Flashcards in Urology Deck (246):
What is a cystogram?
Contrast study of the bladder
What are ureteral stents?
Plastic tubes placed via cystoscope into the ureters for stenting, identification, etc.
What is a cystoscope?
Scope placed into the urethra and into the bladder to visualize the bladder
What is a perc nephrostomy?
Catheter placed through the skin into the kidney pelvis to drain urine with distal obstruction
What is a retrograde pyelogram?
Dye injected into the ureter up into the kidney, and films taken
What is a RUG?
Dye injected into the urethra and films taken.
Rules out urethral injury, usually in trauma patients.
What is a Gomco clamp?
Clamp used for circumcision.
Protects penis glans.
What is a Bell clapper's deformity?
Condition of congenital absence of gubernaculum attachment to scrotum
What is Fournier's gangrene?
Extensive tissue necrosis/infection of the perineum in patients with diabetes
What is a Foley catheter?
Straight bladder catheter placed through the urethra
What is a Coude catheter?
Basically, a Foley catheter with hook on the end to get around a large prostate
What is a suprapubic catheter?
Bladder catheter place through the skin above the pubic symphasis into the bladder
What is posthitis?
What is a hydrocele?
Clear fluid in the processus vaginalis membrane
What is a communicating hydrocele?
Hydrocele that communicates with peritoneal cavity and, thus, gets smaller and larger as fluid drains and then reaccumulates
What is a non-communicating hydrocele?
Hydrocele that does not communicate with the peritoneal cavity.
Remains the same size.
What is a varicocele?
Abnormal dilation of the pampiniform plexus to the spermatic vein in the spermatic cord.
Described as a "bag of worms".
What is a spermatocele?
Dilatation of epididymis or vas deferens
What is epididymitis?
Infection of the epididymis
What is Prehn's sign?
Elevation of the painful testicle that reduces the pain of epididymitis
What is a TRUS?
What is a DRE?
Digital Rectal Examination
What is orchitis?
Inflammation/infection of the testicle
What is pseudohermaphroditism?
Genetically one sex, partial or complete opposite-sex genitalia
What is urgency?
Overwhelming sensation to void immediately
What is dysuria?
Painful urination (usually burning sensation)
What is frequency?
Urination more frequently than usual
What is polyuria?
Urination in larger amounts than usual
What is nocturia?
Awakening to urinate
What is hesitancy?
Delay in urination
What is pneumaturia?
Air passed with urine via the urethra
What is pyuria?
WBCs in urine (UTI: > 10 WBCs/HPF)
What is cryptorchidism?
What is an IVP?
Dye is injected into the vein, collects in the renal collecting system, and an x-ray is taken
What is hematuria?
RBCs in urine
What is the space of Retzius?
Anatomic extraperitoneal space in front of the bladder
What is enuresis?
Involuntary urination while asleep
What is incontinence?
What is a TURP?
TransUrethral Resection of the Prostate
What is PVR?
What is priapism?
Prolonged, painful erection
What is paraphimosis?
Foreskin held (stuck) in the retracted position
What is phimosis?
Inability to retract the foreskin
What is balanitis?
Inflammation/infection of the glans penis
What is balanoposthitis?
Inflammation/infection of the glans and prepuce of the penis
What is a UTI?
Urinary Tract Infection
What is Peyronie's disease?
Abnormal fibrosis of the penis shaft, resulting in a bend upon erection
What is BPH?
Benign Prostatic Hyperplasia
What is epispadias?
Abnormal urethral opening on the dorsal surface of the penis
What is hypospadias?
Abnormal urethral opening on the ventral surface of the penis.
May occur in anterior, middle or posterior of penis.
What is erectile dysfunction?
Inability to achieve an erection
What is sterility?
Inability to reproduce
What is an appendix testis?
Common redundant testicular tissue
What is VUR?
What are the layers of the scrotum?
(1) Skin, (2) Dartos fascia, (3) External spermatic fascia, (4) Cremaster muscle, (5) Internal spermatic fascia, (6) Parietal and Visceral layers of tunica vaginalis, (7) Tunica albuginea
What is the differential diagnosis of scrotal mass?
