RTA Type I—acidotic, hypokalemia, distal tubule (stones!)— urine Ca2+, urine citrate
Type II—proximal tubule, bicarb wasting
Type IV—hyperkalemia, reduces ammonia secretion
Prolactin secreting tumors—bromocriptine, cabergoline. Surgery if can’t take meds.
Graft taking:
Nephron Drugs
Slings:
erosion into vagina, à topical estrogen
erosion into urethra, à excision
Pheochromocytoma—MRI, bright T2 (lightbulb sign). Phenoxybenzamine +/- metyrosine for alpha blockade
Pregnancy—increased GFR, decreased BUN, decreased Cr in last trimester.
No increased stone risk in pregnancy
Kaposi’s sarcoma—treat by decreasing immunosuppression. If not, excise versus radiation. HHV 8.
Penile amputation—reanastomose dorsal nerves and dorsal arteries, deep dorsal vein (preserves skin), urethra, corpora
CAH—increased 17 hydroxyprogesterone.
Karyotype for mixed gonadal dysgenesis is XO/XY.
Deep dorsal vein drains the glans penis and corpora cavernosa, ventral skin
Fertility—FSH >7.6 and testes axis <4.6cm (??), chance of non-obstructive is 89%.
Renovascular hypertension that responds to surgery—elevated of renin >50% over peripheral and contralateral renin.
Bilateral renal a. obstruction—HTN through volume.
Unilateral renal a. obstruction—HTN via renin
Medial fibroplasia—rarely progresses to complete occlusion. Rare to lose renal function, treat with endovascular techniques.
Conn’s Syndrome—hyperaldosterone
Addison’s—hypoaldsterone
Parasympathetic—all cholinergic
Sympathetic—post ganglionic adrenergic
Cystic fibrosis 1:25
Vaginal agenesis associated with renal agenesis.
Bare metal stents, 6 weeks minimum anticoagulation treatment
Testosterone: estradiol <5:1 treat with anastrazole. Aromatase deficiency
Fungal ball in kidney—perc drainage, irrigate with amphotericin B
Infected urachus—perc drainage and culture
Immunosuppression Medications:
ATN: osm <450, Na >40, U/P Cr <20
Cialis—stop for 48 hours and can give nitrates
Transplant—two renal arteries, reimplant one artery only. Either ligation vs reanastamosis. Ligate upper pole artery, renastamose lower pole artery (ureteral blood supply)
Pelvic lipomatosis—perc drainage of kidney. Pelvic lucency. Pear shaped bladder.
Inulin is gold standard for GFR. Creatinine clearance overestimates GFR b/c Cr is secreted.
Collecting Duct/Medullary carcinoma associated with sickle cell.
Central, infiltrative, R>L, most present with metastatic dz—extremely poor prognosis. Very rare.
Martius flap – labial fat pad flap
Stones—calcium oxalate doesn’t depend on urine pH
Main determinant of GFR is capillary hydrostatic pressure.
Ethambutol—blurry vision or loss of vision.
Prostatic urethral tumor—external iliac nodes
PSA—complexed with alpha-1-chemoantitrypsin. Cleaves seminoglen leads to seminal fluid lysis and anticoagulation.
Ureteral changes with stent: decreased peristalsis, mucosal hyperplasia, smooth muscle contractility.
Changes to ureter during bladder filling—increased pressure, increased contractility.
NSAIDs on ureter—decreased contractility.
Chronic obstruction on ureter—decreased contractile pressure.
Medial fibroplasia—string of beads
Intimal fibroplasia—children
Paramedial fibroplasia—20yo F with collateral renal vessels
Erythromycin, INH, Doxycycline, cefotetan are safe for renal dosing.
Pubertal: girls—breasts, boys—testes enlargement
Multiple Sclerosis: 1st sign in men is ED, 1st in females is urgency/retention
Neurofibromatosis—association with pheochromocytoma, renal artery stenosis
Imperforate anus—associated with neurogenic bladder, reflux, crytoorchidism, fistula, renal agenesis
E coli does not produce urease.
Laxative abuse—ammonium acid urate stones
Prolonged labor—associated with adrenal hemorrhage
Juxtaglomerular tumor—diastolic HTN in young pt
Signet cell ring of bladder—GI workup
DHT produced from prostatic stroma
Pudendal nerves responsible for bulbocavernous reflex, S2-4
Candida glabrata—don’t treat with fluconazole, use flucytosine and amphotericin
Renovasal constrictor—endothelin
Cipro—misses anaerobes
2nd hyperparathyroidism—ESRD
PDE5i + nitrate—increased guanylate cyclase, decreased PDE5
Post op retention from periurethral bulking agent—CIC
Finasteride exposure during 1st trimester results in hypospadias
Vaginal adenosis—DES
Pudendal innervates external sphincter
PD plaques located in tunica albuginea
Subcostal nerves—transversus/int oblique
Analogues
Ileostomy—causes uric acid stones secondary to diarrhea
2 year old with normal penis and bilaterally unpalpable testes, see blind vessels. Finish the case.
Female with cyclic ureteral obstruction post-hysterectomy, 2cm cystic mass in pelvic. Excision. Ovarian remnant syndrome.
Wilm’s tumor—histology is #1 predictive factor. Genes 1p or 16q association.
Cystitis radiation hematuria--#1 treatment is alum versus formaldehyde 2nd, etc
Schistosomiasis—ova/eggs in submucosal lesion on lateral aspects
Paratesticular cyst adenoma—imaging is next step, looking for VHL
Kidney—efferent arteriole gives off the vasa recta
Uterine artery located in the broad and cardinal ligaments
Bulky LAD, biopsy shows pure seminoma, AFP 200, treat as non-seminomatous germ cell algorithm.
Retrocaval ureter-persistent of the subcardinal vein, on the R side. Associated with duplicated IVC.
Mechanism of DES—decreased LH. No FSH changes.
Low flow priapism—best test is CBC versus sickle cell trait.
Cerebral neurotransmitter in erections—dopamine
Theophylline levels can increase with Cipro
Capsacin affects type C unmyelinated nerves
Foot drop—peroneal nerve
Urodynamic findings
Absent testes—ipsilateral kidney missing in 20%
Explore a hematocele
Radiolucent stone
Nitroprusside test—used for cysteine stones
Spontaneous testicular hemorrhage—associated with choriocarcinoma or polyarteritis nodosa
Cyclosporine/stones—high urinary uric acid
Papaverine—hepatotoxic
Viral cystitis—adenovirus. Young man with hematuria, treat conservatively.
Nephrocalcinosis—RTA 1.
Nephrocalcinosis of infancy—LGA,premies—loop diuretics for fluid overload (LASIX), high caloric supplementation—vast majority goes away once stop loop diuretics
Primary hyperoxaluria—sponge kidney
Testosterone binding globulin—elevated in cirrhosis, estrogen therapy, hyperthyroidism. Decreased with androgens, obesity and steroids.
Cowper’s glands—lateral to membranous urethra, duct enters in posterior bulbar urethra.
Absence of a fallopian tube, confirms the presence of a testes as some point secondary to MIS.
Intersex disorder—potentially fertile, CAH or female pseudohermaphrodite
Absence of Leydig cells in a testes is mediastinum testes. Purpose is to support the rete testes.
Antibiotics that don’t penetrate cysts: ampicillin, gentamycin, nitrofurantoin, cephalosporins. Can use cipro, Bactrim, doxycycline, erythromycin okay.
Chlorpromazine—treats hyperchloremic metabolic acidosis, blocks chloride transport and inhibits cAMP.
Amino caproic acid inhibits plasmin, prevents clots lysis.
Methemoglobin anemia—treat with methylene blue
Wilms subtypes:
Distal urethral spread—superficial nodes (2/3)
Proximal urethral—pelvic nodes (1/3)
Neonatal torsion—extravaginal torsion
Periorbital ecchymosis—neuroblastoma
DMSA—binds proximal convoluted tubule, makes it ideal differential scan/function, scarring
Mag3—secreted. better for obstruction
DTAP—freely filetered, depends on GFR.
LH acts on Leydig cellsà testosterone
FSH acts on Sertoli cellsà inhibin
Sertoli cells maintain spermatogenesis, and produce MIS and androgen binding protein
Laparoscopy—decreased GFR, decreased UOP, increased renin, increased ADH, increased aldosterone, increased Na.
