GYN / GU

Anatomy Fascia surrounding kidney? Gerota’s List the hilar structures in order from anterior to posterior. Vein, artery, pelvis The right renal artery lies ____ to the IVC. Posterior The ureters cross _____ the Iliac vessels. Over Most common cause of acute renal failure after surgery. Hypotension

Kidney Stones Most common stone Calcium oxalate Struvite Uric Acid Cysteine

Which stones are radiopaque? Calcium oxalate Struvite Uric Acid Cysteine

Indications for surgery Intractable pain or infection Progressive obstruction Progressive renal damage Solitary kidney > 4mm

Testicular CA True/False Number one cancer killer age 25-35 Not all testicular masses require surgery Perform orchiectomy via trans scrotal incision Mets go to lung, retroperitoneum and mediastinum 75% are Germ cell – seminoma or non seminoma LDH correlates w/ tumor bulk

Seminoma True/False #1 Testicular tumor All are have beta-HCG elevation All have AFP elevation Spread to retroperitoneum Are treated w/ chemotherapy (Cisplatin, bleomycin, VP-16) All require XRT

Nonseminomatous tumors True/False Are made up of Embryonal, Teratoma, Choriocarcinoma, Yolk sac 90% (+) HCG and AFP Teratomas not likely to spread to retroperitoneum Require prophylactic retroperitoneal node dissection All stages are treated w/ XRT, orchiectomy, and chemo

Prostate CA Most likely present in anterior or posterior lobe? Most common site of metastasis Bone (check Alk Phos) All stages require prostatectomy Intracapsular depend on age/health Extracapsular treated w/ Leupron, flutamide, b/l orchiectomy, ketoconazole, XRT (bone pain) PSA should go to 0 after 3 weeks

Renal Cell CA Most common site of metastasis Lung Treatment of lung or colon mets Metastectomy (1/3 have mets) Growth into the IVC precludes resection NO! Can pull tumor thrombus out. Adrenal gland is spared during radical nephrectomy NO! Includes Kidney, adrenal, fat, gerota’s fascia and regional lymph nodes

Most common tumor of the kidney Met from lung Met from colon Primary Renal cell CA Met from Breast

What is Von Hippel-Lindau Syndrome Multifocal and recurrent RCC, Renal Cyst, CNS tumors, and Pheochromocytomas

Which of the following are associated RCC paraneoplastic syndromes? Erythropoieten PTHrp Glucogon Insulin ACTH Aldosterone

Bladder CA Type of bladder CA associated w/ schistosomiasis Squamous CA Most bladder CA is transitional

True/False May treat with intravesical BCG or transurethral resection if muscle not involved. Muscle wall invasion = T3 or greater Treatment of >T2 is cystectomy, chemo and XRT Causes painful hematuria

Testicular torsion Peaks at age 10 Usually testicle is viable Torsion is toward the midline Treatment b/l orchiopexy or resection of involved testicle w/ orchiopexy of contralateral testis

Ureteral trauma Type of suture used and why. Absorbable to avoid stone formation Should always stent and leave drain? To avoid stenosis and to identify/treat leak

What is post TURP syndrome? Hyponatremia second to irrigation, which can precipitate seizures from cerebral edema. Treatment of BPH Alpha-blockers and 5-alpha-reductase inhibitors Side effect of TURP Retrograde ejaculation

Neurogenic Bladder Neurogenic Obstructive Bladder Injury above T12 Injury below T12 Incomplete emptying Frequent urination Treated w/ surgery Treated w/ catheratization

Name types of incontinence Stress Urge Neuropathic Overflow Congenital

Treatment of SCC of penis Penectomy w/ 2cm margins Used to test for leaks. Indigo carmine or methylene blue Hypospadius Ventral Epispadias Dorsal Varicocele of the left gonadal vein Suspicious for renal tumor compressing renal vein Success rate of vasectomy reversal 50%

Phimosis – failure of foreskin to retract. Can treat w/ surgery and topical steroids.

