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urology Flashcards

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1
Q

2nd MC of malignancy of the GU tract

A

bladder neoplasms

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2
Q

most bladder cancers are invasive or non invasive

A

non-invasive (more favorable outsomes)

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3
Q

MC type of bladder neoplasm

A

urothelial cell carcinoma (formerly transitional cell)

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4
Q

RF for bladder neoplasms

A

current or former smoker

occupational exposure

genetic factors

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5
Q

bladder neoplasm sxs (MC)

A

painless hematuria (macro or micro)

voiding sxs

urgency
frequency
painful urination

can be mistaken for a UTI

sometimes detected on imaging

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6
Q

diagnostic tests for bladder neoplasms

A

urinalyses

urine culture

cystoscopy to look at the upper tract

urine cytology (can detect uroplastic cells in the urine)

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7
Q

what is a TURBT

A

Transuretheral resection of bladder tumor

both diagnostic and therapeutic

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8
Q

CT urogram is necessary because

A

could have a cancer in the upper tract

need CR check prior because need to be able to process dye

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9
Q

when to avoid IVC (intravesicle chemotherapy)

A

NOT wiht bladder perfs

but can reduce cancer reoccurence by 35%

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10
Q

TUR syndrome

A

irrigant used in TURBT can make you hyponatremic

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11
Q

when would chemo be indicated for baldder neoplasm

A

Chemo started 2-6 weeks after turbt

NMIBC with high risk of recurrence

]NMIBC with high risk of progression

Carcinoma in situ
Residual tumor

High and intermediate risk of reoccurrence

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12
Q

what does F/U for bladder enoplasms look like

A

lifetime surveillance because high rates of reoccurrence

should have a cystoscopy every 3-6 months fora year

if they do find a tumor after the administration of chemotherapy cycles then bladder surveillance starts again

high risk stay at 3 months

if low risk can drop down to 6/9 months and then annually for 5 years

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13
Q

when is upper tract imagining needed after TURBT

A

Low risk NMIBC (non-muscle invasive bladder cancer)

If asymptomatic, do NOT perform routine surveillance upper tract imaging

high risk will require CT urogram every 1-2 years

or mR urograph

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14
Q

hutch diverticula management

A

Partial cystectomy with diverticulectomy is preferred

bladder cancer in diverticula does require cystectomy or partial cystectomy

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15
Q

other than diverticula involved bladder neoplasms whata re some indications for partial cystectomy

A

< 3 cm in size

Not associated with carcinoma in situ

Located in a favorable anatomic location ( not in the urethral orifices)

Radical cystectomy is not commonly performed for non-muscle invasive bladder cancer (NMIBC)

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16
Q

BCG implications for NMIBC tx

A

can be used for immune treatment but if refractory or large may require complete cystecomty

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17
Q

other than refractory to chemo when would a radical cystectomy be implicated

A

very large >10cm

varaitn tumor histology

bladder cripple

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18
Q

what is a “Bladder cripple”

A

Small capacity

contracted bladders (from repeated TURBT or intravesical therapy)

Neurogenic bladder (often incontinent & miserable)

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19
Q

Hydronephrosis is a strong predictor of

A

upstaging to extravesical disease & independent predictor of a worse prognosis

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20
Q

chemo therapy agent most used in the treatment of NMIBC

A

BCG

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21
Q

dx for invasive bladder cancers

A

CT chest
AP lateral

CT abd and pelvis
MRI

CBC
LFTS
Creatinine with GFR

aklaine phos

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22
Q

what is the goldstandard of treatment of MIBC

A

treatment for muscle invasive bladder cancer

Radical cystectomy with or without neoadjuvant chemotherapy

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23
Q

male radical cystectomy for bladder neoplasm usually involves removal of (1)

A

Removal of:

  • bladder
  • perivesical fat
  • prostate
  • seminal vesicles

& prostatic urethra

Nerve-sparing surgery as in prostatectomy

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24
Q

what is not normally performed in a radical cystectomy (male) until positive margin is determined??