Cancer, torsion, epididymitis, hydrocele, spermatocele, varicocele, inguinal hernia, testicular appendage, swollen testicle after trauma, non-testicular tumor (e.g. rhabdomyosarcoma, leiomyosarcoma, liposarcoma)
What are the causes of hematuria?
Bladder cancer, trauma, UTI, cystitis from chemotherapy or radiation, stones, kidney lesion, BPH
What is the most common cause of severe gross hematuria without trauma, chemotherapy, or radiation?
What is the differential diagnosis for bladder outlet obstruction?
BPH, stone, foreign body, urethral stricture, urethral valve
What is the differential diagnosis for ureteral obstruction?
Stone, tumor, iatrogenic (suture), stricture, gravid uterus, radiation injury, retroperitoneal fibrosis
What is the differential diagnosis for kidney tumor?
Renal cell carcinoma, sarcoma, adenoma, angiomyolipoma, hemangiopericytoma, oncocytoma
What is renal cell carcinoma?
Most common solid renal tumor (90%).
Originates from proximal renal tubular epithelium.
What is the epidemiology of renal cell carcinoma?
Primarily a tumor of adults 40-60 years with 3:1 M:F ratio.
What percentage of renal cell tumors are bilateral?
What are the risk factors for renal cell carcinoma?
Male, smoking, von Hippel-Lindau syndrome, polycystic kidney
What are the symptoms of renal cell carcinoma?
Pain, hematuria, weight loss, flank mass, HTN
What is the classic triad of renal cell carcinoma?
1. Flank pain
3. Palpable mass
How are most cases of renal cell carcinoma diagnosed?
Found incidentally on an imaging study
What radiologic test are performed for renal cell carcinoma?
IVP, Abdominal CT with contrast
What is stage I renal cell carcinoma?
Tumor < 2.5 cm no nodes, no metastases
What is stage II renal cell carcinoma?
Tumor > 2.5 cm limited to kidney, no nodes no metastases
What is stage III renal cell carcinoma?
Tumor extends into IVC or main renal vein.
Positive regional lymph nodes but < 2 cm in diameter and no metastases.
What is stage IV renal cell carcinoma?
Distant metastasis or positive lymph node > 2 cm in diameter, or tumor extends past Gerota's fascia
What is the metastatic workup for renal cell carcinoma?
CXR, IVP, CT, LFTs, calcium
What are the sites of metastases for renal cell carcinoma?
Lung, liver, brain, bone.
Tumor thrombus entering renal vein or IVC is not uncommon.
What is the unique route of spread with renal cell carcinoma?
Tumor thrombus in IVC lumen
What is the treatment of renal cell carcinoma?
Radical nephrectomy (excision of the kidney, adrenal gland, including Gerota's fascia) for stages I-IV
What gland is removed with a radical nephrectomy?
What is the unique treatment of metastatic spread of renal cell carcinoma?
2. LAK cells (lymphokine-activated killer) and IL-2
What is a syndrome of renal cell carcinoma and liver disease?
What is the concern in an adult with new onset left varicocele?
Left renal cell carcinoma (the left gonadal vein drains into the left renal vein)
What is the most common histology in bladder cancer?
Transitional cell carcinoma (90%).
Remaining cases are squamous or adenocarcinomas.
What are the risk factors for bladder cancer?
Smoking, industrial carcinogens (aromatic amines), schistosomiasis, truck drivers, petroleum workers, cyclophosphamide
What are the symptoms of bladder cancer?
Hematuria +/- irritative symptoms, frequency
What is the classic presentation of bladder cancer?
What tests are included in the workup for bladder cancer?
Urinanalysis and culture, IVP, cystoscopy with cytology and biopsy
What is stage 0 bladder cancer?
Superficial, carcinoma in situ
What is stage I bladder cancer?
Invades subepithelial connective tissue, no positive nodes, no metastases
What is stage II bladder cancer?
