Urology
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| What is benign prostatic hypertrophy? | Increase in prostate size, no cancer, at transition zone, affects different tissue types including gland. Symptoms of bladder storage and emptying due to irritation and obstruction (cause lower UT symptoms [LUTS]) Impairs QoL and can cause serious complications. Hyperplasia of glands of periurethral prostate and not hypertrophy Symptoms may be stable or worsens rapid, not parallel to histology |
| How is anatomy of prostate? | - The prostate is located in the small (lesser) pelvis just below the bladder. At the front we have the pubis, and in the back the rectum. It surrounds the prostatic urethra - It has 3 lobes: two lateral lobes united at the front by an isthmus, and at the back by the median lobe - The median lobe is located above the entrance of the ejaculatory ducts which bring the sperm into the prostatic urethra. - Lateral lobes tend to increase in volume with age, and the median lobe increases in volume intravesicaly (development up in the bladder) - The gland is surrounded by a fibro-muscular capsule. |
| How is the zonal anatomy of prostate? | 3 Main Zones (central, transition and peripheral zone) Transition (glandular portion of prostate, in direct contact w/urethra, BPH born in this area periurethral, rarely prostate cancer) Central (Non glandular portion surrounds transition zone, dense stroma and transition zone, rarely cause of cancer but important role in BPH develops at age 40 in man) Peripheral Zone (Posterior prostate, in contact with rectum, 80% of gland volume and its the area of prostate cancer) + we can add anterior zone closest to abdomen, non-glandular fibromusclar tissue. |
| How is endoscopic anatomy of prostate? | Inside to Outside: • Trigone and ureteral orifices, • The median intravesical lobe, • The hypertrophied lateral lobes, • The external sphincter and the membranous urethra. • Verumontanum is the most important marker, the safety limit for the external sphincter. • The external sphincter begins just below the verumontanum, consisting of circular bands that fold when the cystoscope passes. |
| How is benign prostate hypertrophy pathophysiology? | Benign, very common, age related condition. Hyperplasia of transition zone, classically from right and left lobes of prostate but sometimes affects middle lobe on posterior face of bladder neck. It causes chronic obstacle of bladder emptying w/risk of repercussions on LUT (fight bladder), UUT (chronic obstructive renal failure) |
| How do we get fight bladder and chronic obstructive renal failure? | Dysuria is characterized by detrusor hypertrophy then appearance of trabeculations and vesical diverticula, in final stage when bladder is distended non-functional causes chronic retention w/overflow urination. Chronic obstructive renal failure (reflux and bilateral dilatation of pelvic calyx cavities can appear) But No anatomic-clinical correlation, and evolution is not systematically towards appearance of complications, can be latent only functional impairment, never becomes cancer but both are favored by aging. |
| What are risk factors for BPH? | Multifactorial, two most important are age and hormonal status. Some factors identified (age > 40 years and PSA >1.5 ng/dl) and prostate volume >40g |
| What are clinical presentation for BPH? | LUTS (obstructive [delayed, dysuria, weak jet, late drops], Irritations [Pollakiuria, urgency, urinary burns], LUTS of micturition phase [filling and post] Severity is assessed by IPSS score, causes impaired QoL, combination with sexual dysfunction is common so it is recommended to assess sexual function in questionnaire. |
| How is DRE in case of BPH? | - Digital rectal examination is systematically performed. It allows to diagnose BPH and to detect a possible prostate cancer associated within the same gland. - In the case of BPH, digital rectal examination will identify certain peculiarities of the prostate: the gland is enlarged in volume (> 20 grams), it is supple, painless, smooth, regular and is accompanied by a disappearance of median furrow. - A rectal examination suggestive of prostate cancer is an indication to perform prostate biopsies with pathological examination regardless of the PSA level. |
| What are acute complications of BPH? | Acute urinary retention (Painful bladder, urge to urinate, tx is urinary drainage placing foli or suprapubic cath) Infections (prostitis and orchiepididymitis) Hematuria (initially microscopic, considered BPH complication after elimination of other possible causes) Acute Obstructive Renal Failure (Acute retention of urine by BPH must be eliminated first) |
