UROLOGY • The arterial blood supply to the adrenal glands is provided primarily by the

ANATOMY AND BLOOD SUPPLY OF THE ORGANS OF THE URINARY SYSTEM inferior phrenic artery
• On the right, the primary venous drainage is directly to the inferior vena cava.
Kidney and Ureter
• On the left, the primary venous drainage is to the left renal vein.
• urinary system: kidney, ureter, and bladder, are located in the retroperitoneum
Kidneys
Bladder and Urethra
• surrounded by perirenal fat and Gerota's fascia Bladder
• superior aspect –is contained within the lower thoracic cavity at the level of the
• A hollow, muscular organ adapted for storing and expelling urine
10th rib
• When it is empty
• posterior aspect –lies against the quadratus lumborum,
o it lies posterior to the pubic symphysis in the pelvis
• renal hilum –lies against the
o and is extraperitoneal
psoas muscle
• dome of the bladder is covered with peritoneum
• upper pole –abuts the liver
• when the bladder is full
• right kidney –anteriorly, is
o it can rise into the abdomen and
adjacent to the duodenum and
o is palpable on physical examination
hepatic flexure of the colon
• can store approximately 350 to 450 mL
• left kidney is bounded
• muscularis propria, also referred to as the bladder detrusor,
anteriorly by the splenic flexure
o forms the muscular wall of the bladder
• Renal blood supply comes from
o Close to the urethra, the muscle fibers become organized into
the renal artery
three layers:
• right and left renal arteries – ▪ inner longitudinal,
come off the aorta just inferior ▪ middle-circular, and
to the takeoff of the superior ▪ outer-longitudinal
mesenteric artery
• arterial blood supply to the bladder comes from the superior, middle, and
• right renal artery –passes inferior vesical arteries, which are all branches of the internal iliac
posterior to the inferior vena artery
cava
• The venous return from the bladder drains into the internal iliac vein.
• renal veins –are anterior to the
renal arteries and drain into the Urethra
inferior vena cava
In men, urinary continence is maintained by the internal and external sphincters.
• renal artery and vein are anterior to the renal pelvis and proximal ureter at
the level of the renal hilum • internal sphincter
o composed of smooth muscle,
• arteries are end-arteries, while the veins anastomose freely
o is formed by the middle circular layer of the bladder wall as it invests the
• left adrenal vein and left gonadal vein  drain into the left renal vein
prostate gland
o on the right, these same vessels drain directly into the vena cava
o it’s contraction during ejaculation prevents retrograde ejaculation by
• urine formed in the kidney  collecting system  renal pelvis  ureter  directing the semen toward the urethral meatus
bladder
• external sphincter
• Ureteral peristalsis originates from pacemaker cells located in the collecting o surrounds the urethra at the level of the distal prostate gland
system of the kidney o is composed of both smooth and striated muscle fibers
• the ureteral lumen is relatively narrower: In women,
o at the ureteral pelvic junction, • There is no internal sphincter and the middle circular layer of the bladder
o at the pelvic brim (where the ureter crosses the common iliac vessels) and muscularis
o at the ureteral vesical junction
• Continence is maintained by the resistance provided by
▪ these areas represent common sites of impaction
o the coaptation of the urethral mucosa and
Adrenal Glands
o the external striated sphincter surrounding the distal two-thirds of the urethra
• are endocrine organs that lie superomedial to the kidneys
• are surrounded by the perirenal fat and contained within Gerota's fascia • Prostate and Seminal Vesicle –are part of the male reproductive system
• right adrenal gland –is positioned posterolateral to the inferior vena cava o Secretions from these two organs make up part of the male semen.
o more superior in relation to the left adrenal gland • Prostate –surrounds the proximal urethra
o can be divided into several zones
 ▪ peripheral zone –most prostate cancers • Penis –is formed by three corpora bodies
▪ central zone –surrounds the ejaculatory ducts as they empty into o two corpora cavernosa and a corpus spongiosum – surrounds the male
the urethra at the verumontanum urethra; these three are covered by the tunica albuginea
• Benign prostatic hyperplasia (BPH) –is caused by enlargement of the • Buck's fascia is the next layer, going outward toward the skin
transition zone surrounding the urethra o splits dorsally to envelop the neurovascular structures and
o common in the elderly population o splits ventrally to surround the corpora spongiosum
o can lead to increased urinary resistance and voiding symptoms • Superficial dartos fascia is just underneath the skin and is contiguous with the:
o Colles fascia in the perineum and
o Scarpa fascia in the abdominal wall
• base of the penis is supported by suspensory ligaments that attach to the linea
alba and pubic symphysis

Testis and Epididymis

• testicles –are surrounded by several fascial layers that are embryologically
derived from the same layers comprising the anterior abdominal wall
• external spermatic fascia –is analogous to the external oblique
• cremasteric muscle envelops the spermatic cord
o analogous to the internal oblique and transversus abdominis
• internal spermatic fascia is analogous to the transversalis fascia
• visceral and parietal layers of the tunica vaginalis testis represent peritoneum
that surrounded the testicle during its descent into the scrotum
• blood supply to the testicles is provided by three arteries:
o gonadal –branches directly from the aorta
o cremasteric –branches from the inferior epigastric artery
o vassal – branches from the superior vesical artery
• venous drainage from the testicles forms the pampiniform plexus at the level
of the spermatic cord
• At the internal inguinal ring: pampiniform plexus coalesces to form the gonadal
vein, which drains into the inferior vena cava (right) and into the renal vein
(left). • common penile artery –is the terminal branch of the internal pudendal artery
• epididymis –is located on the posterolateral aspect of the testis o It divides into three branches that supply blood to the penis:
o stores mature sperm o cavernous arteries supply the corpora cavernosa
• Spermatogenesis occurs in the seminiferous tubules of the testes. o bulbourethral branch supplies the glans, urethra, and corpus spongiosum
• Mature sperm is conducted by the efferent ducts into the epididymis o dorsal arteries run in the neurovascular bundle enveloped by Buck's fascia
• Emission –is the process when the sperm is conducted along the vas deferens and supply the corpus spongiosum and urethra
o under sympathetic stimulation • Venous drainage from the penis is provided by the dorsal and cavernous
• ejaculatory duct –is formed by vas deferens + seminal vesicle veins, which join to form the internal pudendal vein.
• The semen that is deposited into the urethra is carried along the urethra under • Sensory innervation is carried by the dorsal nerves that run with the dorsal
somatic enervation during ejaculation. vessels.
• Autonomic innervation is provided by the cavernous nerves that pierce the Normal Voiding Physiology
tunica albuginea to innervate the smooth muscles found in the corpora • Urinary storage occurs with:
cavernosa. o coordinated relaxation of the bladder wall muscle
▪ beta-adrenergic stimulation
NORMAL VOIDING PHYSIOLOGY o contraction of the urinary sphincter (smooth and striated muscles)
• 2 simple functions of normal micturition: storage and evacuation of urine. ▪ alpha-adrenergic and cholinergic stimulation
• Regulated by the nervous system • Voiding occurs with:
• The lower urinary tract includes the: o coordinated contraction of the bladder smooth muscle –by cholinergic
o bladder, bladder neck, proximal urethra, and the external urethral striated receptors
sphincter o relaxation of the urinary sphincter – by nonadrenergic noncholinergic
• Smooth muscle in the bladder wall relaxes with filling and accommodates pathway stimulated by NO
large volumes of urine at low intravesical pressures. • pontine micturition center in the brain stem coordinates normal voiding
• Bladder neck and proximal urethra remain closed during urine storage by a • detrusor–sphincter dyssynergia:
combination of mechanisms. o uncoordinated voiding with neurologic insults affecting the brain stem or
o Alpha receptors on bladder neck smooth muscle cells activated by the spinal column
sympathetic nervous system, and an increase in muscular tone helps o the bladder and sphincter contract at the same time during voiding  high
maintain close outlet intravesical pressures
o Proximal urethra shares excursions in intraabdominal pressure exerted • Neuronal connections from higher centers of the brain to the pontine
on the bladder to avoid an intraluminal pressure difference between the micturition center regulate voluntary control of micturition.
bladder and the urethra. • can lead to involuntary bladder contractions:
▪ Hypermobility or descent of the bladder neck and base out of o All disorders affecting the upper tract such as strokes and spinal cord
retropubic can lead to stress incontinence. injuries
o An increase in internal urethral sphincter muscle contraction occurs • incontinence can be categorized as: stress, urge, total, and overflow
with transmitted abdominal pressure to the bladder (the guarding reflex) • A thorough history should be obtained, including a history of:
and closes the distal urethra. o voiding complaints,
• Normal micturition requires coordination between the bladder and outlet o urologic diseases,
structures whereby a bladder and drop in outlet resistance occur in rapid o obstetric events, and
sequence. o neurologic diseases
• Urinary tract infections can lead to urinary incontinence and should be ruled
Innervations of the Lower Urinary Tract out.
• short postganglionic axons –innervates the smooth muscle cells in the bladder • A focused neurologic exam should be performed, noting:
o from ganglia located in the adventitia of the bladder o sensory or motor deficits and
o receives afferent input from the pelvic plexus o decrease in anal tone
• pelvic plexus integrates: • An overflow incontinence is suspected?
o sympathetic outflow (hypogastric nerves) –arise from T9 to L2 spinal cord o Check for postvoid urinary residual through: catheterization or bladder
segments ultrasound
o parasympathetic outflow (pelvic nerves) • In female patients, a pelvic exam should be performed with the patient in
▪ these are mixed sensory and motor nerves stirrups.
▪ mediates the sensation of: bladder filling, distention, and pain o Prolapse of any pelvic structures should be noted.
• pudendal nerve –innervates the external urethral striated sphincter o Patient is asked to bare down to assess for stress incontinence or rotational
o provides sensory pathways from the penis descent of the bladder and proximal urethra.
• originate in the S2 to S4 segments of the sacral spinal cord: o Rotational descent can be quantified with a Q-tip test:
o Motor pathways to the bladder (pelvic nerve) and ▪ Insert a lubricated cotton swab into the urethra
o external urethral sphincter (pudendal nerve) ▪ Ask the patient to bear down
• Ascending and descending pathways converge on the dorsal and ventral horns ▪ If the angle of the cotton swab changes by more than 30 degrees,
of the spinal cord to regulate the sensory and motor function of the lower urinary the patient is considered to have significant urethral descent.
tract.
• Neurons in the pontine reticular formation receive sensory input with =
bladder filling, coordinate bladder contraction, lowering of outlet resistance at the
bladder neck and external striated urethral sphincter
SYMPTOMS RELATED TO VOIDING AND THEIR CAUSES Overflow incontinence
Symptoms broadly categorized as: • Secondary to an obstruction of the lower urinary tract
Irritative Obstructive • As urine builds up in the bladder, the intravesical pressure increases and
• dysuria, frequency, and urgency – • weak urinary stream, overcomes the resistance provided by the urinary sphincter.
generally imply inflammation of the • urgency, • All patients at risk for urinary tract obstruction who develop new-onset
urethra, prostate, or bladder • frequency, incontinence should be checked for urinary retention by postvoid bladder
• commonly caused by infection • Hesitancy –a delay in initiating a ultrasound or catheterization of the bladder.
• can also be caused by malignancy urinary stream Hematuria
o if symptoms persist after treatment • Intermittency –repeated starting • with gross or microscopic hematuria + absence of obvious evidence of a urinary
with appropriate antibiotics, and stopping of the urine stream tract infection
malignant processes such as during voiding • evaluation with upper and lower tract studies is needed
transitional cell carcinoma must be • nocturia, and • considered significant microscopic hematuria if:
ruled out • sense of incomplete emptying o > 5 RBC/HPF in spun urine or
o if symptomatic with no specific o > 2 RBC/HPF in unspun urine
etiology, the diagnosis of • Because it can be intermittent, even a single documented episode of
interstitial cystitis or chronic significant microscopic hematuria warrants a complete evaluation
nonbacterial prostatitis is often • upper tract, which includes the kidney and ureter, should be evaluated with an
made o intravenous pyelogram,
o CT scan
• benign prostatic hyperplasia –most common cause of obstructive voiding in ▪ performed with intravenous contrast
men. ▪ delayed images should be obtained once the excreted contrast has
• Urethral strictures –may also obstruct the bladder outlet filled the upper tract collecting system
o are often secondary to: trauma, urethritis or previous instrumentation of the o retrograde pyelogram
bladder • lower tract, which includes the bladder and urethra, should be evaluated by
cystoscopy.
Urinary Incontinence • differential diagnosis for hematuria includes:
Stress incontinence o malignancies, infections, kidney stones, and trauma.
• Refers to incontinence associated with an increase in intra-abdominal • Malignancies of the kidney and bladder classically present with painless
pressure. hematuria.
• Patients often report leakage of urine when coughing, laughing, or during o Patients with gross painless hematuria should be considered to have a
physical exertion. urinary tract malignancy until proven otherwise.
• Secondary to a decrease in the resistance provided by the urinary continence • Bladder and urethral infections are generally associated with symptoms of
mechanisms irritative voiding.
• Generally implies an anatomic disorder, such as: • Pyelonephritis is a clinical diagnosis based on findings of:
o an iatrogenic injury to the external sphincter in a male or o irritative voiding symptoms, fever, and flank pain.
o prolapse of the bladder in a female • Kidney stones are associated with a colicky pain.
• localization of the pain depends on the level of obstruction by the stone
Urge incontinence • An obstruction at the:
• Secondary to an involuntary contraction of the bladder o ureteropelvic junction –flank pain
• Accompanied by a sudden sense of needing to void o lower ureter –colicky pain referred to the lower abdomen or groin.
• May be secondary to:
o inflammation and irritation of the bladder Other Findings
o neurologic disorders such as a stroke or spinal cord injury • Urethral discharge is a common complaint
o usually results from infection with Neisseria gonorrhoeae or Chlamydia
Total incontinence trachomatis
• continuous leakage of urine o discharge is often associated with dysuria
• implies a fistula between the skin or vagina and the urinary tract, proximal to the • Hematospermia refers to blood in the ejaculated semen
sphincter mechanism o is caused by inflammation of seminal vesicles or prostate
• Women with a vesicovaginal fistula secondary to malignancy or trauma will o general rule: self-limiting and no further evaluation or treatment
complain of continuous leakage of urine. • Pneumaturia refers to air in the voided urine
 o can be confirmed by having the patient void in a tub with the urethral • In children, urine can be collected by placing a urine collection bag over the
meatus submerged urethral meatus;
o may result from recent instrumentation of the bladder or from a fistula o however, urine specimen for bacterial culture may need to be obtained by
between the urinary tract and the intestine catheterization or suprapubic aspiration.
• complete urinalysis includes:
Physical Examination: Examination of the Penis, Scrotum, and Testis o testing with a dipstick impregnated with an array of chemical reagents
• Performed with the patient standing and the physician seated on a stool o microscopic examination of urinary sediments obtained by centrifugation
• Initially, inspection of the skin of the penis, scrotum, and the surrounding inguinal ▪ reserve the microscopic examination for patients with abnormalities
region detected using the dipstick
• Testicles should be palpated for masses or tenderness and the size of the • Most standard dipsticks will test for:
testicles should be noted o urinary pH o specific gravity o protein
• Epididymis can be palpated on the posterolateral surface of the testicles o glucose o ketones o bilirubin
• Any nodules should be noted o urobilinogen o hemoglobin
o nitrites o leukocytes
• An effort should be made to determine if palpable lesions are associated with the
testis or the epididymis. • dipstick analysis relies on color changes produced by chemical reactions with
substances in the urine
• The vas deferens can be felt by gently compressing the scrotum above the
o any medications taken that changes the color of the urine, such as
testicles.
phenazopyridine (Pyridium), will interfere with the test.
• Hydroceles represent a buildup of fluid between the two layers of the tunica
• urine pH will reflect the pH of the serum
vaginalis.
o Exceptions to this rule:
o presence of a hydrocele sac can be confirmed by transilluminating the sac
▪ renal tubular acidosis or a urinary tract infection involving a urea-
with a penlight.
splitting organism
• Varicoceles may be palpable in the scrotum and represent dilated veins, which
• specific gravity of the urine reflects the:
are analogous to varicose veins found on the leg.
o hydration status of the patient and concentrating ability of the kidney
• The penis should be gently massaged to express any urethral discharge.
• Proteinuria indicate intrinsic renal pathology or the presence of excess
• The penile shaft and urethra should be palpated along the length of the penis.
protein in the serum.
• Any nodules or fibrotic plaques on the corporal bodies should be noted. o Persistent proteinuria determined using a dipstick should be confirmed by a
24-hour urine collection for protein.
Prostate Exam • Testing for urinary glucose and ketones is useful in screening for diabetes.
• The prostate is examined with the patient leaning over an examination bench • Urinary glucose will usually be detected when serum glucose levels are greater
and resting on his elbows. than 180 mg/dL.
• Alternatively, the patient can be lying in a lateral decubitus position. • A small amount of urobilinogen can normally be detected in the urine.
• Initially, inspection of the anus and surrounding area o a positive test for bilirubin and high levels of urobilinogen may indicate liver
• Using lubrication, the index finger is gently inserted into the rectum. disease or hemolysis
• The prostate is palpated, and any nodules, indurations or asymmetry should be o Presence of the following in the urine can produce a positive result on
noted. dipstick tests for blood: hemoglobin, myoglobin, and red blood cells
• Although the seminal vesicle is too far to reach in most men, they may ▪ a positive dipstick test should be confirmed by microscopy
occasionally be palpable just above the prostate. • A positive urinalysis for leukocytes and nitrites suggests inflammation, which is
• Having the patient Valsalva will often bring the prostate closer to the anus and most commonly caused by a bacterial infection.
facilitate the exam. • The dipstick tests for leukocyte esterase, which is an enzyme found in
neutrophils.
LABORATORY EXAMINATIONS FOR PATIENTS WITH UROLOGIC COMPLAINTS o The urine may be positive for leukocytes in the presence of both
Examination of the Urine hematuria and pyuria.
▪ suspected pyuria should be confirmed by microscopic
• urinalysis is a simple, but powerful tool examination of the urine.
• proper collection of the urine sample is critical • Normal urine does not contain nitrites.
• Ideally, the urine sample is collected by sterilely catheterizing the bladder. o urinary nitrates are converted to nitrites in the presence of Urea-splitting
• A clean midstream catch is usually adequate, especially in men. bacteria include the:
• In women, an abnormal urinalysis may need to be confirmed with a ▪ Proteus ▪ Klebsiella
catheterized specimen to rule out possible contamination by the vaginal flora. ▪ Pseudomonas ▪ Enterococcus
▪ Morganella
 o does not include Escherichia, which is the most common cause of o Inulin is an ideal substance for measuring GFR because it is completely
urinary infections filtered by the kidney without being secreted or reabsorbed by the tubules.