Invades superficial or deep muscularis propria, no positive nodes, no metastases
What is stage III bladder cancer?
Invades perivesical tissues, no positive nodes, no metastases
What is stage IV bladder cancer?
Positive nodal spread with distant metastases and/or invades abdominal pelvic wall
What is the treatment of stage 0 bladder cancer?
TURB and intravesical chemotherapy
What is the treatment of stage I bladder cancer?
What is the treatment of stage II and III bladder cancer?
Radical cystectomy, lymph node dissection, removal of prostate/uterus/ovaries/anterior vaginal wall, and urinary diversion (e.g. ileal conduit) +/- chemotherapy
What is the treatment of stage IV bladder cancer?
+/- cystectomy and systemic chemotherapy
What are the indications for partial cystectomy?
Superficial, isolated tumor, apical with 3-cm margin from any orifices
What is TURB?
TransUrethral Resection of the Bladder
If after a TURB the tumor occurs, then what?
Repeat TURB and intravesical chemotherapy (mitomycin C) or bacillus Calmette-Guerin
What is and how does bacillus Calmette-Guerin work?
Attenuated TB vaccine.
Thought to work by immune response.
What is the incidence of prostate cancer?
Most common GU cancer.
Most common carcinoma in men in the US.
What is the epidemiology of prostate cancer?
Present in 33% of men 70-79 years and 66% of men 80-89 years; more common in African Americans
What is the histology of prostate cancer?
What are the symptoms of prostate cancer?
Nodule found on routine DRE.
Usually begins in the periphery of the gland and moves centrally, thus obstructive symptoms occur late.
What percentage of patients have metastasis of prostate cancer at diagnosis?
What are the common sites of metastasis of prostate cancer?
Osteoblastic bony lesions, lung, liver, adrenal glands
What provides lymphatic drainage of prostate?
Obturator and hypogastric nodes
What is the significance of Batson's plexus?
Spinal cord venous plexus.
Route of isolated skull/brain metastasis.
What are the steps in early detection of prostate cancer?
1. Prostate-specific antigen (most sensitive and specific marker)
When should men get a PSA-level check?
1. All men > 50 years
2. > 40 years if first-degree family history or African American
What percentage of patients with prostate cancer will have an elevated PSA?
What is the imaging test for prostate cancer?
How is the diagnosis of prostate cancer made?
What is the Gleason score?
Histologic grades 2-10:
Low score: well-differentiated
High score: poorly-differentiated
What are the indications for transrectal biopsy with normal DRE?
PSA > 10 or abnormal TRUS
What is stage I prostate cancer?
Tumor involves < 50% of 1 lobe, no nodes, no metastases, PSA < 10, Gleason < 7
What is stage II prostate cancer?
Tumor within prostate, lobe < 50% but PSA > 10, or Gleason > 6, or > 50% of 1 lobe, no nodes, no metastases
What is stage III prostate cancer?
Tumor through prostate capsule or into seminal vesicles, no nodes, no metastases
What is stage IV prostate cancer?
Tumor extends into adjacent structures (other than seminal vesicles) or positive nodes or positive metastases
What does radical prostatectomy remove?
1. Prostate gland
2. Seminal vesicles
3. Ampullae of the vasa deferentia
What is androgen ablation therapy?
1. Bilateral ochiectomy or
2. LHRH agonists
How do LHRH agonists work?
Decrease LH release from pituitary, which then decreases testosterone production in the testes
What is the treatment for stage I prostate cancer?
What is the treatment for stage II prostate cancer?
Radical prostatectomy +/- lymph node dissection
What is the treatment for stage III prostate cancer?
Radiation therapy +/- androgen ablation
What is the treatment for stage IV prostate cancer?
Androgen ablation, radiation therapy
What is the medical treatment for systemic metastatic disease from prostate cancer?
What is the option for treatment in the early stage prostate cancer patient > 70 years with comorbidity?
What is benign prostatic hyperplasia?
Disease of elderly men in which the prostate gradually enlarges, creating symptoms of urinary outflow obstruction
What is the size of a normal prostate?