| What are chronic complications of BPH? | Chronic bladder retention (usually painless, w/out need to urinate expressed by pt, responsible for urination or overflow incontinence (too full bladder)) Blast Stasis Lithiasis (chornic stasis causes bladder stones causing hematuria or UTIs, seen by ASP and US) Chronic Obstructive Renal Failure (Bilateral dilation of the pyelocaliceal cavities is chronic and painless. Uretero-hydronephrosis is responsible for thinning of the renal parenchyma and chronic obstructive renal failure ) |
| What is DD of BPH? | ● Neurological bladder. ● Stenosis of the urethra favored by history of urethritis and trauma of the urethra (eg AVP, pelvic fracture, traumatic probing). ● Bladder neck disease. ● Infections like chronic prostatitis. ● Urinary stones. ● Bladder tumors characterized by the presence of hematuria. Important: Before any hematuria, it is necessary to exclude a bladder tumor by the performing a bladder fibroscopy, and imaging of the upper urinary system. |
| What are complementary exams in BPH? | PSA Rate (detect cancer associated w/BPH, if >4 indication for biopsy, specific for prostate gland but not cancer, can increase w/infection, ejaculation, age...) Creatinine (evaluate UUT and detects renal insufficiency) Cytobacterial exam of urine (eliminates any infection presence, can be eliminated by absence of leukocytouria and negative uroculture) Urodynamic Tests Measuring Flow (debimetry, Measures flow quantifies dysuria, volume must be >150 ml, sees volume, max flow, average flow and mictionnel, bell-shaped curve normal, flattenned is for obstruction/BPH max flow rate 10ml/s) US (sees repercussion on UUT see bilateral dilations of pyelocaliceal cavities thinning of renal parenchyma, impact on LUT detrusor hypertrophy, bladder diverticula, stones, post-void residue, prostate US transrectal/suprapubic, see volume and median lobe) Others (bladder fibroscopy, neuro bladder exam) |
| How do we choose the management? | - The different therapeutic alternatives depend on the importance of the urinary symptoms, the appearance of complications, and the patient's preference. The latter must be informed of the different therapeutic options and the advantages and disadvantages of each of them.. |
| What is indication of abstention/surveillance? | Indications: non complicated HBP, SBAU minmal/moderate w/out impaired QoL pt must be educated, informed and reassured about risk of progression of BPH Dietary and hygiene rules can be introduced mainly reduction of water intake after 18 hours, caffiene and alcohol reduction, constipation tx and cessation of drugs favoring dysuria (anticholinergics, neuroleptics...) |
| What is indication of medical tx? | Indications (uncomplicated HBP, moderate/severe SBAU impairing QoL, symptomatic tx 3 classes: a blockers [be careful of HTA, CAD, elderly], 5 a reductase inhibitors [prescribed prostate >40g, screening requires 2-fold increase in PSA], plants) medical tx may be combined if ineffective |
| What is indication of surgical tx? | Complicated HBP, SBAU moderate/severe resistant to medical tx, pt preference (it is the only cure, excise the adenoma can still develop from peripheral area left in place, 3 interventions [open surgery supra/retro pubic, cervicoprostatic incision [TUIP], Transurethral resection of prostate [TURP]) |
| What does HBP surgery need? | - Surgery for HBP requires a negative ECBU “Examen cytobactériologique des urines” After resection or enucleation, prostatic adenoma should be sent in anatomopathology in search of prostate cancer. |
| What is TURP syndrome? | Transurethral resection of prostate, rare intraop complication in relation to a large passage of hypotonic fluid into circulation, associates pt w/spinal anesthesia, visual disorders, headache, hypotension, bradycardia, and chest pain, these are related to volume overload and hyponatremia. Risk factors abundant are intraop bleeding and operation takes >90 mins, tx of TURP depends on natermia Moderate hyponatremia (>120) : water restriction and diuretics Severe hyponatremia : hypertonic saline w/slow perfusion but has a risk for central pontine myelinolysis. |
| What are the main chronic complications of BPH surgery? | Retrograde ejaculation. Risk varies depending on the intervention: AVH (high adenectomy) > RTUP > ICP (cervicoprostatic incision). Risk for erectile dysfunction and urinary incontinence are low |
| What are alternatives for BPH surgery? | - As an alternative to standard surgical treatments, new endoscopic techniques such as laser light (green laser light) “photo vaporization laser in French” or holmium laser enucleation (HoLEP), thermotherapy or radiofrequency can also be used. |
| How is paliative tx of BPH? | - In case of failure of the medical treatment, patients with an operative contraindication can be treated either by the insertion of an indwelling catheter or by a urethral stent. |
| How is monitoring for BPH? | - Follow-up of a patient with BPH is done with the help of: ● Interrogation with IPSS score. ● Flow measurement. ● Measurement of post-void residue. |
