40

Urology
Ahmad Shabsigh, Michael Sourial, Fara F. Bellows,
chapter Christopher McClung, Rama Jayanthi, Stephanie Kielb,
Geoffrey N. Box, Bodo E. Knudsen, and Cheryl T. Lee

Anatomy 1759 Urethral Stricture / 1764 Urologic Malignancies 1770

Kidney and Adrenal Gland / 1759 Other Causes of Obstruction / 1764 Bladder Cancer / 1770
Ureter / 1760 Genitourinary Trauma 1764 Testicular Cancer / 1771
Bladder and Prostate / 1760 Kidneys / 1765 Kidney Cancer / 1772
Penis / 1760 Ureters / 1765 Prostate Cancer / 1774
Scrotum and Testes / 1760 Bladder / 1766 Urethral Cancer / 1775
Infection 1761 Urethral Injuries / 1766 Common Urologic Conditions 1775
Cystitis / 1761 External Genital Injuries / 1767 Urinary Incontinence and Voiding
Pyelonephritis / 1761 Emergencies 1768 Dysfunction / 1775
Prostatitis / 1761 Acute Urinary Retention / 1768 Erectile Dysfunction / 1775
Epididymo-Orchitis / 1761 Testicular Torsion / 1769 Pediatric Urology 1776
Balanitis and Balanoposthitis / 1762 Fournier’s Gangrene / 1769 Hypospadias / 1776
Urinary Tract Obstruction 1762 Priapism / 1769 Urinary Tract Infections in Children / 1777
Urolithiasis / 1762 Paraphimosis / 1770 Prenatal Hydronephrosis / 1777
Benign Prostatic Hyperplasia / 1763 Emphysematous Pyelonephritis / 1770 Cryptorchidism / 1777

ANATOMY Kocher maneuver, to achieve intraoperative vascular control

during right renal surgery.
The anatomic structures that generally require urologic man-
The kidneys are end organs, which are responsible for
agement include the kidneys, adrenal glands, ureters, bladder,
their vulnerability to infarction. The renal arteries extend from
prostate, seminal vesicles, vas deferens, penis, urethra, scrotum,
the aorta and then branch into several segmental arteries and
and testes. These organs are located in retroperitoneal or extra-
arterioles before becoming glomeruli. Each artery runs poste-
peritoneal spaces. However, a transperitoneal approach may be
rior to their respective renal vein. Occasionally, an accessory
utilized to access the kidney, ureters, bladder, or retroperitoneal
renal artery will arise, but in general, each kidney receives a
lymph nodes during certain urologic operations.
single main renal artery. Each renal vein drains directly into the
Kidney and Adrenal Gland IVC and is located anteriorly to its respective renal artery when
The kidneys are paired retroperitoneal organs that are entering the kidney. The right renal vein is much shorter than
invested in a fibro-fatty layer of tissue known as Gerota’s the left and does not receive collateral venous drainage. The left
fascia. This natural barrier helps to tamponade bleeding and renal vein passes anteriorly to the aorta and receives drainage
thus may provide renal and hemodynamic protection in cases from the left gonadal vein, the left inferior adrenal vein, and a
of renal trauma or spontaneous renal hemorrhage. It also may lumbar vein.
assist in preventing tumor invasion into surrounding struc- The collecting system of the kidney begins as minor caly-
tures in the case of large renal masses. The kidneys are bor- ces near the renal papillae and then coalesces into major calyces.
dered posterolaterally by the quadratus lumborum muscle Major calyces join to form the renal pelvis, which then tapers
and posteromedially by the psoas muscle. Additionally, the down to the ureteropelvic junction (UPJ), from which the ureter
diaphragm drapes across the posterior aspect of the superior emanates. The pelvis is located posterior to its respective renal
pole of each kidney. artery.
The left kidney is bordered anterolaterally by the spleen The adrenal gland is superomedial to its respective kidney
and descending colon. The pancreatic tail borders the antero- within Gerota’s fascia. Adrenal arterial supply arises from mul-
medial left kidney. The right kidney is bordered anterolaterally tiple sources: the inferior phrenic artery, aortic branches, and
by the liver and the ascending colon. The second portion of the renal arterial branches. Venous drainage mirrors arterial supply.
duodenum may be encountered near the right renal vessels and On the right side, the adrenal gland drains directly into the IVC.
thus sometimes requires anteromedial reflection, known as the The right adrenal vein can be quite short (<1 cm) and can be
 Key Points
1 Most small ureteral calculi will pass spontaneously or with 6 Testicular torsion is an emergency where successful testicu-
the use of medical expulsive therapy, but larger stones (>6 mm) lar salvage is inversely related to the delay in repair, so cases
are better treated with ureteral stenting or lithotripsy. with a high degree of clinical suspicion should not wait for a
2 Benign prostatic hyperplasia can be managed effectively radiologic diagnosis.
with medical therapy or minimally invasive endoscopic and 7 Fournier’s gangrene is a rapidly progressive and potentially
robotic surgical techniques depending on the urinary symp- lethal condition that requires aggressive débridement and
toms, patient bother, prostate size, and patient’s therapeutic close follow-up due to the frequent need for repeat
choice. débridement.
3 Patients with recurrent urethral stricture after endoscopic 8 The management of early stage prostate cancer has changed
treatment are unlikely to derive sustained benefit from future significantly, with a much greater emphasis on risk stratifi-
endoscopic therapies and should be referred for urethral cation. Low risk patients are largely treated with active
reconstruction. surveillance.
4 The vast majority of renal trauma can be treated conserva- 9 Treatments for urinary incontinence and voiding dysfunction
tively, with early surgical intervention reserved for persistent are varied depending on the etiology, severity, and bother of
bleeding, renal vascular, or ureteral injuries. the symptom. Behavior modification, bladder retraining,
5 Extraperitoneal bladder ruptures can be treated conserva- and medical therapies can all be effective in improving
tively, but intraperitoneal ruptures typically require surgical symptoms without the need for surgery.
repair.

a source of significant bleeding if inadvertently injured during which can contract and facilitate bladder outlet obstruction. The
renal or adrenal surgery. average prostate measures approximately 30 mL in volume.
Puboprostatic ligaments suspend the prostate to the pubis, and in
Ureter the instance of pelvic trauma, shearing forces can cause disrup-
The ureters are smooth muscle–based tubular structures that tion of the posterior urethra (known as pelvic fracture urethral
connect the renal pelvis to the bladder. The blood supply arises injury). The external urethral sphincter houses the membranous
from the surrounding vasculature. The proximal blood supply urethra and sits just below the apex of the prostate. Vasculature
inserts on the medial aspect of the ureter and arises from the to the bladder and prostate arises from the superior and inferior
aorta and renal artery, and the distal blood supply inserts lat- vesical arteries, which branch from the internal iliac arteries.
erally and arises from the surrounding iliac vessels and their
branches. The arterial supply inserts via a fatty layer of tissue Penis
around the ureter, and thus surgical preservation of the periure- The penis is comprised of three bodies: two corpora cavernosa,
teral tissue is essential to maintain vascularization and achieve which are responsible for erection, and the corpus spongiosum,
successful ureteral reconstruction. which surrounds the urethra and gives rise to the glans penis.
The ureters initially course along the psoas muscle and These three structures are all encased by skin and dartos fascia,
then run distally along the pelvic sidewall. They generally pass as well as an inner investing layer of fascia called Buck’s fascia.
posterior to the uterine arteries, making them susceptible to The corpora cavernosa are spongy sinusoidal bodies that expand
injury during hysterectomy. The ureters enter the bladder lat- with parasympathetic neural stimulation to create an erection.
erally and pass through the bladder wall at an oblique angle, Thick fascia, called tunica albuginea, assists in producing rigid-
which helps prevent reflux of urine during bladder filling. The ity during erection. Each corpus cavernosum features a centrally
ureters propel urine into the bladder via the ureteral orifices. located cavernosal artery, which arises from the penile artery. A
porous septum separates the two corpora and allows for trans-
Bladder and Prostate corporal blood exchange. The corpus spongiosum is located on
The bladder is located extraperitoneally in the pelvis and pos- the ventrum of the penis. The corpus spongiosum lacks a tough
terior to the pubis. A portion of the bladder dome is draped by fascia similar to tunica albuginea and thus does not exhibit the
peritoneum, and rupture or injury at this location can result in same rigidity during erection.
intraperitoneal urine leakage and subsequent chemical peritoni-
tis. The average adult bladder holds approximately 500 mL of Scrotum and Testes
urine; however, in rare cases, capacity can reach up to or greater The scrotum is a potential space that surrounds the testes,
than 1000 mL, in which case the bladder extends towards the epididymis, and spermatic cords. The scrotum is comprised
umbilicus. The sigmoid colon lies adjacent to the bladder and of many layers aside from skin and dartos fascia, and each
can fistulize to the lateral wall or dome of the bladder in cases derives from a particular layer of the anterior abdominal wall.
of diverticulitis or colon cancer. The rectum lies posteriorly to The external spermatic fascia arises from the external oblique
the bladder in men, and the uterus and vagina lie posteriorly to fascia, the cremasteric fascia arises from the internal oblique
the bladder in women. fascia, and the internal spermatic fascia arises from the transver-
The prostate is a walnut-shaped gland that encircles the sus abdominis fascia. The testes are separated from the scrotal
urethra and is located in males immediately beneath the blad- layers by the visceral and parietal layers of the tunica vaginalis,
1760 der neck. Smooth muscle fibers distribute throughout the gland, between which hydroceles form. The spermatic cord contains
the vas deferens, the venous pampiniform plexus, and arterial be treated as an outpatient with oral antibiotics. Fluoroquino- 1761
blood supply to the superior pole of the testis via three separate lones and trimethoprim-sulfamethoxazole are ideal for treating
sources. The testicular artery arises directly from the aorta; the pyelonephritis. Nitrofurantoin should not be used as it does not
deferential artery, which supplies the vas deferens, arises from penetrate renal parenchyma. Patients with concern for sepsis or
the internal iliac artery; and the cremasteric artery, which sup- inability to tolerate oral intake may require hospitalization with
plies the cremaster musculature, arises from the external iliac IV antibiotics while awaiting culture results. Fevers may persist
artery. The presence of multiple arterial sources provides col- for up to 72 hours despite appropriate treatment. The presence
lateral flow and prevents ischemia in the event of injury to a of persistent fevers or symptoms after this time period warrants
particular vascular branch. The venous pampiniform plexus can cross-sectional imaging to rule out renal or perinephric abscess.
dilate to form a palpable or visible varicocele, which can serve Treatment for renal or perinephric abscess usually consists of

