Gen-Surg: Urology & Renal

Nephroblastoma (Wilms Tumor)

Palpable abdominal mass that does not cross midline, often associated with hematuria, constipation, abdominal pain, N/V, HTN, anemia, anorexia, and fever

-RF: family hx, horseshoe kidney (think Turner Syndrome)

-WAGR: Wilms tumor, aniridia, GU malformations, MR

-Dx: Abdominal US, CXR

-Tx: nephrectomy + chemo

Postoperative Urinary Retention

Common complication of both spinal and epidural anesthesia, due to a prolonged blockade of parasympathetic fibers that innervate the bladder with resultant urinary retention

-Obstructive causes → urethral stricture, bladder calculi or neoplasm, FB

-Neurogenic causes → MS, Parkinson’s, CVA, POUR

-Traumatic causes → urethral, bladder, or spinal cord injury

-Extraurinary causes → fecal impaction, AAA, rectal or retroperitoneal mass

-Infectious causes → local abscess, cystitis, genital herpes zoster

Acute Urinary Retention

Inability to void in the presence of a full bladder

-RF: male, prostatic enlargement, epidural/spinal/prolonged anesthesia, antihistamine and narcotic use

-Sx: suprapubic discomfort with urgency and inability to void, unable to void within 8hr after surgery/catheter removal, pain, vomiting, palpable bladder, hypotension, bradycardia, cardiac dysrhythmias

-Dx: bladder US with > 500 mL or urine

-Tx: catheterization

Chronic Urinary Retention

Painless retention of urine that develops gradually

-Sx: suprapubic dullness, rounded midline mass, frequent urination of small amounts or overflow incontinence

-Dx: postvoid residual by catheterization or US

-Tx: catheterization

Detrusor Sphincter Dyssynergia

Consequence of SCI or MS, leading to dyssynergistic contraction of urethral sphincter muscle during voiding

-Sx: daytime and nighttime wetting, hx of UTI/bladder infection

-Dx: postvoid residual > 150mL

-Tx: botox injections

Renal Artery Stenosis

Decreased renal blood flow due to atherosclerosis (elderly) or fibromuscular dysplasia (women <50 years), leading to activation of RAAS system and secondary HTN

-Sx: HA, HTN that is resistant to 3+ drugs, abdominal bruit

-Dx: CTA, MRA, renal catheter arteriography is gold standard

-Tx: revascularization

ACE/ARBs

What anti-hypertensives are contraindicated in bilateral renal artery stenosis, due to the risk of AKI?

Renal Cell Carcinoma

Tumor of the proximal convoluted renal tubule cells, with clear cell being the MC

-RF: smoking, HTN, obesity, male, dialysis

-Sx: hematuria, flank/abdominal pain, palpable abdominal mass, HTN, hypercalcemia, left-sided varicocele, malaise, weight loss

-Dx: Cannon ball METS to lungs and bone, CT, renal US or MRI

-Tx: nephrectomy

Orthostatic Hypotension

Drop of > 20mmHg systolic, >10 mmHg diastolic, or both 2-5 minutes after changing from supine to standing

-Dx: BP and HR measurements after 5 min supine and at 1/3 min after standing

-Autonomic dysfunction is MC, followed by medications

Calcium Oxalate

What type of renal stone is MC?

Nephrolithiasis

Sudden, constant upper lateral back or flank pain over the CVA that may radiate to the groin or anteriorly

-Sx: N/V, frequency, urgency, hematuria

-PE: CVA tenderness

-Dx: UA + non-con CT abdomen/pelvis

-Tx: spontaneous passage likely if <5mm, extracorporeal shock wave lithotripsy if > 5mm, percutaneous nephrolithotomy if > 10mm

Hemodialysis

Blood cycles through a dialyzer that removes waste and toxins, then returns to your body

-Requires an access port, such as AV fistula, AV graft, and central venous catheter (least desirable due to infection risk)

Peritoneal Dialysis

Peritoneal cavity filled with cleansing dialysis fluid then drained, cleaning blood through the internal walls of the abdomen

