ESSAY PAST YEAR UROLOGY (by Melly©)

TOPIC 1: BLADDER TUMORDIAGNOSIS

1) US : Echogenic intravesical mass2) Plain & IVU : bladder filling defect3) Pelvic & abdominal CT : confirm & stage bladder

tumors4) Urine cytology5) Cystoscopy & biopsy : proper staging, degree of

spread6) Metastatic workup : x-ray chest & bone scan

TREATMENT

a) Superficial bladder tumors (2006)(2008)1) Endoscopic: Transurethral resection (TURBT)2) Immunotherapy: Intravesical chemotherapy

(BCG vaccine) 6 weekly instillations followed by maintainance 3 weekly instillation every 6 monthsAim :

i) Reduce tumor recurrenceii) Avoid tumor progression

Indications in multiple, big, T1, recurrent 3) Follow up : US, urine cytology, cystoscopy,

biopsy4) Radical cystectomy (for NMIBC) : high risk

tumors resisting Rx & rapidly recurrent

b) Rx of invasive tumors1) Radical cystectomy (gold standard)2) Radical radiotherapy (less efficient)3) Bladder saving protocol

i) Responding tumor: Initial chemotherapy followed by radiotherapy

ii) Non-responding tumors : salvage cystectomy

TOPIC 2: RENAL TUMORSCLINICAL PICTURE OF RENAL CELL CARCINOMA (2010)(2014)

SYMPTOMS1) Asymptomatic - accidentalloma2) Triad : pain, mass, hematuria3) Varicocele 4) Paraneoplastic syndrome:

- Stauffer syd- Hypercalcemia- Hypertension- Hormonal secretions

5) A renal swelling may be felt by the patient.6) Non-specific symptoms: anorexia, nausea,

vomiting,…7) Metastatic pains.

MANAGEMENT OF RENAL TUMORS ( 2008)(2013)

INVESTIGATIONSa) Laboratory Finding:

1) Urine analysis: Haematuria: gross or microscopic.Proteinuria renal vein thrombosis.

2) Blood picture: anaemia

b) Radiological Findings:1) Plain X-Ray of UT

Enlarged soft tissue shadow of the kidney. Obliterated psoas line.Calcifications 10%

2) IVU:ii) A space occupying lesion distorting

&/or amputating the calyces. iii) In late cases no contrast excretion ?

renal vein thrombosis.3) Upper abd U/S 4) C.T. Scanning tumor staging5) Arteriography vascularity of the tumour6) MRI7) Screening for metastases:

i) X-Ray chestii) Skeletal survey (osteolytic)

TREATMENT (RCC) 1) Radical nephrectomy locally resectable

Indications: large tumor & central position

2) Partial nephrectomy (small tumor & periphery)

2) For inoperable cases : locally irresectable or metastatic

i) Radiation therapy (no response).ii) Hormonal therapy.iii) Cytotoxic chemotherapyiv) Immunotherapy

3) Nephron sparing Surgery (NSS) with sparing margin

TOPIC 3: OBSTRUCTIVE UROPATHYTYPES OF URINARY RETENTION (2007)(2010)

1.ACUTE URINARY RETENTIONPainful inability to void, with relief of pain following drainage of the bladder by catheterization

2.CHRONIC URINARY RETENTIONObstruction develops slowly,bladder is distended (stretched) very gradually over weeks/months, pain is not a feature

CAUSES OF ACUTE URINARY RETENTION (2) (2006)(2007)(2008)(2010)

a) Men: (2005)1) Benign prostatic enlargement (BPE) due to

BPH 2) Carcinoma of the prostate3) Urethral stricture4) Prostatic abscess

b) Women 1) Pelvic prolapse (cystocoele, rectocoele,

uterine)2) Urethral stricture;3) Urethral diverticulum; 4) Post surgery for ‘stress’ incontinence 5) pelvic masses (e.g., ovarian masses)

c) Both Sex

1) Haematuria leading to clot retention2) Drugs

3) Pain4) Sacral nerve compression or damage(cauda

equina)5) Radical pelvic surgery6) Pelvic fracture rupturing the urethra 7) Neurotropic viruses involving the sensory

dorsal root ganglia of S2–S4 (herpes simplex or zoster);

8) Multiple sclerosis9) Transverse myelitis 10)Diabetic cystopathy 11)Damage to dorsal columns of spinal cord

causing loss of bladder sensation (tabes dorsalis, pernicious anaemia)