CHAPTER 40 UROLOGY
as an etiology of chronic testicular pain or infertility. percutaneous drainage and broad-spectrum IV antibiotics.
Prostatitis
INFECTION Acute prostatitis is marked by fever, suprapubic or perineal
pain, and new onset lower urinary tract symptoms, namely dys-
Cystitis uria, frequency, urgency, changes in stream caliber, or difficulty
Uncomplicated cystitis usually presents as new onset urinary emptying the bladder. It is most often caused by urinary patho-
frequency, urgency, and dysuria. Patients may also report lower gens. Digital rectal exam may reveal a tender and soft pros-
back pain, suprapubic pain, foul-smelling urine, or gross hema- tate. Bladder drainage with a Foley or suprapubic tube may be
turia. Urinalysis with microscopy assists with diagnosis by required if urinary retention is present. Treatment consists of a
confirming the presence of pyuria, hematuria, and bacteriuria. long-term course (4–6 weeks) of antibiotics. If not treated in a
Office dipstick may be helpful, as the presence of nitrites reflects timely fashion, acute prostatitis can develop into severe sepsis
bacterial colonization and the presence of leukocyte esterase or a prostatic abscess. Prostatic abscesses may require drainage
reflects pyuria. Risk factors for the development of uncompli- via a transurethral approach or transrectal needle aspiration.
cated cystitis include female gender, sexual activity, and use of Chronic prostatitis may be bacterial or abacterial. Symptoms
spermicides.1 Three days of antibiotics are generally sufficient in both cases include perineal, suprapubic, or penile pain, along
for treatment of uncomplicated cystitis. Fluoroquinolones and with urinary frequency, urgency, or change in stream caliber. Men
trimethoprim-sulfamethoxazole are well tolerated and are eas- may also report pain in the groin, lower back, or testes. Fever is
ily available. Nitrofurantoin, which is also commonly used for not observed in chronic prostatitis, and onset may occur over
uncomplicated cystitis, requires 5 days of treatment. Men with many months. Patients with chronic bacterial prostatitis may
uncomplicated cystitis should undergo 7 days of treatment. also report recurrent UTIs, with cultures consistently exhibiting
Complicated cystitis may arise in the setting of structural or the same bacteria. Differentiation between the two etiologies
functional urinary tract abnormalities, recent urinary tract instru- requires culture of expressed prostatic secretion to confirm the
mentation, recent antimicrobial use, immunosuppressed states, presence or absence of bacteria. Treatment of chronic bacterial
pregnancy, or hospital-acquired infection. Symptoms may be simi- prostatitis includes long-term antibiotics and α-blockers.
lar to uncomplicated cystitis but can progress to pyelonephritis if Chronic abacterial prostatitis is also known as chronic pel-
left untreated. Elderly or very young patients tend to exhibit leth- vic pain syndrome (CPPS). Symptoms are similar to chronic
argy, change in mental status, or anorexia, which may confound bacterial prostatitis, but generally do not respond well to long-
the diagnosis of a urinary tract infection. Patients may require hos- term antibiotics for treatment. It is generally somewhat more
pitalization if febrile or if symptoms are severe. Treatment consists difficult to achieve symptomatic relief when treating CPPS, and
of 10 to 14 days of antibiotics. Fluoroquinolones or trimethoprim- options include α-blockers, NSAIDs, neuromodulators, and/or
sulfamethoxazole are usually effective and should be administered pelvic floor physical therapy.2
based on culture results and/or regional bacteriograms. Asymp-
tomatic bacteriuria does not require treatment unless detected dur- Epididymo-Orchitis
ing pregnancy or if urinary tract instrumentation is planned.1 Epididymitis refers to inflammation of the epididymis. In most
cases of bacterial infection, the testis is also affected, thus is
Pyelonephritis encompassed by the term “epididymo-orchitis.” Common eti-
Pyelonephritis arises when a bladder infection ascends proxi- ologies include sexually transmitted infection, especially in
mally along the ureters to the renal parenchyma. It may also younger males, or urinary tract infection, which is more com-
result from hematogenous spread, such as in the case of intra- monly seen in older males. Other possible etiologies include
venous drug abuse or in patients with bacteremia from other underlying congenital urologic abnormality or incomplete blad-
sources. Patients with pyelonephritis may present with fevers, der emptying. Symptoms include pain and swelling of the epi-
flank pain, nausea, vomiting, and lower urinary tract symptoms. didymis and testis. Some men may report nausea or vomiting,
Physical exam may reveal tenderness of the costovertebral which arises as a result of irritation of the spermatic cord. Uri-
angle. Patients may appear toxic, with poor oral intake. Labora- nary symptoms may be present, but absence of symptoms does
tory evaluation may reveal leukocytosis with elevated neutro- not rule out bacterial epididymo-orchitis. Physical exam gen-
phils. Urinalysis usually demonstrates the presence of pyuria erally reveals a tender, swollen epididymis and testis. Scrotal
and bacteriuria, and urine culture should be sent prior to start- skin erythema or reactive hydrocele may be present as well. A
ing broad-spectrum antibiotics. Imaging should be considered to complete blood count should be performed to rule out leukocy-
rule out obstruction, which could prolong the recovery period tosis, and urinalysis with urine culture should be collected prior
despite appropriate antimicrobial treatment. to initiation of antibiotics. Urethral swab should be performed if
Acute pyelonephritis requires 7 to 14 days of antibiotic sexually transmitted infection is a possible etiology. The clini-
therapy. Mild or moderate cases, even if febrile, can safely cal presentation of testicular torsion can be quite similar to that of
1762 epididymo-orchitis. It may be quite difficult to clinically differenti-
ate the two entities, but one should keep in mind that the onset of
torsion tends to be slightly more acute (within 4–8 hours) than that
of epididymo-orchitis (which generally arises over the course of
24–48 hours). Scrotal ultrasound can assist in diagnosis; how-
ever, in cases of severe orchitis, testicular flow can be compro-
mised, which may raise concern for torsion. Scrotal exploration
should be considered in any equivocal case: a missed torsion can
result in testicular loss secondary to necrosis.
Treatment of epididymo-orchitis consists of single dose
of ceftriaxone and azithromycin if there is concern for sexu-
ally transmitted infection, as well as 14 days of oral antibiotic
PART II

therapy, NSAIDs, and scrotal support. If the patient exhibits

fevers or toxic presentation, hospitalization with IV antibiotics
may be required.

Balanitis and Balanoposthitis

SPECIFIC CONSIDERATIONS

Balanitis refers to inflammation of the glans penis. Balano-

Figure 40-1.  Struvite (infectious) stones are evident on a plain
posthitis arises when the foreskin is also involved. Common radiograph of the abdomen. The red arrows highlight a left Stag-
etiologies include fungal infection, bacterial infection, contact horn calculus filling the renal pelvis and calyces and several stones
dermatitis, or local trauma. Exam reveals a diffusely erythema- in the right lower pole of the kidney.
tous and warm glans penis, with inner preputial erythema as
well if balanoposthitis is present. Treatment includes appropri-
ate hygiene, topical antibiotics or antifungals, and occasionally may lead to dissolution of uric acid stones and reduced fur-
topical steroids. If there is an inappropriate response to treat- ther formation.9 Proteus species, Klebsiella species, and other
ment, the differential diagnosis should include malignancy, pso- urease-producing bacteria metabolize urea into ammonium and
riasis, or infectious agents such as HPV.3 bicarbonate. The alkaline milieu (pH >7) predisposes to infec-
tious (struvite) stones with the precipitation of magnesium,
URINARY TRACT OBSTRUCTION ammonium, and phosphate (Fig. 40-1).
Evaluation for first-time stone formers should include a
Urolithiasis complete medical history and physical exam, basic metabolic
Renal stone disease is a common problem that is a major health panel, calcium, uric acid, urinalysis and culture, and radio-
care burden to society today. The prevalence of stone disease graphic imaging. A noncontrast computed tomography (CT)
in the United States has increased over the past several decades scan is the most sensitive (98%) and specific (97%) exam to
as reported by the National Health and Nutrition Examination detect urolithiasis10 and can provide additional anatomical infor-
Survey (NHANES), and was estimated at 8.8% for the period mation useful for surgical planning, although its use in recurrent
between 2007 and 2010.4 This prevalence has increased with stone formers should be balanced by cost and radiation expo-
factors such as global warming, poor diet choices, and the sure. Low-dose CT is currently the preferred imaging study
obesity trend. Overall, the total estimated annual expenditure for patients with a body mass index (BMI) <30. This imaging
for individuals with claims for a diagnosis of urolithiasis was study uses less than one-third of the estimated effective ionizing
almost $2.1 billion in 2000, representing a 50% increase since radiation dose (3 mSv) compared to standard dose noncontrast
1994.5 Risk factors for stone formation include dietary habits, CT (10 mSv),10 while maintaining excellent sensitivity (95%)
family history, white race, geographical location or occupa- and specificity (97%).11 Plain abdominal X-ray can be used to
tional exposure to heat/dehydration, intestinal disease, and male follow radiopaque stones such as calcium-containing stones or
gender, although the gender gap is decreasing.6 More recently, struvite stones, although at times struvite can be difficult to see
stone formation has also been associated with obesity, metabolic on plain X-ray, especially when the fragments are small. Uric
syndrome, and diabetes mellitus.7,8 acid and triamterene stones are radiolucent on plain abdominal
Stones are most commonly composed of calcium oxa- X-ray but will be visible on noncontrast CT. A full metabolic
late. Other stone compositions include calcium phosphate, uric evaluation with a 24-hour urine collection is indicated in recur-
acid, cystine, medication-related, and infectious stones (stru- rent stone formers, high-risk stone formers, or interested first-
vite or carbonate apatite) or a mix thereof. Stone composition time stone formers.12
can vary based on a number of underlying pathophysiological The natural history of stones is variable and depends pri-
processes. For example, hyperoxaluria may be seen in patients marily on their size and location. Smaller and more distal stones
who have undergone small bowel resection, particularly the ter- are much more likely to pass spontaneously without the
minal ileum. This can result in an increase in unabsorbed fatty 1 need for surgical intervention.13,14 Patients with ureteral
acids and bile salts which undergo saponification by binding stones ≤10 mm can be offered a period of observation if their
with calcium in the bowel. The increase in unbound oxalate is pain is well controlled without signs of infection or renal insuf-
absorbed by the large intestine and subsequently excreted in the ficiency. α-Blockers, which inhibit ureteral peristalsis, have
urine, favoring the formation of calcium oxalate stones. Uric been shown in meta-analyses to be particularly useful in patients
acid stones will form in a context of acidic urinary pH, low uri- with distal ureter stones ≤10 mm, improving the rate of stone
nary volume, and high oral intake of purines. Countering these passage from 54% to 77%,15,16 with shortened time to expulsion
factors by alkalinizing the urine and increasing urine output and fewer colic episodes.17
 Patients who have not passed their stone after a 4- to stone burden, and requires a percutaneous tract into the kidney. 1763
6-week observation period, those with larger stones, or those Most stones larger than 2 cm are treated with PCNL although
who desire immediate intervention, may be offered one of three there is a role for PCNL for smaller stones located in the lower
definitive surgical interventions: shockwave lithotripsy (SWL), pole of the collecting system.18,19 More powerful lithotripters
ureteroscopy (URS), or percutaneous nephrolithotomy (PCNL). (pneumatic, ultrasound) and larger instruments (stone graspers)
Open surgical management of stones has been relegated to can be used to fragment and remove these larger stones through
historic interest for the most part with less than 1% of stone the percutaneous tract. Complications include injury to adjacent
surgery needing to be done open with access to modern endou- organs, acute and delayed renal bleeding due to pseudoaneu-
rologic equipment. The choice of the procedure will depend rysm or arteriovenous fistula formation, sepsis, or renal pelvis
primarily on stone-related factors (e.g., stone size, location, and perforation.