| How is epidemiology of prostate cancer? | Most common cancer in men >50 yrs, exceptional <40 yrs, second cause of mortality after broncho cancer, incidence in autopsy in pt >90 is 70%. highest in US lowest in china, mostly blacks. Incidence increasing due to screening and PSA assays. |
| What are risk factors for prostate cancer? | There are 2 groups at risk: ● Patients with a family history of prostate cancer (8%) especially with at least 2 collateral relatives or cancer in a parent under 55 years of age. ● Afro-Caribbean patients. (africo antillais in french) |
| How is screening for prostate cancer? | Screening in asymptomatic population Based on DRE and PSA dose, recommended age 50-75 if life expectancy <10 years Not recommended for men w/ life expectancy <10 years If PSA>4ng/ml uro consult is imp, for indication of US-guided biopsy |
| When is dx of prostate usually done? | In asymptomatic phase usually |
| How is the DRE findings for prostate cancer dx? | Systematically performed even if PSA normal, suspect cancer in peripheral zone Search for: hard irregular non-painful nodule (not necessarily cancer) or invasion of capsule,seminal vesicles or neighboring organs Any anomaly indicates biopsy |
| What are functional signs of prostate cancer? | Irritative/Obstructive urinary disorders (invasion of bladder trigone by prostate cancer) Hemospermia/hematuria General state alteration Bone pain (bone metastasis) Neurological signs (paresthesia, leg muscle deficit, cauda equina syndrome suggest spinal metastasis and compression. |
| What are clinical exam findings in prostate cancer? | ● Palpation of lumbar fossa. ● Edema of one of the lower limbs. ● neurological exam. |
| What is assay of serum PSA in prostate cancer? | Normal value is <4, Endourethral maneuvers, prostate biopsies and surgery lead to rise in PSA, while DRE, prostate massage, endorectal US or ejactulation lowers levels of PSA <1. Pt w/prostate hyperplasia taking 5a reductase inhibitors drugs should be taken into account when assessing PSA level |
| What is free PSA/total PSA report use in prostate cancer dx? | In prostate cancer free PSA is less elevated than in prostate hyperplasia, if ration >20% more in favor of hyperplasia and if <10% in favor of cancer/prostatitis |
| What are other markers used in prostate cancer? | PSA densities (for biopsies), PSA kinetics (for tx monitoring) |
| What is the usual location of prostate adenocarcinoma? | 70% of cancers sit in the peripheral zone of the prostate, accessible to rectal examination starting from a certain volume. 10% in the central area. 20% sit in the transition zone (which is the area of development of benign prostatic hyperplasia). |
| How is the extension of prostate adenocarcinoma? | Extends to periprostatic fat by capsular penetration, then to seminal vesicles by continguity (direct extension along ejaculatory ducts or from neighboring fat) Very rare rectal involvment in large tumors only, bladder neck/trigone/ureters involvement in locally evolved tumors. Ganglionic extension is pelvic first then retroperitoneal lumbar-aortic, or supra-diaphragmatic. Most frequent metastasis are ganglionic and bony, osteblastic lesions predominate in axial skeleton |
| How is tumor grading? | Gleason's classification, 5 subgroups from 1 (well-differentiated) to 5 (undifferentiated) according to tumor architecture. Prognostic value of gleason's classification is well-established much more unfavorable in less differentiated. Score 2-4 well-differentiated, 5-6 moderate, 8-10 little or no differentiation. |
| What are the indications for prostate biopsy? | Only affirmative exam, indicated in sus case on DRE or elevation of PSA, give dx, Gleason score, number of + biopsies, invasion, inflitration of capsule. |
| What is the modality of realization in prostate biopsy? | The biopsies are performed by ultrasonography, transrectally, under local anesthesia (or rarely general), under antibiotic prophylaxis and after rectal enema. The average number of biopsies is 12 samples. |
| What are complications associated with prostate biopsy? | The patient must be informed of the risks involved in performing biopsies: ● urine retention. ● perineal pain. ● vagal discomfort, hypotension. ● acute prostatitis (2% of biopsies), septicemia, septic shock, death. ● haemorrhagic complications (urethrorrhagia, rectorrhagia, hemospermia, hematuria) especially in patients on anticoagulants or antiplatelet agents. |
| How is endorectal echography used as imaging dx of prostate cancer? | Ultrasound of the prostate has no place in the diagnosis of prostate cancer. Its only use in prostate cancer is guiding biopsies. |
| How is MRI used in dx of prostate cancer? | Test for dx and prognosis, see diffusion and hypervascularization. recommended in cancer of intermediate/high risks to assess site, infiltration and seminal vesicles invasion. Can dx, can guide biopsy, can reveal pelvic lymphadenopathy or bone lesions. |
