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GYN / GU
AnatomyFascia surrounding kidney? Gerota’sList the hilar structures in order from anterior to posterior.Vein, artery, pelvisThe right renal artery lies ____ to the IVC.PosteriorThe ureters cross _____ the Iliac vessels.OverMost 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 CATrue/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
SeminomaTrue/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 tumorsTrue/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? PosteriorMost common site of metastasisBone (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 LungTreatment 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 lungMet from colonPrimary Renal cell CAMet 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/ schistosomiasisSquamous 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
• Treatmentb/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 BPHAlpha-blockers and 5-alpha-reductase inhibitors
Side effect of TURPRetrograde 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 penisPenectomy w/ 2cm margins
Used to test for leaks.Indigo carmine or methylene blue
HypospadiusVentral
EpispadiasDorsal
Varicocele of the left gonadal veinSuspicious for renal tumor compressing
renal veinSuccess rate of vasectomy reversal
50%
Phimosis – failure of foreskin to retract.Can treat w/ surgery and topical steroids.
Infundibular
ligamentRound
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 ectopicPrevious tubal manipulation, PID, hx of ectopic
Endometriosis
SymptomsVaginal bleedingDysmenorrheaInfertilityDyspareuniaBlue mass on rectal edoscopy
Most common site of endometriosisOvaries
TreatmentOCPs
DiagnosisLaparoscopy
Pt comes in with fever, pain, nausea, vomiting, and vaginal discharge during menstration.PID
Risk factorSleeping w/ Davidyock
TreatmentRocephin, 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 CASquamousAdenocarcinomaTransitional CAClear CellRhabdosarcoma
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 risknulliparity, late menopause, early menarche (ie. Estrogen exposure)
Decreased riskOCPs 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 CADebulking followed by chemo (cisplatin and taxol
Initial site of spreadOther ovary
What is Meige’s syndromePelvic 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
• I - confined to endometrium
• II – Cervix
• III – Vagina, Peritoneum, ovary
• IV – Bladder, Rectum
• TAH or XRT
• TAH or XRT
• TAH and XRT
• TAH and XRT
Cervical cancer is associated with HSV?16 and 18
Most common typeSquamous
Nodal basinObturator
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 –TAHIf 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.
RandomContraindications to estrogen therapy
endometrial CA, thromboembolic disease, undiagnosed vaginal bleeding, breast CA
Most common vaginal tumorInvasion of surrounding or distant structure
Appendicitis in pregnancyIncreased risk of premature labor and fetal mortality.
Remember always treat mother as if not pregnant in life and death situations. No mother no baby.