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.