| How is use of abdominal CT in prostate cancer? | Abdominopelvic CT is one of the recommended tests in prostate cancer extension assessment. It may reveal pelvic and retroperitoneal lymphadenopathy or osteoconductive lesions. It can also highlight other tumoral pathologies. |
| How is the use of bone scintigraphy in prostate cancer? | Scintigraphy remains the reference examination for the search for bone metastases by the presence of foci of hyperfixation. Its limit remains its low specificity. In high and intermediate risks D'Amico cancer classification (3 classes low [PSA<10, score <6 T1] intermediate [PSA 10-20, score 7] and high risk [PSA >20, score >8 T2c]) |
| How is use of PET scan w/choline in prostate cancer? | It remains inferior to bone scintigraphy for the diagnosis or follow-up of bone metastases. It is not currently recommended, except in case of biological progression of the cancer after treatment. |
| How is active monitoring in tx of prostate cancer? | The indication for active surveillance is therefore a clinically localized prostate cancer with a low risk of progression for patients whose life expectancy is greater than 10 years. And for : - Patients in the low risk group Amico (PSA <10 ng / mL and Gleason ≤ 6 and T1c or T2a). - 1 to 2 biopsy cores positive on at least 10 samples. - Tumor length <3 mm in total on the sample. |
| What is surgery done for prostate cancer? | Classically, the intervention is performed abdominal retropubic. In the absence of metastases, enlarged total prostatectomy is performed, with monoblock removal of the prostate and seminal vesicles followed by vesico-urethral anastomosis. Ganglion dissection of Prostate Cancer involves removal of the external iliac-iliac, iliac, and lateral iliac nerves to the iliac bifurcation. |
| What are surgical complications associated w/prostate cancer removal surgery? | Urinary incontinence (Mostly transient and recovery aided by perineosphincteritic reeducation, majority are continent w/in 3-6 months) Stenosis of Vesico-urethral anastomosis (0.5-9% of cases favored by prior transurethral resection, intraop bleeding or fistulas, may require one or several dilatations) Erectile dysfunction (always if no conservation of neurovascular pedicles of erection) Infertility and Anejaculation (cst after this surgery) |
| How is hormone therapy medical tx of prostate cancer? | The hormonal treatment of prostate cancer, in case of locally advanced or metastatic disease, aims to reduce circulating testosterone. Castration, whether medical or surgical, is the standard treatment. In cases of chemical castration by LH-RH analogues, the treatment is uninterrupted. Its usual side effects are low libido and erectile insufficiency, hot flashes and sometimes gynecomastia. In the long term, castration can be responsible for osteoporosis with risk of fractures, but also of amyotrophy, anemia or depression. |
| How is complete androgenic blockage as medical therapy for prostate cancer? | Complete androgen blockade (BAC) combines the Luteinizing Hormone-Releasing Hormone (LHRH) agonist with the peripheral antiandrogen. LHRH Antagonist or Agonist The LHRH antagonist allows faster castration than LHRH agonists and does not expose to a peak of testosterone (flare-up). |
| How is radiotherapy in prostate cancer? | Radiotherapy consists of image-guided irradiation of the prostatic lodge at a dose of 76-78 Gy. It is also a curative treatment. It is now used according to a three-dimensional conformational technique, and aims to reduce the side effects related to the irradiation of adjacent organs. However, patients may complain about: - Radiation cystitis; - Radiation rectitis; - Urethral stenosis; - erectile dysfunction; - Radiation-induced tumor with a relative risk of 1.5 for cancer of the rectum or bladder. |
| What are CI of radiotherapy in prostate cancer? | Contraindications include antecedents of anterior pelvic irradiation or rectal inflammatory disease. Radiation therapy may be associated with short-term hormonal therapy of 6 months for cancers at intermediate risk or long-term 3 years for cancers at high risk of progression. |
| How is brachytherapy in prostate cancer? | Interstitial prostate brachytherapy involves the placement of transperineal radioelements under ultrasound, endorectal and general anesthesia control. Most often, it involves the implantation of 125 I iodine grains. The indication to date of brachytherapy is mainly for patients with localized prostate cancer and low risk D'Amico having a life expectancy of more than 10 years. The risks are the same as those of external irradiation. |