CHAPTER 40 UROLOGY
composition/density), and patient-related factors (e.g., comor- General preventative measures include correcting dietary
bidities, coagulopathy, obesity, renal anatomy, and surrounding habits, particularly increasing fluid intake to produce >2.5 liters
structures). of urine per day, limiting sodium, reducing animal protein
Shockwave lithotripsy is the procedure associated with intake, and monitoring foods high in oxalate. Medical therapy
the least morbidity and the lowest complication rate but is also such as thiazide diuretics (helpful for hypercalciuria), urinary
associated with a lower success rate at treating stones as a single alkalization with potassium citrate, or allopurinol may also be
procedure and requires the patient to pass the stone fragments indicated depending on the clinical situation.12
afterwards.15,16 The modality can be used for stones in the prox-
imal ureter (particularly if <10 mm) or non–lower-pole renal Benign Prostatic Hyperplasia
stones <2 cm.15,16 The stone is located under fluoroscopic guid- Benign prostatic hyperplasia (BPH) refers to the histological
ance, which is coupled to an extracorporeal lithotripter aimed findings of smooth muscle and fibroblast/epithelial cell pro-
at the stone. The stone is fragmented in a completely nonin- liferation in the transition zone of the prostate. Lower urinary
vasive manner. Complications associated with this procedure tract symptoms (LUTS) may be secondary to benign prostatic
include subcapsular or perinephric renal hematoma and ureteral enlargement (BPE) causing progressive bladder outlet obstruc-
obstruction by stone fragments (“Steinstrausse”; Fig. 40-2). tion but may also be due to numerous other conditions (e.g.,
Ureteroscopy is the procedure of choice for patients with middle urethral stricture, infection, overactive or neurogenic bladder,
or distal ureteral stones. It also has a higher success rate than malignancy). Although some male patients with LUTS may
SWL in treating >10-mm proximal ureteral stones and renal have BPE, not all patients with an enlarged prostate have LUTS.
stones.15,16 This procedure involves advancing a semi-rigid or The prevalence of LUTS attributed to BPH in men over the age
flexible ureteroscope to the level of the stone and fragmenting of 50 is estimated at 50% to 75% and increases with age with a
it under direct visualization, often using a holmium:YAG laser. prevalence of 80% in men over the age of 70.20 The treatment
The surgeon is able to visualize the stone during fragmentation modalities have dramatically evolved over the past decades,
and thereby has some control over how small the fragments are. with medical management typically used for first-line therapy.
In addition, stone fragments may also be actively removed with Endoscopic and minimally invasive techniques are used for
a small nitinol stone basket. This is where the procedure may those failing or intolerant of medical therapy.
have an advantage over SWL. However, many patients have a Men with BPH/LUTS are evaluated with a complete his-
ureteral stent placed after ureteroscopy, and, although tempo- tory and physical exam including digital rectal exam. LUTS
rary, this remains a major source of morbidity for the patient. should be clearly defined, in addition to their severity and degree
Specific complications of URS include ureteral injury or stric- of bother. Validated questionnaires to quantify the patient’s
ture. PCNL is reserved for patients with larger or more complex symptoms and degree of bother include the American Urologi-
cal Association Symptom Index (AUA-SI) and the International
Prostate Symptom Score (IPSS).21,22 Complications of BPH
such as urinary retention, incontinence, renal failure, hema-
turia, or recurrent infections should also be considered. Basic
workup includes a urinalysis and culture to rule out infection.
After an informative discussion about the risks and benefits of
prostate cancer screening, a serum PSA is measured when life
expectancy is >10 years and if the diagnosis of prostate can-
cer will alter management.23 Other diagnostic testing such as
cystoscopy, cytology, postvoid residual (PVR), urodynamics,
and radiologic imaging of the prostate, although not done rou-
tinely, may be required in patients with a definite indication
(e.g., hematuria), uncertain diagnosis, poor response to therapy,
or for surgical planning.24
The first line of treatment is most commonly pharmaco-
therapy for those men with bothersome symptoms.
2 α-Blockers work by relaxing the smooth muscle of the
prostate and bladder neck. All α-blocker agents are equally
effective,25 and their side effects may include orthostatic hypo-
Figure 40-2.  Ureteral obstruction in a patient with Steinstrausse. tension, dizziness, asthenia, headache, nasal congestion, and
A plain abdominal radiograph (KUB) demonstrates Steinstrausse in retrograde ejaculation. Their effect is usually seen within days.
the right distal ureter between the white arrows. Five-α reductase inhibitors (5-ARIs) block the conversion of
1764 testosterone to dihydrotestosterone (DHT), the hormone primar- been associated with the need for more complex reconstructive
ily responsible for BPH progression. These reduce prostatic size surgeries for definitive management.39,40 For that reason, com-
by 20% to 25%,26 but their effects are seen only after 4 to 6 mon practice is to attempt one endoscopic intervention prior to
months. Side effects include erectile dysfunction, decreased referral for reconstructive surgery.
libido, and, rarely, gynecomastia. 5-ARIs, but not α-blockers, can Surgical reconstruction of the urethra, referred to as a ure-
alter disease progression as demonstrated by two landmark tri- throplasty, can be divided into two general categories: excisional
als, the MTOPS27 and CombAT28 trials. These trials evaluated and tissue substitution. An excisional repair involves resection
combination therapy using α-blockers and 5-ARIs. Patients on of the strictured segment of the urethra, and direct anastomo-
5-ARIs, particularly those with larger prostates, had a reduced sis of the two healthy urethral ends. This repair technique is
risk of both developing acute urinary retention and requiring generally reserved for membranous strictures and short bulbar
surgical intervention. More recently, daily phosphodiesterase-5 strictures. Tissue substitution involves augmenting a narrowed
urethral lumen with free tissue grafts. The most common tissue
PART II

inhibitors, which are most often used for erectile dysfunction

(ED), have now been approved for treating patients with BPH. substitute is buccal (oral) mucosal graft.
These can be particularly valuable in patients with concomitant
ED.29,30 Other Causes of Obstruction
Surgical modalities for BPH continue to evolve towards Retroperitoneal fibrosis (RPF) is a rare cause of ureteric
less invasive endoscopic procedures. Transurethral resection of obstruction secondary to an inflammatory and fibrotic pro-
SPECIFIC CONSIDERATIONS

the prostate (TURP) remains the mainstay of endoscopic pro- cess of the retroperitoneal structures. Most cases (>70%) are
cedures, with low treatment failure and complication rates.31 idiopathic. Identifiable causes in the remaining cases include
TUR syndrome is associated with prolonged use of hypotonic periaortic inflammation due to aneurysms, medications (e.g.,
irrigation fluid, resulting in fluid overload and dilutional hypo- methysergide, ergot derivatives, β-blockers, phenacetin), infec-
natremia. Symptoms include nausea/vomiting, bradycardia and tions (e.g., tuberculosis, schistosomiasis), and malignancy (e.g.,
hypertension, pulmonary edema, mental status changes, and lymphoma, multiple myeloma, sarcoma). Symptoms are non-
rarely death. Other endoscopic modalities used today include specific and may include general abdominal discomfort or back
bipolar TURP and various laser procedures (e.g., Ho:YAG pain, flank pain due to ureteral obstruction, or lower extremity
laser enucleation of the prostate, Ho:YAG laser ablation of the edema due to vena caval compression. Laboratory abnormali-
prostate, and photoselective vaporization of the prostate) with ties such as normocytic anemia, an elevated C-reactive protein,
the goal of enucleating or vaporizing prostatic tissue. Normal or ESR are identified in about two-thirds of cases.41 The classic
saline is used for irrigation with these modalities, which greatly radiological findings consist of a well-defined retroperitoneal
reduces the risk of TUR syndrome. Generally, laser procedures soft tissue mass encasing the great vessels with medialization of
have been associated with shorter catheterization time and the ureters. Contrast enhancement on CT scan, magnetic reso-
length of stay with comparable improvements in LUTS to open nance imaging (MRI), and positron emission tomography (PET)
prostatectomy or TURP.32-34 Open, and more recently laparo- scan can also be used to monitor disease activity and assess
scopic and robotic simple prostatectomy can also be performed response to treatment.42
for patients with moderate-severe, bothersome LUTS due to Patients with symptomatic renal obstruction, renal insuf-
BPH. These are usually reserved for patients with larger pros- ficiency, or signs of infection should be decompressed with
tatic volumes (>100 cc), or patients requiring concomitant blad- either ureteral stents or nephrostomy and monitored for postob-
der surgery (e.g., bladder diverticulectomy or stones).23 structive diuresis. Biopsy of the retroperitoneal mass to exclude
malignancy should be considered prior to commencing treat-
Urethral Stricture ment. Steroid therapy remains the mainstay of medical treat-
A urethral stricture is an area of scarring or fibrosis that causes ment, although other immunosuppressive agents have been
concentric narrowing of the urethra, impeding the flow of urine described.43 If medical treatment fails, open or minimally inva-
as it drains from the bladder. Strictures occur at a prevalence of sive bilateral ureterolysis with intraperitonealization or omental
0.9% of the population in the United States.35 Causes of urethral wrapping of the ureters is indicated.
stricture disease include trauma (19%), iatrogenic causes (33%), Ureteral obstruction secondary to tumor (benign or malig-
inflammatory causes (15%), and idiopathic causes (33%).36 nant) is commonly encountered. Ureteral stenting can be tried
Symptoms of urethral stricture disease include incomplete initially, but it fails in approximately one-half of cases.44 Other
emptying, weak urinary stream, urinary urgency/frequency, strategies such as percutaneous nephrostomy, ureteral stenting
and pain.37,38 in tandem, metallic, and metal-mesh stents have been described.
The anatomy of the urethra in men can be divided into Metallic stents may be more cost-effective due to less frequent
the following segments proceeding from cephalad to caudad: stent exchanges,45-47 although cost savings may be offset by the
prostatic, membranous, bulbous (the area between the pelvic limited life expectancy in this patient population.44
floor and the penoscrotal junction), and penile. A stricture can
occur in any segment of the urethra, but it is most common in
the bulbar urethra.
GENITOURINARY TRAUMA
Options to treat urethral stricture disease can be divided Genitourinary (GU) trauma is rare. Approximately 10% of vic-
into two general categories: endoscopic and surgical reconstruc- tims of abdominal trauma will have a urologic injury.48 Any
tion. Endoscopic treatments include a urethral dilation or stric- portion of the GU tract can be injured including the follow-
ture incision with a cystoscope. The latter is referred to as a ing: kidneys, ureters, bladder, urethra, and the external genita-
direct vision internal urethrotomy. The success rate of one endo- lia including the testicles. Mechanisms of trauma parallel other
scopic attempt to treat a urethral stricture is around 30%.39 injury mechanisms, the majority of which include blunt and
3 The success of repeat endoscopic treatments of a urethral penetrating injuries. This section will be divided into the man-
stricture drops to 13%, and recurrent dilations have agement of each organ involved in the GU system.
Table 40-1 1765

The American Association for the Surgery of Trauma (AAST) renal trauma grading system
GRADE DESCRIPTION MANAGEMENT
1 Contusion or nonenlarging subcapsular perirenal Generally managed conservatively.
hematoma
2 Perinephric hematoma without obvious parenchymal Generally managed conservatively in a stable patient.
laceration on CT, or a <1 cm laceration into the
cortex of the kidney

CHAPTER 40 UROLOGY
3 >1 cm laceration into the cortex without involvement Generally managed conservatively in a stable patient.
of the collecting system
4 A deep laceration into the collecting system with Can be observed expectantly in the stable patient, but
evidence of urinary extravasation on CT, or a may require subsequent urgent or delayed repair. Renal
segmental renal artery or vein injury with artery embolization may be an option for those who fail
contained hematoma, or partial vessel laceration, conservative therapy.
or vessel thrombosis
5 Renal pedicle injury or multiple deep renal lacerations Patients often require surgical exploration, but stable patients
(“shattered kidney”) with only parenchymal injury may be safely treated
conservatively.
CT = computed tomography.

Kidneys Across the board, the most common surgery for renal sur-
The prime goal of renal trauma management is preservation gery in modern times is unfortunately a nephrectomy.55 Early
of renal function. Renal trauma has become largely nonop- renal vascular control may minimize nephrectomy rates.56 This
erative in modern times, especially in the setting of low- to is accomplished by isolating the renal vascular medially prior
intermediate-grade renal injuries from a blunt mechanism of to opening the perinephric hematoma. If uncontrolled bleeding
action. The role of angioembolization through vascular and is encountered once the hematoma is opened, occlusion of the
interventional radiology has further increased this nonopera- renal vasculature can be performed. At that time, a renorrhaphy
tive management.49,50 can be safely done as can a nephrectomy in the setting of a grade
The first goal of renal trauma is to accurately grade the 5 renal injury.
renal injury. The gold standard test to diagnose and stage a renal
injury includes a CT scan with IV contrast, with delayed images. Ureters
In most centers, this is referred to as a “CT urogram,” in which There is no association between the magnitude of ureteral injury
delayed contrast imaging delineates the upper urinary tract and the degree of hematuria that is present.57 A high index of
collecting system. Criteria that would mandate renal imaging suspicion is required. Diagnosis requires either a CT urogram,
include the presence of gross hematuria, microscopic hematuria IVP, or a cystoscopy with a retrograde pyelogram. Unlike renal
with hypotension, and mechanisms increasing the prevalence of injury, the ureters more commonly are injured through iatro-
renal injury (sudden deceleration injuries, flank contusion, etc). genic mechanisms. Common surgical procedures in which the
The American Association for the Surgery of Trauma (AAST) ureters are injured include gynecological, colorectal, and uro-
renal trauma grading system is described in Table 40-1.51,52 logical surgeries. The repair of ureteric injuries depends on the
The management of renal injuries depends not only on the time of identification from initial injury, location, and length of
grade but also on the injury mechanism and clinical symptoms. the injured ureteral segment involved.
Absolute indications for surgical or radiological intervention on Iatrogenic ureteral injuries should be initially managed with
renal trauma include life-threatening hemorrhage, renal pedicle ureteral stent placement when possible. When stenting is not fea-
avulsion, or pulsatile/expanding retroperitoneal hematoma. sible, open repair may be attempted when the patient presents
Moreover, those suffering penetrating renal trauma with a ret- shortly after injury. When stent placement is not feasible or when
roperitoneal hematoma should undergo exploration when hemo- presentation is delayed, nephrostomy tube placement should be
dynamic instability exists. considered until formal repair can be safely done.
In a hemodynamically stable patient with a renal injury, Ureteral injuries of traumatic origin (penetrating injuries,
renal trauma should be initially observed. Data suggests multiple intra-abdominal traumas) should be repaired during
4 that this approach may even be feasible in the setting of the index admission when possible. Hemodynamically stable
isolated, penetrating renal injuries.53 Conservative management patients undergoing laparotomy for other reasons in which a
entails bed rest and hemodynamic monitoring. Patients with a high index of suspicion of a ureteral injury is present should
grade 4 renal injury (Fig. 40-3A to D) should be treated in the have ureteral exploration. Stable patients in this same situation
same manner, and a repeat CT scan should be done to make that are identified to have a ureteral injury should have primary
certain that the urinary extravasation has resolved.54 Otherwise, repair at the time of exploration. If a patient is hemodynamically
urinoma and subsequent abscess formation may occur. If uri- unstable, the ureter can be ligated with subsequent nephrostomy
nary extravasation is persistent, placement of a ureteral stent or tube placement. Ureteral repair can then be delayed until the
nephrostomy tube should be considered. patient is stable for surgery.
1766
A B
PART II