Urothelial carcinoma—chromosome 9
ADPK—chromosome 16
Wilm’s Tumor—chromosome 11
Testes tumor—chromosome 12
ADH stimulation release by osmolality
Renovascular disease—atherosclerosis most common cause
Goldblatt model
Bronchiectasis—associated with cystic fibrosis, CBAVD and azoospermia
Kartageners—situs inversus, normal spermia, immotile sperm
Young’s syndrome—azoospermia due to epididymal obstruction, respiratory disease
COX2 inhibition, NSAID decreased ureteral contractility
Parasympathetic S2-4, erection
Sympathetic T10-L2, emission and detumesence
Somatic S2-4, ejaculation
Papaverine inhibits PDE2-5, increases both cAMP and cGMP
Phentolamine alpha blocker
Peak systolic velocity <30 is arterial insufficiency
Peak diastolic velocity >3 is a venous leak
BCG binds to fibronectin
Anti-androgens block both DHT and testosterone, increase LH, low risk of ED, increase testosterone and estrogen à gynecomastia
Posterior urethral valves—now with incontinence. Prepubertal—detrusor instability. Older—myogenic failure and overflow incontinence.
Posterior kidney—adjacent to quadratus lumborum, diaphragm
Neurofibromatosis—renal artery stenosis, neurogenic bladder, obstruction, pheochromocytoma association
Immunosupression and CIS- don’t give BCG, give mitomycin C
PSA—complexed with alpha-1-chemotrypsin. Serine protease kallirein family.
Estrogen inhibits LH and increases prolactin
Hypercalciuria
Cipro—affected absorption with antacids
Sloughed papilla in sickle cell and NSAIDs
Rectofistual post prostatectomy—treat with colostomy
Rectofistual with catheterizable pouch/TURP—low residue diet, foley drainage
Vesicovaginal fistula (no XRT hx)—immediate vaginal repair
Vesicovaginal fistula (with XRT)—delayed abdominal repair and use omental flap
Recurrent fistula—biopsy first to rule out malignancy
Parathyroid hormone stimulation by calcium
Symptomatic AVF—angiogram
Asymptomatic AVM—observation
Transplant patients—CMV, treat with valciclovir
Kallman’s syndrome—can give GNRH, hypogonadotropic hypogonadism
Kleinfelter’s—adoption, hypergonadotrophic hypogonadism
Children with elevated AFP, should be normal by 18 months old
Absent L testes with obstructive azoospermia, vasogram with dilated seminal vesicle—Most likely an ejaculatory duct cyst.
Ligate deep dorsal vein of the penis during prostatectomy, decreases venous outflow from glans, corpora but not the skin (drains via external pudendal)
Limiting factor for OKT3 is systemic toxicity
Failure of distal ureter to separate from mesonephric duct leads to renal agenesis
Question: 28yo C5-C6, urodynamics with non-compliant bladder, instability, DSD treatment is sphincterotomy and condom cath
Sphincterotomy most common complication is hemorrhage
Ileal conduit with urine leakage despite bilateral ureteral stents, drain the fluid collection (no revision first)
Testicular tumors—memorize algorithm. Review recurrences.
Prostate cancer—treat with hormonal therapy and prevent osteoporosis, bicalutimide (increases E + T)
Renal vein thrombus in a neonate—anticoagulation
Adrenal hemorrhage—abd mass, microhematuria, thrombocytopenia, prolonged labor
RTA—best specimen is 2nd voided urine of the AM with fasting
Conduit least likely to have a positive urine culture—neobladder
Trauma—need contrast in distal ureter via CT with delays or retrograde. UPJ avulsion explore. Extravasation with distal contrast with no symptoms just observe. Symptoms require drainage.
Urothelial carcinoma of prostatic urethra—external iliac nodes
IVP with filling defect in a diabetic/sickle cell is sloughed papillae
10 days post cystocele repair, 5mm VV fistula present. Manage with transvaginal repair.
treatment of mycoplasma hominus, tetracycline
Penile amputation—repair dorsal artery and vein, don’t repair cavernosal artery
TUNA—coagulative necrosis
Renin—direct stimulus is sodium in the distal convoluted tubule
Prostate cancer, T3 s/p RRP, counseling on radiation therapy improves survival, biochemical recurrence
Late relapse from NSGCT, yolk sac histology
GFR post partial predictive of pre surgical GFR
Gemcytabime—thrombocytopenia is limiting side effect
Testicular tumors—LAD operate on post-chemotherapy with AFP <50, palliation
Thiotepa—myelosuppression side effect
Mitomycin—dermatitis
PUR with hydro—decreased compliance
Enteric hyperoxaluria—due to decreased fat and increased calcium –eg Roux-En-Y bypass pt—Ca2+ binds oxalate
Persistent cysteine stones despite diet therapy—alpha mercaptopurine (Thiola)
Bladder diverticulum—allows partial cystectomy
Schistosomasis—stage in the urine, eggs
Treatment of symptomatic E coli resistant in 1st semester with penicillin allergy—nitrofurantoin (resistant rate of amoxicillin is high)
Semen analysis—antisperm antibodies, decreased motility but no changes to sperm count or volume
Urethritis—given tetracycline, two days after stopping develops ulcers. Herpes is correct answer, misdiagnosis
Diabetic s/p CKT—CMV
Blunt trauma—CT with possible renal mass, follow up imaging
Post obstructive diuresis—1st 24 hours due to solute load, >24 hours becomes impaired concentration or decreased sodium reabsorption
Last product of meiosis—spermatid
PAH, secreted. Urea, reabsorbed. Cr, secreted. Glucose, reabsorbed. Inulin, not absorbed or secreted. Mannitol, not absorbed.
Bladder neck—alpha adrenergic
Bladder body—beta adrenergic, responsible for filling
Rapamycin—poor wound healing, main benefit is lack of nephrotoxicity. Interrupts T cell signal transduction.
AFP—made by cytotrophoblasts
Testes cancer, PET scan—only for post chemo pure seminoma to eval for residual mass >3cm
Requiring pharmacological treatment with drugs other than such allowed for grade I complications.
persistence – ureterocele
Ectopic ureter embryology—chephalad origin of the ureteral bud on the mesonephric duct
Kidney – intermediate mesoderm (proà mesoàmetanephros)
Prostate – forms from endodermal evaginations from pelvic urethra
Bulbourethral glands (men) = Skene’s glands (women)
Mesonephric duct à Wolfian ducts (men)
Paramesonephric duct à Mullerian ducts (women)
Sertoli cells make AMH
Origin Upper 2/3 vagina – paramesonephric ducts
Lower 1/3 vagina- from urogenital sinus
Appendix testis is remnant of Mullerian duct
Eye sx (PGE6) most with sildenafil, vardenafil. Least with tadalafil
Tethered cord – detrusor overactivity
Retention after brachytherapy, if fail multiple TOV, wait 1 yr to offer TURP—wait because high risk stricture
1mg finasteride same effect as 5mg re PSA – still multiply by factor of 2
Adrenal adenoma – <10 HU on non-con CT------no further imaging needed
Terminal ileum used for continent catheterizable channel—risk of bleeding issuesà impaired fat soluble vitamin absorption (D,E,A,K)—need K for liver to make clotting factors (II, VII, IX, X) – PT/INR affected
High risk of breast CA in Kleinfelter’s
Avoid anticholinergics in Parkinson’s pts—high anticholinergic burden of other drugs they’re on
Distally—vas posterior to ureter proximally—vas superior and lateral to ureter
Uric acid stone prevention diet= lacto-ovo-vegetarian
(meat, fish, poultry have high uric acid precursor load)—most common cause hyperuricosuria—excess dietary purines
Topiramate (migranes) – ca phos stones – induces distal renal tubule acidosis —rx k citrate
Cystinuria—rx fluid intake 3-4 L/day, k citrate, alpha-mercaptopropionoglycine, d-penicillamine (more sideffects), captopril
Sodium nitroprusside – dx cystinuria
Atezo, nivo—PDL-1 inhibitors – approved for locally advanced or metastatic urothelial carcinoma which progressed w/i 12mo of neoadjuvant or adjuvant cis-platinum based regiment
Lead in:
S2—gluteal muscles, leg rotation (WRONG)
S3—perineal bellows, great toe dorsiflexion (J )
S4—perineal bellows (WRONG)
Successful vasectomy = post vasectomy SA with azoospermia, or rare non-motile sperm (<100,000/ml)
Avanafil (stendra)—shortest time to onset (Tmax)
Tadalafil (Cialis) – longest t ½ -- 17.5 hrs
Avanafil, sildenafil, vardenafil—reduced absorption with fatty meals
Complex scrotal avulsion—observe for 24hrs to allow for viable tissue to declare its self, apply saline soaked packs in interim
Bowenoid papulosis – benign, associated with HPV 16
Penile CIS—requires treatment (imiquimod, laser, 5-FU), associated with HPV 16
Vit C is metabolized to oxalate – 1-2 g/ day intake will increase urinary oxalate excretion
Nonobstructive azospermia- get karyotype and Y chromosome microdeletion study
CBAVD—caused by CF mutation – man and partner need CFTR screening prior to IVF
Low semen volume, acidic (2/2 hypoplasia/absence of SV which alkalizes fluid)
Bowel fistula to urinary diversion—manage conservatively first, foley drain diversion + low residue (elemental) diet, if fails then TPN
Chronic opioid use – can cause hypogonadotropic hypogonadism—lowers GNRH release in hypothalamus
CIS of bladder- if fail induction BCG—offer 2nd course BCG
if fail 2nd course BCG, offer different intravesical chemo (MMC,valrubicin,gemcitabine) vs. clinical trial vs. cystectomy
avoid fluoroquinolones for – uncomplicated UTI, myasthenia gravis pts,
(all men with UTI = complicated UTI)
Contraindications to neoadjuvant chemo for bladder ca = poor performance status, renal impairment (cr clearance <60), hearing loss, peripheral neuropathy, class 3 HF or higher
Evidence base medicine—based on 2ndary resources of evidence (metanalysis, systematic reviews etc.)
primary resources of evidence = original single studies
Total Botox limit -- 400u q 3 mo.