| How is focused US/crytherapy (HIFU) in tx of prostate cancer? | This treatment has the purpose of destroying by focused ultrasound the prostatic tissue produced under general anesthesia and associated with a prostatic resection. The ideal indication is the treatment of recurrent cancers locally after radiotherapy. The risks are the risks associated with anesthesia, transfusion, infection, stenosis, urethrectal or prostatectal fistula, incontinence and erectile dysfunction. Cryotherapy is the only indication of local recurrence after radiotherapy |
| How is chemotherapy in tx of prostate cancer? | Chemotherapy has a recognized place in metastatic prostate cancer resistant to castration and symptomatic. |
| What is the all-in-all therapeutic strategy in prostate cancer? | ● localized prostate cancer: active surveillance or curative treatment (by surgery or radiotherapy). ● locally advanced prostate cancer: curative treatment by surgery in young subjects or hormone-radiotherapy. ● metastatic prostate cancer: hormone therapy. ● prostate cancer in the castration resistance phase: hormonal manipulation with little symptomatic symptoms (androgenic withdrawal syndrome, DistilbeneR, new hormonal therapies) or so symptomatic chemotherapy (bone pain ...). ● and do not forget: 100% care, comfort care (treatment of pain, urinary disorders ...). Surveillance of at least 10 years based on clinical (TR) and biology (PSA level, testosteronemia) is recommended |
| What are urinary stones? | Crystals and protein matrix, 4 steps to form (supersaturation, nucleation, aggregation, crystal retention) Gall stones is a very frequent pathology, 5-10% of general population, age 20-60 male:female 3:1 tripled incindence at age 40, very frequent recurrence (more than 60% over 10 years) Targets mostly high UT (pyelocaliceal cavirties/ureters) but also in bladder sometimes Multidisciplinary tx. |
| What are main ailmentary risk factors for developing stones? | ✔ Alimentary intakes: o Dairy products. o Animal proteins. o Salt (favorizes the hypercalciuria). o Aliments rich in oxalate (chocolate, dry fruits, spinach, sorrel, rhubarb, thea). o Purines (giblets, delicatessen,…). o Rapid sugars (fructose). ✔ The decrease in alimentary fibers consumption. ✔ The insufficient diuresis by the insufficiency in liquid intakes. |
| What are familial and urinary infection risk factors for stones? | A- Familial factors: - We find a familial history in approximately 40% of cases. The cystinuria is the genetic disease mostly frequently found in this context. b- Urinary infection: - Certain germs, like proteus mirabilis, klebsielle and pseudomonas include the enzyme urease, which degrades the urea into a protein matrix upon which mineral salts precipitate in order to form phosphoammoniaco-magnesium stones. They mainly originate from coralliform stones= struvite |
| What are coraliform stones? | - Coralliform stones: designate stones that have radiologically coral shape, because they mold the pyelon, the calyces and the calyceal diverticulum. We equally talk of complex stones of the kidneys. |
| What are pH anomalies risk factors of stones? | - The normal urine pH is 5.8. - An acidic pH favorized the formation of uric acid stones, cystine and calcium oxalate. - An alkaline pH favorizes the infectious lithiasis and phospho-calcium stones. |
| What are anatomic anomalies risk factors for stones? | - Certain anatomic anomalies of the kidneys or the excretory tract favorize urinary stasis and, thus, stones formation. - Once the diagnosis is imposed, we need to treat the stone and the anatomic anomaly, if possible, in order to avoid recurrences. - We can name some anatomic anomalies such as pyelo-ureteral junction syndrome, calyceal diverticulum, the horsehoe kidney «arcuatus » , the mega-ureter , and the vesico-ureteral reflux. |
| What are medications causing stones? | Drugs causing it are infrequent 1%, may be metabolic disorder caused by it or crystallization w/metabolites. Most one is indinavir (anti-HIV protease) may be alkaline and solublized in acid, not visible in ASP and scan If indinavir causes lubar pain stop tx aviod NSAIDs, increase diuresis and obtain urine acidity. |
| How is the revealing mode of lithiasis? | - The lithiasis urinary disease mainly affects the upper urinary tract. - The most common mode of revealing is renal (nephritic) colic crisis. It is then a question of knowing how to recognize the signs of seriousness which can be vital prognostic. - However, urinary stones can be asymptomatic and discovered incidentally during imaging (ASP, reno-vesical ultrasound), or the assessment of chronic renal failure. - Low urinary tract lithiasis is restricted to highly targeted patient populations, such as patients with severe neurological conditions (particularly para- and quadriplegic patients). It always translates a bad bladder emptying which will have to be followed up and treated to avoid the recidivism (tendency to relapse). |