C D
SPECIFIC CONSIDERATIONS

Figure 40-3.  Grade 4 renal injury as demonstrated on abdominal computed tomography imaging with intravenous contrast. A. The yellow
arrow points to extravasated contrast in the right perirenal fat. B and C. The right kidney has been fractured, as seen at the yellow arrow.
Hematoma and extravasated contrast are seen in the mid-anterior pole of the kidney. D. Coronal view. The yellow arrow reveals the upper
pole renal fracture with disruption of the collecting system.

The definitive operative management of a ureteral injury Contrast may be visible at the sight of injury, within the perito-
depends on the location and the extent of devitalization. It is neal space (Fig. 40-4A), or in the perivesical space (Fig. 40-4B).
important to debride devitalized ends of the ureter, whether it Simply capping the Foley catheter alone on a delayed excretory
is from a contusion via a gunshot wound or an iatrogenic ther- phase of abdominal CT imaging is insufficient to diagnose a
mal injury. Upper ureteral injuries that are short can generally bladder injury.61
be resected and anastomosed primarily.58 Ureteral mobilization Two general categories of bladder injuries are extraperito-
with preservation of ureteral adventitia to maintain vascular neal and intraperitoneal injuries. An intraperitoneal injury
supply can aid in bridging short defects. In modern times, more requires repair during the index admission after the patient
aggressive maneuvers to directly anastomose more proximal 5 has been resuscitated. Delayed repairs are associated with
ureteral injuries to the bladder are possible. Maneuvers used to abdominal sepsis. Conversely, extra peritoneal injuries can gen-
bridge the defect of ureteral length for direct anastomosis to the erally be managed with Foley catheter drainage alone. Situa-
bladder include the following: bladder mobilization with liga- tions in which extraperitoneal bladder injuries should be treated
tion of the contralateral bladder pedicles, psoas hitch (tacking with operative repair include complex injuries involving bone
the bladder down to the ipsilateral psoas tendon), and the Boari spicules from a pelvic fracture within the laceration and concur-
flap with downward nephropexy. Creation of a Boari flap uti- rent rectal or bladder lacerations, which increase the possibility
lizes a tubularized flap of anterior bladder wall to bridge long of fistula formation. Bladder neck injuries should also be treated
defects. Bridging defects as high as the proximal ureter have operatively during the index admission as these injuries occa-
been reported in association with this technique.59 When blad- sionally do no heal with Foley catheter drainage alone. Repeat
der-to-ureter anastomosis is not possible with these maneuvers, cystography should be done 7 to 14 days later prior to Foley
the remaining options include trans-ureteroureterostomy (anas- removal to ensure that the laceration, or operative repair, has
tomosing the injured ureter to the contralateral ureter), creation healed.63
of an ileal ureter, or renal auto transplantation to the pelvis.
Urethral Injuries
Bladder Common mechanisms of trauma of the urethra include pelvic
The bladder can be injured through iatrogenic and classic trau- fracture associated injuries and straddle injuries. Pelvic fracture
matic mechanisms. Indications for bladder imaging include associated injuries occur at the level of the membranous urethra,
gross hematuria in the setting of injuries with a correlation for whereas straddle injuries occur at the level of the bulbar urethra.
bladder injury. The most common clinical scenario is gross The clinical hallmark of a urethral injury is blood at the meatus.
hematuria associated with a pelvic fracture, which is associated A retrograde urethrogram should be done when this clinical sign
with a 29% chance of bladder laceration.60 Diagnosis of bladder is present to diagnose an injury, prior to attempted Foley cath-
injuries requires either a CT cystogram or a fluoroscopic cysto- eter placement (Fig. 40-5A).64,65
gram. The sensitivities and specificities of these two modalities The initial step in management of a urethral injury is
are similar.61,62 The bladder should be filled with approximately bladder drainage to prevent urinoma formation and subsequent
300 cc of contrast for either of these imaging modalities. abscess formation. In general, this is accomplished through
 1767
A A

CHAPTER 40 UROLOGY
B

Figure 40-5.  A. Retrograde urethrogram showing an area of nar-

rowing at the double white arrow. This indicates a bulbar urethral
stricture. B. After urethroplasty, a retrograde urethrogram demon-
strates a normal-appearing and patent bulbar urethra at the arrow.
Figure 40-4.  Intraperitoneal and extraperitoneal bladder injuries.
A. During a computed tomography (CT) cystogram, intraperitoneal External Genital Injuries
contrast is seen within the peritoneal space at the red arrow. B. During Penile fractures classically occur with excessive torqueing of
a CT cystogram, extravesical contrast is seen contained within the the erect penis. This excessive torqueing results in rupture of
extraperitoneal space at the red arrow. the tunica albuginea, the fascial coating of the erectile bodies.
Common symptoms include immediate detumescence with
subsequent development of a hematoma. Clinical history and
placement of an SP tube. After stabilization, some centers per- examination alone are sufficient to warrant surgical exploration
form “primary urethral alignment.” This is a dual antegrade with primary suture repair of the corporal body laceration. For
and retrograde endoscopic procedure utilizing fluoroscopy to equivocal cases, ultrasonography or an MRI may be done.68,69
bridge the urethral defect and to place a Foley catheter across Up to 10% of penile fractures are associated with urethral inju-
the injury. Subsequent restructure rates are high, but the severity ries. Blood at the meatus signifies the possibility of a coexisting
of stricture formation may be less when primary alignment is urethral injury. This should be evaluated with either a retrograde
performed.66 If patients are managed with an SP tube alone, the urethrogram or cystoscopy at the time of repair.
site of disruption leaves the patient with a urethral stricture and Scrotal trauma generally occurs from a blunt mechanism.
subsequent restructure. This requires a treatment with a urethro- Injuries to the testis, epididymis, and spermatic cord may occur.
plasty after the patient’s period of convalescence has resolved Hematomas with subsequent ecchymosis are common with such
(Fig. 40-5B). injuries. Testicular rupture occurs with fracture of the fascial
Penetrating injuries to the anterior urethra are rare. In a coating of the testicle, called the tunica albuginea. This may
hemodynamically stable patient with an uncomplicated injury, occur with blunt or penetrating mechanisms. The most spe-
it is expert opinion to perform exploration with primary repair cific findings on ultrasonography are loss of testicular contour
during index admission. Complicated injuries with extensive and heterogeneous echotexture of parenchyma. The highest
tissue devitalization should be managed with SP tube urinary reported sensitivity for testicular rupture on ultrasound is 93%.70
diversion and delayed reconstruction.67 With diagnosis of a testicular rupture or when a high index of
1768 suspicion is present (especially with penetrating trauma), explo-
ration should be performed. Testicular salvage rates are high in
modern times and involve suture repair of the site of rupture.70
When primary repair is not possible, a simple orchiectomy Bladder Anterior prostate
should be performed.

EMERGENCIES
Urethra
Acute Urinary Retention
Acute urinary retention (AUR) can happen in men or women Posterior prostate
and results from a variety of causes, although it most commonly
PART II

occurs in men with benign prostatic hyperplasia (BPH).71,72

Other chronic causes of poor bladder emptying, such as diabetic
neuropathy, urethral stricture, multiple sclerosis, or Parkinson’s
A
disease, can result in episodes of complete urinary retention,
often when the bladder becomes overdistended. This frequently
SPECIFIC CONSIDERATIONS

occurs in the hospital setting when patients have limited mobil-

ity and are receiving medications that decrease bladder con-
tractility, including opiates or anticholinergics. Constipation, a
common side effect of those medications, can itself worsen uri-
nary retention. Significant hematuria can result in the formation
of blood clots, which may block the urethra and cause retention.
Although some patients receiving large doses of narcot-
ics or those with chronically decompensated bladders may not
experience discomfort, most patients with AUR have significant
pain. Untreated severe urinary retention (often accompanied by
overflow incontinence) may result in acute renal failure. Treat-
ment should include placement of a urethral catheter as quickly
as possible. However, BPH or urethral strictures often make the
placement of a catheter difficult. For men with BPH, a coude
(French for curved) catheter is helpful in negotiating past the
angulation in the prostatic urethra (Fig. 40-6A). The curved por-
tion (which is angled in line with the balloon port) is maintained
B
at the 12 o’clock position as it is passed through the urethra
(Fig. 40-6B). A common mistake is to use a smaller catheter to Figure 40-6.  Coudé catheter. A. A schematic drawing of a lat-
bypass the enlarged prostate. However, a larger (18F to 20F) eral view of the prostatic urethra showing the upward angulation at
catheter is less flexible and is more likely to push into the blad- the bladder neck, which a coudé catheter is helpful in negotiating.
der rather than curl in the prostatic urethra. B. The tip of a coudé catheter. Note the curved tip, which should
Smaller catheters, however, are quite useful for bypass- always point to 12 o’clock when inserted.
ing a urethral stricture. A urethral stricture should be suspected
when the catheter meets resistance closer to the meatus, as shown to increase the likelihood of a successful trial without a
many strictures occur in the distal urethra, which is narrower catheter.73 Although finasteride and dutasteride (5α-reductase
than the proximal portion. Using a 12F or 14F catheter often inhibitors) have been shown to reduce the incidence of urinary
will allow the passage of the catheter into the bladder. If cath- retention by 50%, they require several months to take effect and
eter placement is not successful, a urologic consultation should are most beneficial in large prostates; therefore, they will not
be requested. The urologist can either choose to (a) use a cys- provide significant benefit in the short term. Narcotics should be
toscope, guidewire, and urethral dilators to dilate the stricture tapered as tolerated, and constipation should be treated.
and place a Council-tip catheter via Seldinger technique; or Acute spinal cord compression, which is accompanied
(b) place a suprapubic tube approximately two fingerbreadths by saddle paresthesias, is a neurologic emergency that requires
above the pubic symphysis. With regard to the suprapubic tube, neurosurgical or orthopedic consultation. In most cases, except
ultrasound-guidance or aspiration with a finder needle should severe neurologic injuries, patients will be able to resume void-
be used first to localize the bladder and avoid intra-abdominal ing, and the catheter can be removed after 1 to 2 days. Postvoid
contents, although bowel injury is unlikely with a distended residuals should be checked with a portable ultrasound device
bladder filling the pelvis. If hematuria is the cause of retention, (bladder scanner) or by “straight” catheterization to determine
continuous bladder irrigation often is necessary to prevent clot the residual amount of urine left after the patient tries to empty
formation. This is done through a large three-way catheter that his or her bladder. In patients with severe liver dysfunction, the
has an additional port for fluid inflow. Fluid is infused by grav- bladder scanner may inadvertently misinterpret ascites for urine.
ity only because the use of higher pressure may result in bladder The inability to void or the presence of a postvoid residual over
rupture if outflow is occluded. 200 mL is concerning for development of another episode of
Once the bladder is adequately drained, the cause of AUR AUR. Patients may be given the option of an indwelling cath-
should be addressed. For men with suspected BPH, an α-blocker eter for another few days with a subsequent voiding trial or to
such as tamsulosin should be started, and these have been perform clean intermittent catheterization (CIC), whereby, after
predetermined intervals (4–6 hours) or after voiding attempts, 1769
the patient passes a catheter into the bladder and empties it.
This is the preferred method because it reduces the likelihood
of infections from indwelling catheters and may improve blad-
der functionality. However, most patients are resistant to this
approach.