Medial fibroplasia—‘sting of pearls’ – unlikely to progress to complete occlusion or renal failure thus treat HTN with medical management
Retrograde ejaculation – rx pseudoephedrine
Mixed gonadal dysgenesis- testes + streak gonad + incomplete virilization
Pre-sacral vein bleeding—place sterile tack at site of suture
Addition of antireflux mechanism to orthotopic urinary diversion – increased rate of secondary surgery
(no diff in UTI, renal failure, late complications)
Bladder calculi after augmentation cystoplasty—due to mucus + poor bladder emptying
Prevent with daily bladder irrigation + cath via urethra daily to drain bladder completely
Genitofemoral n—anterior thigh (femoral branch) + anterior scrotum (genital branch)
Iliohypogastric n – sensation abdominal wall
Ilioinguinal n – anterior scrotum, mons pubis (BUT NOT THIGH)
Posterior femoral cutaneous n – posterior scrotum, posterior thigh, perineum
Obdurator n – inner medial thigh, motor to adductors
Spina bifida neurologic leision is dynamic—esp early in infancy and at puberty (times of big growth)—consider reimage with spine MRI if bladder/bowel sx suddenly change—tethering cord?
Collecting duct RCC—very aggressive, metastatic disease has shown some response to cisplatin, gemcitabine
Flibaserin (Addyi)—5HT1 antagonist, 5HT2 agonist, dopaminergic, noradrenergic—NO EtOH allowed!
Cystoscopes require at least High Level Disinfection
Paratesticular liposarcoma—60’s M—adjuvant XRT – 2/2 high degree of local recurrence
Other sarcomas besides liposarcoma—if no mets, RPLND
All + RPR or VDRL tests need to be confirmed with FTA-ABS or TP-PA
Rx syphilis = IM penicillin G
Diuretic renography false (-) due to dehydration – inadequate urine flow at time of test
Citrate binds Ca2+
Kidney ptosis = descent 2+ vertebral lengths when move from lying to standing—only pexy it if the descent causes changes in blood flow, obstruction, pain associated with descent
Hypercalcuria in kids—can cause ca2+ containing crystals to form in urine leading to bladder wall/ trigonal irritationà frequency, dysuria
Spot urine calcium : creatinine ratio – kid >2yo , normal ratio < 0.2
No cystoscopy needed for kid w micro hematuria w normal kidney/bladder US
Dog bites to scrotum—washout, debride, close primarily
Human bites—washout, debride, DON’T CLOSE PRIMARILY
Prostatic urothelial CIS after TURP—give BCG
(MMC is less effective against CIS than BCG)
Renal blood flow autoregulation—via afferent arteriole—occurs in innervated or denervated kidneys
Pheo—‘lightbulb’ bright on T2 MRI
Normal production of Cr = 1 mg/kg/hr
earliest renal function impaired by ureteral obstruction = water absorption—defects in aquaporin channels in collecting ducts
agents to lower glucocorticoids
-aminoglutethimide—blocks cholesterolà pregnenolone --- also blocks mineralocorticoids!!! L
-metyrapone –blocks 11-deoxycortisolàcortisone--- no salt wasting 2/2 desoxycorticosterone produc (potent mineralocorticoid)
-ortho-para-DDD (mitotane)—lowers cortisol – rx for adrenocortical CA 2/2 cytotoxcity to adrenal cells
-ketoconazole—lowers cortisol, BUT… don’t use!—liver damage L L
Abx in pregnancy—aminopenicillins, cephalosporins are safe
Young kid with early obstruction (eg. PUV), can develop urine concentrating defects—eg. nephrogenic DI.
Phallus replantation—up to 6hrs warm ischemia time, 16hrs cold ischemia time (avoid freeze burn)
Kid in deceleration MVC with renal trauma—likely a UPJ disruption
Normal cr
0.9-1.3 adult man
0.6-1.1 adult woman
0.5-1 kid 3-18
0.3-0.7 kid <3
Mixed flora UTI in man >50—think vesicoenteric fistula to colon 2/2 diverticulitis
<40 yo –think Crohn’s
Bladder dysfunction in kids after PUV with persistent incontinence—
1)detrusor overactivity -- prepubertal
2)decreased bladder compliance
3)myogenic failure – post-pubertal
Initiation of micturition: complete relaxation striated sphincter musclesà rise in pDetàopening BN + urethra
Delayed bleeding after PCNL—usually AVF or pseudoaneurysm
Plasmid-mediated drug resistance does not occur with Cipro—
bacterial DNA gyrase inhibited thus no bacterial replication and plasmid exchange
Pregnancy in kidney transplant pt—50% preterm delivery, 30% preecalmpsia, 20% IUGR, 10% graft rejection
Healthy newborn with bilateral high grade VUR—most will mature and resolve their high outlet resistance as they mature neuro-urologically in 1st yr of life
Alcoholism can cause hypogonadism
LH cross reacts with beta-hCG assay
beta-hCG—made by syncytiotrophoblasts
MIBG scan—MIBG is an analogue of norepinephrine—used in evaluation for pheochromocytoma
Supravesical urinary diversion w/o cystectomy à recurrent Pyocystis (vesical empyema)—older womanà vaginal vesicostomy (if was male prob need to offer cystectomy)
formalin instillations for refractory hemorrhagic cystitis—start at 1%, then go to 5% then to 10%
must do cystogram 1st to make sure no VUR—if + VUR, need Fogarty catheters up ureters
only go here if failed 1% alum and silver nitrate
if fail this then internal iliac a embolization
if fail then diversion
[alum, silver nitrateà formalinàinternal iliac a. embolizationàurinary diversion]
methrotrexate, cisplatin, vinblastine, Adriamycin—all bone marrow suppression
bleomycin—no bone marrow suppression
sigmoid colon—supplied by sigmoid a. and superior hemorrhoidal a. (from IMA)
major collaterals = middle, inferior hemorrhoidal aa. (from internal iliac a.)