| What is nephritic colic crisis caused by lithiasis? | 80% of renal colics are caused by stones in adults, acute lumbo-abdominal pain from severe tension of excretory tract of UUT upstream of an obstruction. Pressure increase is due to (edema generated in contact w/calculus promoting retention of overlying urine and block of calculus passage, or due to stimulation of vasodilator E2 PGs due to intracavitary hyperpressure) |
| How is the typical renal colic decription? | ● • Brutal (severe) start. ● Acute pain, without analgesic position. ● Unilateral lumbar pain, radiating downwards and forwards along the ureter to the external genitals. ● Evolution by paroxysmal crisis. ● Agitation and anxiety. ● Urinary functional signs: pollakiuria (extraordinary daytime urinary frequency), urinary burns, hematuria (if the calculus is at the level of the uretero-vesical junction). ● Digestive signs: nausea, vomiting, transit stop (ileus), see pseudo-occlusive table. |
| What are clinical exam findings of renal colic? | ● Interrogation: personal and family history of urolithiasis, taking of lithogenic drugs, search for factors favoring renal colic. ● Apraxia (is the normal interval or period of intermission in a fever. Also, the absence of a fever). ● Soft abdomen, sometimes bloat. ● Lumbar fossa sensitive to palpation and percussion ((Positive lumbar ponch). ● Renal colic is resolvable in the majority of cases under symptomatic analgesic treatment well conducted. |
| How is complicated renal colic? | - Is characterized either by the field (pregnancy, chronic renal insufficiency, transplanted kidney, single kidney, known uropathy, pyelonephritis ...), or by the existence immediately or secondarily of signs of gravity. - It requires urgent surgical drainage of the urine (either by JJ probe or by nephrotomy). |
| What is febrile nephritic colic/obstructive pyelonephritis? | This is a medical and surgical emergency. It corresponds to infected urine upstream of an obstructive calculus of the upper urinary tract and infection of the renal parenchyma. - The main clinical signs are: • Fever> 38 ° C. • Chills. • Skin marbrures, hemodynamic instability. • Positive urine strip (leucocytes +, nitrite +, + bacteria). |
| What is anuric renal colic? | Three mechanisms are at its origin: • Functional acute renal insufficiency of septic origin. • Bilateral calculi = rare situation, reflection of a very active lithiasis pathology (cystinuria, primary hyperparathyroidism, important hyperuricemia-hyperuricuria...). • Single kidney: congenital, remnant or functional. • It results in acute renal failure with a very high elevation of creatinine and frequent ionic disorders (hyperkalemia). |
| What is hyperalgic nephritic colic? | - It corresponds to a pain of nephritic colic not calmed by a symptomatic analgesic treatment well conducted with use of NSAID IV and morphine IV in titration. - It then requires hospitalization with reassessment of pain. If the pace and severity of crises do not disappear, emergency urine drainage is necessary. - Sometimes, the pain arises suddenly. This corresponds to the rupture of the excretory pathway or rupture of fornix (junction of the excretory pathway on the renal straw) . In this case, if the obstacle persists, it can cause a large perineal urinoma, also requiring emergency drainage of the excretory tract. |
| What is the DD of lithiasis? | GI (hepatic colic, cholecytisis, diverticulitis, appendicitis, strangulated inguinal hernia) GYN (ectopic pregnancy, torsion ovarian/appendix) Medical pathology (pneumonia, lumbar osteoarthritis) Vascular pathology (abdominal aortic aneurysm, mesenteric infarct) Segmental renal infarct Papillary necrosis. |
| How is hematuria in lithiasis? | -It is most often microscopic discovered with the urinary strip but can be macroscopic. - It results from irritation of the urothelium by calculi. |
| How are urinary infections in lithiassi? | - The urinary-lithiasis infection association is frequent. However, it is difficult to determine whether the calculus was secondarily infected or whether the infection preceded the calculus and was responsible for its formation. - Several situations are possible: • Asymptomatic bacteriuria. • Recurrent cystitis. • Recurrent pyelonephritis |
| How is renal insufficiency in lithiasis? and asymptomatic? | The kidneys can be destroyed by bilateral asymptomatic stones. It is most often coralliform stones. ✔ Asymptomatic: - An asymptomatic calculus can be discovered accidentally on an ASP, an ultrasound or a scanner made for other reasons. |
| How are LUT lithiasis? | - The stones of the lower urinary tract (bladder, urethra) are more rare. - The bladder stones are most often the fact of a subvesical obstacle (benign prostatic hypertrophy, cervical sclerosis), or an intravesical foreign body (son?(fils), bladder catheter balloon). - They are usually found in front of functional urinary signs: hematuria, urinary burns, pollakiuria. -In contrast, in well-targeted populations, lithiasis of the lower urinary tract is very common. This is mainly the case of neurological patients with severe motor impairment: quadriplegia, advanced multiple sclerosis ... |