DIAGNOSIS OF ACUTE URINARY RETENTION (2006)(2008)

a) History of difficulty or passage of stone

b) Clinically1) Palpation & percussion of abd : full tender

bladder2) DRE for prostatic enlargement, post urethral

stone3) Genital exm for phimosis, caruncle4) Neurological exm : flaccid anus,

diminishes /absent bulbocavernous reflex, perianal hypoplasia (neurogenic hyporeflex bladder)

c) US : show full bladder

d) PXR : show stone in urethra / spina bifida / sacral agenesis (neurogenic bladder)

e) IVU : evaluate renal condition (hydronephrosis) / full bladder in post voiding film

f) Voiding cystourethrography : Dx post urethral valve

g) Urethral calibration & urethrography : Dx stricture

h) Urodynamic testing : suspected neurogenic bladder

TREATMENT OF ACUTE URINARY RETENTION (2004)(2016)(2008)(2009)

a) Initial Management : 1) Urethral catheterisation 2) Suprapubic catheter ( SPC)

b) Late Management: Treating the underlying cause

HYDRONEPHROSIS (2012)

DEFINITION Descriptive term refer to dilatation of pelvis and

calyces. It can occur with or without obstruction.

CLINICAL DIAGNOSISSymptomsWide range: asymptomatic→ renal colicDepending on:

i) Degree: complete or partialii) Time interval: acute or chroniciii) Etiology: intrinsic Vs extrinsiciv) Laterality: unilateral or bilateral

SignsWide range: no signs

1) Abdominal mass2) Volume overload3) Azotemia

MANAGEMENT

MANAGEMENT OF OBSTRUCTIVE ANURIA (2009)(2013)

ANURIA vs RETENTION OF URINE (2008)

ANURIA URINE RETENTION

Complete cessation of

urine formationDEFINITION

Inability to evacuate

bladder completely

BadGENERAL

CONDITIONGood

Supravesical obstruction

(bilateral/unilateral in

solitary kidney)MECHANISM

Infravesical

obstruction

1) BPH

2) Urethral stricture

Hydronephrosis Gray-scale USNCCT

Stone No stoneTreatmentobstructionRenogram+ RINo obstruction

S. creat Follow-upNormal HighNonconclusin

IVPconclusiveMRUNonconclusiveCT+ contrastTreatment Retro & Antegrade

1) No desire to urinate

2) No pain or loin pain CP

1) Desire to urinate

2) Severe agonizing

suprapubic pain

Empty bladderEXAM

Full bladder

(suprapubic buldge)

1) Abnormal kidney

function tests

2) US : hydronephrosis,

empty bladder

3) Catheter : no urine

IX

1) Normal kidney

function tests

2) US : full bladder

3) Catheter : urine

pass

1) Urethral

catheterization then

remove obstruction

(Rx of cause)

2) PCNL if stone

Rx

Evacuation of

bladder by urethral

catheter

TOPIC 4: TRAUMA1.RENAL TRAUMA(2012)(2013)

DIAGNOSIS1) Symptoms :

Flank pain Hematuria Abdominal distension, n&v Abdominal swelling Hypotension secondary to bleeding

2) Signs: Shock, decrease bp Ecchymosis of flank Flank mass

Fracture ribsINVESTIGATION

1) Lab: Urinalysis Hematuria Serial Hct value

2) Imaging: CT abdomen & pelvis IVU US Plain X ray chest & abd

MANAGEMENT Emergency measure:1) Rx of shock 2) Resuscitation3) Evaluate associated injury

Active observation (blunt trauma): monitor bp, pulse rate, repeated hct & imaging

Surgical exploration:Absolute indication in life threatening he & large expanding pulsatile retroperitoneal hematoma

TREATMENT1. Drainage2. Suture tear, repair3. Partial nephrectomy4. nephrectomy

2.BLADDER RUPTURE

TYPES: (2009)1) Intraperitoneal

2) Extra peritoneal3) Combined

DIAGNOSIS (2007)(2008)(2009)(2013)(2014)a) History of trauma

b) Symptoms : - Gross hematuria (82%)- Abdominal tenderness (62%)- Suprapubic bruises, ecchymosis, coolness- Urinary extravasation (rupture)

c) Clinical examination1) General : signs of shock2) Abdominal exm :