middle sacral artery—from aorta
R colic artery – from SMA
Newborn female with interlabial bulge, cystic mass anterior to rectum, doesn’t change with catheterization—imperforate hymen
Rhambdomyosarcoma—solid on US, not cystic
Stones on MRI – poorly visualized—MRI does not visualize calcium
Infant with metastatic neuroblastoma----observe only---if kid <1yo, mets usually spontaneously regress
In older kids if mets don’t regressà chemo
Penicillin allergy—don’t give cephalosporins, carbopenems
Docetaxel + ADT –mHSPC
recurrent calcium phosphate stones (brushite) – resorptive hypercalcuria—primary hyperparathyroidism
phosphate renal leak hypercalcuria—elevated vit D—caOX or mixed CaOx, CaPhos stones
renal hypercalcuria – CaOx stones—rx HCTZ
rate of bladder filling for UDS in kids – (expected bladder capacity)/10 = __ ml/min
urethral cancer
-distal urethra – drains to superficial inguinal nodesà deep inguinal nodes
-proximal urethra – drains to external iliac nodes à hypogastric nodes, obdurator nodes
Crash C-sectionà pedicle cut to bowel segment of bladder augment---> observe, repeat UDS in some time
Over time, augment segment develops collateral flow from native bladder
Illeal conduit e- disturbance—hypokalemic, hyperchloremic metabolic acidosis
Jejunum e- disturbance—hyponatremic, hyperkalemic, hypochloremic metabolic acidosis
Stomach e- disturbance—hypokalemic, hypochloremic metabolic alkalosis
Renovascular HTN likely to respond to stent/surgery—elevation of ipsilateral renal v. renin by at least 50% over peripheral renin and contralateral renal vein renin
(elevation from one side and not other)
Young, pregnant woman with bladder tumor—wait till term delivery then resect—almost always LG and noninvasive—TUR can induce contractions and premature delivery
Marked increase in PSA after nadir w/i 6mo of XRT for CaP -- sign of recurrence/occult metastatic disease
PSA bounce effect—rise greater than 0.1-0.5, followed by durable decline – common after brachy
Usually 9-30 mo after rx, usually peaks at PSA of ~2-3
ASTRO definition of BCR = 3 consecutive rises in PSA after nadir
Pheonix definition of BCR = nadir +2
Blunt trauma to scrotumà US with heterogenous, avascular mass—hematoma with possible testicular rupture
40% of non op management of intratesticular hematoma led to infection/infraction L --MUST EXPLORE—drain the hematoma to save the testicle
Can observe if hematoma is very small and not symptomatic
Enterococcus uti—usually sensitive to penicillins, extended spectrum penicillins (piperacillin), nitrofurantoin, fosfomycin
Lower stage NSGCT w/ scrotal violation undergoing primary RPNLD—need to excise scrotal scar + spermatic cord remnant
Post chemo RPNLD for NSGCT—need to take spermatic cord remnant + gonadal vein
Re: requesting your medical records--patient is not entitled to doc’s psychotherapy notes
Enteric hyperoxaluria (IBD, short gut syndrome)—rx increase ca2+ intake (ca2+ binds oxalate in gut)
Spinal cord leisions
-Above pons—detrusor overactivity w/ synergistic activity of internal and external sphincters
-Between pons and sacral cord—DESD
-Detrusor internal sphincter dyssynergia – only with lesion above lower thorasic spine sympathetic outflow
-Sacral cord and below—detrusor areflexia
Normal semen volume > 1.5ml
Post prostatectomy, isolated LN metastasis—rx life-long ADT
Neobladder UDS: Pabd, Pves, ¯ urethra
void through abd straining, which causes bladder compression, causes external sphincter relaxation and decrease in urethral pressure
0.05% betamethasone – phimosis
Renal revascularization surgery—indicated when >75% stenosis bilaterally or in solitary kidney, and not severe renal loss (Cr <4)
Electromagnetic lithotripter vs. electrohydraulic lithotripter – less pain with electromagnetic 2/2 increased entry surface area of the energy
Can’t use bactrim or nitrofurantoin in G6PD kid --- neonatal hyperbilirubinemia
Lower starting dose of PDE5i if taking indinavir (cytochrome p450 inhibitor)
Essential HTN vs. pheo—do oral clonidine check—essential HTN responds, pheo doesn’t
DVIU ok to try if <1.5cm
Spinal US to assess spinal cord very useful in kids <4mo
Time to castration
LHRH antagonist (degarelix)—3d
Ketoconazole + bilat orch—12hrs
Estrogen—1-2 wks
LHRH agonist (leuprolide)—3-4wks (also has temporary rise in T levels when start it)
Pseudomonas can’t convert nitrateànitrites (E coli, serratia, klebsiella, proteus convert to nitrites)
Elevated sperm DNA fragmentation—no increased risk congenital abnormalities
Uroflow bladder volume <125-150cc is inconclusive (voided volume + PVR)
Hypercoagulability in ESRD pt 2/2 nephrotic syndrome---- due to urinary loss antithrombin III, prt C, prt S (natural anticoagulants)
Sports drinks—increase in urine citrate, urine pH
Using ileum vs. colon for reconstruction
Prefer colon if prior pelvic XRT—transverse colon out of field
Less bowel obstruction if use colon
Less nutritional issues with colon (b12, bile acid salt absorption)
Diarrhea from use of ileum—secretory (bile salts), osmotic (decrease bowel transit time if ileocecal valve used
Rx cholestyramine (bile salts), bulking agents and slow motility (osmotic)
Penile cancer invasion—T1b—LVI, T2—spongiosum, T3—cavernosa
Nodes—
N1- up to 2 unilat + notes
N2- >2 unilat or bilat nodes
N3- any number fixed --------------rx: chemotherapy first, then node dissection
Vaginal approach to repair high-riding vesicovaginal fistula—use peritoneal flap preferentially
Acute interstitial nephritis—caused by PPIs—microhematuria, proteinuria, renal failure, rash, joint pain
Rx: remove offending agent, +/- steroids, ACEi
predictors of persistent bleeding after renal injury—Hematoma >3.5cm thickness, arterial blush, depth of injury
abnormalities of Wolffian duct development in women—check for renal anomalies
don’t use shoulder braces in Trendelenburg—can cause brachial plexus injury—weakness/tingle arms/wrists
ureteral stricture >2cm – DON’T use endoscopic techniques – poor outcomes
proximal—(short)-U-U, (long) illeal ureter, autotransplant/hitch/long Boari
ureterocalicostomy—ideal pt for this is proximal shorter stricture, thin lower pole parenchyma
Renal nephrometry score—10-12 = highly complex 7-9 = moderate complex 4-6 = low complexity
R.E.N.A.L (radius, endo/exo, nearness collecting, anterior/posterior, Location relative to polar lines
Horseshoe kidney w/ stone >1.5cm—PCNL---open/robotic pyelolithotomy difficult 2/2 aberrant vasculature
Get PCN access posterior + medial
Drug eluting stent placedà wait at least 6mo to hold anticoag, ideally wait 12mo
Bulbocavernosal reflex in woman—squeeze clitorisà pelvic floor contraction, increase in EMG activity
Indicates intact sacral arc reflex
This reflex is present in most (70%) but not all, neurologically intact women
Struvite stones—urease producing bacteriaàà Proteus, staph aureus
All GSW to genitalia require surgical exploration, clean/debride, if appropriate attempt repair
Don’t use low-dose CT scan in pt with BMI >30---reduced sensitivity for stones due to being TOO FAT
Sipuleucel-T = immunotherapy for CRPC w/ asx/minimally sx metastatic disease
Salvage RARP after receiving XRT, get rectal injuryà diverting colostomy, come back later to reconstruct
ANOVA—2+ independent variables, 1 dependent variable
t-test—analysis of independent measures (eg. compare means from two different groups)
Pearson coefficient—assessing the relationship b/w two variables
Autonomic hyperreflexia in spinal cord injry pts—HTN + reflex bradycardia
AVF after kidney bx – 70% close spontaneously w/i 18mo
Kleinfelter’s – xxy—hylanization of seminiferous tubulesàsmall firm testes, subfertility
Leidig cells present but T production abnormally low, elevated estradiol à poor secondary sex char., gynecomastia
Increased risk extragonadal germ cell tumors , Leydig tumors, Sertoli tumors,
Increased risk breast cancer
Cognitive impairment
2mo out after RARP, sudden change in LUTS—eval for possible lymphocele (CT pelvis)
Bladder preservation for MIBC—can try chemoXRT + midcycle TURBTà if persistent diseaseàcystectomy
àif no diseaseàcomplete chemoXRT
Sacrocolpopexy – for apical prolapse (C point on POPQ)
POPQ—all points relative to hymenal ring
Stage 0—no prolapse
Stage 1—distal prolapse >1cm above hymen
Stage 2—distal prolapse is +/- 1 cm above/below hymen
Stage 3—distal prolapse is protrudes >1cm but not all vagina prolapsed
Stage 4—complete prolapse of vagina
fever, difficulty walking 6wks after sacrocolpopexy—MRI to eval for discitis (likely L5-S1 discitis) 2/2 suture
Persistent asx funguria—look for cause—PVR (retention), renal US (hydro? Stones? Fungus ball? Abscess?)