Where does BPH occur?
What are the symptoms of BPH?
Obstructive-type symptoms (e.g. hesitancy, weak stream, nocturia, intermittency, UTI, urinary retention)
How is the diagnosis of BPH made?
History, DRE, elevated PVR, UA, cystoscopy, U/S
What lab tests should be performed for BPH?
UA, PSA, BUN, Cr
What is the differential diagnosis of BPH?
Prostate cancer (biopsy); neurogenic bladder (history of neurologic disease); acute prostatitis (hot, tender gland); urethral stricture (RUG, history of STD); stone; UTI
What are the treatment options for BPH?
alpha-1 blockade, antiandrogens, TURP, TUIP, open prostate resection, transurethral balloon dilation
Why do alpha-adrenergic blockers work for BPH?
Relaxes sphincter and prostate capsule
What is finasteride (Proscar)?
Blocks transformation of testosterone to DHT.
May shrink and slow progression of BPH.
What is terazosin (Hytrin)?
May increase urine outflow by relaxing prostatic smooth muscles
What are the indications for surgery in BPH?
Urinary retention, hydronephrosis, UTIs, severe symptoms
What is TUIP?
TransUrethral Incision of Prostate
What percentage of tissue removed for BPH will have malignant tissue on histology?
Up to 10%
What are the possible complications of TURP?
Failure to void, bleeding, clot retention, UTI, incontinence
What is the incidence of testicular cancer?
Rare; 2-3/100,000 men per year
What is the most common solid tumor of men 20-40 years?
What are the risk factors for testicular cancer?
Does orchiopexy as an adult remove the risk of testicular cancer?
What are the symptoms of testicular cancer?
Painless mass, swelling, firmness of testicle
What percentage of patients with testicular cancer present with an acute hydrocele?
What percentage of patients with testicular cancer present with symptoms of metastatic disease (e.g. back pain, anorexia)?
What are the classifications of testicular cancer?
Germ cell tumors (seminomatous, non-seminomatous, teratoma, mixed, choriocarcinoma); Non-germinal (Leydig cell, Sertoli cell, gonadoblastoma)
What is the major classification of testicular cancer based on therapy?
Seminomatous and non-seminomatous
What are the tumor markers for testicular tumors?
What are the tumor markers by tumor type?
B-HCG: choriocarcinoma, embryonal carcinoma, seminomatous carcinoma
AFT: embryonal carcinoma, yolk sac tumors, non-seminomatous carcinoma
What is the difference between seminomatous and non-seminomatous germ cell testicular tumor markers?
Non-seminomatous: 90% have positive AFP and/or B-HCG.
Seminomatous: 10% are AFP positive.
Which testicular tumors almost never have an elevated AFP?
Choriocarcinoma and seminoma
In which testicular tumor is B-HCG almost always found elevated?
How often is B-HCG elevated in patients with pure seminoma?
How often is B-HCG elevated with nonseminoma?
What other testicular tumor markers may be elevated and useful for recurrence surveillance?
LDH, CEA, HCS, GGT, PLAP
What are the steps in workup for testicular cancer?
PE, scrotal U/S, check tumor markers, CXR, CT
What is stage I testicular cancer?
Any tumor size, no nodes, no metastases
What is stage II testicular cancer?
Positive nodes, no metastases, any tumor
What is stage III testicular cancer?
What is the initial treatment for all testicular tumors?
Inguinal orchiectomy (removal of testicle through a groin incision)
What is the treatment of stage I and II seminoma?
Inguinal orchiectomy and radiation to retroperitoneal nodal basins
What is the treatment of stage III seminoma?
Orchiectomy and chemotherapy
What is the treatment of stage I and II nonseminoma?
Orchiectomy and retroperitoneal lymph node dissection vs. close followup for retroperitoneal nodal involvement
What is the treatment of stage III nonseminoma?
Orchiectomy and chemotherapy
What percentage of stage I seminomas are cured after treatment?
Which type of testicular cancer is most radiosensitive?
Why not remove testis with cancer through a scrotal incision?