Testicular Torsion
The differential diagnosis of acute scrotal pain includes testicu-
lar torsion.74 This usually occurs in neonates or adolescent boys
but may be observed in other age groups. The blood supply to

CHAPTER 40 UROLOGY
the testicle is compromised due to twisting of the spermatic cord
within the tunica vaginalis, resulting in ischemia to the epididy-
mis and the testis. In newborns, an extravaginal torsion also can
occur with twisting of the tunica vaginalis and spermatic cord
together. Risk factors for torsion include undescended testis,
testicular tumor, and a “bell-clapper” deformity—poor guber-
nacular fixation of the testicles to the scrotal wall.
Clinical history is vital for diagnosis.75 Patients describe a
sudden onset of pain at a distinct point in time, with subsequent
swelling. Physical examination may demonstrate a swollen,
asymmetric scrotum with a tender, high-riding testicle. Children
normally have a brisk cremasteric reflex that usually is lost in
the setting of torsion. The diagnosis is made by clinical history
and examination but can be supported by a Doppler ultrasound,
which typically shows decreased intratesticular blood flow rela-
tive to the contralateral testis. If an ultrasound is not promptly
available, timely surgical exploration should be performed.
Immediate surgical exploration can salvage an ischemic
testis.76 At the time of surgery, the contralateral testes also must
be explored and fixed to the dartos fascia due to the pos-
6 sibility that the same anatomic defect allowing torsion
exists on the contralateral side. Midline (along the median
raphe) or bilateral transverse scrotal incisions are made. Once
the testis is detorsed, it should be assessed for viability after
being given time for normal blood flow to resume. One can
assess the blood flow using intraoperative Doppler or by incis-
ing the tunica vaginalis and observing tissue viability. The testes
are fixed to the dartos fascia with a small, nonabsorbable suture
on their medial, lateral, and dependent aspects, taking care to Figure 40-7.  Fournier’s gangrene. A. Necrotic scrotal skin from
ensure that the spermatic cord is not twisted before doing so. An Fournier’s gangrene. B. Debridement of gangrenous tissue. Note
orchiectomy should be performed to avoid later risk of abscess the extensive debridement, which is commonly required. The right
formation only if the testis is clearly necrotic. testicle required removal in this case (the left is wrapped in gauze),
but typically, the testes are not involved with the necrotic process.
Fournier’s Gangrene
Fournier’s gangrene is a necrotizing fasciitis of the male geni- patients may require a colostomy. Patients frequently require
talia and perineum that can be rapidly progressive and fatal if return trips to the operating room for further debridement.
not treated promptly (Fig. 40-7). The mortality rate has been Negative pressure wound therapy systems have been shown to
reported to be as high as 67%.77 Risk factors for Fournier’s reduce hospitalization time by aiding in wound healing.81
gangrene include perirectal abscesses, diabetes, obesity, and Reconstructive strategies involving skin grafting are needed
chronic alcoholism.78 The often polymicrobial infection spreads when large tissue defects result from extensive tissue damage.
along dartos, Scarpa’s, and Colles’ fascia. Clinical signs include
perineal and scrotal pain, inflammation, necrosis, and crepitus.78 Priapism
The diagnosis is largely made on clinical suspicion; however, Priapism is a persistent erection for greater than 4 hours unre-
radiographic findings on CT imaging often assist with the diag- lated to sexual stimulation.82 Priapism is divided into two types,
nosis, including soft tissue air associated with fluid collections based on the underlying pathophysiology. The most common
within the deep fascia.79 type—low-flow/ischemic priapism—is a medical emergency.
Prompt and aggressive surgical debridement of nonvia- On examination, the penis is very tender, and both cavernosal
ble tissue and broad spectrum antibiotics are necessary bodies will be rigid while the glans will be flaccid. Decreased
7 to prevent further spread (Fig. 40-7A). Fecal diversion venous outflow with persistent inflow results in increased
with endorectal tubes serve as an option for conservative fecal intracorporal pressure and tumescence, which is the normal
diversion.80 If there is damage to the external anal sphincter, process of erection. Diminished arterial inflow due to elevated
1770 intrapenile pressure usually is brief under normal circumstances. physician to use hand compression.86 If the foreskin cannot be
Priapism is essentially a compartment syndrome. With pro- manually reduced, surgical intervention is required.
longed erection (priapism), the sustained decrease in arterial
inflow ultimately causes tissue hypoxia, acidosis, and edema Emphysematous Pyelonephritis
and results in long-term fibrosis and impotence, and sometimes Emphysematous pyelonephritis is a life-threatening infection
frank necrosis. Risk factors include sickle cell disease or trait, that results from complicated pyelonephritis by gas-producing
malignancy, medications, cocaine abuse, certain antidepres- organisms. It is an acute necrotizing infection of the kidney that
sants, and total parenteral nutrition.82-84 If a cause is not identi- occurs predominantly in diabetic patients.87 Patients frequently
fied, a hematologic workup is necessary to rule out malignancy present with sepsis and ketoacidosis. Escherichia coli appears
or blood dyscrasias. to be the most frequent organism responsible for this infection.
The management of priapism is rapid detumescence with Patients require supportive care, IV antibiotics, and relief of any
the goal of preservation of future erectile function. The ability to urinary tract obstruction. Third-generation cephalosporins have
PART II

achieve normal erections is directly related to the length of the been suggested as the initial antibiotic of choice and fluoroqui-
episode of priapism. Ischemic priapism can be confirmed with nolones avoided due to high rates of resistance.88 Emphysema-
a penile blood gas from the cavernosal bodies demonstrating tous pyelonephritis can be subdivided based on the extent of
hypoxic, acidotic blood. Initial management can include sys- infection. Cases where gas is isolated to the kidney frequently
temic treatment of the underlying disorder (fluid and oxygen can be managed conservatively with the placement of a neph-
SPECIFIC CONSIDERATIONS

for sickle cell patients) but this should be done concurrently rostomy tube to allow drainage of purulent material. When there
with an active treatment to reduce the priapism.82 The initial is extensive involvement of the perirenal tissue, conservative
intervention may be therapeutic aspiration or injection of sym- management may not be successful and strong consideration
pathomimetics (phenylephrine). Insertion of a large-gauge needle should be given to nephrectomy, particularly if the patient is
(16–21 gauge) into the lateral aspect of one corporal body displaying signs of sepsis.89,90
allows thorough aspiration and irrigation of both corporal bod-
ies because of widely communicating intercavernosal channels. UROLOGIC MALIGNANCIES
Injection of phenylephrine (diluted 100–500 mcg/mL and given
Bladder Cancer
in 1 mL increments every 3–5 minutes for up to 1 hour before
determining failure) into the corporal bodies works to cause Epidemiology and Presentation.  In 2018, 81,190 men and
vasoconstriction, but the patient should be monitored for acute women will be diagnosed with bladder cancer, and 17, 240 will
hypertension and reflex bradycardia especially in patients with die from their disease.91 The disease is highly prevalent, with over
high cardiovascular risk. 700,000 patients living with the disease in the United States as
A surgical shunt is sometimes necessary to resolve the of 2016. Men have nearly three times the incidence of women.
episode if phenylephrine fails. Distal (corporoglanular) shunts Tobacco use is the most frequent risk factor, followed by
should be performed first because they are the easiest to perform occupational exposure to various carcinogenic materials such
and the lowest amount of complications. A Winter shunt uses a as industrial solvents (e.g., aromatic amines). Other risk fac-
large biopsy needle to create holes between the glans and cor- tors include arsenic, radiation, cyclophosphamide, and chronic
pora; however, if this fails, an operative procedure can be per- exposure to foreign bodies (stones and catheters) and specific
formed to remove the distal tips from each corpora (Al-Ghorab). urinary parasites. The most common bladder cancer histology
Proximal shunts such as Grayhack (corporal-saphenous vein) in the United States is urothelial carcinoma (UC), accounting
or Quackel (proximal cavernosumspongiosum) shunts may be for 90% of tumors, which tends towards a better prognosis as
required in refractory cases. compared to the rarer forms, including squamous cell carcinoma
The other form of priapism (high-flow/traumatic priapism) (<10%), adenocarcinoma (1–2%), and small cell cancer (<1%).
is rare and is related to penile or perineal trauma resulting in a Unfortunately, there is no reliable screening test for bladder
cavernous artery–corporal body fistula. This form is not painful cancer, although patients felt to be at high risk may undergo urine
because it is not related to ischemia and can be managed con- sampling for microhematuria or abnormal cytology. Smoking
servatively with observation. Many cases will resolve with time; cessation should be advised in all tobacco users as a preventive
those that do not can undergo selective arterial embolization.82 measure. The most common symptoms at presentation are hema-
turia (gross or microscopic) and/or irritable voiding (urgency,
Paraphimosis frequency, and dysuria). Office cystoscopy is an effective means
Paraphimosis is a common problem that represents a true medi- to diagnose bladder cancer.
cal emergency for uncircumcised men. When the foreskin is Staging.  Clinical staging is completed with CT or MRI to
retracted for prolonged periods, constriction of the glans penis assess intraabdominal nodal and visceral sites of metastasis. The
may ensue. This is particularly likely in hospitalized patients upper tracts should be evaluated with CT urography or retro-
who are confined to bed or who have altered mental status grade pyelography. Chest radiograph provides initial evaluation
and are unable to respond to pain. Delay can be catastrophic of the thorax and mediastinum. A bone scan should be obtained
as penile necrosis may occur due to ischemia. Penile blocks, if the patient complains of bone pain, has known locally
pain medication, and sedation are sometimes necessary before advanced or metastatic disease, or an unexplained elevation in
manual reduction. It is useful to apply firm pressure to the the serum alkaline phosphatase level. Pathologic staging has
edematous distal penis for several minutes.85 Although painful, been outlined by the American Joint Committee on Cancer.92
this reduction in penile edema can be the key to success. With Transurethral resection of bladder tumor (TURBT) should
the fingers pulling the constricting band distally, the thumbs include an examination under anesthesia (EUA) and sampling of
can push the glans penis back into normal location. Compres- the bladder muscular wall to fully assess depth of invasion. The
sion wraps have shown some benefit without the need for the presence of induration or a mass on EUA denotes extravesical
tumor extension and may alter the patient’s treatment plan. It which require catheter drainage for several days if small (com- 1771
may also be appropriate to biopsy multiple areas of mucosa to mon) or open repair if large and intraperitoneal (rare). Cys-
identify multifocal carcinoma in situ (CIS). Restaging TURBT tectomy and urinary diversion may result in prolonged ileus,
within 2 to 6 weeks is recommended in the patient with incom- bowel obstruction, intestinal anastomotic leak, urine leak, or
plete, under-sampled, or uncertain resection. This is especially rectal injury. A urine leak from the ureteroileal anastomoses
important in the patient with Tis, Ta, or T1 disease, as well as is a common cause of ileus, intra-abdominal urinoma, abscess
the patient with suspected T2 disease who is being considered formation, and wound dehiscence. Deep venous thrombosis
for a bladder preservation treatment strategy. Invasion into the is common after cystectomy due to the advanced age of most
lamina propria and certainly the muscular wall demonstrates patients, proximity of the iliac veins to the resection and lymph
increased potential for distant metastases; muscle invasion is node dissection, and the presence of malignancy. The utility of
rarely treated completely with TURBT and requires additional

