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Urology Flashcards

0
Q

Where are the kidneys located anatomically? What are the kidneys surrounded by?

A

The kidneys lie in the retroperineum on the psoas and quadratus lumborus muscles; they are encased by Gerota fascia (so are the adrenals)

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1
Q

What are the embryologic components of the kidney? What structures do these components form?

A

Pronephros (4th week): primitive kidney
Mesonephros (4-5th weeks): ureters, pelvis, calyces, and collecting system
Metanephros (5th week): glomeruli and PCT thru DCT

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2
Q

What is different about the course of the left and right renal ARTERIES?

A

The right renal artery passes behind the IVC whereas the left renal artery enters directly from the aorta

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3
Q

What is the branching pattern of the renal arteries?

A

Renal artery, 5 segmental branches, interlobar, arcuate, interlobular, afferent, glomerular capillaries, efferent, vasa recta capillary system

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4
Q

What is the difference between the left and right renal veins?

A

The right renal vein drains straight into the IV; the left renal vein courses anterior to the aorta and then drains into the IVC

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5
Q

Which veins drain into the left renal vein during its longer course?

A

The left gonadal, the left adrenal, and the lumbar veins

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6
Q

What are three embryologic abnormalities that can occur with the kidneys?

A

Pelvic kidney: cannot pass the umbilical arteries
Horseshoe kidney: catch the IMA
Renal agenesis: bilateral is incompatible with life (potter syndrome)

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7
Q

How much of the cardiac output goes to the kidneys? How much of the renal plasma flow is filtered? What is the equation for eRPF? GFR?

A

EASY 20% and 20%

Remember: eRPF = UxV/Px ((urine concentration x urine flow rate)/plasma concentration) with PAH as the substrate; GFR is the same equation but with Cr instead

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8
Q

Which 4 organs play a role in the RAA system?

A

Liver: produces angiotensinogen
Kidneys (JGA): produces Renin
Lungs: produces ACE
Adrenal gland: synthesizes Aldosterone

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9
Q

What are the five most common causes of hematuria in pediatric patients? Adult patients?

A

Pediatrics: UTI, Glomerulonephritis, Congenital urinary tract abnormality, urolithiasis, or trauma
Adults: UTI, Glomerulonephritis, bladder cancer, urolithiasis, or BPH

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10
Q

What can help distinguish between a renal cause of hematuria and a post-renal cause?

A

RED BLOOD CELL CASTS

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11
Q

What the S/Sx’s of ADPKD? What are 2 complications that can occur with ADPKD?

A

S/Sx’s include: HTN, flank pain, hematuria, or proteinuria

Complications: chronic renal failure, berry aneurysms

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12
Q

What percentage of patients with ADPKD develop berry aneurysms? What percentage of CRF patients have ADPKD?

A

10-30%

10%

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13
Q

Which disease should come to mind when presented with enlarged kidneys on exam or imaging studies?

A

ADPKD or ARPKD

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14
Q

Which organs are affected in a child with ARPKD? What are the likely causes of death in these patients?

A

Kidneys and liver both have multiple cysts

COD: renal failure or liver fibrosis

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15
Q

Which etiologies should be considered with a false positive urine dipstick for blood? Which substrates can appear to cause gross hematuria but yield a false urine dipstick for blood?

A

Myoglobinuria

Anthocyanin from beers and berries, rifampin, porphyria, pyridine

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16
Q

What is the classic triad of symptoms for RCC? What percentage of patients will present with this triad? What other symptoms may be present?

A

Triad: flank pain, palpable mass, hematuria seen in 10-15% of patients
Other symptoms: fatigue, weight loss, cachexia, or signs of a paraneoplastic syndrome

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17
Q

What types of paraneoplastic syndromes can be seen in RCC?

A

Cushings (ACTH), polycythemia Vera (EPO), hypercalcemia (PTHrp), galatorrhea (prolactin)

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18
Q

How is RCC diagnosed? How is the definitive diagnosis made?

A

CT or MRI; do not use a percutaneous biopsy (too many false negatives + chance of seeding the tract); confirmation is made after surgical excision

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19
Q

What role does ultrasound play in the diagnosis of RCC?

A

It can help distinguish between a solid and cystic lesion

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20
Q

What is the standard of treatment for a kidney tumor? When is this not the case?

A

Radical nephrectomy (standard): Remember definitive diagnosis is only made after removal

Partial nephrectomy if solitary kidney, bilateral tumors, or VHL disease

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21
Q

What are 3 complications of a partial nephrectomy for the treatment of RCC?

A

Urinary fistula (requires stent and/or catheter), IVC invasion by tumor cells, 10% chance of recurrence

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22
Q

How does RCC spread?