Could result in tumor seeding of the scrotum
What is the major side effect of retroperitoneal lymph node dissection?
What is testicular torsion?
Twisting of the spermatic cord, resulting in venous outflow obstruction, and subsequent arterial occlusion, leading to infarction of the testicle
What is the classic history of testicular torsion?
Acute onset of scrotal pain usually after vigorous activity or minor trauma
What is a bell-clapper deformity?
Bilateral non-attachment of the testicles by the gubernaculum to the scrotum
What are the symptoms of testicular torsion?
Pain in the scrotum, suprapubic pain
What are the signs of testicular torsion?
Very tender, swollen, elevated testicle, non-illumination, absence of cremasteric reflex
What is the differential diagnosis of testicular torsion?
Testicular trauma, inguinal hernia, epididymitis, appendage torsion
How is the diagnosis of testicular torsion made?
Surgical exploration, U/S (solid mass) and Doppler flow study, cold Tc-99m scan
What is the treatment for testicular torsion?
Surgical detorsion and bilateral orchiopexy to the scrotum
How much time is available from the onset of symptoms to detorse the testicle?
< 6 hours will bring about the best results
What are the chances of testicle salvage after 24 hours of torsion?
What are the signs and symptoms of epididymitis?
Swollen, tender testicle, dysuria, scrotal pain, fever, chills, scrotal mass
What is the cause of epididymitis?
Bacteria from the urethra
What are the common pathogens of epididymitis in elderly patients and children?
What are the common pathogens of epididymitis in young men?
What is the major differential diagnosis for epididymitis?
What is the workup for epididymitis?
U/A, urine culture, swab if STD suspected, +/- U/S with Doppler or nuclear study to rule out torsion
What is the treatment for epididymitis?
What are the causes of priapism?
Low flow (e.g. leukemia, drugs, sickle-cell disease, erectile dysfunction treatment gone wrong)
High flow (e.g. pudendal artery fistula, usually from trauma)
What is the first-line treatment for priapism?
1. Aspiration of blood from corporus cavernosum
2. alpha-adrenergic agent
What are the 6 major causes of erectile dysfunction?
1. Vascular (decreased blood flow or lead of blood from the corpus cavernosus)
2. Endocrine (low T)
3. Anatomic (structural abnormality of the erectile apparatus, e.g. Peyronie's disease)
4. Neurologic (damage to nerves, e.g. post-operative, IDDM)
5. Medications (clonidine)
6. Psychologic (performance anxiety)
What lab tests should be performed for erectile dysfunction?
Fasting glucose (rule out diabetic neuropathy); serum testosterone; serum prolactin
What is the incidence of calculus disease?
What are the risk factors for calculus disease?
Poor fluid intake, IBD, hypercalcemia, renal tubular acidosis, small bowel bypass
What are the 4 types of stones?
1. Calcium oxalate/phosphate (secondary to hypercalcemia)
2. Struvite, MgAmPh (infection stones; seen in UTI with urea-splitting bacteria; may cause staghorn calculi; high urine pH)
3. Uric acid (stones are radiolucent, seen in gout, Lesch-Nyhan, chronic diarrhea, cancer, low urine pH)
4. Cystine (genetic predisposition)
What type of stones are not seen on AXR?
What stone is associated with UTIs?
What stones are seen in IBD and bowel bypass?
What are the symptoms of calculus disease?
Severe pain (patient cannot sit still); renal colic (typically pain in the kidney/ureter that radiates to the testis or penis); hematuria
What are the classic findings with calculus disease?
Flank pain, stone on AXR, hematuria
How is the diagnosis of calculus disease made?
KUB, IVP, U/A and culture, BUN/Cr, CBC
What is the significance of hematuria and pyuria?
Stone with concomitant infection
What is the treatment for calculus disease?
Narcotics for pain, vigorous hydration, observation.
Further options: ESWL (lithotripsy), ureteroscopy, percutaneous lithotripsy, open surgery, metabolic workup for recurrence
What are the indications for intervention in calculus disease?