| What is urine strip test for dx of lithiasis? | Rapid detection of hematuria or UTI, any pt presenting sus acute renal colic, long-term care measures urine pH and follow-up. excellent test, sensitive enough detects leukocyturia >10^4/ml Nitrite detection indicates bacteria, threshold 10^5 Negative if no leukocyturia/bacteruria, risk for false negative very low (3%) but possible for nitrite case of low bacteriuria, nitrate restricted diet, infection by atypical bacteria not producing nitrite) |
| How are cytologies of urine in lithiasis dX? | - Is to be performed in addition to the urine test strip if it is positive. - It is essential in case of suspicion of obstructive pyelonephritis and must be performed before any antibiotic therapy. - A culture and an antibiogram must be carried out in order to secondarily adapt the antibiotherapy. |
| How are blood cultures and std biology for lithiasis dx? | C- Blood cultures : - They must be carried out systematically and repeatedly in a fever> 38.5 ° C during obstructive pyelonephritis. - They allow detecting a possible sepsis. d- standard Biology : - FNS. - Creatinine. - Ionogram (Na, K, Cl, CO2). |
| What is metabolic balance of first intention in dx of lithiasis? | ● A blood test: serum creatinine, serum calcium, fasting blood glucose, serum. ● A collection of urine over 24 hours: creatinine, total volume, calcium, sodium, urea, urates. ● A report (test/collection of) on morning urine (fasting): pH, density, dipstick test* (en francais, BU: bandelette urinaire), crystalluria. - The conditions for 24-hour urine collection must be precise. - It is important that the patient does not change his eating habits for the achievement of this test (bilan in French, probably means test/report). - It must be done more than one month after an acute episode or urological. |
| What is IR spectrophotometry used in lithiasis dx? | - It can be performed on spontaneously expelled stones or on fragments collected after treatment. - It makes it possible to precisely determine the molecular and crystalline composition of the calculi. - Depending on the composition and structure of the calculation, different causes may be proposed. |
| What is use of radio examinations in lithiasis dX? | - In emergency, the imaging examinations are indicated to affirm the diagnosis of renal colic (dilation of the superior excretory way, calculi...), to evaluate the gravity (single kidney, urinoma ...), and to specify the chances of spontaneous expulsion. Calculi (size, location and morphology). - Their indication and the acceptable time to obtain them are dependent on their accessibility and the clinical context (simple NC*, complicated NC*, special fields, diagnostic doubt...). - Imaging is also essential before an invasive urological treatment to better specify the morphology of the urinary tract and the characteristics of the calculation. |
| What is KUB use in lithiasis dx? | - Very easy to perform in an emergency. However of poor sensitivity and specificity in providing evidence of the presence of a calculi (40 to 58% and 60 to 77% respectively). - Therefore, KUB should not be done in isolation (alone) and should be coupled with another imaging test. - Moreover, it only informs about the presence of a stone and not about the possible complications. - Calculi are considered opaque to x-rays (radiography), or simply radiopaque, when they are seen on KUB. - Calculi are considered radiolucent (radio-transparent) when they are only visible on echography (ultrasound). Radiolucent (radio-transparent) calculi are seen on the scanner. - When the calculus is visualized on the KUB, it can be used to follow the progress of the calculus. |
| What is use of reno-bladder US? | - Noninvasive, inexpensive and fast, but operator-dependent. - The ultrasonography (echograpghy) of the excretory urinary pathways is associated in combination with KUB and can be used in the management (treatment) of renal colic in emergencies. - It best detects the stones located at the pyelo-ureteral and uretero- bladder junction, especially if it is performed with full bladder. - The calculus appears hyperechoic, with posterior acoustic shadowing |
| How does reno-bladder US confirms lithiasis dx? | - It confirms the clinical diagnosis of NC by objectifying (showing) a dilation of the pyelocaliceal cavities and / or the ureter (image). However, any dilatation does not mean obstruction (hypotonic sequelae (or sequential Hypotonia – both are correct) of an obstacle, bladder distention during the examination), and any obstruction does not immediately result in an expansion that can appear a few hours later (20 to 30% of the sudden obstructions on ureteral calculus are not identified (or objectified since the French document said objectivées). - It also describes the renal parenchyma, a thinning which can be explained by a chronic obstacle. |