If no predisposing cause found, and asx, repeat ucx in 1-3 mo
If sx funguria, treat with po fluconazole
Tumor spillage during Wilm’s tumor resection—makes then stage3à XRT+dactinomycin+vincristine+doxorubicin
PARPi—use in BRCA2 + mCRPC, -- cause dsDNA breaks in tumor cell
Abi, enza—androgen pathway
mTOR- evorlimus,temsirolimus (kidney)
taxanes--microtuble i targeting mitotic spindle(eg. docetaxel)
pazoponib/sunitinib/sorafenib- TKi (kidney)
nivolumab,atezolizumab—checkpoint I (PDL-1 and PD-1 i) – blocks PDL-1, PD-1, allows for T cell activation
Kidney donor—GFR must be >80, BMI<30, no substance abuse, no psych conditions, 18+ yo,
Some centers take donor with HTN if only on 1 med
Palmer’s point—entry with Veress needle when suspect adhesions—L costal margin, midclavicular line
US + FNA prior to sentinel node dissection for penile cancer—decreases number of false negatives
Sentinel node could miss a + node that is extensively involved with metastatic dz causing lymphatic obstructionà sentinel node radiotracer/isosulfan blue dye won’t penetrate and you wouldn't know to excise
PD1, PDL1—checkpoint inhibitors—allows for T cell activation and killing tumor cell
Eg. nivolumab, atezolizumab
Linear US probe—highest resolution image (vs. sector transducer—scans wide region but with low resolution)
Conditions that increase SHBG: liver cirrhosis, aging, hyperthyroidism
Conditions that decrease SHBG: DM, obesity, glucocorticoid use, nephrotic syndrome
Strict sperm morphology is not a predictor of fertility
Penis layers: skin—dartos—bucks—tunica albugenia
Scrotum layers: skin—dartos—external spermatic fascia—cremaster—internal spermatic fascia—tunica vaginalis—tunica albugenia
Removal of both testesà drop in T levelàincreased pituitary secretion of LH due to loss of (-) feedback loop—LH can cross-react with beta-HCG assay leading to false elevation of beta-HCG
In a pure seminoma testes cancer pt, give exogenous T and recheck, see if beta-HCG normal
Cystinuria—caused by mutations in SLC7A9,SLC3A1—proximal tubule transporters regulating reabsorb filtered cystine
Rx- 1st—hydrate, alkalinize
2nd—chelation with thiopronin (alpha-mercaptoproprionylglycine) or D-penicillamine
Give single dose of MMC after NephU to prevent intravesical recurrence
Post obstructive diuresis—if normal e-, asx, no evidence of fluid overload—monitor UOP, vital signs, give free access to po fluids
½ NS if give fluids—rate slightly below full replacement
Don’t use LR or NS
Paternity in spina bifida male—associated with an L5 or sacral neurologic level
1st line for non-metastatic CRPC
apalutamide, enzalutamide (no longer recommended to give bicalutamide)
NO prior docetaxel
Asx or minimally symptomatic mCRPC, good performance status, no prior docetaxel
abiraterone + pred, enzalutamide, docetaxel, sipuleucel-T
1st gen antiandrogen, ketoconazole + steroid, observation
symptomatic mCRPC, good performance status, no prior docetaxel
abiraterone + pred, enzalutamide, docetaxel
ketoconazole + steroid/XRT/mitoxantrone
XRT for bone mets (w/o visceral dz)
DON'T give estramustine or sipuleucel-T
symptomatic mCRPC, poor performance status, no prior docetaxel
abiraterone + pred, enzalutamide
ketoconazole + steroid/XRT (w/o visceral dz)
docetaxel, mitoxantrone—only when poor performance status is 2/2 cancer
XRT for bone mets—only when poor performance status is 2/2 cancer (w/o visceral dz)
DON'T give sipuleucel-T
YES prior docetaxel
Asx or minimally symptomatic mCRPC, good performance status
abiraterone + pred, cabazitaxel, enzalutamide
2nd line: ketoconazole + steroid—if abi/pred, cabazitaxel, enzalutamide unavailable
retreat with docetaxel if was having good effect
XRT for bone mets (w/o visceral dz)
Palliative care to mCRPC, poor performance status
For select pts can offer abi/pred, enza, ketoconazole + steroid/XRT
No systemic chemotherapy or immunotherapy
Bone health
do preventative med (ca2+, vit D)
denosumab/zolendrenic acid to prevent skeletal events
RANK-ligand i—inhibits osteoclast mediated bone destruction
Bisphosphonates—potent bone resorption inhibitors
Retention post AUS placement—24-48hrs Foley ok post op. later onset retentionà SPT placement
If persistent retention need cysto, UDS, possible revision
If start Desmopressin for nocturia—check Na+ @ 1wk and @4 wks.
Women getting Botox vs. Interstim—Botox higher treatment satisfaction
No difference in average # urge incontinence episodes, frequency, in # reporting complete resolution sx
Transverse fascial incision for specimen extraction = less incisional hernia
Large caval thrombus—hypothermia + cardiopulmonary bypassà most frequent complication = coagulopathy, hemorrhage (platelet and clotting factor dysfunction)
Male undergoing clinic cysto—reduced discomfort with:
-allowing men to watch on monitor
-increased hydrostatic pressure when passing membranous urethra
-classical music
TRT—only proven risk is of fertility impairment—no definitive evidence of risk stroke/MI/DVT/prostate CA
Extramammary Paget’s disease—rare adenocarcinoma from apocrine gland bearing skin—assoc. w/ abd malignancy 45%-- need CT c/a/p
Rx—wide local excision
Lovenox – is a low molecular weight heparin – 40 daily
Unfractionated heparin- 5000 q12
Estimate prostate volume: 0.52 x length x width x height (in cm)
PSA density: PSA /volume—density
>0.15---associated with greater risk CA
Retention 12hr after bulking injectionà in and out catheterization
Don’t want indwelling foley because this could cause bulking agent to mold around foley
Small cell prostate cancer—rx: chemo, XRT (cisplatin + etoposide, or paclitaxel/docetaxel + topotecan)
Small cell bladder cancer—chemo + xrt (no cystectomy)--- cisplatin + etoposide
Perioperative management before adrenalectomy for
Cushing’s Syndrome—stress-dose steroids, tight glycemic control
Pheo—alpha blockade, hydration +/- beta blockers (phenoxybenzamine, add metyrosine if in adequate alpha-blockade)
Conn’s (aldosteronoma)—K+ sparring diuretics
Pheo in VHL, MEN2a, familial pheochromocytoma—rx partial adrenalectomy
Most likely location of corporal perforation during IPP placement = at corporal septum
(weakest portion of corporal body)
Calcification of vas--- pathognomonic DIABETES
Hypomagnesuria—inflammatory bowel disease
mild/mod VUR—bowel bladder dysfunction = most important factor predicting risk of breakthrough UTIs
abx prior to UDS—only for at risk pt (advanced age, GU tract abnormalities, poor nutritional status, immunocompromise)
autologous pubovaginal sling—good for rx stress incontinence w/ intrinsic sphincter deficiency that has failed other treatment eg. mid urethral slings, bulking
off-label imipramine rx for mixed incontinence
kid with concern for blunt trauma, microscopic hematuria—do F.A.S.T. first, if abnormal then CT scan
MVC with lower abd trauma, GHà pelvic hematoma, extraperitoneal bladder injury, foley keeps clotting off
Explore INTRAperitoneal, repair bladder, foley
Don’t go extraperitoneal 2/2 don’t want to disrupt the pelvic hematomaàhemorrhage
Fish oil – rx for mild/moderate hypercalciuria
Prosatitic utricle—present in 10-15% proximal hypospadias, remnant of Müllerian duct (paramesonephric duct)—can make catheterization difficult
Gartner’s cyst—remnant of Wollfian duct (mesonephric duct)
Pre-pubertal mature teratoma—partial orchiectomy
C diff—mild –po flagyl, more severe po vanc + IV flagyl, toxic megacolon/ileus/abd distention rectal vanc/flagyl
Follow a bx proven small benign renal mass with annual CXR, abdominal imaging—no need to re-bx
Would look for tumor growth acceleration as indicator of malignancy, no need for repeat bx
Spina bifida kid with concern for bladder augment rupture (abd pain, fever, n/v), (-) cystogram—get CT cystogram to eval for bladder rupture
Autologous fascial sling placed, 1mo later PVR 300à do CIC – sling will loosen
If still not loose enough at 3-4mo—consider incise sling
Newborn with adrenal hemorrhage—mass, anemia, jaundice (blood absorbed by retroperitoneum)—can get scrotal ecchymosis
US to eval—exclude neuroblastoma—serial US to observe—usually spontaneously resolve
OAB—behavioral therapy trial minimum 8-12wks, therapeutic trial of meds minimum 4-8wks
Haven’t failed a therapy unless no effect after those windows
Post prostate bx sepsis—carbapenem or amikacin