A

urethrectomy

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25
what does a radical cystectomy in a female look like
removal of the bladder and ``` the enterior pelvic exenteration which the uterus cervix fallopian tubes ovaries anterior vagina ``` if in a low stage can consider bladder sparing techniques
26
Muscle Invasive Bladder Cancer: Surgical Complications (top two)
gastrointestinal complications and | infection
27
incontinent types of urinary diversion
ileal condut segment of the intestine is turned into a stoma from the uretors
28
other than ileal conduit what type of urinary diversions can be performed
orthotopic neobladder continent cutaneous reservoir
29
important considerations if terminal ilium is utilized in diversion
If terminal ileum utilized in diversion --> patient needs vitamin B12 supplementation for life
30
complications of ileal conduit
upper tract deterioration over the long term UTI stomal or parastomal hernia peri-stoma skin irritation/infection/ulceration
31
orthotopic urinary reconstruction important consideration for studer pouch
of or relating to the grafting of tissue in natural NEED to have a negative urethral margin
32
how is the continence maintained in a continent cutaneous reservoir
maintained by ileo cecal valve
33
bladder stones are usually seen in some type of
outlit obsturction
34
Preferred method of cystolitholopaxy in pediatric patients
percutaneous suprapubic NOT transurethral but that's more common
35
what are come complications of cystolitholapaxy
UTI bleeding perforation of bowel urethral stricture
36
RF for kidney neoplasms (RCC)
``` smoking HTN male occupation exposure acquired renal cystic disease ```
37
Kidney Neoplasms MC and Most agressive
CLEAR CELL RCC (most aggressive) Arises from proximal convoluted tubule
38
kidney neoplasms -classic triad
Flank mass Hematuria Pain occurs in ~10% of patients
39
other sytmptoms not in the classic triad for RCC
Fever, chills, weight loss, cachexia Anemia Elevated erythrocyte sedimentation rate, C-reactive protein, alkaline phosphatase, &calcium Polycythemia-high hmt and gb
40
labs for RCC
CBC, CMP, UA
41
PN should be prioritized in patients with:
``` Anatomic or functional solitary kidney Bilateral renal tumors Known familial RCC Pre-existing CKD Proteinuria ```
42
Determinants of long-term renal function after PN:
Pre-op renal function Warm ischemia duration (≤ 25 mins optimal) Comorbidities Amount of preserved kidney
43
RN preferred for higher risk kidney tumors IF following criteria are met
High tumor complexity with risk of complications No existing CKD or proteinuria Normal contralateral kidney with anticipated post-op GFR > 45
44
RN compared to partial nephrectomy
Less incidence of hemorrhage Less incidence of urine leak / fistula Less re-operation complications RN increases the risk of CKD as compared to PN
45
when would you use thermal ablation to treat RCC
Thermal ablation is an option for renal masses localized to kidney ≤ 3 cm in diameter
46
labs you need after treating RCC
BUN Creatinine, UA, eGFR (possible CBC, LDH, LFTs, alkaline phosphatase (ALP), Calcium)
47
kidney neoplasms
Flank mass Hematuria Pain occurs in ~10% of patients
48
other sytmptoms not in the classic triad for RCC
Fever, chills, weight loss, cachexia Anemia Elevated erythrocyte sedimentation rate, C-reactive protein, alkaline phosphatase, & calcium Polycythemia
49
labs for RCC
CBC, CMP, UA
50
PN should be prioritized in patients with:
Removal of tumor with negative surgical margins Renal reconstruction Approaches: open, laparoscopic, robotic
51
Determinants of long-term renal function after PN:
Pre-op renal function Warm ischemia duration (≤ 25 mins optimal) Comorbidities Amount of preserved kidney
52
Kidney Neoplasms (RCC)