Culture Radiologic Studies of the Urinary System Imaging of Kidney and Ureter
• urine culture is the most definitive test for symptomatic patients CT scans
• >105 organisms/mL of urine is consistent with a urinary tract infection • study of choice for general imaging of the kidney and ureter
• in irritative voiding symptoms, such as frequency and dysuria, 100 • primary advantage is the amount of information it provides:
organisms/mL of a known urinary pathogen is sufficient evidence of a bacterial o kidney stones that are radiolucent on plain x-ray are readily visible
infection o Uptake of contrast by the renal parenchyma during the nephrogram phase
• recurrent or resistant infections, it is important to identify the organism and of the CT scan provides a rough estimate of the kidney function
test for antibiotic sensitivities by using a urine culture o A comparison of the uptake of contrast by each kidney provides an estimate
• Neisseriae, Mycobacteria, and anaerobes, require special culture techniques of the differential function between the right and left kidneys.
and a local laboratory should be consulted regarding the specific requirements o collecting system can be evaluated for subtle filling defects and
hydronephrosis
Tests of Kidney Function o allows for evaluation of other organ systems in the abdomen and pelvis
• Urine-specific gravity can be measured in the office by using a dipstick. • useful when renal or ureteral malignancy is suspected
o As renal function decreases, the ability of the kidney to concentrate urine • for evaluation of hematuria
decreases. o the study should be performed with and without IV contrast,
o This is reflected by a proportional change in specific gravity. o and delayed images should be obtained after the contrast has been
o specific gravity is also dependent on hydration status, thus with a excreted into the renal pelvis and ureter.
progressive decrease in renal function, the specific gravity does not • Renal cell carcinomas classically appear as solid, enhancing masses.
decrease below approximately 1.015 • Transitional cell tumors of the renal pelvis and ureter often present as filling
• Serum creatinine level is a better approximation of kidney function. defects on delayed images.
o Creatinine is an end-product of muscle creatine metabolism and is excreted o can obstruct the collecting system and hydronephrosis may be seen
by the kidney. • for evaluation of malignancy,
o are less affected by hydration status o Oral contrast should be given
o does not reflect early loss of renal function ▪ This will facilitate delineation of any pathologically enlarged lymph
o remain in the normal range until approximately 50% of the kidney nodes in the retroperitoneum and pelvis.
function is lost.
• endogenous creatinine clearance rate –best measure of kidney function that Intravenous pyelogram (IVP)
does not involve infusion of exogenous substances • A better test when the primary goal is to evaluate the collecting system.
o Creatinine clearance • To obtain an IVP:
▪ is defined as the volume of plasma from which creatinine is o radiologic contrast is infused
completely removed per unit of time o a series of plain x-rays are taken of the abdomen and pelvis
▪ is a clinical approximation of the glomerular filtration rate (GFR) and • The diameter and contour of the renal pelvis is readily appreciated on IVP, and
renal function congenital anomalies of the ureter and renal pelvic filing defects are easily
▪ is calculated from a 24-hour urine collection according to the seen.
following formula: Clearance = UV/P • retrograde pyelogram can be performed when an IVP is not diagnostic, or if the
• U –urine concentration of creatinine and patient is allergic to IV contrast
• P –plasma concentrations of creatinine,
• V –urine flow rate A magnetic resonance image (MRI) obtained with contrast medium such as
▪ Normal creatinine clearance is 90 to 110 mL/min. gadolinium can generally be used in place of a CT scan when renal insufficiency
▪ creatinine is secreted in small amounts by the proximal tubule or contrast allergy prohibits the use of CT contrast.
▪ thus, creatinine clearance will slightly overestimate GFR at all
levels of kidney function. • retrograde pyelogram is performed by visualizing the ureteral orifice through a
• This effect is most pronounced when kidney function is cystoscope and cannulating the ureters with a 6 to 8 F catheter
severely compromised, where creatinine clearance can o Radiologic contrast is injected through the catheter and the collecting system
overestimate GFR by as much as 1.5- to twofold. is visualized in real-time by fluoroscopy.
• gold standard for measuring GFR involves infusing and measuring the o a urine sample or a saline wash sample from the upper tract can be
clearance of inulin. collected through the ureteral catheter and sent for cytology or culture.
 ▪ Urine collected from each of the upper tracts may allow for Renal Scan
localization of malignancy or infection to the right or left side. • A nuclear medicine study
o primary disadvantage: invasive procedure; usually performed in the OR • Determine renal function and evaluate drainage of the renal pelvis and ureter
under anesthesia • After intravenous administration of a radioactive tracer, the kidneys are imaged.
• technetium-99m dimercaptosuccinic acid (DMSA) is used if the primary
Renal ultrasound purpose of the study is to image the renal cortex to detect parenchyma
• The least-invasive imaging modality for the kidney scarring, which is often seen in pediatric patients following an episode of
• Kidney stones are identified as a hyperechoic lesion associated with pyelonephritis
hypoechoic "shadowing" behind the stone o This tracer is bound to the proximal tubule and is slowly excreted, a
• fluid is hypoechoic, therefore renal cysts and hydronephrosis are readily property that makes it an ideal agent for visualizing the kidney cortex.
identified.
• Renal masses appear as hyperechoic lesions and generally warrant further A. Renal scan in a patient with aureteropelvic junction obstruction. Renal scan
evaluation with a CT scan. obtained using technetium-99m mercaptoacetyltriglycine (MAG-3). A quantitative
• In the pediatric population, it is the first screening test obtained when a assessment of uptake of MAG-3 by the renal parenchyma approximately 2 minutes
congenital abnormality of the urinary system is suspected following injection suggests that the differential functions of the left and right kidneys
are 52 and 48%, respectively. B. Following administration of Lasix, the T1/2 for the
Imaging of the Bladder and Urethra washout of the nucleotide in the renal pelvis of the right kidney is 9 minutes and 30
Aurethrogram seconds; however, the nucleotide never washes out of the left kidney. T1/2 >20
• Performed in suspected urethral stricture or traumatic urethral disruption minutes is consistent with obstruction.
• A Foley catheter is inserted just beyond the tip of the meatus
• The catheter balloon is inflated with approximately 0.5 mL of fluid Technetium-99m diethylenetriamine-pentaacetic acid (DTPA)
• Radiologic contrast is injected in a retrograde fashion • is excreted following glomerular filtration
• A plain x-ray is taken. • can be used to determine the GFR DTPA and to evaluate the drainage of the
• Alternatively, the urethra is visualized during the injection using fluoroscopy. collecting system
• Once DTPA is excreted into the renal pelvis, Lasix can be given and the half-life
Antegrade urethrogram (T1/2) of the tracer activity is measured.
• Can also be performed during a voiding cystourethrogram (VCUG). • A high T1/2 (greater than 20 minutes) is consistent with an obstruction.
• For a VCUG, a small-diameter catheter is inserted into the bladder and a
cystogram is obtained. Technetium-99m mercaptoacetyltriglycine (MAG-3)
• The patient is then asked to void the contrast and aurethrogram is taken.
• Both filtered by the glomeruli and secreted by the tubules. Thus, it is well suited
• Pediatric population: it is most commonly performed to rule out: ureteral
for:
reflux or a posterior urethral valve.
o imaging the renal cortex,
• Adults: cystogram is most common to rule out a bladder perforation in a o estimating differential renal function, and
trauma patient o evaluating drainage of the renal pelvis.
Testicular Ultrasound CAUSES AND TREATMENT OF THE CATEGORIES OF INCONTINENCE
• is most commonly performed to evaluate testicular pain or a palpable lesion
• Urinary incontinence refers to unintended leakage of urine from the bladder.
noted on physical examination.
o The vast majority of patients are women past middle-age.
• The differential diagnoses for acute testicular pain include: o In the elderly population, approximately 50% of nursing home residents
o testicular torsion,
o epididymalorchitis, and
Stress Urinary Incontinence
o scrotal abscess.
• On Doppler ultrasound the • occurs with increase in intra-abdominal pressure
o absence of blood flow = testicular torsion • associated with activities such as coughing, laughing, or exercise
o increased blood flow = epididymalorchitis • result from:
• For palpable lesions of the testicle, an ultrasound is well suited for distinguishing o loss of urethral support  rotational descent of the bladder  change in
between solid and cystic lesions. the normal angle between the urethra and proximal bladder
o Solid masses in the testicle or in the epididymis should be considered a ▪ relationship between these two structures is important for proper
malignancy until proven otherwise and functioning of the urinary sphincter
o orchiectomy should be performed to make a definitive diagnosis.
 o a lax urethral support  poor transmission of intra-abdominal pressure ▪ Common causes include:
(which normally helps to coapt the urethral mucosa and form a water-tight • urinary tract infections
seal) • bladder prolapse
o intrinsic sphincter deficiency • stress incontinence
o combination of the two • bladder outlet obstruction
• variety of conditions contribute to the structural changes: • if stress incontinence is the primary problem, the urge incontinence will resolve in
o Labor and childbirth: more than half of patients after surgical treatment for stress incontinence
▪ Prolonged labor, • Anticholinergics are effective, particularly when combined with timed voiding.
▪ number of childbirths, and • biofeedback programs are effective for motivated patients with milder
▪ use of delivery forceps symptoms.
▪ partial disruption of the innervation to the pelvic floor • A permanent sacral nerve stimulator can be implanted to inhibit bladder
musculature – the most important mechanism contractions and help prevent urinary incontinence.
• Other factors include:
o aging,
Total Incontinence
o pelvic surgery,
o trauma, • Continuous leakage of urine
o hypoestrogenic states, and • Implies that a fistula exists between the urinary tract and the skin or vagina.
o neurologic conditions that result in denervation of the urinary sphincter. • In industrialized: the most common cause of a vesicovaginal fistula is routine
• In men: it is most commonly caused by intrinsic sphincter deficiency following pelvic surgery such as vaginal hysterectomies, (75% of cases).
radical prostate surgery or transurethral prostate resection. • In developing countries, the major cause of vesicovaginal fistulas is birth
• Mild stress incontinence may be improved by conservative measures such trauma.
as: • Other causes include: malignancy, inflammatory bowel disease, and urinary
o using estrogen supplements in postmenopausal women, tuberculosis.
o pelvic floor exercises, and • confirmed by instilling dye into the bladder and evaluating the color of the
o timed voiding. draining vaginal fluid.
• the most effective treatment options involve surgery • Cystoscopy and vaginoscopy can be performed to localize the fistula.
• In female: a urethral sling procedure can be performed • The treatment generally involves surgical repair:
o to increase urethral resistance and o if a fistula is identified immediately following the responsible iatrogenic injury,
o to correct mild to moderate degrees of urethral prolapse. a trial of conservative management with catheter drainage of the
▪ most procedures involve placing a sling material around the bladder is reasonable.
urethra and tacking the material to the rectus fascia. o The principles for surgical repair are the same as for repair of fistulas in
• artificial urinary sphincter –the most effective procedure in male other parts of the body.
o has three components: o A tension-free closure with multiple, nonoverlapping lines of closure is
▪ A fluid-filled sphincter is placed around the bulbar urethra, critical to the success of the repair.
▪ a pump is placed in the scrotum and o When possible, vascularized tissue should be interposed between the
▪ a reservoir is placed in the prevesical space layers of closure.
o The sphincter increases urethral resistance and helps prevent incontinence.
o When the patient wishes to void, he opens the sphincter by compressing Overflow Incontinence
the pump in his scrotum and moving fluid from the sphincter to the • often termed false incontinence,
reservoir. • is secondary to urinary retention, resulting either from an obstruction or an
atonic bladder.
Urge Incontinence • Patients with new onset of urinary incontinence should be catheterized or
• An overactive bladder is characterized by involuntary detrusor contractions. have a bladder ultrasound to check for a postvoid residual.
• urinary incontinence results if these involuntary contractions generate sufficient • If the urinary retention is secondary to bladder outlet obstruction, the cause of the