CHAPTER 40 UROLOGY
subcutaneous heparin in the perioperative period can minimize
therapy for adequate local control. the risk of venous thromboembolism. Contemporary series from
Recurrence rates of non–muscle-invasive bladder can- high volume centers report readmission rates of 25%, complica-
cers are high, ranging from 50% to 70%.93 Adjuvant treatment tion rates of 50% to 60%, and perioperative mortality in the first
strategies have thus been adopted after TURBT to reduce these 90 days at 5% to 10%.99,100
rates. Intravesical chemotherapy used in conjunction with Urinary diversion can be accomplished using an incon-
TURBT can reduce the risk of recurrence by 44% to 73% in tinent or continent abdominal stoma or orthotopic continent
patients with primary Ta and T1 tumors and by 38% to 65% in reconstruction. The evolution of patient selection and surgical
patients with recurrent Ta, T1, and Tis tumors when compared technique has led to improved outcomes for orthotopic diver-
to TURBT alone.94 Intravesical immunotherapy using bacil- sion, although there are still patients who are better served with
lus Calmette-Guérin (BCG) also provides a significant reduc- an ileal conduit. Motivated patients are considered for ortho-
tion in recurrence that is greater than 50% in this population. topic neobladder diversion if they have a preoperative serum
Despite improved rates of disease-free survival, standard induc- creatinine less than 2.0 mg/mL, normal preoperative bowel
tion courses of intravesical chemotherapy and immunotherapy function, a negative urethral margin based on intraoperative
do not improve disease-specific survival.94 However, when an frozen section at the time of cystectomy, and an intact sphincter
induction course of BCG is followed by a series of maintenance after complete tumor resection.
doses consisting of weekly BCG given for 3 weeks at 3, 6, 12, Alternatives to cystectomy include observation, systemic
18, 24, 30, and 36 months after induction, disease-free and over- chemotherapy, radiation therapy, or a combination of chemo-
all survival can be prolonged.95 In patients who fail an initial therapy and radiation. These modalities may be required in
or maintenance course of intravesical therapy, it may be rea- patients who are a poor surgical risk, who refuse surgery, or
sonable to try another agent; however, one must consider the who are elderly.
risk of progression and not delay definitive treatment. Roughly Bladder preservation using radiation as the definitive ther-
15% to 30% of patients presenting with non–muscle-invasive apy may be feasible in selected patients. In this context, trimo-
tumors will eventually progress to muscle invasion. Radical cys- dality therapy is preceded by aggressive TURBT and offers an
tectomy remains the most effective single-modality treatment improved rate of survival when performed in conjunction with
for patients with muscle-invasive bladder cancer, refractory chemotherapy. Up to 42% 5-year disease-specific survival can
high-risk non–muscle-invasive disease, and especially lymph be achieved in patients with preserved bladders, with the best
node–negative disease with a reported 10-year recurrence-free overall survival outcome in younger patients with lower stage
survival of organ-confined lymph node–negative (<pT2N0) dis- tumors without lymphovascular or nodal involvement.
ease between 69% and 87%.94,96,97 More recently, immunotherapeutic treatments have
Surgical Considerations.  Cystectomy is indicated in the treat- shown significant promise in the treatment of locally advanced
ment of refractory NMIBC or to assert local control for muscle and metastatic bladder cancer. Five agents have recently been
invasive bladder cancer (MIBC).98 Effective local control in approved for patients who have progressed on or after platinum-
the pelvis is achieved in 93% of cases with cystectomy. Indica- based chemotherapy or have progressed within 12 months of
tions for partial cystectomy are limited and generally apply to neoadjuvant or adjuvant treatment. These agents include PD-L1
isolated tumors or those within diverticulum. Classic teaching inhibitors (atezolizumab, avelumab, durvalumab) and PD-1
suggests that patients with CIS should not be candidates, though inhibitors (nivolumab and pembrolizumab). Response rates for
the use of intravesical BCG to treat CIS may have broadened these agents are ∼15% to 20% but may have extended median
this application. For patients with MIBC, neoadjuvant systemic overall survival as much as 10.3 months when compared to
chemotherapy with M-VAC or gemcitabine and cisplatin (prior chemotherapy.101,102
to cystectomy) offers a survival advantage when compared to
radical cystectomy alone.98 Testicular Cancer
Robotic approaches for cystectomy are increasingly used, Testicular cancer is the most common cancer in men age 20 to
but the urinary diversion is still usually performed through an 40 years and the second most common cancer in young men
open incision. The benefits of the robotic portion are decreased age 15 to 19 years. Metastases to the testis (usually lymphoma
blood loss during the pelvic dissection (due to the pneumoperi- in older men) are rare. In 2018 there were 9310 new cases and
toneum). However, recent evidence (randomized controlled 400 deaths from the disease.91 The incidence of testis cancer
trials of open vs. robot-assisted radical cystectomy) did not varies around the world.103 It contains a heterogeneous group of
demonstrate any difference in oncologic efficacy or complica- tumors, of which 95% are germ cell tumors; the rest originate
tion rates. from stromal cells (Leydig or Sertoli cells). Germ cell tumors
Complications of bladder cancer surgery involve bladder can be classified as either seminomatous or nonseminomatous.
perforation during transurethral resection of the bladder tumor, Seminoma constitutes more than 50% of all testis cancer. The
1772 Stages I to IIA nonseminomatous testis cancer is poten-
tially cured with RPLND or chemotherapy.111 Persistently high
tumor markers after radical orchiectomy or high-stage meta-
static germ cell tumors warrant systemic chemotherapy. Due to
the high rates of teratoma or viable germ cell tumor, postchemo-
therapy bulky masses are resected by RPLND or other surgi-
cal procedures. The overall survival rate of localized disease
is outstanding (99% at 5 years). Patients with more advanced
distant metastatic disease (stage III) have 75% survival rates.
The overall prognosis is generally better for seminomatous than
nonseminomatous germ cell tumors.112
PART II

Surgical Considerations. Radical orchiectomy is done

through an inguinal incision extending from the external
inguinal ring to the internal inguinal ring. The spermatic cord
is ligated at the internal ring with long silk sutures for easier
Figure 40-8.  Scrotal ultrasound of the right testis. A heteroge- identification during a future RPLND. Integrity of the scrotal
SPECIFIC CONSIDERATIONS

neous echoic mass is seen. skin during orchiectomy is important. Complications of radi-
cal orchiectomy include scrotal hematoma, chronic pain, and
hernia.
For RPLND, a midline incision is usually made from the
incidence of bilateral GCT is approximately 2.5%.104,105 There xiphoid process to the pubic symphysis. All the lymphatic tissue
are four established risk factors for testis cancer: cryptorchidism, is removed from the targeted areas using the classical split and
family history of testis cancer, a personal history of testis can- roll technique, and all lumbar vessels are tied. Postganglionic
cer, and intratubular germ cell neoplasia. Most patients present sympathetic nerve sparing is possible in most cases for pres-
with testicular pain or a testicular mass. Respiratory symptoms, ervation of ejaculatory function.113 Robotic-assisted RPLND
back pain, weight loss, or gynecomastia may indicate metastatic is growing, with faster recovery time and similar short term
disease (10–20%). A testicular mass is considered malignant till oncologic results.114 Complications after RPLND include bowel
proven otherwise. Similarly, retroperitoneal lymphadenopathy obstruction, excessive bleeding, chylous ascites, and ejaculatory
in young men should be considered metastatic testicular cancer. dysfunction.
Standard initial workup includes scrotal ultrasound
(Fig. 40-8) and serum tumor markers (α-fetoprotein, quanti- Kidney Cancer
tative human chorionic gonadotropin, and lactate dehydroge- Renal cell carcinoma (RCC) results in approximately 3.8%
nase). Most consider percutaneous biopsy contraindicated due of all new cancers, with an estimated 65,340 new cases and
to the rare but historical risk of disturbing the natural lymphatic 14,970 deaths related to kidney cancer in 2018.91 Despite several
drainage to the retroperitoneum and possible seeding of the advancements with immune-based and targeted molecular ther-
scrotum.106 Radical inguinal orchiectomy is the gold standard apies demonstrating durable clinic responses, RCC still remains
treatment for excision of the primary tumor. Partial orchiec- primarily a surgical disease and classically does not respond to
tomy through an inguinal approach may be considered in some conventional chemotherapy regimens or radiation therapy.
cases, including a suspected diagnosis of lymphoma. Chest and Most patients diagnosed with RCC in the modern era
abdominal axial imaging are the main staging tools. Testicular typically present with an incidentally discovered renal mass
cancer has a very predictable pattern of spread. Right testicular on abdominal radiographic imaging. Differential diagnosis of
cancer tends to metastasize to the interaortocaval lymph node, a renal mass includes malignant tumors (e.g., RCC, urothelial
followed by paracaval and paraaortic lymph nodes. Left-sided carcinoma, sarcomas, lymphoma, metastasis), benign tumors
testicular cancer rarely crosses to the paracaval lymph nodes.107 (e.g., cysts, angiomyolipoma, oncocytoma), and inflammatory
Clinical TNM staging includes local stage, distant metastasis, lesions (e.g. abscesses, xanthogranulomatous pyelonephritis,
and tumor markers. tuberculosis). Renal CT imaging with intravenous contrast
Depending on the stage and histology of the primary remains the single most important radiographic test to delineate
tumor, multiple treatment options are available. These include the nature of the mass. In general, any solid renal mass that
active surveillance, retroperitoneal lymph node dissection enhances by more than 15 Hounsfield units is an RCC until
(RPLND), and adjuvant chemotherapy or radiation therapy. proven otherwise. However, even if there is contrast enhance-
Active surveillance for localized disease follows a tight sched- ment on axial imaging, approximately 15% to 30% of solid
ule of physical exams, tumor markers and imaging studies. The renal masses are benign on final surgical pathology.115 Renal
cancer recurs in 20% to 30% of patients on active surveillance. tumor biopsy can help distinguish between malignant or benign
The presence of embryonal carcinoma and vascular invasion tumors, but this has not been widely adopted by the urological
seem to be interrelated predictors of recurrence.108 Recurrence community, despite series showing their high diagnostic yield,
usually occurs within the first 2 years and in the retroperito- concordance with surgical pathology, and safety.116-118 Biopsy
neum.109 Pure seminoma is radiosensitive; stages I, IIa, and IIb remains particularly useful in patients considering surveillance
disease can be treated with external-beam radiation to the retro- or thermoablative therapy, or in patients with suspicion of
peritoneal nodes. Alternatively, a single dose of carboplatin for metastasis or lymphoma.
stage I seminoma was found to be just as effective as radiation Major recognized risk factors for RCC include smoking,
therapy.110 More advanced seminoma is treated with platinum- obesity, and hypertension. Although most RCCs are discovered
based systemic chemotherapy. incidentally, some patients present with signs or symptoms
which may be the result of local tumor growth (e.g., flank pain, 1773
hematuria, perirenal hematoma), paraneoplastic syndromes
(e.g., hypertension, weight loss, hypercalcemia, polycythemia/
anemia, abnormal liver function tests), or metastatic disease.
RCC metastasizes primarily to the lungs, lymph nodes, bone,
liver, adrenal glands, and brain. Familial RCC subtypes with
classical clinical manifestations are also well described. The von
Hippel-Lindau disease, occurring as a result of a mutation in
the tumor suppressor gene VHL (3p25-26), commonly mani-
fests itself with clear cell RCC, pheochromocytomas, retinal

