CHAPTER 39- UROLOGY.txt

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CHAPTER 39- UROLOGY.txt
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  1. whats the fascia called around the kidney?
    gerota's fascia
  2. name structures anterior to posterior
    renal vein, renal artery, and renal pelvis
  3. Whats the right renal artery's relationship to the IVC
    Right renal artery crosses posterior to the IVC
  4. Whats is the relationship between the ureters and iliac vessels
    Ureters cross over iliac vessels
  5. Can you ligate the left renal vein?
    the left renal vein can be ligated from the IVC secondary to increased collaterals (left adrenal vein, left gonadal vein, and left ascending lumbar vein)
  6. what does the epididymis connect to?
    vas deferens
  7. What is the most common cause of acute renal insufficiency following surgery?
    hypotension
  8. What are the symptoms of kidney stones?
    severe colicky pain, restlessness
  9. What does urinalysis show with kidney stones?
    • 1) blood
    • 2) stones
  10. What can abdominal CT show w/kidney stones?
    can demonstrate stones and associated hydronephrosis
  11. Name the different types of kidney stones:
    • 1) calcium oxalate (phosphate) stones-
    • 1- most common (75%); radiopaque
    • 2- inceased in patients with terminal ileum resection due to increased oxalate absorption in colon

    • 2) Mg ammonium phosphate (struvite stones)-
    • 1- 15% radiopaque
    • 2- can occur with infections (proteus mirabilis) that are urease producing
    • 3- can cause staghorn calculi (fill the renal pelvis)

    • 3) Uric acid stones
    • 1- 7%; radiolucent
    • 2- increased in patients with ileostomies, gout and myeloproliferative disorders

    • 4) Cysteine stones
    • 1) 2%; radiolucent and radiopaque
    • 2) associated with congenital disorders in the reabsorption of cysteine
  12. Surgery for kidney stones:
    • 1) intractable pain or infection
    • 2) progressive obstruction
    • 3) progressive renal damage
    • 4) solitary kidney
    • 5) 90% of kidney stones opaque; >6mm not likely to pass

    • 6) Tx:
    • 1) ESWL (extracorporeal shock wave lithotripsy)
    • 2) ureteroscopy with stone extraction or placement of stent past the stone obstruction
    • 3) percutaneous nephrostomy tube
    • 4) open nephrolithotomy
    • 5) urethrotomy
  13. Testicular cancer:
    • 1) #1 cancer killer in men 25-35
    • 2) Symptom: painless hard mass
    • 3) Testicular mass- the patient needs an orchiectomy through an inguinal incision (not a trasscrotal incision --> does not want to disrupt lymphatics). The testicle and attached mass constitute the biopsy specimen.
  14. Are most testicular masses benign or malignant?
    most testicular masses are malignant
  15. What imagining modality can help with the diagnosis of testicular cancer?
    • 1) ultrasound
    • 2) chest x-ray to check for pulmonary metastases
    • 3) chest and abdominal CT- to check for retroperitoneal and mediastinal burden
  16. Which marker is correlated with tumor bulk?
    1) LDH

    Also need a B-HCG and AFP level
  17. What type of tumors are most testicular cancers?
    90% of tumors are germ cells- seminoma or nonseminoma
  18. How are undescended testicles associated with testicular Ca
    • 1) Undescended testicles (crytorchidism) increases the risk of testicular Ca.
    • 2) most likely to get seminoma
  19. Seminoma:
    • 1) #1 testicular tumor
    • 2) 10% of seminomatous tumors have beta-HCG elevation
    • 3) should not have AFP elevation (if elevated, need to treat like nonseminomatous)
    • 4) spreads to retroperitoneum
    • 5) seminoma is extremely sensitive to XRT
    • 6) Treatment:
    • 1- all stages get oriectomy and retroperitoneal XRT- some patients have occult retroperitoneal metastases
    • 2- if the paraaortic nodes in the abdomen are enlarged, need to extend XRT to the mediastinum
    • 3) positive nodes, metastatic disease, or bulky retroperitoneal disease--> chemo (cisplatin, bleomycin, VP-16)
    • 4) if the patient still has disease after XRT and chemo, needs to go with surgery
  20. Nonseminomatous testicular Ca
    • 1) types-
    • 1- embryonal
    • 2- teratoma
    • 3- choriocarcinoma
    • 4- yolk sac