A

Lympatically and hematogenously (renal vein and IVC classically invaded)

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23
Q

What is the follow up for a patient with surgical removal of RCC?

A

CT scan (abdomen/pelvis), CXR, urinalysis, and LFTs every 6 months

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24
What is the 5 year survival for patients with different stages if RCC?
Stage 1: >97% (confined to local parenchyma) Stage 2: 74-96% (confined within Gerota fascia) Stage 3: 40-70% (lymph node or vein involved) Stage 4: <36% (distant metastasis)
25
What percentage of kidney tumors are RCC? What percentage of visceral cancers are RCC? Why is this important clinically?
85% 3% This is the rationale for radical nephrectomy!
26
Who is at risk for RCC? Urolithiasis? Incidence and recurrence rate of urolithiasis?
RCC: males (2:1) in their 50s and 60s Urolithiasis: males (3:1); 1 in 100-500 (average risk of approximately 1%); recurrence is 36% within 1 year and 50% within their lifetime
27
What are the different types of stones and their relative probability? Which stones are radiolucent?
Calcium oxalate/phosphate: 75 Struvite: 10-15 Uric acid: 10-15 Cystine: <1 Uric acid and Indinivir stones
28
Which anatomical sites are likely to get obstructed by a kidney stone?
Ureteropelvic junction, Mid to distal ureter (iliac constriction site), ureterovesical junction, pelvic brim (constriction site)
29
What are the S/Sx's of urolithiasis?
Abrupt onset of flank pain that radiates to the groin (colicky pain), N/V, hematuria, and/or abdominal distention from Ileus
30
What are 6 risk factors for developing urolithiasis?
1. Hypercalcemia 2. Dehydration 3. Immobilization 4. Lesch-Nyhan disease 5. Drugs (Indinivir, probenecid) 6. IBD, PUD
31
What is the gold standard imaging modality for urolithiasis? What other tests can be used?
Non-contrast CT; US (reserved for pregnancy - can detect hydronephrosis but not all caliculi); KUB (inexpensive and detects most stones but cannot detect hydronephrosis)
32
Which lab tests, when used with US or KUB increase their positive predictive value?
Urinalysis positive for microscopic hematuria | Serum Chemistry with elevated creatinine
33
What is the conservative approach to managing urolithiasis?
For stones less than 5 mm treat with analgesia and fluids (IV or PO) and tell the patient to catch/strain their urine for stone analysis
34
What are the surgical management options for urolithiasis?
1. Extracorporeal shock wave lithotripsy (ESWL) 2. Ureteroscopy 3. Percutaneous nephrolithotripsy 4. Open surgery
35
What are the contraindications for ESWL? What are the possible complications?
1. Pregnancy, bleeding disorders, or radiolucent stones | 2. Subcapsular hematoma, transient HTN, urosepsis, Steinstrasse syndrome
36
What are the complications of ureteroscopic removal of kidney stones?
Ureter damage: stricture, perforation, sepsis, avulsion
37
What are the indications for percutaneous nephrolithotripsy?
If the patient has a staghorn caliculi or a large stone or if ESWL and ureteroscopy are not viable options
38
When is open surgery used for the treatment of urolithiasis?
It has largely fallen out of favor but can be used for a complete staghorn stone
39
What is the orientation of the ureter to the iliac vessels?
The ureters pass anterior to the iliac vessels at the bifurcation of the internal and external vessels
40
What is the embryologic origin of the bladder?
The cloacae divides into the anal canal and urogenital sinus (the largest part of the sinus becomes the bladder); the bladder drains via the urachus which becomes the median umbilical ligament
41
What is the name of the bladder muscle? How many layers does the muscle have? What type of epithelium lines the inner layer?
The Detrusor muscle; 3 layers (inner longitudinal, middle circular, outer longitudinal); the inner layer is lined by transitional epithelium
42
Where is the trigone of the bladder located? What does this structure contain?
At the base of the bladder; two ureter orifices and the urethral orifice
43
Which arteries supply blood to the bladder? Where do these vessels originate?
The inferior and superior vesical arteries which originate from the internal iliac artery
44
How is bladder function controlled?
Sympathetics (T10-L2): relaxation of the Detrusor and contraction of the internal sphincter Parasympathetics (S2-S4): contraction of the Detrusor and relaxation of the internal sphincter
45
Which site of the urothelial lined collecting system is the most likely site for carcinoma?
THE BLADDER
46
What are the 3 types of possible bladder cancers? Etiologies?
Transition cell carcinoma (98%): smoking, cyclophosphamide, chemical dyes Squamous cell carcinoma: chronic irritation (chronic UTIs, Indwelling catheter, schistosomiasis) Adenocarcinoma: metastasis (usually direct spread from GI tract)
