Eight hours after undergoing an open right hemicolectomy and a colostomy for colon cancer, a 52-year-old man has wet and bloody surgical dressings. He has had episodes of blood in his stools during the past 6 months, which led to the detection of colon cancer. He has hypertension and ischemic heart disease. His younger brother died of a bleeding disorder at the age of 16. The patient has smoked one pack of cigarettes daily for 36 years and drinks three to four beers daily. Prior to admission, his medications included aspirin, metoprolol, enalapril, and simvastatin. Aspirin was stopped 7 days prior to the scheduled surgery. He appears uncomfortable. His temperature is 36°C (96.8°F), pulse is 98/min, respirations are 14/min, and blood pressure is 118/72 mm Hg. Examination shows a soft abdomen with a 14-cm midline incision that has severe oozing of blood from its margins. The colostomy bag has some blood collected within. Laboratory studies show: Hemoglobin 12.3 g/dL Leukocyte count 11,200/mm3 Platelet count 210,000/mm3 Bleeding time 4 minutes Prothrombin time 15 seconds (INR=1.1) Activated partial thromboplastin time 36 seconds Serum Urea nitrogen 30 mg/dL Glucose 96 mg/dL Creatinine 1.1 mg/dL AST 48 U/L ALT 34 U/L γ-Glutamyltransferase 70 U/L (N= 5–50 U/L) Which of the following is the most likely cause of this patient's bleeding?

Insufficient mechanical hemostasis

A 57-year-old man presents with acute-onset nausea and left flank pain. He says his symptoms suddenly started 10 hours ago and have not improved. He describes the pain as severe, colicky, intermittent, and localized to the left flank. The patient denies any fever, chills, or dysuria. His past medical history is significant for nephrolithiasis, incidentally diagnosed 10 months ago on a routine ultrasound, for which he has not been treated. His family history is unremarkable. The patient is afebrile, and his vital signs are within normal limits. On physical examination, he is writhing in pain and moaning. Severe left costovertebral angle tenderness is noted. Gross hematuria is present on urinalysis. A non-contrast CT of the abdomen and pelvis reveals a 12-mm obstructing calculus at the left ureterovesical junction. Initial management, consisting of IV fluid resuscitation, antiemetics, and analgesia, is administered. Which of the following is the best next step in the management of this patient?

Percutaneous nephrostolithotomy (PCNL)

Extracorporeal shockwave lithotripsy (ESWL)

A 61-year-old man comes to the physician because of several episodes of dark urine over the past 2 weeks. He does not have dysuria or flank pain. He works in a factory that produces dyes. Since an accident at work 5 years ago, he has had moderate hearing loss bilaterally. He takes no medications. He has smoked a pack of cigarettes daily for 29 years and drinks one alcoholic beverage daily. Vital signs are within normal limits. Physical examination shows no abnormalities. His urine is pink; urinalysis shows 80 RBC/hpf but no WBCs. Cystoscopy shows a 3-cm mass in the bladder mucosa. The mass is resected. Pathologic examination shows an urothelial carcinoma with penetration into the muscular layer. An x-ray of the chest and a CT scan of the abdomen and pelvis with contrast show a normal upper urinary tract and normal lymph nodes. Which of the following is the most appropriate next step in management?

Transurethral resection of tumor with intravesical BCG instillation

Transurethral resection of tumor with intravesical chemotherapy

Three hours after undergoing open proctocolectomy for ulcerative colitis, a 42-year-old male complains of abdominal pain. The pain is localized to the periumbilical and hypogastric regions. A total of 20 mL of urine has drained from his urinary catheter since the end of the procedure. Temperature is 37.2°C (98.9°F), pulse is 92/min, respirations are 12/min, and blood pressure is 110/72 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 99%. Physical examination shows a 20 cm vertical midline incision and an ileostomy in the right lower quadrant. There is no fluid drainage from the surgical wounds. The urinary catheter flushes easily and is without obstruction. Cardiopulmonary examination shows no abnormalities. Serum studies show a blood urea nitrogen of 30 mg/dL and a creatinine of 1.3 mg/dL. Which of the following is the most appropriate next step in management?

Administer intravenous furosemide

Renal cell carcinoma surgery for USMLE Step 2 CK: High-Yield Surgery Lessons

🗺️ Anatomy - Kidney's Surgical Map

Kidney and surrounding fascial layers (axial view)

Surgical Layers (Superficial → Deep):
- Pararenal fat
- Gerota's (Renal) Fascia: Encloses kidney & adrenal.
- Perirenal (Perinephric) fat
- Renal Capsule: Adherent to parenchyma.
Renal Hilum (Anterior → Posterior):
- 📌 VAP: Vein, Artery, Pelvis.
Vascular Landmarks:
- Right Renal Artery: Longer, passes posterior to IVC.
- Left Renal Vein: Longer, passes between SMA & Aorta.

⭐ The left renal vein receives the left gonadal and adrenal veins before crossing the aorta, a critical consideration during left-sided nephrectomy.

🧬 Pathology - The Cancer Code

Origin: Arises from renal tubular epithelium. Most common subtypes:
- Clear Cell (75%): From Proximal Convoluted Tubule (PCT).
  - Histo: Polygonal cells with abundant clear cytoplasm (full of lipids/glycogen).
  - Genetics: Loss of VHL gene on chromosome 3p.
- Papillary (15%): From PCT.
  - Histo: Papillary architecture.
  - Genetics: MET proto-oncogene mutations.
- Chromophobe (5%): From collecting ducts.
  - Histo: Large eosinophilic cells, perinuclear halo ("plant-like"). Excellent prognosis.

⭐ The classic triad (hematuria, flank pain, palpable mass) is seen in <10% of patients. Most RCCs are found incidentally on imaging.

📌 VHL = 3 letters → Chromosome 3p deletion.

Management - The Surgeon's Choice

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⚠️ Complications - Post-Op Perils

Hemorrhage: Major risk from the renal pedicle. Can cause a large retroperitoneal hematoma. Monitor vitals and hemoglobin.
Urine Leak (Urinoma):
- More common after partial nephrectomy.
- Presents as flank pain, fever, or high drain output.
- Dx: Drain fluid creatinine >> serum creatinine.
Acute Kidney Injury (AKI):
- Risk ↑ with pre-existing CKD or radical nephrectomy.
- Monitor urine output and creatinine.
Adjacent Organ Injury:
- Left-sided: Spleen, pancreas tail, colon.
- Right-sided: Liver, duodenum, colon.
Other: Pneumothorax (supracostal incision), ileus, DVT/PE.

⭐ Classic Complication: Injury to the spleen is the most common visceral injury during a left radical nephrectomy, potentially requiring splenectomy.

⚡ High-Yield Points - Biggest Takeaways

Partial nephrectomy is the standard of care for most T1 tumors (<7 cm) to preserve renal function.

Radical nephrectomy (kidney, Gerota's fascia, +/- adrenal gland) is reserved for large, invasive, or centrally located tumors.

Laparoscopic and robotic approaches are preferred for most cases, offering reduced morbidity.

Tumor thrombus extension into the renal vein or IVC is a critical surgical consideration.

Cytoreductive nephrectomy can improve survival in select patients with metastatic disease prior to systemic therapy.

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Renal cell carcinoma surgery