    • 2) Alpha fetoprotein and beta-HCG- 90% have these markers
    • 3) spreads hematogenously to lungs
    • 4) also spreads to retroperitoneum
    • 5) classically, tumors with increased teratoma components are more likely to metastasize to the retroperitoneum
    • 6) Surgical Treatment:
    • 1- Stage I- orchiectomy, prophylactic retroperitoneal node dissection
    • 2- Stage II or greater- orchiectomy, XRT, and chemo (cisplatin, bleomycin, VP-16); surgical resection of residual metastases
  21. Prostate Cancer: what is the most common site?
    posterior lobe
  22. where does prostate cancer most commonly metastasize to?
    • 1) bone
    • 2) osteoblastic; x-ray demonstrates hyperdense areas
  23. What are some consequences of resection?
    • 1) many patients become impotent after resection
    • 2) can also get urethral strictures
  24. Diagnosis of prostate Ca:
    • 1) transrectal Bx
    • 2) CXR
    • 3) abd/pelvic CT
    • 4) PSA
    • 5) alkaline phosphatase
    • 6) possible bone scan
  25. Intracapsular tumors and no metastases (T1 and T2)
    • 1) XRT
    • 2) radical prostatectomy with pelvic lymph node dissection (if lifespan >10 years)
    • 3) do nothing depending on age/health
  26. Extracapsular invasion or metastatic disease:
    • 1) Hormonal Tx:
    • 1- leuprolide (LH-RH blocker)
    • 2- flutamide (testosterone blocker)
    • 3- bilateral orchiectomy
    • 4) ketoconazole
    • 5) XRT for bone pain

    • 2) Chemotherapy:
    • 1- reserved for metastatic disease not responding to hormonal therapy
  27. What do you do for stage I disease found with TURP?
    nothing
  28. After a prostatectomy, what do you expect PSA to be?
    With prostatectomy, PSA should go to 0 after 3 weeks. If not, get bone scan to check for metastases
  29. What is normal PSA?
    normal PSA <4 in a patient who has a prostate gland
  30. What can increase PSA?
    • PSA can be increased with:
    • 1) prostatitis
    • 2) BPH
    • 3) chronic catheterization
  31. What causes increased alkaline phosphatase in a patient with prostate ca?
    metastasis or extracapsular disease
  32. Renal Cell Carcinoma (hypernephroma)
    • 1) #1 primary tumor of kidney (15% calcified)
    • 2) risk factor: smoking
    • 3) Abdominal pain, mass, and hematuria
  33. What percent of people with renal cell carcinoma have metastatic disease at time of diagnosis and what can you do?
    1) 1/3 have metastatic disease at the time of diagnosis.

    2) can perform wedge resection of isolated lung and colon metastases
  34. What is the most common location for renal cell carcinoma (RCC) metastases?
    lung
  35. What other effects can RCC have?
    Erythrocytosis can occur secondary to increased erythropoietin (HTN)
  36. Treatment for renal cell carcinoma:
    • 1) radical nephrectomy with regional nodes
    • 2) XRT
    • 3) chemotherapy

    • 1- radical nephrectomy takes kidney, adrenal, fat, gerota's fascia, and regional nodes
    • 2- predilection for growth in the IVC; can still resect even if going up IVC--> can pull the tumor thrombus out of the IVC
    • 3- partial nephrectomies should be considered only for patients who would require dialysis after nephrectomy
    • 4- embolization can be used to palliate large tumors or as preop for large tumors to facilitate removal
  37. Most common tumor in kidney
    metastasis from the breast
  38. What are the paraneoplastic syndromes associated with RCC?
    • 1) erythropoetin
    • 2) PTHrp
    • 3) ACTH
    • 4) insulin
  39. What is the treatment of transitional cell Ca of renal pelvis?
    radical nephroureterectomy
  40. Oncocytomas
    benign
  41. Angiomyolipomas
    1) hamartomas; can occur with tuberous sclerosis