pressure to overcome the urethral resistance, obstruction should be addressed.
• Two terms distinguish the etiology of overactive bladders: • Urinary retention following pelvic surgery is usually temporary and resolves
o detrusor hyperreflexia –involuntary bladder contractions secondary to an following several days of catheter drainage or intermittent catheterization.
upper tract neurologic insult, such as a stroke or spinal cord injury • Spinal cord injury above the level of the sacrum can result in a hyperreflexic
o detrusor instability –involuntary contractions resulting from irritation of the bladder.
bladder itself o there is spinal shock –a period of bladder atony during the immediate 6
to 8 weeks following the injury
 o Other causes of an atonic bladder include DISCUSS STONE DISEASE
▪ diabetes, • Stone disease is one of the most common urologic diseases
▪ sacral spinal cord injury, and • affecting 1/8 white men by age 70 years.
▪ pernicious anemia. • is most common in 20- to 40-year-olds
• If long-term management is required for an atonic • men-women ratio=3:1
bladder: clean, intermittent catheterization is a safe and
• prevalence: 2 to 3%
effective option.
• 50% risk of recurrent stone formation within 5 years
URODYNAMIC TEST AND ITS COMPONENTS • successful treatment involves:
o management of the acute stone
• Aurodynamics test –to better delineate the components of incontinence. o long-term medical management to prevent future stone formation
• To perform the test:
o A small catheter, usually 7F, with multiple channels is inserted into the Acute Kidney Stone
bladder to allow simultaneous filling of the bladder and transducing of
Upper Urinary Tract Obstruction
intraluminal pressures.
HYDROURETERONEPHROSIS (HN)
There are four primary components to urodynamics testing. • (with the ureteral dilation extending to the level of the obstruction) The hallmark
Cystometry of partial or complete upper urinary tract obstruction
• Involves measuring detrusor pressures at various bladder volumes.
• Detrusor pressure is calculated as the pressure measured in the bladder CT: very mild to severe, with associated parenchymal thinning in chronic cases.
lumen minus the intra-abdominal pressure measured by a catheter in the In the acute setting, the degree of HN does not necessarily correlate with the degree
rectum of obstruction, as it may take time for severe HN to develop.
• As the bladder fills, involuntary detrusor contractions are recorded and the
bladder sensory function is assessed by noting when the patient feels the INTRINSIC, as with calculi or ureteral tumors, or due to EXTRINSIC COMPRESSION
need to void. due to varied causes, such as an intra-abdominal tumor, iliac aneurysm, or gravid
uterus.
• After filling the bladder, the patient is asked to void and evidence of detrusor–
external sphincter dyssynergia is noted by monitoring external sphincter
LAB: Serum creatinine may be elevated, but with compensation of other kidney so it
contractions by electromyography
may not indicate renal impairment.
Pressure-flow study
partial obstruction may result in permanent loss of function on the affected side if
• Assess for bladder outlet obstruction not alleviated within several weeks.
• A decreased urinary flow rate may result from either bladder outlet obstruction or Complete occlusion can cause permanent dysfunction within 2 weeks.
a poorly contracting bladder.
• Both vesical pressure and maximum urinary flow rate are simultaneously MANAGEMENT
measured to assess the bladder outlet ENDOSCOPIC PLACEMENT OF A URETERAL STENT, which is a temporary
plastic tube with curls on each end to prevent migration. Stents allow flow both
Urethral pressure study through the lumen and around it. When chronic stenting changed every 3 months
• Assess the resistance provided by the urinary sphincter to prevent severe encrustation with urinary sediments.
• To perform: • Stents commonly become colonized with bacteria, but symptomatic infections are
o the bladder is filled to 150 to 200 mL less common.
o patient is asked to Valsalva • Once a stent is in place, mild residual HN often will persist due to ureteral
▪ Valsalva leak point pressure –the abdominal pressure that aperistalsis and urinary reflux, but unless
produces urinary leakage • severe, it does not represent residual obstruction.
▪ < 60 mm H2O is consistent with intrinsic sphincter deficiency. • When stent placement is unsuccessful or fails to provide adequate drainage due
to severe extrinsic compression, a percutaneous nephrostomy (PCN) should be
Videourodynamics placed.
• The bladder is filled with radiographic contrast • This is the preferred approach when a patient is unstable because it requires less
• The bladder is imaged in real time on a fluoroscopic screen anesthesia and provides more rapid and reliable decompression of the renal
• The relationship between the bladder, the urethra, and various pelvic landmarks collecting system.
can be noted, and the status of the bladder neck can be assessed during rest,
Valsalva, and voiding.
Presentation and description Calculi ≥7 mm
• acute stone is defined as a urinary stone obstructing the kidney or ureter, and • more likely to become impacted or to have a prolonged passage through the
causing symptoms ureter.
• The classic symptoms of an obstructing kidney stone include: • intervention at the time of presentation is preferred for larger stones (except
o colicky flank pain and hematuria, in cases where the calculus is in the very distal ureter) due to the likelihood
o often accompanied by nausea and vomiting. of repeat emergency room visits for severe symptoms.
• Location of stone in relation to pain:
o Ureter—ipsilateral lower abdomen. Radiologic work-up
o distal, intramural ureter —referred to the inguinal and perineal areas • The diagnosis of a urinary stone can be confirmed radiologically.
• On physical exam, costovertebral angle tenderness can usually be • A plain x-ray of the abdomen and pelvis is the simplest test to obtain,
appreciated. however:
• hematuria accompanying stone disease may be microscopic or gross o radiolucent stones, such as uric acid stones and cystine stones, may
o 15% of acute renal stones present without hematuria not be visualized,
• with a superimposed UTI may present with fever and irritative voiding o stool in the colon may make it difficult to identify smaller stones in the ureter
symptoms. • noncontrast helical CT scan –the test of choice for diagnosing an acute stone
• with an infected urinary system and a completely impacted stone may even o All stones, regardless of composition, are visualized
present with signs and symptoms of sepsis. ▪ Exception: small percentage of indinavir stones.
▪ Indinavir stones form in HIV-positive patients treated with the
Urolithiasis, or urinary calculus disease (10%) protease inhibitor indinavir sulfate.
• well suited for evaluating the degree of hydronephrosis resulting from an
Calculi are crystalline aggregates of one or more components, most commonly
obstructive stone
calcium oxalate.
o intravenous pyelograms,
They also may contain calcium phosphate, magnesium ammonium phosphate
o renal ultrasounds
(struvite), uric acid, or cystine.
o CT scans
PLAIN RADIOGRAPHS: Calcium- and struvite-containing stones
A. Plain x-ray of a large, right ureteral stone somewhat obscured by the spinal
CT SCANS will demonstrate all calculi except those composed of crystalline-excreted
column. B. Oblique view of the same patient clearly reveals the large stone in the
indinavir, an antiretroviral medication.
right midureter. C. A retrograde pyelogram was performed to better define the
NONCONTRAST CT SCANS have become the study of choice to evaluate for
anatomy of the urinary collecting system.
urolithiasis.
Management
CAUSES OF URINARY CALCULI:
1. Hypercalciuria due to hyperparathyroidism, sarcoidosis, “renal leaks,” or • Majority will pass spontaneously
idiopathic overabsorption can lead to calcium-containing stones. • Only 10% of patients presenting with an acute renal stone require hospital
2. gastric bypass, which has been attributed to increased oxalate excretion in the admission
urine. After bypass, dietary calcium is bound by unabsorbed dietary fats • should be managed as an inpatient:
(saponification), preventing it from binding dietary oxalate, thereby making o intractable pain,
oxalate more available for intestinal absorption. o severe nausea with inability to tolerate oral intake,
3. gout are at risk for uric acid stones due to increased urinary uric acid and o urinary infection, or
decreased urine pH, which diminishes uric acid solubility. o renal insufficiency.
▪ All other patients can be managed on an outpatient basis.
LOCATION: • For pain: meperidine or morphine (IM) are effective
ASYMPTOMATIC: renal pelvis or bladder, but they are a very common cause of • Oral narcotics should be prescribed as necessary.
symptomatic ureteral obstruction. • Encourage hydration to promote passage of the stone & patients should be
instructed to filter their urine.
The obstruction may be partial or complete. • Retrieved stones can be analyzed for chemical composition.
Smaller stones (up to 6 mm) • obstructing stones and no evidence of urinary infection: given up to 4 weeks to
• severe symptoms, such as flank pain and nausea, but typically pass without spontaneously pass their stone
intervention beyond supportive care. o No detectable renal damage occurs within 4 weeks of even complete
• α-Blockers, which relax the distal ureter, may be given to reduce renal colic. ureteral obstruction.
• emergent intervention is indicated in the presence of a urinary infection
• percutaneous nephrostomy tube or a ureteral stent should be placed to Surgical Management
establish drainage of the obstructed urinary system
• Extracorporeal shock wave lithotripsy (ESWL) –the least-invasive treatment
• Following treatment of the urinary infection, the stone can be treated electively. option for renal stones
• Stones 4 to 5 mm in diameter have at least a 40 to 50% chance of passing o Shock waves are generated outside the body and focused on the stone.
spontaneously; o The shock waves harmlessly propagate through intervening tissue and attain
• stones >6 mm in diameter have less than 5% chance of passing sufficient intensity to fragment the stone only when it reaches the
o and is considered for early intervention calculus.
o The stone is placed in the focal point of the shock waves by using
MANAGEMENT: ultrasound or fluoroscopy.
1. STENTING : Temporize obstructing stones which allows proximal collecting o 50 to 80% overall stone-free rate when treating stones less than 3 cm.
system decompression. o Smaller stones are associated with a higher success rate
2. Extracorporeal shockwave lithotripsy: o residual stones can be retreated
3. Percutaneous Nephrostolithotomy - if demonstrates any instability. o Extremely hard stones are relatively resistant to fragmentation by ESWL;
4. Ureteroscopy - definitive treatment of renal or ureteral calculi such as:
DEFINITIVE TREATMENT: ▪ cystine stones,
UTEROSCOPY PERCUTANEOUS EXTRACORPOREAL ▪ calcium phosphate stones, and
NEPHROSTOLITHOTOMY SHOCKWAVE
LITHOTRIPSY ▪ calcium oxalate monohydrate stones
Ureteroscopy is performed PCNL is performed through a ESWL is completely
with a flexible or semirigid percutaneous tract into the noninvasive and uses a
device that is passed to the kidney, where a larger scope device that delivers
level of the calculus. Under and various energy sources convergent shockwave
direct visualization, a laser (laser, ultrasound) are used to energy to the calculus
fiber is passed through the fragment and aspirate large under fluoroscopic
scope, and energy is renal calculi. guidance.
delivered to fragment the This approach is well suited to However, the lower efficacy
calculus. staghorn calculi. rate of ESWL, when
Fragments are extracted, compared with ureteroscopy
although they PCNL, highlights the point Extracorporeal shock wave lithotripsy. Shock waves are generated
usually will pass that despite ESWL being extracorporeally and are focused on the stone by the ellipsoidal reflector.
spontaneously. ess invasive, patients will
often undergo multiple • Endoscopic options for the surgical treatment of upper tract stone disease
procedures to be rendered
include:
stone free.
strictures due to scarring Significant bleeding, and if the renal hematomas, and
o retrograde ureteroscopy and
from trauma to the ureter. tract used to access the kidney splenic rupture has been o percutaneous nephroscopy
If performed in the setting traverses the lower aspect of the seen after the treatment of a • Selection of the specific approach depends on the size and location of the
of infection, endoscopic pleura, hydrothorax. Large left-sided stone. stone.
irrigation can force bacteria amounts of irrigating fluid • a large stone filling multiple renal calyces is best treated using a percutaneous
into the renal parenchyma approach to directly access the kidney through the flank.
and result in sepsis o The scopes used through a percutaneous flank incision are shorter and
larger in diameter compared to aureteroscope.
• RECURRENT STONES will benefit from examination of stone composition and o larger and more powerful instruments can be inserted through the
24-hour urine metabolic workup to determine the underlying etiology. working port to fragment the stone.
• Better hydration is useful for all etiologies. • distal ureteral stone, is easily accessed in a retrograde fashion by
• Alkalization of the urine (e.g., potassium citrate). ureteroscopy.
• Patients with calcium-containing stones do not benefit from a reduction in o The scope is inserted through the urethra, into the bladder, and up the ureter