Hand-assisted lap radical Nx vs. lap radical Nx—hand-assisted has wound complications (hernia, infx)
No neoadjuvant chemo for bladder ca if GFR <60, ++ hearing loss, ++periph neuropathy, ++ HF
Metastatic ccRCC failed TKI, good performance statusà everolimus
t-test— comparing 2 groups, dependent variable is a continuous variable
ANOVA— comparing more than 2 groups, dependent variable is a continuous variable
Fischer’s exact test—expected number of subjects in group is <5, dependent variable is a binary variable
Chi-Squared test—when expect number of subjects in group is >5, dependent variable is a binary variable
Abiraterone—irreversible inhib of CYP17—thus need to give Predisone to allow for synth of androgens, — don’t get (-) feedback on HPA axis, this leads to back up of steroid precursors that then get shunted to production of aldosteroneàHTN, fluid retention, hypoK,
(stop conversion of cholesterolàandostrenedione, DHEA)
hepatotoxicity
Bilateral adrenal hemorrhage, hypotenstion, normal H/H—acute adrenal insufficiency—Rx steroids
Non-pulmonary visceral mets w NSGCT—poor prognosis—rx BEP x4
(BEP x3, EPx4—appropriate for good prognosis NSGCT)
(VIP or high dose chemo + bone barrow transplant—salvage therapy if relapse/refractory)
Calciphylaxis—DM, obesity, ESRD—obliterative small vessel vasculopathy
Etoposide—bone marrow suppression
Uric acid stones—diet restrict animal protein, alkalinize urine pH >6 using K citrate, allopurinol
Detumescence—1st caverenosal smooth muscle contraction, 2nd initial rise in intracorporal pressure, followed by slow pressure decrease, 3rd rapid drop in intracorporal pressure
Groin/thigh pain after transobdurator sling placement—rx conservative therapy w/ NSAIDs and wait
If pain still present 6-8wks later, refer to pain clinic for trigger point injections
If fails all treatment can cut sling and remove
Advanced colon CA pt presenting w/ new vesicocolonic fistula—need to bx to make sure its not CA recurrence
Angiotensin II – maintains GFR during hypoperfusion by constricting efferent arteriole
most important step for successful hypospadias UCF repair – intra-op urethral calibration—looking for urethral stricture distal to fistula site
pilot with bilateral renal asx stones – URS for highest stone free rate
pt going to renal transplant with asx kidney stone—proceed with transplant
Fowler’s Syndrome—young woman, no neurologic dz – suddenly develops AUR
UDS will show abnormal firing on EMG
mCSPC—ADT w/ [abi+pred, enza, apa, docetaxol, EBRT] --- or --- ADT alone
doxycycline—ok to use in impaired renal func—excreted in in feces, not in urine
young boy, nonpalpable testes, normal penile development, taken for scrotal exploration—vas deferens and spermatic vessels end blindly at the internal ring—observe, NTD—anorchid but got enough T at 16wks dev, will need TRT at puberty
Podophyllin – treat genital warts
Wet umbiliclus in infant—patent urachus vs. omphalitis vs. granulation of healing stump vs. patent vitelline or omphalomesenteric duct vs. infected umbilical vessels vs. external urachal sinus
Anuria after hysterectomy—suspect iatrogenic ureteral injury—anuria implies complete obstruction until proven otherwise
Two most common spots—(a) at level of broad ligament, (b) at vaginal cuff/ bladder trigone
Standard inguinal lymph node template:
(superiorly) inguinal ligament, (laterally) sartorius, (medially) adductor longus
5AR deficiency—elevated T concentration at puberty—will have absent Mullerian structures (Sertoli cells in testes make Mullerian Inhibiting Substance), normal testosterone-dependent Wolfian structures
Don’t do varicocelectomy and V-V at the same time—venous outflow from testes after varicocelectomy is via vasal vessels which are divided during vasectomy or V-V—risk testicular atrophy
Complete ureteral obstruction causes immediate
Preglomerular vasodilation – in both bilateral and unilateral ureteral obstruction
Efferent arteriolar vasoconstriction – in bilateral (but NOT in unilateral) ureteral obstruction
Colovesical fistula to continent cutaneous diversion—catheter drainage with low residue diet
Conus medularis in neonate ends at L3 (in adult its at L2)
“good risk” NSGCT—primary testicular or retroperitoneal disease, no non-pulmonary visceral mets, negative or low markers
No such thing as ‘poor risk’ seminoma – only ‘good’ and ‘intermediate’
dartos fascia, Colles' fascia, and insertion of the fascia lata represent a continuation of the same fascial layer
S2,3,4 – give rise to pudendal n—striated external sphincter, penis sensation
sympathetic chain T10-L2—responsible for ejaculation
k citrate comes in waxy tablet— not infrequent for these wax matrix tablet casts to be seen in poop
radical pelvic surgery (gyn or colorecatal etc.)—damage to pelvic nerves—
detrusor areflexia, hypocontractile bladder, reduced compliance, fixed external sphincter
cranberry juice—prevents bacteria from adhering to uroepithelial cells
normal phallus size for neonate = >2.5cm
spermatogoniaàprimary spermatocyteàmeiosisàsecondary spermatocyte (2N) àmeiosisà spermatids (1N)
spermatids eventually become mature spermatozoa
complications after inguinal node dissection for penile cancer—highest when done for palliative reasons
post obstructive diuresis—if giving IVF, give rate at ½ the previous hours UOP
in a sick/volume overloaded pt—consider check spot urine for osmolality, sodium, K+
ureteral stents after URS—increase pain, urinary sx, narcotic use
AIN—stop offending agent, observe—if no resolution, renal bx to confirm dx
Fluoroquinolones, ampicillin, cephalosporins all can cause
If have 6 core prostate bx and want to put pt no active surveillance, need to get a 12 core bx first (don’t want to under-sample)
Randalls plaque—calcium apatite
Increase/decrease C-arm tube current (mA)—increases/decreases radiation dose to pt/doc/all people in room
Parathyroid levels suppressed with intestinal absorptive hypercalciuria—transient elevations in serum Ca2+ due to intestinal Ca absorption
Hypercalciuria:
|
|
Absorptive |
Renal leak |
Primary hyperparathyroidism |
|
Serum ca2+ |
normal |
normal |
é |
|
Parathyroid function |
ê |
é (2o) |
é (1o) |
|
Fasting urinary ca2+ |
normal |
é |
é |
|
Intestinal ca2+ |
é |
é (2o) |
é (2o) |
Give single dose MMC w/i 24hrs of TURBT—works best in alkali urine
Don’t give if intraperitoneal perf, concurrent urethral stricture dilation, urethra injury—tissue necrosis
Prostate cancer on MRI—low on T1, low on T2
Prostate hemorrhage post bx—high on T1, low on T2
Tuberous Sclerosis—renal AMLs—TSC1,TSC2--- also get pulmonary AMLs
Hamartomas – Hamartomas, Adenoma sebaceum, Mentral retardation, Ash leaf spots, Rhabdomyoma, Tubers, Optic hamartomas, Mitral regurgitation, Astrocytomas, Seizures
Oxalobacter formigenes in the intestines—anaerobe in gut that metabolizes 50% of ingested oxalates
Poor risk met RCC (LDH > 1.5 times upper normal, low Hgb, Ca2+ > 10, time from dx of cancer > 12 months, mets to multiple organs, poor performance status) – temsirolimus
If on CIC, only tx symptomatic infections—40-80% colonized with bacteria
Mildly cloudy urine and pyuria are not criteria enough alone
trimethoprim—alters creatinine, but not true GFR—blocks tubular secretion of creatinine
(normally 90% Cr filtered, 10% secreted)
Most important parameters associated with bladder Ca progression: -tumor stage, -grade, -presence CIS
Sick guy, 2.7cm sx renal mass, biopsy at time of ablation inconclusive, 6mo later enhancing on scan again—repeat bx
Will likely need second ablation procedure
Confirmed elevated cortisol on 24-hr urine—next get plasma ACTH—(determine if Cushing’s syndrome is ACTH-dependent or -independent)
ACTH-independent: adrenocortical carcinoma, ectopic ACTH production
ATCH-dependent: pituitary adenoma (cortisol should suppress with low-dose dexamethasone)
HG-PIN + ASAP on prostate bxà either re-bx or examine path specimens with deeper sections
Most common site of sympathetic n. injury during RPLNDà hypogastric plexus anterior to aortic bifurcation
Primary control of Aldosterone secretion is by renin
Mod-severe hydro on prenatal USà normal US 1-2mo postnatalà à STILL NEED VCUG
Don’t need if mild-mod hydro prenatally
Cystinuria—inadequate tubular reabsorption of C.O.L.A (cystine, ornithine, lysine, arginine)