    2) large tumors (>4cm) may be symptomatic and require excision or embolization
  42. Von Hippel Lindau syndrome
    • 1) multifocal and recurrent RCC
    • 2) renal cysts
    • 3) CNS tumors
    • 4) pheochromocytomas
  43. What type of bladder Ca is it usually?
    transitional cell cancer
  44. Symptom of bladder Ca
    painless hematuria
  45. Who is it most common in and what is prognosis based on?
    • 1) males
    • 2) prognosis based on stage and grade
  46. Risk factors for bladder Ca:
    • 1) smoking
    • 2) aniline dyes
    • 3) cyclophosphamide
  47. Diagnosis of bladder cancer:
    • 1) cystoscopy
    • 2) IVP
  48. Treatment:
    1) intravesical BCG (Bacillus Calmette-Guerin) or transurethral resection if muscle is not involved (T1)

    • 2) If muscle wall is invaded (T2 or greater)-
    • 1- cystectomy with ileal conduit
    • 2- chemotherapy (MVAC: methotrexate, vinblastine, adriamycin (doxorubicin), and cisplatin)
    • 3- XRT

    3) Metastatic disease- chemotherapy
  49. Ileal conduit standard
    • Avoid stasis as this predisposes to:
    • 1- infection
    • 2- stones (calcium resorption)
    • 3- ureteral reflux

    Reservoirs or neobladders may also be options
  50. Squamous cell Ca of bladder is caused by:
    schistosomiasis infection
  51. Testicular torsion
    • 1) peaks in 15 year olds
    • 2) involved testis almost never viable
    • 3) usually has intravaginal torsion of the spermatic cord if viable
    • 4) torsion is usually toward the midline
    • 5) Treatment: bilateral orchiopexy
    • 1- if not, resection and orchiopexy of contralateral testis
  52. Ureteral trauma
    • 1) if going to repair end-to-end
    • 1- spatulate ends
    • 2- use absorbable suture to avoid stone formation
    • 3- stent the ureter to avoid stenosis
    • 4- place drains to identify and potentially help treat leaks

    2) avoid stripping the soft tissue on the ureter, as it will compromise blood supply
  53. where does Benign Prostatic Hypertrophy (BPH) arise from
    transitional zone
  54. What are symptoms of BPH?
    • 1- nocturia
    • 2- frequency
    • 3- dysuria
    • 4- weak stream
    • 5- urinary retention
  55. Initial therapy for BPH:
    1) Alpha blockers- terazosin, doxazosin (relax smooth muscle)

    2) 5-alpha-reductase inhibitors- finasteride --> inhibits the conversion of testosterone to dihydrotestosterone (inhibits prostate hypertrophy)
  56. Surgical therapy for BPH:
    • TURP (Transurethral resection of the prostate) :
    • 1- for recurrent UTIs
    • 2- gross hematuria
    • 3- stones
    • 4- renal insufficiency
    • 5- failure of medical therapy
  57. Post-TURP syndrome
    1) hyponatremia secondary to irrigation with water; can precipitate seizures from cerebral edema