Infundibular ligament Round ligament

Abortion Missed – 1st trimester bleeding, closed os, positive sac on US, no heartbeat Treatened – 1st trimester bleeding, heartbeat Incomplete – tissue in os Ectopic – acute abd pain, (+) HCG, negative US, missed period, vaginal bleeding, hypotension

Ectopic Level of HCG which raises ??? 3000 If < repeat in 48hrs (>66% - US) 3 risk factors for ectopic Previous tubal manipulation, PID, hx of ectopic

Endometriosis Symptoms Vaginal bleeding Dysmenorrhea Infertility Dyspareunia Blue mass on rectal edoscopy

Most common site of endometriosis Ovaries Treatment OCPs Diagnosis Laparoscopy

Pt comes in with fever, pain, nausea, vomiting, and vaginal discharge during menstration. PID Risk factor Sleeping w/ Davidyock Treatment Rocephin, Doxy

Chlamydia HSV Syphillis Gonorrhea Chancre Vessicle Granuloma lymphadenopathy Foul thick discharge w/ GNC

Due to a ruptured ovarian follicle which occurs 14 days after menses and can be confused with appendicitis. MITTELSCHMIRTZ

Type of cancer associated with vaginal CA Squamous Adenocarcinoma Transitional CA Clear Cell Rhabdosarcoma Treatment is XRT

Vulvar CA Associated w/ multiparous, thin, elderly Usually unilateral <2cm treated with WLE and ipsilateral inguinal lymph node dissection >2cm Vulvectomy, ipsilateral ILN dissection XRT if margin <1 cm

Ovarian CA Increased risk nulliparity, late menopause, early menarche (ie. Estrogen exposure) Decreased risk OCPs and bilateral tubal

Types of ovarian CA Teratoma Granulosa-theca Sertoli-Leydig Struma ovarii Choriocarcinoma Mucinous Serous Papillary Thyroid tissue Estrogen secreting beta-HCG Androgen secreting

Staging One or both ovaries Distant metastases Limited to pelvis Spread thoughout abdomen Stage I Stage II Stage III Stage IV

Treatment of Ovarian CA Debulking followed by chemo (cisplatin and taxol Initial site of spread Other ovary

What is Meige’s syndrome Pelvic ovarian fibroma which ruptures and leads to ascites and hydrothorax. How do you treat? Resection of tumor resolves symptoms

Krukenberg tumor Stomach CA which metastasized to ovary

Pt is a 50 yo female w/ hx of breast CA who now appears with vaginal bleeding. DX: Endometrial CA

Endometrial CA Most common malignant tumor in female genital tract. Serous and Papillary – worst prognosis Risk factors – nulliparity, late 1st preg, obesity, unopposed estrogen, tamoxifen

Endometrial staging TAH or XRT I - confined to endometrium II – Cervix TAH and XRT I - confined to endometrium II – Cervix III – Vagina, Peritoneum, ovary IV – Bladder, Rectum

Cervical cancer is associated with HSV? 16 and 18 Most common type Squamous Nodal basin Obturator

Cervical staging I – Cervix II – Upper 2/3 of vagina III – Pelvis, side wall, lower 1/3 vagina, or hydronephrosis IV – Bladder, rectum Stages I & IIa – TAH Stages IIb to IV - XRT

Ovarian Cyst US demonstrates septation, Increased vascular flow, solid components, or papillary projections? If postmenopausal – oophorectomy w/ intraop frozen and if CA –TAH If premenopausal – oophorectomy w/ intraop frozen and if CA need to decide how aggressive and if pt wants children

Incidental Ovarian mass at time of laparotomy Follow same algorithm as for cyst.

Random Contraindications to estrogen therapy endometrial CA, thromboembolic disease, undiagnosed vaginal bleeding, breast CA Most common vaginal tumor Invasion of surrounding or distant structure Appendicitis in pregnancy Increased risk of premature labor and fetal mortality. Remember always treat mother as if not pregnant in life and death situations. No mother no baby.