dietary calcium unless they have absorptive hypercalciuria, which most do o represents a less-invasive approach when compared to percutaneous
not. In fact, patients with higher dietary calcium have, on average, fewer nephroscopy
episodes of urolithiasis. o Once the stone is endoscopically visualized through a nephroscope or
aureteroscope, small stones can be snared and removed with a number
of specialized instruments, such as a stone basket or a three-prong
grasper.
• Larger stones can be fragmented intracorporeally by using a variety of Medical Treatment
energies, including • Without medical treatment, more than half will have recurrent stones within 5
o laser, years.
o ultrasound, or • Kidney stone with the following characteristics are at a high risk for recurrence
o mechanical force. and should undergo a metabolic work-up:
▪ Energy is applied to the stone through the working port of the o prior history of stone disease
scope and the stone is fragmented under direct vision. o family history of stone disease o chronic urinary tract infections
o inflammatory bowel disease o gout
Medical Management Stone Composition o bone disease o nephrocalcinosis.
• stone should be analyzed to determine its composition • The need for an extensive work-up and treatment in first-time stone formers is
controversial.
• Calcium oxalate stones are the most common stones found in patients in the
United States • all patients with a history of stone disease should be instructed to make
several lifestyle changes that reduce the risk of stone formation
• Hypercalciuria –can lead to urinary stone formation
o drink enough water to produce at least 2 L of urine per day.
o can result from increased resorption of bone as a consequence of:
o limit protein and salt intake,
▪ hyperparathyroidism,
o and should not ingest excessive amounts of vitamin C.
▪ from primary calcium loss by the kidney, or
o should not limit calcium intake
▪ from pathologically increased absorption of calcium in the jejunum
▪ because several studies show that higher calcium diets are
• Hyperoxaluria occurs in patients with:
associated with a reduced risk of stone formation
o chronic diarrhea or inflammatory bowel disease.
• metabolic work-up performed after at least 1 month following an acute stone
▪ Fatty stools in these patients result in saponification of intestinal
episode.
calcium.
• A simple evaluation includes:
• Intestinal oxalate that is unbound to calcium is available for absorption and is
o radiologic imaging such as a CT scan or IVP,
eventually excreted by the kidney.
o complete blood count,
• An increase in urinary oxalate may also result from
o serum chemistries, urinalysis, and urine culture.
o excess vitamin C ingestion and
• Patients with abnormalities on this simplified evaluation, or patients at higher risk
o primary hyperoxaluria – is caused by an enzymatic defect in the liver
for recurrent stone disease, should be further evaluated with a 24-hour urine
• calcium phosphate stones –The second most common calcium-based stones,
collection for
which most often occur in patients with distal (type I) renal tubular acidosis
o calcium, oxalate, magnesium, phosphorus, uric acid, and creatinine.
o Not all urinary stones are calcium based.
• Based on the specific metabolic abnormality, directed therapy can be
o Struvite stones are usually composed of: magnesium, ammonium,
prescribed.
phosphate, carbonate apatite
• more empiric therapy simply based on 24-hour urinary calcium appears to be
• Struvite stones form in alkaline urine resulting from urinary infections with
equally effective
nitrate-reducing bacteria such as Proteus, Pseudomonas, or Klebsiella
species and are usually large stones that fill multiple calyces • normal levels of urinary calcium can be treated with potassium citrate, which
acts as an inhibitor for stone formation in the urine.
• Uric acid stones form in acidic urine with a pH level <5.5.
o Medical therapy to alkalinize the urine will dissolve uric acid stones and • Thiazide diuretics, which decrease urinary calcium excretion, can be added in
can circumvent the need for surgical intervention. patients with increased urinary calcium.
o Pure uric acid stones are radiolucent and are associated with
▪ gout, BENIGN PROSTATIC HYPERPLASIA
▪ myeloproliferative diseases, and Etiology and description
▪ administration of chemotherapy. • BPH refers to the stromal and epithelial proliferation in the prostate gland that
• Cystine stones are faintly radiopaque on plain film. may eventually result in voiding symptoms.
o occur in primary cystinuria, which is inherited as an autosomal recessive • occurs primarily in the transition zone of the prostate gland
disorder • histologic evidence of BPH is rare in men who are younger than 40 years of
▪ Also have increased urinary loss of ornithine, arginine, and age;
lysine. • it can be found in approximately 70% of men in their seventies, and in nearly
all men in their nineties.
Bilateral staghorn calculi seen on CT scan. Staghorn calculi extend into multiple • Although androgen production is required for BPH to occur, androgen merely
calyces and are most commonly struvite stones, composed of magnesium, plays a permissive role in the development of BPH.
ammonium, and phosphate
• The precise hormonal, autocrine, and paracrine factors involved in stimulating • A digital rectal exam and a focused neurologic exam should be performed
BPH are unknown. because symptoms such as urgency and frequency may be signs of a neurologic
disorder.
Natural History • A urinalysis should be obtained in all patients
• BPH can present with both obstructive and irritative voiding symptoms – • urine culture should be obtained in patients with dysuria or abnormal urinalysis
collectively as lower urinary tract symptoms (LUTS). • In patients presenting with urinary retention or severe voiding symptoms, a check
• Patients may complain of a of serum creatinine levels to evaluate renal function is reasonable.
o decreased urinary stream o frequency • Cystoscopy performed with hematuria or with a suspected urethral stricture
o nocturia o urgency • with a very poor stream, or for patients complaining of a sense of incomplete
o hesitancy o intermittence emptying, a postvoid residual should be measured by ultrasound or by
o a sense of incomplete emptying catheterization.
• Although these symptoms are certainly related to a bladder outlet obstruction • A renal ultrasound should be performed in patients with an elevated creatinine.
secondary to an enlarged prostate, other, less-clearly defined factors are • For select patients, a pressure-flow study may be necessary.
involved. • To distinguish a decrease in urinary flow resulting from:
• There is a minimal relationship between o bladder outlet obstruction
o the degree of symptoms, o or from failure of the bladder to effectively contract
o the size of the prostate, ▪ a small-diameter catheter can be inserted into the bladder to
o and the degree of urethral obstruction. transduce bladder pressures during voiding
▪ Therefore, treatment should primarily be dictated by the ▪ High bladder pressure and low flow rates are consistent with
• patient's symptoms and obstruction.
• the extent to which the patient is bothered by the ▪ Low bladder pressure and low flow rates suggest a neurogenic
symptoms, bladder that is unable to effectively contract.
• Without treatment, the symptoms of BPH tend to wax and wane over the short-
term; Medical Therapy
• With long-term follow-up, the common trend is toward a worsening of symptoms. • BPH is not always progressive.
• As the transition zone of the prostate enlarges and becomes progressively more • mild symptoms can be managed by watchful waiting
obstructive, the bladder initially undergoes compensatory hypertrophy. • more severe symptoms should be treated based on the degree of bother.
o As long as the hypertrophied bladder is able to generate enough pressure to Absolute Indications Relative Indications
overcome the increased outlet resistance, the patient is able to void to Urinary retention Postvoid residuals
completion. Bladder stones Hematuria
o As the bladder outlet resistance continues to increase, the bladder may not Upper tract dilation Recurrent UTIs
be able to generate enough pressure to overcome the outlet resistance. Renal failure
• Persistent bladder outlet obstruction and increasing postvoid urinary • There are two components to the bladder outlet obstruction resulting from BPH:
residuals mechanical and dynamic.
o lead to a decompensated bladder characterized by a o mechanical component refers to the urethral compression resulting from
▪ thin bladder wall, large capacity, and poor contractility. the enlarged prostate.
• Without intervention, potential sequelae of a decompensated bladder include o dynamic component refers to the smooth muscles in the urethra and
urinary retention requiring emergent catheterization, upper tract dilation, prostatic stroma that contract and further obstruct the bladder outlet.
and renal failure. • alpha1-adrenergic innervation –smooth muscles at the bladder outlet
• The differential diagnosis for a patient presenting with LUTS includes • The first line therapy for BPH is an alpha blocker, which targets the dynamic
o urinary tract infection, component of the bladder outlet obstruction.
o prostatitis, bladder stones, • Three alpha blockers that are available in the United States for the treatment of
o urethral stricture, and BPH are: terazosin, doxazosin, and tamsulosin.
o neurogenic bladder. • Terazosin and doxazosin are selective for alpha1-adrenoceptors, which are
• The work-up for LUTS should include a thorough voiding history. found in the prostate, as well as in the vascular endothelium and central nervous
• The symptoms can be quantified by having the patient fill out an international system.
prostate symptom score (I-PSS) questionnaire o significantly lower blood pressure, especially in men with clinical
o This questionnaire has been validated as a useful means for assessing hypertension.
and following symptoms resulting from BPH. o are good choices in the approximately 30% of men with BPH who also
o Treatment is recommended for an I-PSS greater than 7. have clinical hypertension.
 o most common side effects with these two medications are: o Saline cannot be used because electrolytes in the irrigation fluid will
▪ dizziness and orthostatic hypertension. dissipate the electric current used to resect the prostate.
o Both medications should be titrated up over 1 to 2 weeks to their target o some of the irrigation fluid is absorbed through venous channels in the
dose. prostate
• Tamsulosin is the newest alpha blocker. ▪ If enough fluid is absorbed, TUR syndrome may develop from the
o selective for the 1a-adrenoceptor subtype, which is predominately found in resulting hypervolemia and dilutional hyponatremia and may
the prostate. experience
o effect on blood pressure is clinically insignificant • hypertension • bradycardia
o its primary advantage is that it does not need to be titrated. • nausea • vomiting
o started at its effective dose. • visual disturbance • mental status changes
o Retrograde ejaculation, which refers to the passage of semen into the • seizures
bladder during ejaculation, and rhinitis are more common o During the procedure and the postoperative period, patients should be
• All three alpha blockers appear to be equally effective for the treatment of BPH. monitored for evidence of TUR syndrome, which occurs in approximately 2%
• Patients in urinary retention require emergent catheterization and the catheter of patients.
should be left in place for at least 24 hours to allow the acutely distended bladder o Patients with evidence of TUR syndrome should be treated with diuretics,
to remain decompressed. and electrolyte imbalances should be corrected.
• Tamsulosin may be preferred for previously untreated patients who present in o Following a TUR, patients are hospitalized overnight for continuous bladder
acute urinary retention. irrigation.
• Before attempting catheter removal, tamsulosin can be started at the therapeutic o The hematuria is usually minimal by the following day, and the bladder
dose without need for titration. irrigation can be stopped.
• Other common medical therapies for BPH include saw palmetto and o If the urine remains clear or light pink while off irrigation, the catheter can be
finasteride. removed and the patient discharged from the hospital.
• Saw palmetto is derived from the American dwarf palm tree and is sold in the o Although TURs are associated with minimal morbidity, bleeding can
United States as an herbal supplement. occasionally be significant.
o improved symptoms and urinary flow o In an attempt to further minimize the morbidity of BPH surgery, other
o is safe with no significant adverse effects; technologies for ablating the prostate have been advocated.
o the precise mechanism of action is not known. o use lasers or produce thermal ablation by using radiofrequency or
• Finasteride is commonly used for the treatment of BPH as well as for the microwave energy
treatment of hair loss. o are slightly less morbid than a TUR, they are also less effective than TUR in
o Development of prostatic hyperplasia requires the presence of androgen, relieving the BPH-related obstruction.
and more specifically, dihydrotestosterone.
o A 5-reductase inhibitor,
o blocks the conversion of testosterone to dihydrotestosterone
o is effective in decreasing the risk of urinary retention and hematuria in men
with very large prostate glands.
o has no proven benefit in men with LUTS and smaller prostate glands