If bilat varicoceles, eg. grade III on L , grade I on R—fix both – don’t do for subclinical (only seen on US)
Gynecomastia in male—alteration in T:E ratio—either due to reduced T or elevated E
Prolactin-secreting pituitary tumor vs. estrogenic drugs vs exogenous T vs. Testicular tumor vs. idiopathic
Recurrent Ca2+ stone former started on HCTZ àdevelopls DM and borderline low K ----rx K citrate—supplements potassium back
CMN- <5mo—mass infiltrates—nephrectomy + surveillance
Wilms- 2-3yo—mass displaces/compresses—if bilatà chemo
RCC- older
Reflex bladder and urethral activity coordinated by reflex center in Pons (pontine micturition center)
Risk for bleeding, perirenal hematoma after ESWL—hypertension, bilateral ESWL
Transvaginal vesicovaginal fistula repair—Martius flap (labial fat pad flap) or myocutaneous labial flap for low lying fistulas, if can’t reach for a high fistula àperitoneal flap (can easily access via vagina)
Avoid groin incision—Gracilis flap, avoid abdominal incision—omental flap
Clinical stage 1 seminoma—negative CT scan, negative markers—15% risk of relapse to retroperitoneal LNDs
Options: surveillance vs. XRT vs. single-dose carboplatin
If XRT—5% relapse—but…..risk of secondary malignancy (leukemia, lymphoma)
Medullary sponge kidney—‘bunch of grapes’, ‘bouquet of flowers’ --if stones+ hypercalciuria—rx thiazes
**dilation of distal portion of collecting ducts associated with numerous cysts, diverticula
Complete androgen insensitivity syndrome—if leave testes – risk developing SEMINOMA (20% by age 30)
Disorders of sexual development (DSD)— (partial/pure gonadal dysgenesis (46 XY or 46 XY/XO genotypes)—gonadoblastoma
HUS—ecoli O157:H7--enterocolitis with bloody diarrhea, fever, gross hematuria, and oliguric renal failure
Rx: supportive care
Predictive of finding fibrosis post chemo for NSGCT—absence of teratoma in primary, mass size reduction post chemo >90%, size of post chemo mass, pure embryonal in primary
Surgical treatment for met RCC long bone lesions indicated when—lytic lesion >3cm, weight bearing bone
NSGCT- Rete teste involvement—risk 25% relapse to RPLNs , LVI—risk 50% relapse RPLNs
Chemo leads to impaired fertility in at ~ 30%
Fertility preserved in 80-90% in modified (nerve sparing) RPLND—RPLND is curative in 2/3 pts
XRT and carboplatin—NOT INDICATED IN NSGCT
Lower pH in DM uric acid stone formers – due to insulin resistance and impaired ammonia production/excretionàreduced urine pH and uric acid stones
Denosumab (RANKLi) or monthly bisphosphonate –only give to men with bone mets—doesn’t work for ppx
Beta-2, beta-3 adrenergic receptors mediate bladder relaxation and filling
s/p partial nx, develop pyelocutaneous fistula with urine leak, large urinoma—rx: perc drainage
if doesn’t resolve, need to eval for obx—cysto w/ RPG, ureteral stent, foley
most accurate way of estimating prostate volume by US—planimetry
orthotopic neobladder after cystectomy, night time incontinence—due to loss of afferent input from detrusor to CNS
noninvasive micropapillary UC—immediate cystectomy (no neoadjuvant chemo)
ilioinguinal nerve during hernia repair—runs in cremaster
omphalomesenteric duct—connection of umbilicus to small bowel
urethral cancer—if unilaterally positive inguinal LNs, do unilateral inguinal lymph node dissection
young healthy kid, very minor trauma (wrestling with brother) develops GHà get US, kidneys, bladder—may be underlying Wilm’s Tumor, hydronephrosis, multicystic kidney, blood vessel anomaly
endemic bladder stones in kids---children from North Africa, Middle East, and Far East—cereal based diet, lacking in animal proteinàdietary phosphate deficiencyà low urinary phosphate, high urinary ammonia—ammonium acid urate stones
lap RPNLD has more bleeding vs. open RPNLD-- ¯\_(ツ)_/¯
antimuscarinics don’t affect LPP –the LPP is determined by external sphincter (striated muscle)
to get to non-smoking pulmonary risk, smokers need to quit 2mo before surgery
CT vs US vs KUB for estimating stone size
US accurately estimates, KUB underestimates (underestimates >90% stones >1cm)
US overestimates 33% stones <1cm, underestimates 33% stones>1cm
Neural pathways for sexual function
T10-L2—sympathetic (shoot)
S2-4—parasympathetic (point)—reflexic erection
S2-4—motor perineal muscles— reflexic erection
Granulomatous prostatitis (caseating granuloma on TRUS bx) after BCG—benign, don’t need rx
Testicular intratubular germ cell neoplasia (ITGCN) found on bx—50% risk progressing to invasive germ cell tumor—Rx radical orchiectomy vs. XRT (not good option if concerned for fertility)
All PPIs are associated with increased risk C. difficile –impaired stomach H+, decreased barrier to bacteria??
EPO production in kidney is primary regulated by HIF-1 alpha
Stimulated primarily by hypoxia (renal interstitial fibroblasts)
Kid with pyelonephritis, febrile, but on appropriate IV abx, normal kidney/bladder US but still febrile—observe up to 72hrs - normal to have fever up to this long
High velocity injury to abd with ureteral contusion—repair immediately (reimplant vs. UU etc.) – risk of microvascular damage with stenosis/stricture/necrosis.
Rx for metabolic acidosis after ileal conduità K+ citrate (Na+ bicarbonate, Na+ citrate are 2nd line due to issues with HTN from increased Na+ load)
Hunners Leision—rx fulgurate/laser therapy/injection with triamcinolone
Pure gonadal dysgenesis—bilateral streak gonads
Mixed gonadal dysgenesis—one streak gonad, one testicle
CAH—two ovaries
Active surveillance for renal mass—get CT or mri (not US) w/i 6 mo then annually
ADPCKD—HTN is due to intrarenal vessel constriction by cystsà activates rennin/angiotensin system
Thus, use ACEi/ARB for antihypertensive therapy
Non clear-cell RCC w/ poor prognostic features—temsirolimus
MSKCC scoring system for RCC—serum LDH, serum Ca2+, hemoglobin, performance status, interval from diagnosis to treatment
Neonates and infants with febrile UTI—cover for enterococcus—ampicillin, first gen. cephalosporin
Ketamine—ketamine cystitis—indistinguishable from non-Hunner’s interstitial cystitis
Small fibrotic bladderà results in need for cystectomy
Chylous acites—more with L sided procedures than R
ACHT, cortisol both feedback inhibit CRH
Normal ACTH and Cortisol = diurnal variation High AM, Low PM
Catecholamines (adrenal medulla) derived from—tyrosine, phenylalanine
Adrenal medulla –neuroectoderm
Adrenal cortex—mesoderm
Don’t use OPA to sterilize cystoscopes—repeat exposure can trigger anaphylaxis
MRI brain (only) is ok with newer Interstim (Interstim II)
CT scan for renal trauma limited ability to evaluate for vein injury
Renal contusion = normal renal imaging but w/ hematuria
Penile shaft reconstruction—highest % graft take, good cosmetic outcome = unmeshed split thickness skin graft
Meshed—contracts—poor function/cosmesis
Full thickness—less % graft take
Local skin flaps—worse cosmetic outcome
When using argon beam—careful not to over-fill abdomen with gas if not venting—drop in tidal volumesàrelease pneumo
Megaureter—function <40% --surgery to repair
Sexual dysfunction associated with urethroplasty—ejaculatory dysfunction, (temporary ED, but this resolves)
PDE5i don't improve urinary flow rates (tadalafil can improve IPSS)
Semen fructose is low in ejaculatory duct obstruction or CBAVD
No PDE5i w/i 6mo of myocardial infarction---CAN give MUSE pellets
No PDE5i w/ hereditary retinal conditions—retinitis pigmentosa
Muscle invasive urothelial carcinoma w/ squamous differentiation—neoadj cisplatin-based chemo then cystectomy
If tumor was pure squamous cell carcinomaà immediate cystectomy
Balloon dilation ureteral strictures –short term success, long term outcomes not favorable—can cause secondary stricture that's much longer and worseàà for short strictures, do ureteroscopic endoureterotomy
T-tests, ANOVA, correlation coefficients, linear multiple regression—compare results of a dependent variable that is measured as a continuous variable—can compare groups with means, standard deviations
Indications for pre-transplant nephrectomy—kidney stones, renal mass, chronic pyelo, uncontrollable HTN, excessive proteinuria
Lipid soluble abx—TMP, tetracyclines, fluoroquinolones, chloramphenicol ––penetrate cysts well (eg. ADPKD)
Adrenal mass—first eval with non-con CT--- if < 10 HU = adrenal adenoma
Tumor spillage with Wilm’sà increases to at least Stage III.