CHAPTER 40 UROLOGY
angiomas, central nervous system hemangioblastomas, pancre-
atic cysts, and other tumors. Other familial syndromes include
hereditary papillary RCC (papillary type 1 RCC), familial
leiomyomatosis (papillary type 2 RCC), and Birt-Hogg-Dube
syndrome (chromophobe RCC, hybrid oncocytic tumors, and
oncocytoma). Familial RCC syndromes should be suspected in Figure 40-10.  Intraoperative image of a small renal mass in prepa-
younger patients and patients with multicentric and/or bilateral ration for partial nephrectomy.
tumors.
Clear cell RCC is the most common subtype, accounting
for 70% to 80% of all RCCs. Papillary RCC occurs in 10% to surgical approaches, including laparoscopy with robotic assis-
15%, type 1 being associated with a better prognosis, and type 2 tance, have virtually supplanted open procedures for localized
a worse prognosis. Other subtypes include chromophobe RCC, RCC (Fig. 40-10). Partial nephrectomy is most appropriate for
collecting duct carcinoma, and unclassified type. patients with small tumors, solitary kidney, bilateral tumors,
RCC may locally progress and cause invasion of the renal or familial RCC. Some tumors may not be amenable to abla-
capsule and perirenal fat or the collecting system. RCC may also tive therapies or partial nephrectomy, in which case radical
directly progress into the venous system in the form of a tumor nephrectomy would be employed.126
thrombus that can extend into the IVC and into the right atrium. Radical nephrectomy involves removal of the entire
Staging is the single most important prognostic factor for kidney with dissection external to Gerota’s fascia. The colon
RCC.119,120 Studies demonstrate a 70% to 90% 5-year survival is retracted medially after incising the white line of Toldt, fol-
rate for organ confined disease (stages I–II), compared to 0% to lowed by meticulous hilar dissection with ligation of the renal
10% for patients with systemic metastases (stage IV).119 Other artery and vein. The adrenal gland is usually spared unless
important prognostic factors include histological subtype,121 the tumor involves the gland or is immediately adjacent to it.
tumor size, lymph node involvement, and site of metastases.122 Lymphadenectomy remains controversial, and it is usually per-
Management options for small renal masses (<4 cm) formed in patients with adenopathy on preoperative imaging
includes active surveillance, thermoablative techniques, or sur- or in patients with palpable lymph nodes intraoperatively. In
gical excision (Fig. 40-9). Percutaneous or laparoscopic ther- partial nephrectomy, renal artery clamping is often performed
moablative techniques (cryoablation, radiofrequency ablation, to minimize blood loss while the tumor is excised. The goal
high-intensity focused ultrasound) have been used to treat small is to remove the tumor with negative surgical margins while
renal masses, but they are associated with an increased risk of minimizing warm ischemia time to preserve as many func-
local recurrence.123,124 tional nephrons as possible. With increasing experience, partial
Since the first laparoscopic radical nephrectomy nephrectomy is now also performed on much more complex
described by Clayman et al in 1991, 125 minimally invasive renal masses, including completely endophytic, central, and
hilar tumors. Very large tumors or tumors with vena-caval
thrombi can be removed robotically in experienced hands,127,128
but most are still removed using an open approach.
In minimally invasive surgery, both partial and radical
nephrectomy can be done via either a transperitoneal or retro-
peritoneal approach. In open cases, a subcostal flank approach
provides direct access to the retroperitoneum and is preferred
for lower pole exposure, but it can limit access to the hilum,
particularly with large renal masses. The anterior subcostal
approach is preferred for larger renal masses. Bilateral ante-
rior subcostal incisions (chevron incision) provides excellent
vascular exposure (e.g., IVC thrombectomy, bilateral tumors).
Midline incisions are usually reserved for renal trauma and
for reconstructive procedures. Less commonly performed, the
thoracoabdominal approach involves access usually above the
10th rib and is used for large upper pole or adrenal masses,
IVC thrombectomy, or tumors involving adjacent structures.
Figure 40-9.  Computed tomography scan of the abdomen with Complications include injury to adjacent organs, and for partial
intravenous and oral contrast. A small mid right posterior mass is nephrectomy, pseudoaneurysms/arteriovenous fistula formation
seen. and delayed urinary leak.
1774 Prostate Cancer deprivation therapy provide excellent cancer control. Cryother-
Prostate cancer is the most common noncutaneous cancer in apy, or high intensity focused ultrasound (HIFU) and focal
men; 164,690 new cases of prostate cancer were diagnosed in therapy are emerging options that may be acceptable for some
2018 and 29,430 men died from their disease.91 Screening for patients with low-risk disease.
prostate cancer with detailed history, digital rectal examination, Level I evidence has established the role of adjuvant radia-
and serum prostate specific antigen (PSA) tests have changed tion therapy after radical prostatectomy for patients with posi-
the natural history of the disease. Since the introduction of pros- tive surgical margins, extracapsular extension, and high-grade
tate cancer screening in the mid-1980s, the incidence of meta- disease.136,137 After definitive treatment of localized prostate
static prostate cancer has decreased by half. Currently 99% of cancer, rising PSA is an extremely reliable indicator of recur-
newly diagnosed patients will survive more than 10 years.91 rence or progression. However, it may take over 10 years for
While early screening for African American patients metastasis to appear on imaging studies.138 Once prostate cancer
metastasizes, it is no longer curable. Medications that lower
PART II

or patients with a family history of prostate cancer is widely

accepted, screening for all men is more controversial. Despite serum testosterone or androgen receptor blockers are able to
data from large randomized clinical trials showing a decrease control the disease, often for years. In addition, chemotherapy,
in mortality after prostate cancer screening, the U.S. Preventive immunotherapy, and radioisotope therapy at different stages
Services Task Force recommended against the routine use of of the disease increase the life expectancy of the patients or
improve the quality of life. The cancer inevitably becomes resis-
SPECIFIC CONSIDERATIONS

prostate cancer screening.129 Its recommendation was based on

the harm and toxicity of overtreatment of nonlethal disease.130 tant to these treatments. Nevertheless, patients with incurable
The American Urologic Association subsequently recom- prostate cancer can live many years, and a large number die of
mended informed and shared decision-making and screening for causes other than prostate cancer.
high-risk disease for men between the ages of 55 and 69 with a Over the past few years, we have witnessed major devel-
life expectancy more than 10 years.131 opments in the management of metastatic castrate resistant
If the digital rectal examination is abnormal or if the PSA prostate cancer (mCRPC). New agents that interrupt androgen
level is above expected for patients’ age and size of the prostate, synthesis (e.g., abiraterone acetate)139,140 and new modulators of
a prostate biopsy is usually performed. Newer tests such as the androgen receptors (e.g., enzalutamide)141,142 have significantly
4K score, prostate health index, and PCA3 are sometimes used improved the life expectancy of patients with both androgen
to inform the decision to proceed with biopsy. Recently, MRI sensitive and resistant metastatic prostate cancer. Similarly,
innovations in immunotherapy and chemotherapy delivery have
fusion transrectal ultrasound-guided biopsy improved the accu-
advanced the management of advanced prostate cancer.
racy of prostate biopsy.
Since most patients survive the disease, risk stratification Surgical Considerations.  Open radical retropubic prostatec-
systems are routinely utilized to guide staging and treatment. tomy is done through a lower midline incision from below the
Clinical TNM stage, serum PSA levels, and the Gleason grading umbilicus to the pubic symphysis. After entering the space of
system are utilized in clinical practice. More recently, genetic Retzius, the external iliac, obturator, and internal iliac lymph
testing on biopsy specimen was included in national guidelines. nodes are removed. The cavernosal nerves located on the pos-
Historically, the Gleason scoring (GS) system included a pri- terolateral surface of the prostate capsule are usually spared on
mary and secondary score based on the most common and sec- the side(s) with low risk of extracapsular extension of the dis-
ond most common histologic patterns. Grades range from 1 for ease. Then the prostate is removed in a retrograde fashion, and
the most differentiated to 5 for the least. The grades are added to the urethrovesical anastomosis is completed in an interrupted
create a resultant Gleason score.132 However, since no patients fashion.
are assigned a score of less than 5 anymore, the grading system Robotic radical prostatectomy using the da Vinci robotic
has been modified to a scale from 1 to 5. Grade one includes a surgical system (Fig. 40-11) is now the most common tech-
GS of 3 + 3 = 6 or less, grade 2 for GS 3 + 4, grade 3 for GS nique (over 90% of all patients in the United States) for the
4 + 3, grade 4 for GS 4 + 4 and grade 5 for Gleason score of
9 or 10.133 Imaging studies like CT and bone scans are used to
rule out metastatic disease in high-risk patients. The two most
common sites of metastatic disease are pelvic/retroperitoneal
lymph nodes and boney structures. Modern CT PET scans have
a limited role at this point.
Treatment for localized prostate cancer is guided by can-
cer aggressiveness and patient’s preferences. Active sur-
8 veillance is recommended for patients with low-risk
disease grade 1–2, early-stage disease (cT1c), and small volume
disease as determined by biopsy. Large prospective cohorts and
randomized clinical trials have established the safety of this
approach.134,135 The risk of progression to metastatic disease
with close follow-up and repeat prostate biopsies is less than 2%
in over 12 years. Radical prostatectomy and pelvic lymph node
dissection (robotic, laparoscopic, or open), image modulated
radiation therapy (IMRT), and brachytherapy are the standard of
care for curative treatments. All provide equal cancer specific
survival for low and intermediate risk cancers. For higher risk Figure 40-11.  The da Vinci Surgical System used commonly for
prostate cancer patients, both surgery and IMRT with androgen radical prostatectomy.
surgical treatment of localized prostate cancer. Robotic surgery often nocturia), or obstructive symptoms such as hesitancy, 1775
has lower blood loss and faster convalescence, less bladder weak stream, and incomplete bladder emptying. These condi-
neck contracture, and lower early postoperative complications. tions can have a negative impact on quality of life,152-154 but they
Some data show a faster return of continence and lower rates of are also associated with serious health issues, including depres-
erectile dysfunction. The most common postoperative compli- sion, anxiety, social isolation,155 and even falls and fractures in
cations include infection, urine leaks, ileus, lymphocele, and, the elderly.156
very rarely, rectal or ureteral injury. Urinary incontinence can be divided into several catego-
To minimize the impact of these side effects, researchers ries, although patients (particularly women) may suffer from
have used different ablative techniques to obliterate the areas of more than one type.157 Urge incontinence is the involuntary
significant cancer. By avoiding the need for whole gland radia- loss of urine associated with an urge to void. Stress leakage