-Accessed via a peritoneal catheter, associated with high risk of clotting and infection

Acute Cystitis

Infection of the bladder, MC caused by E. coli

-Sx: dysuria, frequency, urgency, hematuria, suprapubic pain, tenderness

-Dx: UA shows pyuria and + leuk esterase/nitrates, urine culture is definitive

-Tx: nitrofurantoin + phenazopyridine for analgesia

Acute Pyelonephritis

Infection of the upper GU tract

-Sx: fever, chills, back/flank pain, N/V, dysuria, frequency, urgency

-PE: CVA tenderness, fever, tachycardia

-Dx: UA shows pyuria, WBC casts, culture is definitive

-Tx: fluroquinolones

Urethritis

Urethral discharge and penile/vaginal pruritis, most often due to chlamydia or gonorrhea

-Sx (all): discharge, abdominal pain, abnormal vaginal bleeding, dysuria

-Dx: NAAT, gram stain

-Tx: ceftriaxone + doxycycline

Epididymitis

Epididymal pain and swelling thought to be secondary to retrograde infection or reflux of urine

-MC due to chlamydia if 14-35 y/o, E. coli if > 35 y/o

-Sx: gradual onset of localized testicular pain and swelling, groin/flank/abdominal pain, fever, chills, irritative sx

-PE: scrotal swelling and tenderness, epididymal induration, + Prehn sign, + cremasteric reflex

-Dx: scrotal US

-Tx: fluroquinolones if > 35, doxycycline if <35 y/o

Prostatitis

Prostate gland inflammation secondary to an ascending infection

-Sx: frequency, urgency, dysuria, hesitancy, poor stream, straining to void, incomplete emptying, tender prostate, fever, chills, perineal pain

-PE: boggy prostate

-Dx: UA + urine culture

-Tx: fluroquinolones if > 35, ceftriaxone + doxy if < 35

Testicular Cancer

MC solid tumor in young men

-RF: cryptorchidism, Caucasian, Klinefelter’s syndrome, hypospadias

-Sx: painless testicular mass that does not transilluminate

-Dx: scrotal U/S, elevated AFP and b-hCG

-Tx: radical orchiectomy + chemo + radiation

Germinal Cell

MC type of testicular cancer, divided into nonseminomas and seminomas

-Nonseminomas → increased AFP and beta-hCG, resistant to radiation

-Seminomas → lacks tumor markers, sensitive to radiation, slower growing, stepwise spread

Non-Germinal Cell

Type of testicular cancer, which can be further divided into Leydig cell tumors, sertoli cell tumors, gonadoblastoma, and testicular lymphoma

Bladder Carcinoma

Transitional cell is MC

-RF: smoking, male

-Sx: painless hematuria

-Dx: cystoscopy with biopsy

-Tx: endoscopic resection with cystoscopy every 3 months

CKD

Presence of either kidney damage or decreased kidney function for > 3 months

-GFR < 60 or damage seen in structural/functional abnormalities like glomerular disease, vascular disease, tubulointerstitial disease, and cystic disease

-Asx until GFR falls to 10-15, where nonspecific symptoms of malaise, weakness, insomnia, inability to concentrate, and N/V develop

1

What GFR stage is this?

>90

2

What GFR stage is this?

60-89

3a

What GFR stage is this?

45-59

3b

What GFR stage is this?

30-44

4

What GFR stage is this?

15-29

5

What GFR stage is this?

<15 or dialysis treatment

Albumin

What is the main protein lost through urine in CKD?

1

What albuminuria rating is this?

ACR <30, which is normal to mildly elevated

2

What albuminuria rating is this?

ACR 30-299, which is moderately elevated

3

What albuminuria rating is this?

ACR > 300, which is severely elevated

Gleason

What grading system is used for prostate cancer?

LR

What is the most appropriate IV fluid for a preop patient who is NPO?

Hyperkalemia

What is an indication for urgent preoperative dialysis in a patient?

TURP

What is the most appropriate definitive management for a patient with BPH?

Calcium Chloride

What should be administered to a patient with hyperkalemia, in order to stabilize the cardiac membrane?