureterectomy

64

benign or malignant: oncocytomas

benign

65

hamartomas; can occur with tuberous sclerosis; benign

angiomyolipomas

66

multifocal and recurrent RCC, renal cysts, CNS tumors, and pheochromocytomas

Von Hippel-Lindau syndrome

67

- usually transitional cell CA
- painless hematuria
- males; prognosis based on stage and grade

bladder cancer

68

risk factors: bladder cancer

smoking, aniline dyes, and cyclophosphamide

69

dx: bladder cancer

cystoscopy

70

tx: bladder cancer

intravesical BCG or transurethral resection if muscle is not involved (T1)
- if muscle wall is invaded (T2 or greater) -> cystectomy with ileal conduit, chemotherapy, and XRT
- mets: chemo

71

chemo regimen: T2 or greater bladder cancer

MVAC:
- methotrexate
- vinblastine
- adriamycin (doxorubicin)
- cisplatin

72

standard reconstruction option stage T2 or greater in bladder cancer

ileal conduit is standard reconstruction option

73

why is ileal conduit standard reconstruction option for stage T2 or greater bladder cancer?

avoid stasis as this predisposes to infection, stones (calcium resorption), and ureteral reflux

74

possible options for reconstruction in management of bladder cancer

- ileal conduit
- reservoirs
- neobladders

75

cause of squamous cell CA of bladder

schistosomiasis infection

76

- peaks in 15 year olds
- tx: bilateral orchioplexy (if testicle not viable, resection and orchioplexy of contralateral testis)

testicular torsion

77

testicular torsion: usual location

torsion is usually toward the midline

78

ureteral trauma: if going to repair end to end...

- spatulate ends
- use absorbable suture to avoid stone formation
- stent the ureter to avoid stenosis
- place drains to identify and potentially help treat leaks

79

why avoid stripping soft tissue on ureter in repair of ureteral trauma?

avoid stripping the soft tissue on the ureter, as it will compromise blood supply

80

where does BPH arise in the prostate?

arises in the transitional zone

81

nocturia, dysuria, weak stream, urinary retention.

benign prostatic hypertrophy

82

initial therapy: BPH

- alpha blockers (terazosin, doxazosin - relaxes smooth muscle)
- 5 alpha reductase inhibitors - finasteride (inhibits the conversion of testosterone to dihydrotestosterone -> inhibits prostate hypertrophy

83

inhibits the conversion of testosterone to dihydrotestosterone -> inhibits prostate hypertrophy

finasteride (5-alpha reductase inhibitors)

84

when do you consider TURP for BPH?

for recurrent UTIs, gross hematuria, stones, renal insufficiency, or failure of medical therapy

85

post-TURP syndrome

hyponatremia secondary to irrigation with water; can precipitate seizures from cerebral edema

86

tx: post-TURP syndrome

careful correction of Na with diuresis

87

complication of most patients s/p TURP

retrograde ejaculation

88

- most commonly secondary to spinal compression
- patient urinates all the time
- nerve injury above T12

neurogenic bladder

89

tx: neurogenic bladder

surgery to improve bladder resistance

90

- incomplete emptying
- nerve injury below T12; can occur with APR

neurogenic obstructive uropathy

91

tx: neurogenic obstructive uropathy

intermittent catheterization

92

- incontinence due to cough, sneeze
- because of hypermobile urethra or loss of sphincter mechanism; women

stress incontinence

93

tx: stress incontinence

kegel exercises, alpha-adrenergic agents, surgery for urethral suspension or pubovaginal sline

94

- incomplete emptying of an enlarged bladder
- obstruction (BPH) leads to the distention and leakage
- Tx: TURP

overflow incontinence

95

tx: ureteropelvic obstruction

pyeloplasty

96

tx: vesicoureteral reflux

reimplantation with long bladder portion

97

most common urinary tract abnormality

ureteral duplication

98

tx: ureteral duplication

reimplantation if obstruction occurs

99

tx: ureterocele

resect and implant if symptomatic

100

ventral urethral opening

hypospadias

101

tx: hypospadias

repair at 6 months with penile skin

102

dorsal urethral opening

epispadias

103

tx: epispadias

surgery

104

- usually joined at lower poles
- complications: UTI, urolithiasis, and hydronephrosis
- tx: may need pyeloplasty

horseshoe kidney

105

tx: polycystic kidney disease

resection only if symptomatic

106

- occurs in patients with bladder outlet obstructive disease (wet umbilicus)
- connection between umbilicus and bladder

failure of closure of the urachus

107

tx: failure of closure of the urachus

resection of sinus/cyst and closure of the bladder; relieve bladder outlet obstruction

108

what can cause epididymitits?

sterile epididymitis can occur from increased abdominal straining

109

worrisome for renal cell CA (left gonadal vein inserts into left renal vein; obstruction by renal tumor causes varicocele); could also be caused by another retroperitoneal malignancy

varicocele

110

fluid-filled cystic structure separate from and superior to the testis along the epididymis
- tx: surgical removal if symptomatic

spermatocele

111

management: hydrocele in adult

if acute, suspect tumor elsewhere (pelvic, abdominal); translucent

112

MCC is diverticulitis and subsequent formation of colovesical fistula
- Dx: cystoscopy

pneumaturia

113

cause of WBC casts

pyelonephritis, glomerulonephritis

114

cause of RBC casts

glomerulonephritis

115

fever, rash, arthralgias, eosinophils

interstitial nephritis

116

pregnancy rate after repair of vasectomy

50%

117

tx: priapism

aspiration of the corpus cavernosum with dilute epinephrine or phenylephrine
- may need to create a communication thru the glans with scalpel

118

risk factors: priapism

sickle-cell anemia, hyper coagulable states, trauma, intracorporeal injections for impotence

119

tx: SCC of penis

penectomy with 2 cm margin

120

used to check for urine leak

indigo carmine or methylene blue

121

tx: phimosis found at time of laparotomy

dorsal slit

122

decreased production in patients with renal failure

erythropoietin