Bruises in lower abdominal regionAbdominal tenderness or rigidity

(peritonitis)Signs of pelvic fracture with ecchymosisTenderness over pelvic bones

d) Laboratory investigationsUrine analysis : microscopic or gross hematuria

e) Radiological diagnosis1) Plain x-ray abdomen & pelvis (pelvic

fracture)2) CT cystography3) Ascending cystogram*

Shows extravasation of dye from UB i) In Intraperitoneal rupture of dye

seen extravasting in whole abdomenii) In extraperitoneal rupture, dye seen

only around UB

TREATMENT (2007)(2008)(2009)(2013)(2014)1) Emergency measures & correction of shock2) Intraperitoneal (emergency)

- Immediate exploration- Drainage & repair of tear- Catheter (7-10 days)

3) extra peritoneal tears : (conservative)- bladder drainage by catheter for 7 days- antibiotic- follow up for 10 days (imaging)

3.MANAGEMENT OF TRAUMATIC RUPTURE OF POST-URETHRA (2005)

DIGNOSIS1) History of trauma2) Retention of urine3) Lower abdominal pain4) Bleeding at external urinary meatus5) Signs of shock6) Suprapubic tenderness with/out contusions in

lower abdomen & perineum(ass bladder injury)7) Rectal exam reveals prostatic displacement in

most cases8) Urethral catheterization should be avoided as it

mayi) aggravate urethral trauma ii) introduce infection into pelvic hematoma

9) Retrograde urethrography is diagnostic : shows extravasation of contrast into perivesical space

TREATMENT1) Resuscitation & management of associated

serious injuries2) Suprapubic cystostomy in all avoid opening tissue

planes to evacuate periprostatic hematomaSuprapubic drainage is kept for 6 months

combined antegrade cysto-urethrography (suprapubic cath)

The latter is managed either i) Endoscopically (visual internal

urethrotomy) orii) Surgically ( bulboprostatic anastomotic

urethroplasty)

TOPIC 4: PROSTATEMANAGEMENT OF BPH ( 2004)(2014)

INVESTIGATIONSa) Uroflowmetry (simple & non invasive)N max flow rate (Q-Max) : > 18 ml/sec(if <10 ml/sec = obstruction or weak detrusor ms

b) Lab investigationsUrinalysisSerum creatinineSerum PSA

b) Imaging1) Abdominal ultrasonography:

*size of gland, PVR, associated stone, hydronephrosis,

2) KUB: radio-opaque calculi3) Intravenous Urography:

secretory function of the kidney

basal smooth filling defect in the bladder 4) Urethro-cystoscopy : in case of hematuria

TREATMENT OF BPHI) Non- symptomatic BPH : Reassurance, Follow up

II) Symptomatic BPH:a) Conservative Rx:medical treatment

1) 5- alpha - reductase inhibitors: Doxazosin, Tamsolucin2) Alpha adrenergic blockers: Finastride,

Dutastride

b) Surgical treatment: 1) Trans-urethral resection of the prostate

(TURP)Gold standard 90% of cases

2) Open surgical prostatectomy (enucleation adenectomy)i) Very large BPHii) Concomitant bladder lesion needs open

surgeryiii) Patient limitation (limited hip joint

mobility)

INDICATION PROSTATECTOMY ( 2008)1) Repeated AUR2) Chronic UR3) Severe obstructive symptoms4) Failure of medical treatment5) Haematuria6) Complications : Rec. UTI, Hydronephrosis,

Bladder stones or diverticula

COMPLICATIONS PROSTATECTOMY (2008)1. Comp of anesthesia2. intra op :

a. bleedingb. TUR syndromec. Trauma

3. Immediate post op:d. Bleeding, primary reactione. Problem with catheterf. Re-retention

4. Delayed post op:a. Bleedingb. Infection UTIc. Urine leak, incontinenced. Urethral stricture

PATHOLOGY OF PROSTATE CANCER (2004)

Histopathology1) Adenocarcinoma

More than 95%. Arises from the epithelium of prostatic acini or

small peripheral prostatic ducts

2) Transitional cell carcinomaLess than 4%Arises from Prostatic urethra, central prostatic

ducts or direct extension from TCC of the urinary bladder

DIAGNOSIS OF PROSTATE CANCER ( 2012)1) CP2) Digital Rectal Examination (DRE)

An abnormal DRE is defined by :i) Asymmetric enlargement of the glandii) A prostatic noduleiii) Firm to hard consistency

Only 50% of pts with abnormal DRE prove to have prostate cancer

Normal DRE does not exclude cancer

3) Prostatic biopsyIs essential for the diagnosisTransrectal ultrasound – guided prostatic