Surgical Management
• Surgery should be recommended for patients
o who continue to be bothered by their symptoms or
o who experience urinary retention despite medical therapy.
o with upper tract dilation,
o renal insufficiency secondary to BPH, or
o bladder stones.
• Surgery for BPH is most commonly performed endoscopically;
• open prostatectomy should be performed if the prostate gland is greater than
80 to 100 g.
• transurethral resection (TUR) of the prostate
o standard endoscopic procedure for BPH
o is performed with a nonhemolytic fluid such as 1.5% glycine.
 • Paraneoplastic findings
o result from soluble substances released by the tumor or by immune cells in
response to the tumor.
o resulting from localized disease resolve following a nephrectomy.
• Stage, grade, and performance status- Well-established predictors of
prognosis
o Tumor grade is determined by using the Fuhrman grading system, which
categorizes nuclear grade.
o Performance status is determined by the patient's ability to provide selfcare
and perform normal, day-to-day activities.
• Indicators of poor prognosis: CASH
o cachexia, anemia, hypercalcemia, and sarcomatoid histologic features.

Work-up
• All patients with a history of gross or microscopic hematuria
o Cystoscopy
o CT scan, MRI, or renal ultrasound - upper tract imaging study.
• Solid, enhancing mass in the kidney -> 90% chance of being a renal cell
carcinoma
• Renal biopsy is unnecessary
o associated with a high false-negative rate because of potential sampling
error and difficulty interpreting the pathology from a biopsy sample.
o may be helpful in patients with a history of another primary malignancy or in
patients with metastatic disease in whom the primary site is unknown.
• Simple cyst - common, benign finding
o oncocytomas
▪ do not have a characteristic radiologic finding
▪ diagnosis is made histologically following a nephrectomy
o angiomyolipomas
▪ benign lesions common in patients with tuberous sclerosis
▪ characteristic appearance on CT scan, and nephrectomy is
generally not necessary to confirm the diagnosis
o Large angiomyolipomas, - high risk of bleeding and embolization should
be considered for lesions large than 4 cm.
UROLOGIC CARCINOMA • Complex cyst - may harbor a malignant tumor.
• Malignant component - multiple septations, irregular cyst wall, calcifications,
Renal Cell Carcinoma and wall or septations that enhance with IV contrast on CT or MRI.
Etiology and description
• represents ~3% of all malignancies. Histologic subtypes of renal cell carcinoma
• Male:female ratio = ~3:2. A. Clear cell tumors - ~80%
• ~1/3 of patients has metastatic disease. o ~75% of sporadic clear cell tumors have a mutation of the von Hippel-Lindau
Presentation and prognosis (VHL) gene found on chromosome 3.
• Advance disease -> findings of a palpable mass, flank pain, and hematuria. B. Papillary subtype - 10 to 15% -
• Most renal tumors are incidentally discovered on ultrasounds and CT scans o associated with activation of the MET proto-oncogene or cytogenetic
performed for unrelated disorders. abnormalities involving chromosomes 7 and 17.
• Paraneoplastic manifestations o Both clear cell and papillary subtypes are thought to arise from the proximal
o anemia, tubules of the nephron.
o hepatic dysfunction (Stauffer syndrome), C. Chromophobe and collecting duct subtypes represent most of the remaining
o cachexia, renal cell carcinomas
o polycythemia, and o to arise from the distal tubules and collecting duct of the nephron
o hypercalcemia.
D. Medullary cell carcinoma - rare subtype • meticulous attention needs to be paid to preventing bleeding and urine leaks, and
o occurs in younger patients with sickle cell trait this is most effectively accomplished by an open surgical
o uniformly associated with a poor prognosis.
E. Sarcomatoid lesions in a tumor also suggest a poor prognosis;
o lesion is not considered a separate subtype.