Urinary tract obstruction, persistant infection, impaired renal function
What are the contraindications of outpatient treatment of calculus disease?
Pregnancy, diabetes, obstruction, severe dehydration, severe pain, urosepsis/fever, pyelonephritis, previous urologic surgery, only one functioning kidney
What are the 3 common sites of obstruction in calculus disease?
1. UPJ (UreteroPelvic Junction)
2. UVJ (UreteroVesicular Junction)
3. Intersection of the ureter and the iliac vessels
What are the common types of incontinence?
Stress, overflow, urge
What is stress incontinence?
Loss of urine associated with coughing, lifting, exercise, etc.
Seen most often in women, secondary to relaxation of pelvic floor following multiple deliveries.
What is overflow incontinence?
Failure of the bladder to empty properly.
May be caused by bladder outlet obstruction (BPH or stricture) or detrusor hypotonicity.
What is urge incontinence?
Loss of urine secondary to detrusor instability in patients with stroke, dementia, Parkinson's disease, etc.
What is mixed incontinence?
Stress and urge incontinence combined
How is the diagnosis of incontinence made?
H&P, U/A, PVR, urodynamics, cystoscopy or VCUG may be necessary
What is the Marshall test?
Women with stress incontinence placed in the lithotomy position with a full bladder leaks urine when asked to cough
What is the treatment for stress incontinence?
Bladder neck suspension
What is the treatment for urge incontinence?
What is the treatment for overflow incontinence?
Self-catheterization, surgical relief of obstruction, alpha-blockers
What is the etiology of UTI?
Ascending infection, instrumentation, coitus in females
What are the 3 common pathogens in UTI?
1. E. coli
3. Klebsiella, Pseudomonas
What are the predisposing factors for UTI?
Stones, obstruction, reflux, diabetes, pregnancy, indwelling catheter or stent
What are the symptoms of UTI?
Lower UTI: frequency, urgency, dysuria, nocturia
Upper UTI: back or flank pain, fever, chills
How is the diagnosis of UTI made?
Symptoms, U/A (> 10 WBCs/HPF)
When should workup be performed for UTI?
After first infection in male patients (unless Foley in place).
After first pyelonephritis in prepubescent females.
What is the treatment for UTI?
Lower: 1-4 days of oral antibiotics
Upper: 3-7 days of IV antibiotics
Why should orchiopexy be performed?
Decrease the susceptibility to blunt trauma; increase the ease of followup exams
What type of bony lesions is seen in metastatic prostate cancer?
What percentage of renal cell carcinoma show evidence of metastatic disease at presentation?
What is the most common site of distant metastasis in renal cell carcinoma?
What is the most common solid renal tumor in children?
What are posterior urethral valves?
Most common obstructive urethral lesion in infants and newborns.
Occurs only in males, found at the distal prostatic urethra.
What is the most common intraoperative bladder tumor?
What provides drainage of the left gonadal vein?
Left renal vein
What provides drainage of the right gonadal vein?
What are the signs of urethral injury in the trauma patient?
High-riding, ballottable prostate, blood at the urethral meatus, severe pelvic fracture, ecchymosis of scrotum
What is the evaluation for urethral injury in the trauma patient?
What is the evaluation for a transected ureter intraoperatively?
IV indigo carmine and then look for leak of blue urine in the operative field
What aid is used to help identify the ureters in a previously radiated retroperitoneum?
How can a small traumatic extraperitoneal bladder rupture be treated?
How should a traumatic intraperitoneal bladder rupture be treated?
What percentage of patients with an injured ureter will have no blood on U/A?
What is the classic history of papillary necrosis?
Patient with diabetes taking NSAIDs or patient with sickle cell trait
What unique bleeding problem can be seen with prostate surgery?
Release of TPA and urokinase (treat with e-aminocaproic acid)
What is the scrotal blue dot sign?
Torsed appendix testis
What is Peyronie's disease?
Curved penile orientation with erection due to fibrosis of corpora cavernosa
What is a ureterocele?
Dilation of the ureter (treat with endoscopic incision or operative excision)