(TRUS) biopsyIndications :

i) Elevated PSA ii) Abnormal DREiii) Both

4) Imaging in the diagnosis of prostate cancera) Ultrasonography abdominal or trans- rectal

i) No specific sonographic pattern: homogenous, heterogeneous, iso, hypo, or hyper echoec

ii) Size of the glandiii) Post void residualiv) Effect on upper urinary tractv) Assessment of other abdominal organs

b) MRI c) Imaging of Skeletal metastasis

i) Bone scan (high sensitivity but low specificity- high false +ve result)

ii) Conventional Skeletal radiography (low sensitivity but high specificity)

iii) Bone CT

TOPIC 5: EMERGENCIESMANAGEMENT OF TESTICULAR TORSION ( 2007)(2014)

a) NEONATAL TESTICULAR TORSION

CLINICAL PICTUREThe infant is restless, reluctant to feeding.Hard, large scrotal mass, -ve

transillumination.

TREATMENTIt is controversial1) No treatment the testis is already necrotic.2) Surgical orchiectomy with contralateral orchipexy.

b) PUBERTAL TESTICULAR TORSION (Intravaginal torsion)

CLINICAL PICTURE

Sudden onset of acute testicular pain and swelling.

Severe tenderness.Nausea and vomiting.Transverse lie of the testis.Scrotal elevation will increase pain.Secondary hydrocele may develop.

TOPIC 6: CONGENITALPOSTERIOR URETHRAL VALVE (2014)

CLINICAL PRESENTATIONBilateral flank masses (hydronephrosis)Distended bladderPoor urinary stream (+/- dribbling)Diagnostic test: VCUGTherapeutic goal: preserve renal fx, avoid renal

failure30% at risk for progressive renal insufficiency

DIAGNOSIS a) Ultrasound

Key hole signThick-walled distended bladder

b) VCUG (diagnostic test)See bladder neckSudden cut off between narrow & dilated part

With/out reflux

TREATMENT

1) Stabilize critically ill baby2) Urethral ‘feeding tube’3) Transurethral ‘fulgration’ of valves4) Vesicotomy if renal function is impaired

TOPIC 7: UROLITHIASIS / STONESETIOLOGY OF BLADDER STONES (2006)

1) Supersaturation of urineDt excessive excretion of poorly soluble salts

in urineEg : Ca, oxalate, phosphate, uric acid, cysteine,

xanthine

2) Deficiency of inhibitors of crystallization Eg : Mg, pyrophosphate &/ citrates

3) Stasis along urinary tract

4) InfectionShreads of pus may provide nucleus upon

which crystals may form+ infection by urea splitting org as proteus

alkalinization of urine encourage ppt of phosphates

COMPOSITION OF URINARY STONES (2012)1) Calcium stones

75% of UT calculiRadio-opaqueEither :

i) Calcium oxalateii) Calcium phosphate

2) Uric acid stones5-15% of UT calculiRadio-lucent

3) Triple phosphate stones ‘struvite’= staghornFormed of magnesium ammonium phosphate

(MAP)4) Cystine stones

1% UT calculiFaintly radio-opaqueFormed in acid urine (pts with excessive

excretion of cystine in urine dt hereditary metabolic abnormality)

MANAGEMENT OF UPPER URINARY TRACT CALCULI A. Diagnosis :CP

1. Pain : colicky, dull aching (stretch capsule)2. Hematuria3. Irritative symptoms : urgency, frequency,

dysuria4. Symptoms of comp : infection , obstruction5. Obstructive anuria

B. Emergency treatment of

1) Renal (ureteric) colic2) Obstructive (calculus) anuria

C. Treatment of stones (2004)(2006)(2007)i) SIZE

- Small- Large

ii) SITE:- Ureter: ureteroscopy*, ureterolithostomy- Kidney: PCNL*, pyelolithotomy, nephrolithotomy, pyelonephrolithotomy, partialradical nephrectomy- Bladder: cystolithotripsy*, cystolithotomy- Urethra: push to bladder, meatotomy

iii) COMPOSITION

A) INVESTIGATIONS OF UROLITHIASISa) Laboratory:

1) Urine analysisMay show haematuria.Pyuria and bacteruria are frequent.The type of crystals present in the urine

may predict the composition of the stone. 2) Blood urea & serum creatinine : estimate of

the total renal function.

b) Imaging :1) X-rays

PXR of the abdomen : radio-opaque calculi (80-90%)

To differentiate renal & gall bladder stones :i) A right lateral view when a radio-opaque

shadow(s) is shown in the right renal area.

ii) A renal calculus overlies the vertebral bodies whereas gallstones are far anterior.