High tumor complexity with risk of complications No existing CKD or proteinuria Normal contralateral kidney with anticipated post-op GFR > 45
53
RN compared to partial nephrectomy
Less incidence of hemorrhage Less incidence of urine leak / fistula Less re-operation complications RN increases the risk of CKD as compared to PN
54
when would you use thermal ablation to treat RCC
Thermal ablation is an option for renal masses localized to kidney ≤ 3 cm in diameter
55
labs you need after treating RCC
BUN Creatinine UA eGFR (possible CBC, LDH, LFTs, alkaline phosphatase (ALP), Calcium)
56
majority of relapses in RCC occur when
Majority of relapses occurs within first 3 years following surgery More rigorous follow-up in first 3 years post-op
57
characteristic of kidney stone pain
Flank pain Abdominal pain / Groin pain (depends on stone location) pain DOES NOT cross midline
58
shortcomings of xray for stones
Unable to visualize radiolucent stones (uric acid stones) Poorly sensitive for stones overlying the bony pelvis
59
preferred diagnostic test for renal stones
CT favored over IVP “Low dose” CT available
60
cons of uLS for stone dx
Poorly visualizes stones located in ureter has limited sensitivity for stones < 2-3 mm
61
SE associated with flomax
(tamsulosin) flomax is used in conjunction with hydration and medical expulsion therapy (spontaneous stone passage) floppy iris if a pt has cataract surgery schedule with stones don't use flomax
62
Urgent stent placement vs. Nephrostomy tube placement when would it be indicated
Indicated in the setting of obstruction & signs of infection (fever, leukocytosis, hemodynamic instability)
63
CI and consideration for lithotripsy (SWL) / Extracorporeal Shockwave Lithotripsy (ESWL)
Stone located with fluoroscopy or ultrasound Cannot target radiolucent stones (uric acid stones) without use of contrast not ideal for stones low in the kidney or pelvic or uric acid stones Pregnancy* Coagulopathies Presence of cardiac arrhythmia / pacemaker Aortic aneurysm & Renal artery aneurysm UTI
64
complications of SWL
Risk of “steinstrasse” (German for “stone street”) with large stones treated with SWL / ESWL Renal injury Contusion Hemorrhage Hypertension Diabetes mellitus Renal impairment
65
Percutaneous Nephrolithotomy (PCNL) what is it and what is it reserved for
Stone extraction with rigid or flexible nephroscope Nephroscope can be used in conjunction with laser Likely will require stent placement Nephrostomy tube Overnight stay in hospital at minimum (usually 1-2 days) Percutaneous Nephrolithotomy (PCNL) Large (>2 cm) stones Complex stones Staghorn calculi Lower pole stones > 1 cm Complex renal anatomy
66
gold standard in the treatment of BPH
Electrosurgical-based TURP is the GOLD STANDARD treatment in BPH
67
what does TURP stand for?
Transurethral Resection of the Prostate (TURP) Electrosurgical-based TURP is the GOLD STANDARD treatment in BPH
68
indications for TURP
Acute urinary retention Bladder calculi Azotemia: elevation of blood urea nitrogen (BUN) & serum creatinine levels; abnormally high levels of nitrogen-containing compounds in the blood Recurrent UTI Recurrent hematuria Worsening LUTS refractory to medical therapy
69
complications of TURP
Dilutional hyponatremia (TUR Syndrome, occurring in 1-2% of patients ALSO ``` Urinary tract infections Urethral stricture (up to 10%) Urinary incontinence (up to 10%, usually mild & self-limiting) Retrograde ejaculation (60-90%) Need for re-operation (3-8%) ```
70
what is a urolift
Involves implantation of tissue retracting elements inserted under cystoscopic guidance using the Urolift® delivery system
71
Consider simple prostatectomy over TURP in the following:
Large prostates --> 80 g or larger | Patients who need additional procedures (diverticulectomy, bladder stone removal)
72
screening for prostate cancer