Metastatic work-up - All patients with a renal mass

• liver function tests,
• chest x-ray, and
• imaging of the abdomen and pelvis with a CT scan or MRI.
o performed with and without IV contrast.
• vena cavagram or MR angiogram with coronal sections
o any suspicion of renal vein or inferior vena cava involvement by a tumor
thrombus, Laparoscopic cryoablation
o to evaluate the extent of caval involvement. • small renal lesion (less than 3 cm in diameter)
• Bone scan and a head CT • Usually a double freeze–thaw cycle is used to ablate the tumor.
o metastatic lesions on imaging of the chest, abdomen, and pelvis • effective treatment for small, peripheral lesions.

Treatment Metastatic renal cell carcinoma

Localized renal cell carcinoma • response rates for treatment with immunotherapy range from 10 to 20% and the
• ~75% of patients treated for localized renal cell carcinoma are cured of their median survival is 12 to 17 months
disease • resistant to radiation and standard chemotherapies.
• Any metastatic lesion to the central nervous system can become rapidly
Radical nephrectomy (standard) symptomatic and should be addressed by the radiation oncologist and
Classical neurosurgeon prior to initiating any further treatment.
• removal of the kidney, the ipsilateral adrenal gland, and all the fat contained • Cytoreductive nephrectomy and interleukin-2 or interferon-based
within Gerota's fascia. immunotherapy.
• if there is no evidence of adrenal involvement by the tumor on the CT scan, the • patients with relatively good prognosis, as determined by a good performance
adrenal gland can be spared. status and a limited number of metastatic sites,
• Combination of neoadjuvant nephrectomy and immunotherapy
Radical nephrectomy o current standard of care for patients
• using either an open or a laparoscopic approach.
• Laparoscopic approach is associated with less postoperative pain and a more Partial nephrectomy.
rapid return to normal activities. (standard of care) • The patient is placed in a flank position.
• The kidney should be cooled with ice before clamping the artery with a bulldog
Partial nephrectomy clamp.
• less than 4 cm in size • The tumor is sharply excised with a margin of normal tissue.
• equally effective option for cancer control. • The collecting system is identified and divided if necessary.
• preferred in patients who are at risk for renal insufficiency secondary to • The collecting system and bleeding vessels are meticulously oversewn with
conditions such as hypertension, recurrent stone disease, or diabetes. absorbable sutures.
• The capsule is closed and covered with fat
 Bladder Cancer Tumor grade and stage - correlate independently with prognosis.
Epidemiology, etiology, description • Transitional cell cancer is most commonly graded on a scale between 1 and 3,
representing well, moderate, and poorly differentiated tumors.
• more common in men
• Superficial cancers - tumors that involve the bladder mucosa (Ta and CIS) or
• median age- 68
lamina propria (T1)
• Western
o CIS is a unique designation that signifies a flat, high-grade tumor confined to
o Transitional cell carcinomas - >90%
the mucosa,
o Squamous cell carcinomas - >5%,
o CIS generally implies a higher risk of recurrence following treatment.
o Adenocarcinoma - <2%
• In the developing countries, Staging of bladder cancer.
o Squamous cell carcinomas = 75% of bladder cancers are T stage determined by depth of invasions:
▪ most of these are secondary to Schistosoma haematobium
• Cis = carcinoma in situ;
infection.
• Ta = mucosa;
▪ associated with chronic inflammation caused by chronic
indwelling Foley catheters and bladder stones. • T1 = lamina propria;
• no convincing evidence for a hereditary factor. • T2a = superficial bladder muscle;
• Transition Cell Carcinoma is strongly linked to environmental exposures. • T2b = deep bladder muscle;
o Smoking accounts for more than 50% of bladder cancers • T3a = perivesical fat (microscopic);
▪ 2-naphthylamine and 4-aminobiphenyl -significant carcinogens • T3b = perivesical fat (gross);
o associated with industrial exposure to aromatic amines in • T4 = adjacent structures such as prostate, rectum, or pelvic sidewallMuscle
▪ dyes, paints, solvents, leather dust, inks, combustion invasive
products, rubber, and textile. o Tumors that invade the muscular layer of the bladder wall (T2) or beyond
o Prior radiation treatments to the pelvis and acrolein, a urinary metabolite of (T3 and T4)
cyclophosphamide, increase the risk of bladder cancer. o ~25% time of diagnosis.
• coffee and artificial sweeteners are not believed to increase the risk of bladder o should undergo a metastatic work-up,
cancer in humans. • CT scan of the abdomen and pelvis,
• chest x-ray,
Presentation • serum chemistries, and
• painless hematuria • liver function tests.
• Hematuria, ▪ If the patients are asymptomatic with normal calcium and alkaline
o Gross or microscopic -> requires a urologic evaluation. phosphatase,
o Microscopic hematuria as a result of bladder cancer may be intermittent • bone scans are unnecessary
▪ bladder cancer cannot be ruled out with a repeat negative o The life expectancy for most patients with overt metastatic disease is less
urinalysis. than 2 years;
o Persistent, irritative voiding symptoms may be a result of carcinoma in ▪ ~25% of patients with only limited regional lymph node metastases
situ (CIS) or muscle-invasive bladder cancer. discovered during cystectomy and pelvic lymph node dissection
▪ irritative voiding symptoms that do not resolve with treatment for a may survive beyond 5 years.
urinary tract infection (upper urinary tract)
• cystoscopy Treatment
• radiographic imaging Superficial Bladder Cancer (Ta, T1, CIS)
Work-up 1. Endoscopic resection and fulguration of the bladder tumor
1. Bladder cytology is 95% accurate for diagnosing high-grade tumors and CIS 2. No further metastatic work-up -> Low-grade, superficial TCCa
• accuracy for diagnosing low-grade carcinoma is only 10 to 50 3. Polyclonal, field-change defect and continued surveillance is mandatory.
• high false-positive rates and high false-negative rates,
• Abnormal cystoscopic exam or suspicious bladder wash cytology -> Underlying genetic changes that resulted in the bladder cancer have occurred in the
evaluated with an operating room cystoscopy -> suspicious lesions should entire urothelium, making the entire urothelium susceptible to future tumor formation.
be endoscopically biopsied. • Risk of recurrence = ~70% within 5 years.
• The risk of disease progression,
2. Retrograde pyelogram and possibly ureteroscopy - Blood effluxing from either o increase in tumor grade or stage, depends on the initial tumor grade.
ureteral orifice
• The risk of progression for TCCa After cystectomy, the urine is diverted using segments of bowel.
o grades I - 10 to 20%, A. Incontinent diversion
o grades II - 19 to 37% • Ileal conduit.
o grades III - 33 to 67 o A small segment of ileum is taken out of continuity with the GI tract
• Carcinoma in situ alone or in association with Ta or T1 papillary tumor carries a while maintaining its mesenteric blood supply.
poorer prognosis, with a recurrence rate of 63 to 92%. o The ureters are anastomosed to one end of the conduit and the
other end is brought out to the abdominal wall as a stoma.
4. History of superficial TCCa – o The urine continuously collects in an external collection device
• undergo surveillance with cystoscopy and bladder wash cytology every 3 worn over the stoma.
months for 2 years. B. Continent urinary diversions
o If they are disease free during this period, the follow-up intervals can be 1. Indiana pouch is a urinary reservoir created from detubularized right colon
gradually increased and an adjacent limb of terminal ileum
5. Intravesical therapy - High-risk, superficial TCCa a. The terminal ileum is plicated and brought to the abdominal wall,
• is effective for patients in reducing the risk of recurrence. creating a catheterizable stoma.
o most effective bacilli Calmette-Guérin (BCG), which is a live, attenuated b. The native ileocecal valve provides the continence mechanism.
strain of Mycobacterium bovis. (live, attenuated organism, it can cause c. is emptied by clean intermittent catheterization of the stoma four to
tuberculosis-like symptoms if it is absorbed into the bloodstream) six times per day.
o mediated by a nonspecific immune cytokine response. 2. An orthotopicneobladder is a similar reservoir that is connected to the
o recommended for carcinoma in situ, T1 tumors, and high-risk Ta tumors urethra
(large, high-grade, recurrent or multifocal tumors). a. Various segments of intestine, including small and large bowel,
o Contraindications: active hematuria, immunodeficiency, and active urinary may be used in constructing the orthotopicneobladder.
tract infection. b. The orthotopicneobladder most closely restores the natural storage
6. Adjuvant therapy and voiding function of the native bladder.
• increase the time to disease recurrence, there is no evidence that any of these c. Patients have volitional control of urination and void by Valsalva
intravesical chemotherapies can prevent disease progression maneuver
o intravesical triethylenethiophosphoramide (thiotepa),
o mitomycin C,
o doxorubicin, and
o epirubicin.
• With treatment, superficial bladder cancer has a good prognosis with 5-year
survival rates of 82 to 100%.

Muscle Invasive Bladder Cancer (T2, T3, T4)

The gold standard for organ-confined, muscle-invasive bladder cancer (T2 and T3)
is
1. radical cystoprostatectomy in men Bladder preserving strategy for T2-T3 TCCa is applied using a
o removal of the bladder, prostate, and pelvic lymph nodes. • combination of
o A total urethrectomy also is performed if the urethral margin is positive. o external beam radiation,
2. anterior pelvic exenteration in women. o chemotherapy and
o removal of the bladder, urethra, uterus, ovaries, and anterior vaginal wall. o endoscopic resection.
o bladder neck margin is negative, the urethra and anterior vaginal wall may ▪ local recurrence of bladder cancer is as high as 50 to 60% despite
be spared. completion of bladder preserving therapy.
o With treatment, the 5-year survival rates for pathologic
▪ T2, - 63 to 80%, Transitional cell carcinoma is considered a chemosensitive cancer.
▪ T3, - 19 to 57%, • The standard treatment of metastatic bladder cancer is MVAC, which is a
▪ T4a - 0 to 36%, combination of methotrexate, vinblastine, Adriamycin, and cisplatin.
▪ N+ - 15 to 44% o replaced by a combination of gemcitabine and cisplatin (fewer toxic
effects)
• chemotherapy also is advocated in the adjuvant setting for high-risk, localized
disease.
Indiana pouch.
A. An ileocecal segment is used to construct a continent • American Cancer Society recommends offering annual prostate cancer
reservoir that is emptied by periodic catheterization. screening to men starting at 50 years of age who have at least a 10-year life
B. The ileocecal segment is detubularized and expectancy.
(C) fashioned into a pouch. The terminal ileum is plicated and brought to the • Society recommends offering PSA screening at 45 years of age in African
abdominal wall, creating a catheterizable stoma. American men and in men with a family history of prostate cancer.
Orthotopicneobladder. A and B.
1. A continent reservoir is created by detubularizing a segment of ileum, Work-up
2. (C) fashioning the bowel into a pouch, and (D) anastomosing the • The diagnosis of prostate cancer is made by biopsy.
neobladder to the urethra. o Using transrectal ultrasound guidance, the biopsy needles are directed at
the peripheral zones where prostate cancer tends to develop.
Prostate Cancer
Epidemiology and description The Gleason system (grading)
• most common cancer in men • The two most predominant histologic patterns - scale from 1 to 5.
• the second most common cause of cancer-related death in the United States. • The two Gleason grades are added to give a Gleason score, on a scale from 2
• Increased screening and early detection of prostate cancer - decline in prostate to 10.
cancer mortality • Gleason scores of 8 to 10 -> high-grade tumors,
• Risk of prostate cancer o High-grade prostatic intraepithelial neoplasia (PIN) is considered a
o Family history: affected family members and if three first-degree relatives premalignant lesion that may indicate the presence of adjacent cancer.
o Race: African Americans • Gleason scores of 5 to 7 -> intermediate-grade tumors.
o environmental factors
o can be lowered by a Staged using the TNM system.
▪ low-fat diet, • The most common sites of metastasis for prostate cancer are the axial bones
▪ as well as by various nutritional supplements including lycopene, and pelvic lymph nodes
vitamin E, and selenium o no formal metastatic work-up is necessary.

Metastatic Work-up
• bone scan and pelvic CT scan
o PSA greater than 20 ng/mL or a PSA greater than 10 ng/mL + Gleason
score 8 to 10 tumor-> increased risk of metastatic disease
o Bone pain

Prostate Cancer Screening

• Until prostate cancer metastasizes or becomes locally advanced, it does not
generally cause symptoms.
• Diagnosis
o elevated PSA - serine protease that is synthesized by the prostate
epithelium and is elevated in prostate cancer.
▪ PSA greater than 4 ng/mL will have a positive prostate
biopsy
o abnormal digital rectal examination (DRE)
• Both BPH and prostate cancer increase serum PSA.
o Several variations of the PSA test
▪ age specific PSA (higher normal PSA ranges for older age groups),
▪ PSA density (PSA/size of prostate measured on ultrasound),
▪ PSA velocity (change in PSA/year), and
▪ percent-free PSA (free PSA/total PSA).
• lower fraction of serum PSA is free
• not bound to serum proteins in men with prostate cancer
than in men with BPH.
Treatment Nonsteroidal antiandrogens (flutamide and bicalutamide)
Localized Prostate Cancer • added to block the low levels of androgens produced by the adrenal
medulla.
• Prostate cancer tends to progress slowly and have a long, natural history.
• Generally offered to patients with at least a 10-year life expectancy. Radical retropubic prostatectomy
• High-grade tumors (Gleason score of 8 to 10) may represent an exception to this • The dorsal venous complex over the apex of the prostate is ligated with a distal
rule; stitch and a proximal stitch, and then divided.
o without treatment, they are at a significantly higher risk of developing • The neurovascular bundles containing the nerves for erectile function are
symptomatic disease and dying from their disease. dissected off the prostate.
o Curative therapy (regardless of life expectancy) • The urethra is divided and the prostate is separated from the anterior rectum.
• The vasa deferentia are divided and the seminal vesicles are dissected and
Surgery
removed with the specimen.
• Radical retropubic prostatectomy (RRP) – common
• The bladder neck is reanastomosed to the distal urethral stump.
o pelvic lymph node dissection is generally performed for staging purposes at
the time of surgery.
UROLOGIC INFECTIONS
o care should be taken to avoid injuring the urinary sphincter located just distal
to the apex of the prostate. Cystitis
▪ The neurovascular bundles that run along the posterolateral border Descriptions
of the prostate contain the cavernous nerves, which are responsible • inflammation of the bladder mucosa and is usually caused by bacterial
for erectile function. organisms.
o Complications: • E. coli is the most common cause of urinary tract infection (UTI), including
▪ urinary incontinence - 5 to 10% cystitis.
▪ erectile dysfunction - 14 to 30% of cases o Other common causative organisms include Proteus, Klebsiella,
• Perineal radical prostatectomy Enterococcus, and Staphylococcus saprophyticus.
• Cryotherapy • Women with higher risk for UTI than men because their urethra is shorter.
• Fecal flora contaminating the vaginal mucosa can ascend through the female
Radiation therapy urethra.
• External radiation therapy (XRT) o bacterial factors, such as type 1 pili found on some strains of E. coli,
o 60 to 80 Gy is delivered by conformal radiotherapy. mediate adhesion and are more likely to cause UTI
o SE: o host factors such as vaginal pH, can promote vaginal colonization and UTI
▪ GUT- frequency, dysuria, hematuria, and decreased bladder
capacity. Manifestations
▪ GIT - diarrhea, rectal pain, and rectal bleeding.
• urinary frequency, urgency, and dysuria.
▪ sexual dysfunction -40 to 50% of previously potent men are
• Uncomplicated cystitis does not generally cause fevers or leukocytosis.
impotent 5 years
• Brachytherapy
Work-up
o percutaneous placement of radioactive seeds into the prostate.
o less side effect • Urinalysis – voiding symptoms
o less effective • Urine culture - more definitive diagnosis of a UTI