For favorable histology—XRT + vincristine+dactinomycin+doxorubicin
Hinman Allen syndrome—non-neurogenic neurogenic bladder—eval with uroflow w/ EMG
Early sign of septic shock—respiratory alkalosis 2/2 tachypneaà
then with hypoperfusion à tachycardia, oliguria, increased CO, increased plasma norepinephrine
VHL—hemangioblastomas of cerebellum (including retinal angiomas), RCC, cystadenoma of epididymis
Nitrofurantoin doesn’t affect warfarin
DESD—lesion above sacral cord lesion
PTH and vit D work on distal tubule—reabsorb Ca2+
Turner’s – 45XO—horseshoe, short stature, webbed neck, shield chest
Intrauterine insemination (IUI)—need at least 5mil total motile sperm count (ejac vol x sperm[ ] x % mobility)
Assessment of renal function in pt with ileal conduit—look at fractional excretion of Na+
(sodium handling in ileal segment not significant altered 2/2 ammonium substitutes for Na in the Na/H antiporter in bowel lumen)
Wilm’s tumor associated syndromes
Denys-Drash
male pseudohermaphrodism (proximal hypospadias, cryptorchidism), membranoproliferative glomerulonephritis, nephroblastoma
Beckwith-Weidemann
Macroglossia, nephromegaly, hepatomegaly
WAGR
Wilms, aniridia, gonadoblastoma, retardation
Unilateral partial ureteral obstruction the aspect of renal function that is preserved = urinary dilution
Functions that are impaired in unilateral obx= urinary concentration, ammonia excretion, K+ reabsorption, N+ reabsorption
Brushite stone is most resistant to ESWL
Cysteine, CaOx monohydrate also resistant
Sleep apnea—nocturia and nocturnal enuresis—
hypoxiaàincreased RA pressureà increase in ANPàdecrease in ADHàincreased nocturnal urine production
Clomid (clomiphene citrate)—SERM—works by causing release of GnRHà increased LH,FSH
IMA—supplies L colon via—L colic artery, superior hemorrhoidal artery.
If IMA ligated, blood supply to L colon
Proximally---via middle colic artery (branch of SMA),
Distally-------via middle and inferior hemorrhoidal
Middle colic + hemorrhoidal coalesce to form marginal a. of Drummond
Delay surgery after heart stent placement to minimize risk of stent thrombosis:
Bare metal stent--- minimum 4wks
Drug eluting stent--- minimum 12 mo
Children with corrected severe obstructive uropathy (eg. PUV) will sometimes show a persistent decrease in renal concentrating ability—can worsen with growthà very high urine output ensues
Need voiding dairy to characterize prior to starting additional therapy
Suspicion for ectopic ureter in young girl causing continuous wetness—get MRI to assess
Cystoscopy, vaginoscopy can miss very small ectopic ureter (often upper pole moiety)
Primary landing zone for PCa nodal metastasis—internal iliac nodes
CVA associated with --- neurogenic DO—involuntary bladder contraction with appropriate relaxation of internal + external sphincters
Confirm AML on MRI with ---T2 w/ fat suppression
Chronically encrusting indwelling SPT—culture urine for urease producing org—biofilms
May need to eventually eval for stones (cysto, CT) to eradicate stones as nidus for reinfection
Lynch (hereditary non polyposis colorectal ca)—associated with ovarian, colon, GU cancers
Mismatch repair genes—MSH2, MSH6, MLH1, PMS2
Older pt with complicated UTI after appropriate tx needs urologic w/o—cysto, CT urogram etc.
Eval for stones, strictures, malignancy
Factor most predictive of PCa mortality in pts w/ recurrence after definitive local therapy = PSA doubling time
Short time to recurrence also bad but fast PSA doubling time is more predictive
NCCN Very low risk vs. low risk PCa—PSA density <0.15 vs. >0.15
(Other criteria for very low risk: PSA <10, cT1c, up to 3 cores of GG1, no core with more than 50% cancer, PSA density <0/15)
Onuf’s nucleus – external sphincter contraction---anterior horn of S2-S4 of sacral cord, pudendal motor neurons that innervate external striated urethral sphincter
To gain control of renal hilum when aorta obscured (thrombus, hematoma etc.) find IMVàdissect medial to IMV to find anterior surface of aorta
Optimize mitomycin C—urine alkalization (eg. NaBicarb) to prevent drug degradation, elimination of residual urine, overnight fasting (dehydration), increase drug [ ] to 40mg/20ml
Clorthalidone—used in hypercalciuria
FENA= (plasma_Cr x urine_Na)/(plasma_Na x urine_Cr)
<1% --prerenal, 1-4% intrinsic, >5% obstructive
Psychogenic erections don’t occur if spinal cord lesion is above T9
Efferent sympathetic outflow thought to be at T11 and T12 levels
If injury to sacral cord, no reflexogenic erections but preserved psychogenic erections
Erection during cysto case—wait to allow for natural detumescenceà if still erect, give intracavernosal phenylephrine
Verrous carcinoma of penis—Buschke-Löwenstein tumor—locally destructive but unlike penis SSCa has very low malignant potential for metsà if find node, observe after resection—likely reactive
If need additional length on neobladder to reach urethral stump can ligate R colic artery
Allopurinol—can give for recurrent CaOx stones with high urine uric acid, normal calcium
Extensive intraurethral condyloma—intra-urethral 5-FU
If burden less, can use Holmium laser ablation (can’t use CO2 due to its absorption in water)
Abx for cystectomy—3rd gen cephalosporin w/i 1 hr of incision and d/c w/i 24hrs
Alternative = aminoglycoside + metronidazole w/i 1 hr of incision and d/c w/i 24hrs
ED and premature ejaculation—treat the ED first
Penile duplex US— cavernous arterial insufficiency if PSV <25 (>35 is normal)
Normal EDV <5
PSMA—found in prostate, intestines, salivary glands—is a ubiquitous molecule
If Cr ~2 and desire retentive diversion –need more investigation into renal function
Can do it if: Cr clearance >35
can achieve urine pH 5.8 w/ ammonium challenge
can increase urine osmolarity to 600 w fluid restriction
primary benefit to vaccinating boys 9-valent HPV vaccineà reduced genital warts
school age children and adolescents—should give ASSENT to treatment and can dissent if don't agree to proceed
consent obtained from parent(s)/guardian
R sided never spare RPLND—maintain antegrade ejaculation by preserving postganglionic sympathetic fibers posterior to vena cava
On the L side, post ganglionic sympathetic fibers run lateral and anterior to aorta
Arrhythmia precipitate in ESWL in 8-21% -- more with ungated procedure. Usually stop w/ cessation of ESWL
Whittaker test (no diuretic is used for this test)
Normal <14
Mild obstruction 14-20
Moderate obstruction 21-34
Severe obstruction >35
horseshoe kidney—calyces point posteriorly
high normal Ca2+ on lytes and multiple stones in young person—get PTH to r/o hyperparathyroidism
ccRCC—“clear” because of glycogen deposits (NOT FAT)
ipilimumab + nivolumab—CR rate in untreated metastatic ccRCC= ~10%
sunitinib-- ~1%
high dose IL-2—5-10%
least retropulsion of stones with--- lower pulse energy, high frequency, long pulse width
meat allergy—can still use Evicel—doesn’t contain protein that could cause rxn
pazopanib noninferior to sunitinib (both TKIs) but with better side effect profile
pembrolizumab + axitinib better than sunitinib alone
fibromuscular dysplasia --- noninflammatory, non-atherosclerotic vascular desease---female predominance
mid to distal renal a. and segmental branches
middle aged female with difficult to control BP, or asx found on imaging
medical manage if controlling BP
surveillance regularly for kidney health
if meds don't control BP, becomes sxà percutaneous angioplastyàà only if fails, proceed to surgery
treatment of NSF (after MRI contrast) --- hemodialysis
Whitaker Test—used to differentiate residual or recurrent upper renal collecting system obstruction from dilatation secondary to permanent changes in musculature
perc into kidney, instill fluid at 5-10cc/min, measure pressure in renal pelvis and bladder.
Unobstructed system—easily tolerates this high flow rate
Obstructed system—pelvic pressure >12 cm H20, or constant rise in pressure
Globozoospermia—round headed sperm (no acrosome)—won’t be able to penetrate egg to fertilize—do ICSI
Normal micturition reflex—under voluntary control, originates in pons
Sudden, complete relaxation of striated sphincter musclesà rise in detrusor pressureàopening of bladder neck and urethra
Partially calcified Renal a. aneurysm in women of childbearing age à repair surgically---risk of rupture if untreated
If fully calcified this is more stable
In general, if <1.5 cm in size can manage conservatively with lifestyle and diuretics
ASAP prostate bx—small glands consistent with PCa are found but in insufficient number to make dx of PCa
Daily expected urine production 40ml/KG