Screening in men between 40-54 y.o. who are at average risk is not recommended Men 55-69 y.o.  weigh risks & benefits of screening with patient  shared decision making between patient & provider Consider screening every 1-2 years
73
PSA testing not recommended in
Routine PSA screening not recommend in men over 70 y.o. or men with a life expectancy of less than 10-15 years
74
how would you normally diagnose prostate cancer
Prostate biopsy when prostate cancer is suspected If biopsy negative but PSA continues to rise consider multiparametric MRI
75
Gold standard of definitive therapy in patients that are surgical candidates for prostate cancer
``` Radical Prostatectomy (RP) Robotic-assisted * msot common but there is also ``` Open retropubic * Laparoscopic Open perineal
76
(RALP)
Robotic-Assisted Laparoscopic Prostatectomy (
77
follow up for RALP
Post-op: JP drain Discharged with foley for 10-14 days Anastomosis needs to heal Kegels Erectile dysfunction counseling Medication (for penile rehabilitation) Vacuum erection device (VED) training
78
screening after s/p prostatectomy for cancer
PSA in 3 months; will continue to track PSA
79
most common type of testicular tumor | and most common presentation
Germ cell tumors (95%) Seminoma: localized seminoma most common presentation (50% of cases) Non-seminoma germ cell tumors (NSGCT
80
3 RF for testicular cancer
Cryptorchidism (undescended testicle) Intra-tubular germ cell neoplasia (ITGCN) Family or personal history of testicular cancer
81
other than a mass what other sxs might you expect to see with a testicular cancer
Abdominal mass (retroduodenal mets) Anorexia, Nausea, Vomiting, GI hemorrhage Back pain (retroperitoneal disease) Bone pain (skeletal mets) Central or peripheral nervous system symptoms (cerebral, spinal cord, or peripheral root involvement) Supraclavicular mass (lymph node mets) Cough, Hemoptysis, Shortness of breath (pulmonary mets)
82
workup for testicular cancer (think tumor markers and imaging)
Alpha-fetoprotein (AFP) Beta-human chorionic gonadotropin (bHCG), lactate dehydrogenase (LDH) Also, consider CT or MRI to assess for lymph node involvement
83
screening most testicular resection Men with stage I cancer &; no risk factors for relapse
Surveillance for 5-10 years following orchiectomy CXR, CT, MRI Serum tumor markers (AFP, bHCG, LDH) at scheduled intervals Adjuvant chemotherapy Radiation chemotherapy Annual H&P (including testicular examination, lymph node & skin cancer survey)
84
most common renal tumor of childhood
Wilm’s Tumor Accounts for 6-7% of all childhood cancers Median age is 3.5 years at presentation
85
Classic pathologic finding (triphasic pattern containing 3 cell types):
Blastemal, Stromal, Epithelial
86
how does wilm's tumor arise
Embryonal tumor developing from the remnants of the immature kidney Most commonly occurs sporadically but 10% of children with WT have a congenital malformation syndrome
87
treatment of wilm's will depend on
High propensity for tumor rupture Intra-op tumor spillage results in UPSTAGING & requires abdominal RADIATION
88
“unfavorable histology” with wilm's tumor
Tumors with ANAPLASIA (large nuclei, abnormal mitotic figures, & hyperchromasia) = “unfavorable histology” Patients with above features have higher risk for relapse or death
89
SXS wil Wilm's
wagger Aniridia hemihypertrophy Abdominal pain, hematuria, HTN also possible symptoms
90
Aniridia
absence of the iris
91
hemihypertrophy
overgrowth of one side of the body as compared to the other
92
biopsies with Wilm's tumor
Pre-op & Intra-op biopsies are usually CONTRAINDICATED
93
Chemotherapy utilized pre-operatively with wilm's in
Bilateral WT Predisposition syndromes Solitary kidney
94
definitve treatment of stones
Ureteroscopy (URS)
95
definitve treatment of stones
Ureteroscopy (URS)

Surgery (18 decks)

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