Management.
Metastatic Prostate Cancer
• Bacterial UTI
Androgen-ablative hormone therapy
o women -> 3 days of antibiotics
• first-line therapy for metastatic prostate cancer o men -> 7 days of antibiotics
o by performing bilateral orchiectomies or o younger men -> evaluated for correctable structural anomalies
o by administering gonadotropin releasing hormone (GnRH) agonist. ▪ with an IVP or CT scan with IV contrast, and a cystoscopy.
• Testosterone synthesis by the Leydig cell in the testicles is stimulated by • Asymptomatic bacteriuria
luteinizing hormone (LH) from the pituitary. o No treatment
o The release of LH requires a pulsatile discharge of GnRH. ▪ ~30% of elderly nursing home residents
• a constant GnRH stimulation paradoxically results in inhibition of LH and ▪ 5% of sexually active women.
testosterone. ▪ chronic indwelling Foley catheters.
 o Asymptomatic patients + urea-splitting organisms should be treated with o history of kidney stones, anatomic abnormalities such as aureteropelvic
antibiotics. junction obstruction, or malignancies that may cause extrinsic
▪ Pregnant women -> increased risk for developing pyelonephritis compression of the urinary system.
o Obstructed and infected urinary system -> most important principle
Pyelonephritis ▪ surgical emergency that requires prompt intervention to establish
Descriptions drainage.
• percutaneous nephrostomy tube placement
• Pyelonephritis refers to inflammation of the renal parenchyma and collecting
system. • cystoscopic placement of a ureteral stent.
o Bladder outlet obstruction causing bilateral hydronephrosis can be relieved
• Etiology agents: Gram-negative bacteria such as E. coli, Proteus,
by the placement of a Foley catheter.
Pseudomonas, and Klebsiella
6. Other findings on CT scan and MRI may require surgical intervention.
o gain access to the urinary system through the urethra and ascend to the
o Small renal and perirenal abscesses -> conservatively managed with
kidney.
antibiotics in clinically stable patients.
• Women are generally more susceptible to UTI and pyelonephritis because of the
o Inadequate clinical improvement or if the abscess is large -> percutaneous
shorter urethra in females compared to males.
immediately drained
7. Emphysematous pyelonephritis is often seen in older diabetic patients and
Manifestations
represents a medical emergency
• Clinical diagnosis: presence of fever, flank pain, and infected urine. o Air bubbles produced by gas-forming organisms (renal parenchyma on x-ray
• Older patients and young children may present with less-specific symptoms or CT scan)
o such as mental status changes, abdominal discomfort, and low-grade fevers o promptly treated with percutaneous drainage;
. o no evidence of clinical improvement -> urgent nephrectomy
Work Up 8. Adult patients -> no permanent sequela following successful treatment of
• Urine culture pyelonephritis.
o not be available for 48 hours 9. Infant kidney -> developing can be devastating.
o urinalysis can be used to support a presumptive diagnosis of o Pyelonephritis can lead to permanent parenchymal scarring and loss of renal
pyelonephritis. function.
• serial blood cultures o Ureteral reflux - most common abnormality resulting in pyelonephritis in
infants and children
Management ▪ carry an infectious organism from the bladder to the kidney, and
1. Healthy adults with no significant comorbidities can be treated as an outpatient; severe reflux can cause hydronephrosis and urinary stasis.
2. Most patients diagnosed with pyelonephritis are admitted to the hospital. o Renal ultrasound and a voiding cystourethrogram.
3. Broad-spectrum IV antibiotics, such as ampicillin and gentamicin o Long-term antibiotic prophylaxis
▪ When patients are afebrile, they can be discharged on oral
antibiotics. Xanthogranulomatous Pyelonephritis
▪ Uncomplicated pyelonephritis -> treated for a total of 14 days • Descriptions: rare form of chronic pyelonephritis.
▪ Uncomplicated pyelonephritis + structural or functional • Work Up: CT scan or MRI -> presence of calcification and large cystic lesions
abnormalities -> treated for 21 days. (presumptive)
o After 24 hours of antibiotic therapy, the urine should be sterile and • Manifestation: chronic flank pain and low-grade fevers.
leukocytosis should be minimal. • Management: Nephrectomy -> rule out a malignant process.
o Continue to have periodic fever spikes for several days after initiating o Following the nephrectomy, a definitive diagnosis of XGP is made
treatment. histologically by the presence of inflammatory cells and large lipid-laden
▪ results to resolving inflammation in the kidney rather than an active macrophages
infection.
o No radiologic studies is necessary Fungal Infections
4. No clinical improvement following 2 to 3 days of treatment,
Descriptions
o CT scan with IV contrast
o MRI, a renal ultrasound, or a CT scan without contrast - for renal • Most fungal infections of the urinary tract are opportunistic infections.
insufficiency or allergy to IV contrast • Candida is responsible for the vast majority of fungemia and funguria.
5. Upper tracts • Risk factors
o immunosuppression o diabetes o antibiotic use
o steroid therapy o long-term use of urinary catheters.
Work Up • PE: prostate is extremely tender to palpation,
• Cystoscopy, affected areas-> white patches on the bladder wall. • in the digital exam -> be gentle to prevent shedding bacteria into the blood
• CT scan and IVP -> fungal mass. stream.
• Laboratory exam -> elevated white blood cell count
Types • Urinalysis and urine culture findings -> consistent with a bacterial infection.
Simple fungal infections • Treatment for acute bacterial prostatitis = treatment for pyelonephritis.
o Afebrile and hemodynamically stab stable -> continue with oral
• Urine culture -> positive for more than 105 organisms/mL and are confined to the antibiotics for a total of 3 weeks.
bladder.
• asymptomatic or they may cause irritable voiding symptoms such as dysuria
Chronic prostatitis
and frequency.
• Treatment • all other forms of prostatitis associated with local symptoms
Plan A Plan B • Bacterial prostatitis
▪ stopping any antibiotics, or removing 1. Bladder irrigation with o recurrent urinary tract infections by the same organism.
urinary catheters and amphotericin B -> infections that o Treatment -> 30 days of antibiotic therapy with a fluoroquinolone or
▪ temporarily instituting intermittent do not resolve with Plan A (50 mg/L trimethoprim/sulfamethoxazole.
catheterizations. of water administered at 42 mL/h) • Nonbacterial prostatitis
o local symptoms of prostatitis without a history of urinary tract infections
o The etiology is poorly understood
Complex fungal infections o Treatments -> alpha blockers, antibiotics, anticholinergics, and
• refer to infections involving the upper urinary tract or infections resulting in benzodiazepines
positive blood cultures.
• Treatment: TRAUMA
o If fungal balls are present in the upper urinary tract, the effected kidney
Kidney
should be treated by
▪ percutaneously removing the fungal ball and • ~10% of traumas - kidneys.
▪ directly irrigating the renal pelvis with amphotericin B. • Helical abdominal CT scan with IV contrast.
o IV amphotericin B
▪ gold standard for complex fungal infections. Work Up: CT scan
• binds the ergosterol component of fungal cell Adult
walls and disrupts the cellular membrane • all penetrating traumas
▪ Systemic effects: rigors, chills, and fevers,
• for blunt trauma
• treatment can be minimized by premedicating o gross hematuria, or with microscopic hematuria
with steroid, meperidine, ibuprofen, and o systolic blood pressure less than 90 mm Hg
dantrolene. o flank contusions
o lower rib fractures,
Prostatitis
Descriptions Pediatric patients
• common disease that accounts for approximately 8% of urology-related office • able to maintain blood pressure despite an almost 50% loss of circulating
visits. volume.
• complain of pain and discomfort that generally localizes to the perineal region o hypotension is a poor indicator for radiologic work-up.
• no clinical or histologic evidence of inflammation. • gross hematuria
• E. coli, Proteus, Klebsiella, and Pseudomonas (same for both UTI and fecal flora) • microscopic hematuria
• potential renal trauma
Types
Acute prostatitis Management
• system findings such as: fever, chills, and leukocytosis. • Grade 1 - ~95% of renal traumas
• febrile and often complain of frequency, urgency, dysuria and a decreased • Managed nonoperatively - ~98% of renal injuries
urinary stream.
• may even present in shock with tachycardia and hypotension.
 Absolute indications for surgical Relative indications for surgical mgmt Ureter
mgmt. • Ureteral injuries are rare, with the majority of injuries resulting from penetrating
o persistent bleeding resulting in o major urinary extravasation, trauma.
hemodynamic instability or o vascular injury • often present without hematuria
o an expanding perirenal hematoma. o devitalized parenchymal tissue • often discovered during radiographic work-up or abdominal exploration
▪ Smaller vascular injuries +
• If a ureteral injury is suspected
devitalized renal tissue = no o an intravenous pyelogram,
surgery o a retrograde pyelogram, or a
▪ Smaller vascular injuries + > 20% o contrast CT scan
of the devitalized renal tissue –
▪ delayed images should be obtained after the contrast has
Surgery entered the collecting system.
• Surgical repair depends on the level of injury and the length of the injured
segment
Staging System for Renal Injury Developed by the American Association for the Surgery of
▪ tension-free,
Trauma ▪ water-tight
Grade Description of Injury ▪ closure after widely débriding the injured segment.
o For coverage of large ureteral defects,
Contusion or nonexpanding subcapsular hematoma ▪ interposition of intestinal segments or bladder flaps may be
1
No laceration required to achieve a tension-free repair.
Nonexpanding perirenal hematoma ▪ adventitia surrounding the ureter - carefully preserved to maintain
2
Cortical laceration <1 cm deep without extravasation the tenuous, ureteral blood supply.
3 Cortical laceration >1 cm without urinary extravasation
Bladder
Laceration: through corticomedullary junction into collecting system
or • Hematuria, gross or microscopic, is the hallmark of bladder injury.
4
Vascular: segmental renal artery or vein injury with contained • >90% of patients - Pelvic fracture
hematoma o ~10% bladder ruptures.
Laceration: shattered kidney or ▪ Retrograde cystogram is the most accurate test for ruling out a
5 bladder rupture
Vascular: renal pedicle injury or avulsion
• it is critical to adequately distend the bladder (400 mL or
Managed nonoperatively 40 cm H2O) and obtain a postdrainage film to look for
• placed on bedrest until resolution of gross hematuria -> After resuming extravasation of contrast.
ambulation -> monitored for recurrence of gross hematuria, which requires • Radiographic imaging
reinstitution of bedrest. o all patients with hematuria and pelvic fractures, or
o with penetrating trauma to the pelvis and lower abdomen.
Surgical Management • Absence of a pelvic fracture.
• Surgical exploration-> following CT staging (midline approach) o radiographic imaging - pelvic contusions or urethral injuries
1. Renal vessels should be identified and controlled prior to opening Gerota's • CT cystogram – alternatives for abdomen and pelvis
fascia in order to allow the vessels to be rapidly occluded if massive • Management (depends on the site of rupture)
bleeding is encountered. o Extraperitoneal ruptures -> managed conservatively with prolonged
2. Injuries to the collecting system -> repaired by a watertight closure. catheter drainage;
3. Devitalized tissue should be excised and meticulous hemostasis should be o Intraperitoneal ruptures -> explored and surgically repaired
obtained by ligating open segmental vessels.
4. If bleeding cannot be controlled or only minimal vitalized tissue remains, a Urethra
nephrectomy should be performed • Symptoms
• Immediate exploration for hemodynamic instability + CT scan cannot be o Classical
performed ▪ blood at the meatus
1. One-shot intravenous pyelogram (1 mL/kg of body weight of 30% contrast ▪ inability to void
administered 10 minutes before x-ray), o perineal hematoma
2. intraoperatively to evaluate the kidneys and confirm the presence of a o a "high-riding" prostate on digital rectal exam
functioning contralateral kidney • Retrograde urethrogram -> before attempting to catheterize the bladder
 o a small Foley catheter is placed just inside the meatus • The majority of fetal hydronephrosis resolves by birth or within the first year of
o Foley balloon is inflated with 1 to 2 mL of water. life.
o Lateral decubitus films are taken while 30 to 50 mL of radiographic contrast • Fetal intervention is rarely necessary
is gently injected through the catheter. o bilateral hydronephrosis
▪ renal ultrasound and a VCUG obtained shortly after birth
Posterior Urethra o and severe oligohydramnios (palpable abdominal mass) – following birth
• prostatic and membranous urethra, occurs in the context of pelvic fractures. • Unilateral hydronephrosis - obtained electively at approximately 1 month of life.
• >90% - pelvic fracture • higher risk for pyelonephritis,
o 10% urethral injuries. • all neonates diagnosed with unilateral or bilateral hydronephrosis should be
Although a suprapubic tube provides effective urinary drainage started on antibiotic prophylaxis (i.e., amoxicillin, 10 mg/kg per 24 hours).
• without risking further disruption of the urethra, • Pyelonephritis during the first year of life, when the kidney is still immature, leads