    2) Treatment: careful correction of Na with diuresis
  58. TURP + ejaculation
    most patients with TURP have retrograde ejaculation
  59. Neurogenic bladder
    • 1) most commonly secondary to spinal compression
    • 2) patient urinates all the time
    • 3) injury above T12
    • 4) Treatment: surgery to improve bladder resistance
  60. Neurogenic obstructive uropathy
    • 1) incomplete emptying
    • 2) injury below T12; can occur with APR
    • 3) Treatment: intermittent catherization
  61. Stress incontinence (cough, sneeze)
    • 1) because of hypermobile urethra or loss of sphincter mechanism
    • 2) Treatment:
    • 1- kegel exercises
    • 2- alpha-adrenergic agents
    • 3- surgery for urethral suspension or pubovaginal sling
  62. Urge incontinence
    • 1) sense of urgency or frequency
    • 2) because of involuntary detrusor contraction without neurologic disorder
    • 3) Treatment:
    • 1- anticholinergics
    • 2- behavior modification
    • 3- cystoplasty
    • 4- urinary diversion (last resort)
  63. Neuropathic incontinence
    • 1) urgency or frequency
    • 2) decreased bladder capacity; associated with neurologic conditions--> spinal cord dysfunction, stroke, multiple sclerosis
    • 3) Treatment:
    • 1- treat underlying neurologic disorder
    • 2- behavior modification
    • 3- surgical options- cystoplasty or urinary diversion
  64. Overflow incontinence
    • 1) incomplete emptying and enlarged bladder
    • 2) obstruction (BPH) leads to the distention and leakage
    • 3) Treatment: TURP
  65. Congenital incontinence
    • 1) continuous leakage and nocturnal enuresis; sphincter mechanism is bypassed
    • 2) Tx: surgical correction (bladder exstrophy, ureteral diversion)
  66. Ureteropelvic obstruction
    treatment: pyeloplasty
  67. vesicoureteral reflux:
    treatment: reimplantation with long bladder portion
  68. ureteral duplication
    most common urintary tract abnormality

    treatment: reimplantation
  69. ureterocele
    treatment: resect and reimplant
  70. hypospadias
    • 1) ventral
    • 2) repair at 6 months with penile skin
  71. epispadias
    • 1) dorsal
    • 2) Treatment: surgery
  72. Horseshoe kidney
    1) usually joined at lower poles

    • 2) complications:
    • 1- UTI
    • 2- urolithiasis
    • 3- hydronephrosis

    3) may need pyeloplasty
  73. polycystic kidney disease:
    resection only if symptomatic
  74. Failure of closure of urachus
    • 1) connection between umbilicus and bladder
    • 2) occurs in patients with bladder outlet obstructive disease (wet umbilicus)
    • 3) Treatment: resection of sinus/cyst and closure of the bladder; relieve obstruction
  75. Epididymitis
    sterile epididymitis can occur from increased abdominal straining
  76. Varicocele
    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
  77. hydrocele in adult
    if acute, suspect tumor elsewhere; transluscent
  78. pneumaturia
    most common cause is diverticulitis and subsequent formation of colovesical fistula
  79. WBC casts:
    • 1) pyelonephritis
    • 2) glomerulonephritis
  80. RBC casts:
    glomerulonephritis
  81. Interstitial nephritis
    • 1) fever
    • 2) rash
    • 3) arthralgias
    • 4) eosinophils
  82. vasectomy
    50% pregnancy rate after repair of vasectomy
  83. priaprism:
    • Treatment:
    • 1) aspiration of the corpus cavernosum with dilute epinephrine or phenylephrine
    • 2) may need to create a communication through the glans with a scalpel
    • 3) Risk factors:
    • 1- sickle-cell anemia
    • 2- hypercoagulable states
    • 3- trauma
    • 4- intracorporeal injections for impotence
  84. Squamous cell carcinoma of the penis
    penectomy with 2 cm margin
  85. Which two substances can be used to check for urine leak?
    • 1) indigo carmine
    • 2) methylene blue
  86. What do you do if you find phimosis at the time of laparotomy
    treatment: dorsal slit
  87. Is normal erythropoetin produced in patients with renal failure?
    no, erythropoetin is decreased in patients with renal failure
  88. What is a spermatocele and how do you treat it?
    A spermatocele is a fluid-filled cystic structure separate from and superior to the testis along the epididymis

    Treatment: surgical removal

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