| How is use of abdominal CT w/out contrast in lithiasis dx? | - It is a quick test, independent of the patient and the operator, but radiating. - ALL calculi are visible on the scanner, apart from the medical calculi (I asked a fellow French student about this sentence and apparently it is translated into exactly). CT without injection has a very high sensitivity (96%) and specificity (98%) for the diagnosis of urolithiasis and detects millimeter calculations. - In addition to the direct visualization of the calculus, other indirect signs can help in the diagnosis: dilation of the pyelocaliceal cavities, infiltration of the perirenal or peri-ureteral fat, thickening of the ureteral wall with next to (near) the calculi (rim sign)… (image 10). - In addition, the scanner makes it possible to measure the Hounsfield density/unit (HU) of the stones and thus to orient towards a particular composition of the calculi and to predict the effectiveness of the ECL |
| What are treatment modalities of lithiasis in cases of emergency? | - Treatment (management) in case of an emergency is mainly that of renal colic and aims to relieve the patient when it is simple, and to divert urine in emergency (I guess he means introducing a catheter to empty the urine) when it is complicated. |
| What is tx of simple renal colic? | ✔ Non-steroidal anti-inflammatories: - Two mechanisms of action: ● They block the cyclo-oxygenases involved in the inflammatory cascade. They reduce local edema and inflammation and lead to relaxation of the smooth muscle fibers of the ureter, thus reducing (decreasing) peristalsis. ● They decrease the glomerular filtration rate. Analgesics: • Level 1 (paracetamol): in combination with NSAIDs in case of low intensity pain. • Level 3 (morphine):in case of contraindication to NSAIDs. In combination with NSAIDs in the case of significant pain. In case of resistance to NSAID therapy., To be used in the form of IV titration of morphine hydrochloride. Water restriction if painful phase, urine seiving |
| How is tx of complicated acute renal colic? | - The treatment is then surgical and consists of draining urine from the upper urinary tract. - Urine drainage is in the majority of cases ensured by a ureteral catheter, which can be internal (then called probe JJ), or external - In the case of the JJ probe, the upper loop has its place in the ( pyelon)??? and the lower loop in the bladder. - The external ureteral catheter is often preferred to the JJ probe in case of purulent pyelic urines. In this case, the conversion to JJ probe is generally performed after 48 hours of apyrexia. |
| What are managements in case of drainage failure? | - In case of failure of drainage of the urine by the natural ways, a percutaneous nephrostomy is carried out under ultrasound control. Its installation requires dilated pyelocalicielles cavities. - In all cases, a pyelic urine sample must be taken intraoperatively for bacteriological analysis. |
| How is management in case of obstructive pyelonephritis? | - In case of obstructive pyelonephritis, parenteral antibiotic therapy should be instituted as soon as possible after the bacteriological samples taken: • Associating a C3G with an aminoglycoside. • Secondarily adapted to the antibiogram. • Oral relays can be considered at 48 hours of apyrexia. • Total duration of 10 to 21 days. |
| What is extracorporeal lithotripsy (ECL) surgical tx of lithiasis? | - This is a non-invasive method. - Principle: an extracorporeal generator produces acoustic waves. These are focused on the calculation by a radiological tracking system in order to spray it. - Technique: performed on an outpatient basis, under simple sedation. An ECBU must be done a few days before and an ASP the day before to check that the calculus is still in place. - Indications: first-line for the treatment of kidney stones <20 mm. Radiopaque stone (they must be visible at the ASP), density <1000 UH. Reference treatment in children. |
| What are CI and complications of ECL? | - Contraindications: o Pregnancy. o Untreated urinary infection. o Obstacle downstream of the stone. o Aneurysm of the renal artery or aorta. o Uncorrected bleeding disorders. - Complications: o CN post-LEC by migration of residual fragments (20%). o hematuria. o Urinary infections. o Renal hematoma. |
| What is ureteroscopy surgical tx of lithiasis? | - Principle: retrograde natural introduction of a ureteroscope to visualize and work in contact with the stones. - Extraction of the calculus at the laser ± fragmentation clamp. Risk of ureteral lesions (perforation, stripping). - Indications: o LEC-resistant stone (density> 1000UH), or contraindication of LEC. o In competition with LEC for kidney stones <2 cm. o Stones of the pelvic ureter. - Complications: o hematuria. o Pain of renal colic by ureteral clot. o Urinary infection. |