o a urethral Foley should be placed across the injury when possible. to permanent deterioration in renal function.
• If the disruption is only partial
o placing a guidewire into the bladder by using a flexible cystoscope, or Ureteropelvic Junction Obstruction
even a flexible ureteroscope, and placing a catheter over the wire. UPJ obstruction is the most common cause of hydronephrosis found on prenatal
• If complete urethral disruption ultrasound.
o two flexible cystoscopes, inserted through the meatus as well as through UPJ obstruction also is commonly observed in children and young adults.
a suprapubiccystostomy, can be used to align the urethra Intrinsic and extrinsic causes of UPJ obstruction exist and can be determined by
o guidewire can be placed across the aligned urethra to permit insertion of a presentation.
Foley catheter. Intrinsic UPJ obstruction - due to an adynamic or stenotic segment of proximal
▪ Early urethral alignment can often obviate the need for formal ureter.
surgical repair of the urethra. This impairs flow of urine into the ureter, particularly during times of high flow, and
▪ Cannot be aligned, a definitive repair should be performed in 4 to 6 causes dilatation of the collecting system. Over time, elevated renal pelvic pressures
months. and recurrent infections can injure renal parenchyma.
• Early exploration following pelvic trauma should not be performed in order to Abnormal lower pole (i.e., accessory) renal arteries may be a secondary cause of
avoid disrupting the pelvic hematoma and causing additional bleeding. UPJ obstruction by kinking the proximal ureter.
Nuclear scans (mercaptoacetyltriglycine or 99mTc diethylene-triamine-penta-
Anterior Urethra acetic acid) have replaced the IVP as the diagnostic modality of choice.
• bulbous and penile urethral. Delayed clearance of contrast or radiotracer implies obstruction.
• isolated injuries that most commonly result from a straddle injury. Invasive pressure-flow examinations (Whitaker test) rarely are performed.
• resut to direct trauma to the penis. Not every case of UPJ obstruction requires operative intervention.
• Pelvic fractures are rare Patients with infections or impaired renal function require repair to improve
drainage.
• More distal injuries - Buck's fascia and resulting hematomas dissect along the
Open dismembered pyeloplasty is considered the gold standard approach,
penile shaft
especially in infants.
• More proximal injuries - Colles' fascia and produce a perineal hematoma
An endoscopic approach, endopyelotomy, is also an option in older children and
adults. not as effective as.
Treatment (blunt and penetrating) Surgery involves ureteroscopy and a full-thickness lateral incision into the affected
o immediate exploration, ureteral segment with a laser or knife taking care not to injure the renal hilar vessels
o débridement, and (or accessory vessels in cases of a crossing vessel).
o direct repair. • the most common cause of hydronephrosis in neonates, young children and
o Suprapubic cystostomy and delayed repair after clear demarcation of injured adult
tissues: High-velocity gunshot • Precise etiology is poorly defined
o Perineal incision: Proximal injuries o abnormal development of the smooth muscle at the UPJ.
o Circumferential, subcoronal incision and degloving the penis: Distal injuries o an aberrant lower pole vessel crosses the UPJ, possibly resulting in extrinsic
compression.
PEDIATRIC UROLOGY • Neonates - asymptomatic,
Hydronephrosis • Older children – flank or abdominal pain.
• Hydronephrosis, or dilation of the upper urinary tract, may signify a • Initial evaluation - renal ultrasound and a VCUG to rule out coexisting reflux.
congenital anomaly with the potential for adversely impacting renal function. • If a UPJ obstruction is suspected,
o a nuclear renal scan -> Lasix administration
 ▪ assess differential function in the right and left kidneys, • second most common cause of hydronephrosis
▪ assess renal pelvic drainage by timing the washout of nuclear • 70% of infants presenting with a urinary tract infection
isotope following. • detected after birth -> female preponderance (85%)
• Mild to moderate hydronephrosis resulting from a UPJ obstruction -> be safely • often an inherited anomaly
observed and will usually resolve by 2 years of age. • 10x common in whites
o Antibiotic prophylaxis should be continued until the UPJ obstruction • up to 45% of siblings of children with reflux also have reflux.
resolves completely. • Diagnosed by demonstrating ureteral reflux on VCUG
• Surgical repair (dismembered pyeloplasty - The dyskinetic segment of the • Primary reflux is a congenital anomaly caused by a deficiency of the longitudinal
collecting system at the UPJ is resected, and the ureter and renal pelvis are bladder muscle surrounding the intramural portion of the ureter.
brought over any crossing vessels that may be present and then anastomosed) • Secondary reflux results from bladder outlet obstruction and an increase in
o Severe hydronephrosis intravesical pressure.
o diminished renal function, o corrected by addressing the underlying bladder outlet obstruction.
o high-grade obstruction or Evaluated for primary reflux
o breakthrough infections while on antibiotic prophylaxis.
• Infants with hydronephrosis on prenatal ultrasound,
• The ureter in older patients may readily accommodate endoscopic instruments
• history of a urinary tract infection, or
and a UPJ obstruction may be incised using either a percutaneous or
• siblings diagnosed with reflux
aureteroscopic approach.
As the infant bladder grows and the bladder wall thickens, most low-grade refluxes
• Kidneys with minimal function may best be treated with a simple nephrectomy.
resolve.
• ~ 85% of all grades I and II reflux
Vesicoureteral Reflux • 30 to 40% of grades III and IV reflux
• Vesicoureteral reflux (VUR) is the second most common cause of • 9% of grade V reflux will
hydronephrosis. 2/3 of infants with UTI have VUR • it is critical that patients managed conservatively are maintained on antibiotic
• white children (10 times as common , girls 5-6x . Older than 1 year old prophylaxis.
• The incidence of VUR decreases with advancing age. Surgical repair + antibiotic prophylaxis -> breakthrough infection
• Primary reflux is a congenital anomaly caused by insufficient intramural • surgical correction before the onset of puberty for girls with persistent reflux.
tunneling of the distal ureter, although bladder outlet obstruction may cause o Reason: after the cessation of longitudinal growth, the likelihood of
unilateral or bilateral secondary reflux when the ureters are anatomically normal. spontaneous resolution of reflux is small, and during pregnancy, reflux
• The primary danger : reflux of infected urine cause recurrent pyelonephritis, then places women at a higher risk of pyelonephritis and miscarriage.
scarring and cumulative renal damage. o Boys are at a lower risk of infection secondary to reflux.
• Neonates w/ hydronephrosis detected on prenatal ultrasound or infants/children o most practitioners recommend stopping antibiotic prophylaxis after early
experiencing UTI= voiding cystourethrogram childhood and continuing to observe persistent reflux.
• VUR is graded according to the International Classification System. The gold standard for intervention is an open surgical reimplant of the ureter into
• Spontaneous resolution of VUR, which is the norm, is a function of the grade of the bladder.
VUR. • Another option involves cystoscopically injecting a bulking agent, such as
o low-grade (1–2) most resolve collagen or a synthetic material.
o grade 3 and 4 reflux 30% to 50% resolve o The bulking agent is injected submucosally with the goal of increasing
o grade 5 reflux – 9% Resolve. resistance at the ureteral orifice and preventing reflux.
INITIAL MANAGEMENT:
Surgical repair with ureteral reimplantation is effective, overtreatment for those
destined to resolve spontaneously.
Conservative management, ( antibiotic prophylaxis) may result in breakthrough
infections with resistant organisms.
Submucosal injection of bulking agents at the ureteral orifice (Deflux¯) is being
used with increasing frequency.
• Although patients with high-grade VUR still undergo ureteral reimplantation,
those with low-grade VUR are increasingly
more likely to undergo submucosal injection of bulking agents instead of being
managed conservatively.
• It is a minimally invasive technique that may, in some patients, obviate the need
for long-term suppressive antibiotics. Submucosal bulking is not effective in every
case, and patients with severe reflux will likely need reimplantation.
 Ureterocele o Treatment for such patients should be individualized, and reconstructive
A ureterocele is a cystic dilation of the terminal ureter thought to result from a procedures should be performed with the goal of establishing drainage,
persistent membrane between the ureteral bud and the urogenital sinus. preventing reflux and decreasing risk of future urinary infections
genitourinary anomalies such as duplicated collecting systems or an ectopic
ureteral location. Posterior Urethral Valve
present during childhood and can present in multiple ways depending on size and • Posterior urethral valves can be a particularly damaging cause of bilateral
degree of obstruction. hydronephrosis in a newborn boy.
Patients may have hydronephrosis and pyelonephritis. • The “valves,” which are tissue folds located in the prostatic urethra, cause
Symptoms of prolapsing ureterocele : bladder outlet obstruction, and rarely, a bladder outlet obstruction.
large ureterocele can present as an intralabial mass in a newborn child. • Diagnosis is established with a VCUG, which may show poor bladder emptying
Diagnosis can be confirmed with cystoscopy, VCUG, or IVP. and a dilated posterior urethra.
Patients with a functioning renal moiety can undergo endoscopic incision of the • A Foley catheter should be placed in the bladder to decompress the urinary
ureterocele; however, VUR is common postoperatively. system in the hopes of facilitating recovery of renal function. Treatment involves
A ureterocele in a nonfunctioning duplicated system may require a cystoscopic ablation or resection of the valve.
heminephrectomy to avoid infections. • Even after ablation of the valves and elimination of the urethral obstruction,
• cystic dilation of the distal ureter associated with a stenotic ureteral opening patients with posterior urethral valves are at significant risk of renal failure,
• four times more frequently in girls than in boys and occur almost exclusively in depending on the degree of prenatal obstruction.
whites. • Bladders frequently suffer damage and become partially defunctionalized from
• ~80% are associated with the upper-pole moiety of a duplicated ureter. prolonged prenatal obstruction, and normal voiding patterns
• If a duplicated urinary collection system is present, • often are not established.
o the upper-pole ureter inserts more caudally and medially in relation to the • The most serious outcome of posterior urethral valves is pulmonary hypoplasia
lower-pole ureter. due to intrauterine oligohydramnios, and efforts have been made prenatally to
• Orthotopic - Ureteroceles with the orifice in the bladder trigone transplacentally decompress the urinary bladder and prevent this dreaded
• Ectopic - ureteroceles with the orifice distal to the bladder neck development
• The majority of neonatal ureteroceles are diagnosed postnatally during work-up • Posterior urethral valves are obstructive urethra lesions usually diagnosed in
prompted by prenatal hydronephrosis. male newborns and infants.
• After birth, the ureterocele can be seen on both ultrasound and VCUG. • The valves are thin, membranous folds located in the prostatic urethra.
o A VCUG - better localize the ureterocele and evaluate for reflux. • Posterior urethra valves are the most common cause of bilateral
• Findings: vary based on the location of the ureterocele and size of the ureteral hydronephrosis detected on prenatal ultrasound.
opening. o The test of choice to confirm the diagnosis following birth is a VCUG
o If a duplicated ureter is present, 65% of the ureters to the lower-pole kidney • Older children with undiagnosed posterior urethral valve often present with
will reflux. urinary incontinence.
o An orthotopicureterocele usually produces ipsilateralhydronephrosis; • The first step treatment: endoscopic ablation of the valve.
▪ a large, orthotopicureterocele may obstruct the contralateral ureter o A Foley catheter should be placed in the bladder until the procedure can be
and produce bilateral hydronephrosis. performed.
o An ectopic ureterocele can obstruct the urethra, resulting in bladder outlet Depending on the degree of obstruction, patients with posterior valves are at high risk
obstruction and may also produce bilateral hydronephrosis. of renal failure, and renal function should be closely monitored
o Ureteroceles associated with a single collecting system are generally
less obstructive and usually found incidentally in adult patients.
o It is common for infants with undiagnosed ureteroceles to present with
urosepsis.
▪ emergently treated by endoscopically incising the ureterocele and
establishing ureteral drainage.
o Uninfected neonates can be electively treated with endoscopic incision.
▪ ~25% will develop reflux and may require a secondary procedure,
such as ureteral reimplantation
• Infants presenting after 1 year of age with aureterocele will have had long-
standing obstruction and are less likely to have functioning renal tissue
draining into the affected ureter.