47
What are the most common presenting symptoms in patients with newly diagnosed TCC of the bladder?
HEMATURIA (90%); also frequency, urgency, or dysuria may be present
48
What is the recurrence rate of TCC of the bladder? What accounts for this rate of recurrence?
Low grade: 50% High grade: up to 90% Field defect
49
What is the gold standard for diagnosis of bladder cancer? What are the other options available?
Cystoscopy w/ tissue biopsy; cytology of urine for malignant cells (high specificity) or imaging studies (CT, MRI, or US) to identify bladder thickening or a mass
50
What are the stages of TCC of the bladder?
1. Tis: carcinoma in situ 2. Ta: no invasion 3. T1: submucosal invasion 4. T2: muscularis invasion 5. T3: pervesical fat invasion 6. T4: adjacent tissue invasion
51
What is the treatment modality for stages Tis-T1 of TCC of the bladder? How should this be monitored in the future?
TURBT (transurethral resection of the bladder tumor): also used initially to stage the tumor; repeat cystoscopy every 3 months for 2 years, then every 6 months for 2 years, then yearly
52
What is BCG and in which cancer can it be used to decrease recurrence?
Bacillus Calmette-Guerin therapy (intravesical infusion of an attenuated strain of S. bovis); used for TCC up to and including stage 1
53
What are 2 surgical procedures reserved for patients with TCC that cannot be respected with TURBT?
Partial cystectomy: small tumors with minimal invasion (usually have a thin wall that increases TURBT risk) Radical cystectomy: tumors with invasion through the muscular wall
54
What is the non-surgical treatment for higher stage TCC of the bladder?
Radiation therapy; chemotherapy (cyclophosphamide, doxorubicin, cisplatin, etc.)
55
What is the prognosis for metastatic TCC of the bladder?
Usually < 2 years
56
What are some possible causes of a neurogenic bladder?
Spinal cord injury/neoplasm/congenital defect, stroke, multiple sclerosis, NPH, parkinson disease, etc.
57
What are some S/Sx's of a neurogenic bladder?
Frequency (> 8 times/day), urgency, incontinence, or urinary retention
58
What are 2 possible complications of a neurogenic bladder?
UTI or pyelonephritis
59
What is the standard for diagnosis of a neurogenic bladder?
Cystoscopy w/ urodynamics
60
What should be done while working up a patient with a neurogenic bladder?
Studies to find the root cause (i.e. Spinal cord imaging, brain imaging, etc.)
61
What are the three general types of treatment or management available for patients with a neurogenic bladder?
1. Behavioral therapy 2. Medical management 3. Surgical management
62
What are the types of behavioral therapy that can be used for a patient with a neurogenic bladder?
Clean intermittent catheterization after initial voiding; scheduled voiding to decrease frequency
63
What are some pharmacological therapies available for patients with a neurogenic bladder?
Antimuscarinics ( several unpleasant side effects) Prophylactic antibiotics
64
What are the surgical options for patients with a neurogenic bladder?
Bladder augmentation to increase the size; Botox injections to relax the internal sphincter
65
What is urinary incontinence? What are the 4 major types of urinary incontinence? Pathophysiology?
The involuntary leakage of urine 1. Urge (over active Detrusor muscle) 2. Stress (weak internal sphincter) 3. Mixed (strong Detrusor w/ weak sphincter) 4. Overflow (incomplete emptying due to a weakened Detrusor or an obstruction)
66
What should be involved in the initial work up of a patient with incontinence?
A thorough history, physical exam, and urinalysis
67
What are 5 tests that can be used to help diagnose urinary incontinence?
1. Bladder diary 2. Stress test 3. Post void residual 4. Urodynamics (gold standard) 5. Cystoscopy (only if other tests are inconclusive)
68
What are the 3 general types of management available for patients with a neurogenic bladder?
1. Behavioral management 2. Medical management 3. Surgical management
69
What are the types of behavioral management used to help patients with incontinence?
1. Timed voiding (at regular interval) 2. Pelvic floor training (strengthens the IS) 3. Fluid and dietary management 4. Weight loss
70
What types of medication are available for patients with urinary incontinence? Examples?
1. Anticholinergics (oxybutynin, solifenacin, tolterodine) 2. Alpha agonists (nasal decongestants) 3. Alpha antagonists ("osins") 4. Beta 3 agonists (mirabegron)
71
What are the surgical options available for urinary incontinence?
1. Botulinum injection (over active) 2. Sacral neuromodulation 3. Bladder augmentation (over active) 4. Bulking agent injection (stress) 5. Sling (stress) 6. Artificial urinary sphincter (stress)

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