2) IVU is essentialA post-voiding film is essential to show

ureterovesical and intramural calculi.

3) Ultrasonography Valuable in :

i) Pregnancyii) Anuric patientsiii) Allergic to the contrast material

It shows the acoustic shadow of the stone, stasis or hydronephrosis are also shown.

4) Non contrast spiral CT Used in radiolucent stones or ureamic patients To show the site, size and +/- type of stone

B) EMERGENCY TREATMENT

a) RENAL (URETERIC) COLIC:1) Antispasmodics (e.g khelline, buscopan,

papaverine,) + pain killers (e.g. voltaren, indocid,) IM + diuretics

2) Opiates (only the exceptional case)

b) OBSTRUCTIVE (CALCULUS) ANURIA:1) Short term conservative trial for 12 hours with

diuretics (lasix 6 amp or 15% mannitol) + antispasmodics

2) A plain X-Ray and ultrasonography show the obstructing stone(s) and the condition of the kidneys.

3) Ureteric catheterization or JJ stent in every case

4) Urinary diversion PCN above the level of the obstruction is required

C) TREATMENT OF STONES

i) SMALL STONES less than 5mm in diameter usually pass spontaneously aided by adequate hydration: + Diuretics, e.g. thiazides one tablet daily + Antispasmodics e.g. khelline products, hyocine (buscopan) or papaverine(no-spa) .

ii) LARGER RENAL & URETERIC STONES :1) Extracorporeal shock wave lithotripsy

(ESWL) suitable for stones < 2 cm in diameter not assc with distal obstruction/active

infection

2) Percutaneous nephrolithotomy done under fluoroscopic (X-Ray) controlsuitable for most renal calculi

iii) SURGERY : the role of surgery is declining

I) Rx of upper urinary calculi

a) FOR RENAL STONES

The kidney is exposed extraperitoneally by a supracostal incision with the patient lying in lateral position.

1) Pyelolithotomyextraction of stone through an incision in renal

pelvisthe operation of choice

2) Nephrolithotomyextraction of stone thr an incision in renal

parenchymasuitable for some calyceal stones which

cannot be extracted via the renal pelvis

3) Extended pyelolithotomy or pyelo-nephrolithotomy is indicated in branched (staghorn) stones.

4) Partial Nephrectomy, excision of the lower third of the kidney indicated in case of stone in the lower calyx

whose drainage is defective

5) Nephrectomy should be avoided even in mx of staghorn

stonesit is only done for a functionless destroyed

kidney, or as a life saving measure because of intraoperative bleeding during renal stone surgery

b) URETERAL STONES

Ureterolithotomy is indicated for 1) large stones2) stones with distal stricture3) after failure of endourologic manipulations.

c) LOWER THIRD OF THE URETER STONES suitable for ureteroscopic manipulations including:

Disintegration of larger stones by US or electrohydraulic waves or by the pneumatic lithoclast or by Laser beam.

d) IMPACTED STONES IN THE INTRAMURAL URETER can be extracted cystoscopically after transurethral incision of the sub mucosal ureter (ureteral meatotomy).

II) Rx of lower urinary calculi

a) BLADDER STONESStone : cystolithotripsyStones : cystolithotomy

1) Single, medium sized stones (1-2 cm in diameter)Crushed by lithotrite (litholapaxy)

2) Large calculi Manage by extraperitoneally through

suprapubic midline incision (litholatomy)

b) URETHRAL CALCULI1) Posterior urethral calculi are cautiously

pushed back by a urethral sound or by a

urethroscope to the bladder to be treated as bladder calculi.

2) Impacted stones at the fossa navicularis can be extracted by doing meatotomy of the external urinary meatus.

3) Bulbar urethral stones can be extracted through the perineum (bulbar urethrolithotomy).

4) Stones in the penile urethra are pushed back to the bulbar urethra and treated as such

TREATMENTa) Manual detorsion (done from medial to

lateral) Not recommended as it is not a final solution , torsion:

i) may recurii) may be incomplete so the pain is relieved

but the testis is still ischemic

b) Surgical exploration1) Affected testis

if viable detorsion and orchiopexyif not viable do orchiectomy.

2) Contralateral testis orchiopexy.