CHAPTER 40 UROLOGY
tion or removal, these focal ablative therapies aim to balance the occurs with increases in intra-abdominal pressure, such as
long-term impact on quality of life with survival. Laser, high- coughing or sneezing, and may relate to loss of sphincteric
focused ultrasound, cryotherapy, and photodynamic ablations function, urethral hypermobility from pelvic floor laxity
have showed similar results in early studies. (often related to parity), or following prostate surgery in men.
Overflow incontinence occurs in the setting of obstruction,
Urethral Cancer with urine leakage occurring with movement causing over-
Urethral carcinoma (UC) is a rare disease, the true incidence flow of urine from a distended bladder. Genitourinary fistulas
of which is unknown. It accounts for less than 1% of genito- typically result in the most severe form of incontinence with
urinary cancers.143,144 It is a disease of the older adult. Risk fac- constant leakage of urine regardless of presence or absence
tors include chronic inflammation from sexually transmitted of activity or movement. Examples include vesicovaginal or
diseases (human papillomavirus 16 and 18 in squamous cell ureterovaginal fistulae most often due to gynecologic surgery,
carcinoma),145 chronic urethral stricture, and indwelling cath- or rectourethral fistulae in men from cancer, radiation, or sur-
eterization. Furthermore, urethral diverticulum and recurrent gical intervention.
urinary tract infections increase the risk for women. Treatments for urinary incontinence and voiding dysfunc-
The majority of patients present with irritative and tion are varied depending on the etiology, severity, and
obstructive voiding symptoms, bleeding, or a palpable mass. 9 bother of the symptom. Urge leakage and overactive blad-
Urothelial carcinoma is the most common histology; 29% der can be treated by (a) behavioral modification (timed void-
of women have adenocarcinoma, and both genders can have ing, adjustment to fluid intake, timing of diuretic medication,
squamous cell carcinoma. Untreated or refractory UC typically and improved constipation); (b) bladder retraining (pelvic floor
metastasizes through lymphatic channels to the inguinal and physical therapy158); (c) medications (anticholinergics159 and β-3
pelvic lymph nodes and hematologically to distant organs. Cys- agonists160); or (d) minimally invasive procedures (sacral neuro-
toscopic biopsy establishes the diagnoses. An MRI of the pelvis modulation,161 percutaneous tibial nerve stimulation,162 or blad-
is extremely helpful for defining local extension of the disease der chemodenervation with detrusor botulinum toxin
while CT scans of the chest, abdomen, and pelvis identify meta- injection163).
static disease. Finally, it is also important to evaluate the entire Stress incontinence in women can be addressed by pelvic
urinary tract. floor strengthening exercises, vaginally placed removable sup-
The 5-year overall survival rates for distal urethral tumors port with a pessary, injection of urethral bulking agent, or sling
is significantly better than for proximal cancers, 68% versus procedures using polypropylene mesh or autologous tissue. In
40%, respectively.143,146 The median 5-year cancer-specific sur- men, stress leakage is due to either iatrogenic causes or neuro-
vival is approximately 46%.144 Prognosis is dictated by patients’ logic disease. Treatments include strengthening exercises as in
age, race, clinical stage, and location of the tumor. women, slings, or implantation of an artificial urinary sphincter.
If feasible, local endoscopic resection for low-volume, Overflow incontinence treatment is directed at the cause of
low-stage disease is preferable. Adjuvant intravesical instilla- obstruction, often benign prostatic enlargement in men, with
tion of Bacillus Calmette-Guérin (BCG) should be considered bladder drainage, medications such as α-blockers or 5-α reduc-
for patients with proximal noninvasive disease.147 Due to the tase inhibitors, or surgical removal of the obstructing gland.
paucity of robust data, management of locally advanced dis- When fistulas are present, adherence to surgical principles such
ease is more challenging. Either radical cystectomy or radiations as tension-free multilayer closure, nonoverlapping suture lines,
are acceptable options. Unfortunately, local recurrence rates and tissue interposition when possible offers the highest likeli-
are high after aggressive monotherapy (63%).148 More recent hood for success.
data support the use of multimodal therapy.149,150 Small series
of combinations of perioperative chemotherapy, surgery, and Erectile Dysfunction
radiation indicate the best cancer control.151 Erectile dysfunction (ED) is defined as the inability to achieve
and maintain an erection adequate for sexual intercourse. For-
COMMON UROLOGIC CONDITIONS merly, this was known as a type of sexual dysfunction, but it is
now understood that ED may be an early symptom of cardiovas-
Urinary Incontinence and Voiding Dysfunction cular disease due to endothelial dysfunction. ED is a common
Urinary incontinence is defined as the involuntary loss of urine. disease for men later in life with a prevalence rate believed to
This is more common in women than men for a variety of rea- range anywhere from 30% to 50% depending on age. Two large
sons, including anatomic differences such as a shorter urethra population-based studies, the Massachusetts Male Aging Study
and risk factors such as childbirth. Many patients may also suf- (MMAS) and the European Male Aging Study (EMAS), exam-
fer from bothersome symptoms without leakage of urine such ined men age 40 to 79 years and found that ED rates increased
as overactive bladder (frequency and urgency of urination and with age.164,165
1776 Erections are triggered via sexual stimulation setting off
a cascade of events. Nitric oxide is released from nerve fibers
and activating guanylyl cyclase leading to an increase in cyclic
guanosine monophosphate (cGMP). The cGMP pathway leads
to smooth muscle relaxation within the corpora cavernosa allow-
ing blood to fill the lacunar spaces. Once the lacunar spaces
are full, the expanded tissue compresses the subtunical venules
thereby trapping blood within the penis and blocking venous out-
flow. Phosphodiesterase type-5 hydrolyzes cGMP to reverse the
process.166
There are multiple mechanisms leading to ED including
PART II

vasculogenic, neurogenic, iatrogenic, and psychologic, but

often it is multifactorial. Vasculogenic ED can be a result of
cardiovascular disease and endothelial dysfunction leading to
cavernosal artery insufficiency. Diseases such as hypertension
(odds ratio [OR] 1.35–3.04), diabetes (OR 2.57), dyslipidemia
(OR 1.83), and tobacco abuse (OR 1.4) all may increase the
SPECIFIC CONSIDERATIONS

risk for ED.167 Nerve injuries due to diseases (diabetes, Parkin-

son’s, multiple sclerosis, spinal cord injury) or surgery (radical
prostatectomy, abdominoperineal resection, and other radical
pelvic procedures) can lead to interruptions in the nerve signal-
ing that causes nitric oxide release and therefore lead to ED.
Iatrogenic causes may be a result of surgery (described earlier)
or medication use, as in some antihypertensives, opiates, anti-
androgens, and psychotherapeutics.168 Psychogenic ED, a com-
mon reaction to stress and anxiety, is a result of noradrenaline
release causing smooth muscle contraction and thereby inhibit- Figure 40-12.  A three-piece penile implant for the treatment of
ing erections.169 erectile dysfunction. The prosthesis is composed of two cylinders
placed in the penis, a fluid reservoir placed in the pelvis (upper left),
Treatment for ED begins with lifestyle modification by
and a pump placed within the scrotum (bottom left).
identifying any reversible risk factors such as stress/anxiety,
medications, unhealthy diets, lack of exercise, and tobacco
abuse.170 Medical therapy then begins with the use of phospho- erection or priapism, so dose titration must be closely moni-
diesterase type-5 inhibitors (PDE5i). These work by prolonging tored. Intraurethral suppositories are composed of alprostadil in
the activity of cGMP, leading to continued smooth muscle relax- the form of a pellet which is then placed in the urethra and mas-
ation allowing more blood inflow into the penis. Common drugs saged for absorption. With suppository use, there are concerns
include sildenafil, tadalafil, vardenafil, and avanafil. They differ about efficacy (only 46–65%) and compliance due to a burning
in time to peak concentration (lowest in avanafil, sildenafil, and sensation that limits the interest of some users.175,176
vardenafil), half-life (highest in tadalafil), and the impact of lip- Third-line treatment of ED is with surgery placement of a
ids in foods (sildenafil and vardenafil must be taken on an empty penile prosthesis. There are three main types (malleable, two-
stomach). Common side effects include a headache, heartburn, piece, and three-piece). The malleable device does not inflate/
facial flushing, nasal congestion, and myalgias.171 Patients on deflate and merely bends in and out of position for intercourse.
nitrate-containing medications should not be given PDE5i due The two-piece and three-piece devices are inflatable and dif-
to the risk of severe hypotension. Vision related conditions fer on the presence of a separate fluid reservoir. The two-piece
like macular degeneration, retinitis pigmentosa, and nonarter- device has the fluid maintained in the lower half of the penile
itic anterior ischemic optic neuropathy are cause for increased cylinders, whereas, the three-piece device has a fluid reservoir
awareness and possible ophthalmologic consult.172 placed in the pelvis or abdominal wall (Fig. 40-12). Overall,
Second-line options for ED include vacuum erection the inflatable prosthesis has high patient and partner satisfaction
devices (VED), intracavernosal injections (ICI), and intraure- rates, >92% and >91%, respectively.177
thral suppositories. The VED is a mechanical device composed
of a cylinder placed around the penis which then uses a vacuum
to create negative pressure and pull blood into the penis. In PEDIATRIC UROLOGY
order for blood to stay in the penis after the vacuum is released,
a tight constriction band must be placed at the base of the penis. Hypospadias
There is poor compliance due to difficulty with use and the Hypospadias, a condition which may be considered a form of
common reactions of petechia, temporary paresthesia, color incomplete maturation of the genitalia, is a common abnormal-
changes, and the penis being cold to touch.173,174 Alternatively, ity that occurs in 1 out of 250 to 300 newborn boys. The most
ICI uses vasoactive substances (prostaglandin E1 [alprostadil], obvious aspect of hypospadias is a urethral opening that is not at
papaverine, and phentolamine) either alone or in combination the tip of the glans, and 70% to 80% of affected babies will have
to trigger the erection cascade.168 Patients are trained to give a meatus on the mid to distal shaft or proximal glans. A lesser
themselves a self-injection when they want an erection, and it number will have more proximal openings, whether penoscrotal,
takes approximately 5 to 15 minutes until they are fully rigid if scrotal, or perineal. In addition to an abnormally located meatus,
they respond. With ICI, there is greater concern for prolonged boys usually have deficient ventral foreskin. Associated penile
curvature, more common in the severe varieties, is referred to vesicoureteral reflux, ureteropelvic junction obstruction, ectopic 1777
as chordee. ureter/ureteroceles, and other upper tract abnormalities. Typi-
No diagnostic studies are needed for the majority of boys cally, nothing needs to be done for these children until after
with hypospadias as there is typically no increased risk of renal birth, at which point a baseline renal ultrasound can be per-
or bladder anomalies. Children with associated cryptorchidism, formed. Other studies such as a VCUG or Lasix renal scans can
especially with proximal hypospadias and a nonpalpable tes- then be done depending on the degree of dilation. Diagnosis of
tis, have an increased risk of a having a coexisting disorder of upper tract obstruction is usually based on progressive worsen-
sexual differentiation (DSD) and need to undergo a thorough ing of dilation or renal function on serial examinations.
evaluation including hormonal studies, karyotype, and pelvic Special consideration must be given for children with
ultrasonography.178 bilateral hydronephrosis or hydronephrosis associated with a

CHAPTER 40 UROLOGY
Distal hypospadias can usually be repaired in one stage solitary kidney, especially if linked to oligohydramnios. Since
with success rates of greater than 95%. Most would advocate fetal urine production accounts for much of the amniotic fluid,
a staged approach to proximal hypospadias with correction of low levels can be a sign of a severe abnormality of the urinary
penile curvature at the first stage and formal urethral reconstruc- tract. Reduced amniotic fluid is of great consequence since nor-
tion at the second.179 Adults with corrected hypospadias usually mal lung development is dependent on normal amniotic fluid
have normal sexual function and fertility. volumes and children with oligohydramnios can be born with
significant pulmonary insufficiency. Boys with bilateral hydro-
Urinary Tract Infections in Children nephrosis and low amniotic fluid are at high risk for having
Urinary tract infections (UTI) are common in children, and posterior urethral valves (PUV). Boys with PUV have as much
there is a greater chance of underlying anatomic abnormalities. as a 25% risk of developing end stage renal disease at some
Children may have conditions such as vesicoureteral reflux, point in their lives.182 Prenatal intervention such as placement
ureteropelvic junction obstruction, ureteroceles, or ectopic ure- of vesicoamniotic shunts have not been shown to reduce the
ters as causes of these infections. Because of this association, risk of renal failure.
in the past all children with febrile infections would undergo
complete evaluations including renal ultrasonography (US)
Cryptorchidism
as well as invasive studies such as voiding cystourethrogra-
Cryptorchidism or undescended testes (UDT) is a common
phy (VCUG). However, defining pyelonephritis as having a
condition occurring in 3% of full term and 30% of premature
positive renal cortical scan, only 30% to 40% of children with
babies. Many of these testes will descend spontaneously due
febrile UTI will have reflux. Thus the majority of children with
to the normal gonadotropin release that occurs in the first few
febrile infections, and a greater percentage of those with afe-
months of life, so the true incidence is roughly 1% of boys.
brile infections (cystitis), will be anatomically normal.180 These Untreated cryptorchidism will lead to testis damage, and there
data have led to a change in imaging guidelines for children is evidence that permanent changes may occur by 3 years of age.
with UTI. Ideally, surgical treatment should occur prior to this age. UDT
Guidelines put out by the American Academy of Pediat- is usually an isolated finding, but it may occur as a part of a
rics have markedly changed the way children with infections systemic condition such as Prader-Willi, Eagle-Barrett, or other
are evaluated.181 These guidelines suggest that infants less than such complex multisystem syndrome. Surgery is the treatment
2 months of age with febrile infections should undergo both a of choice; hormonal treatment has no role.
renal US and VCUG. Children between 2 months and 2 years The consequences of untreated cryptorchidism include
who have their first documented infection only need have a infertility and malignant degeneration. One study on fertility
renal ultrasound performed. A VCUG is only needed if there suggested that men with a history of unilateral cryptorchidism
are abnormalities detected on the ultrasound such as hydrone- will have no difference in paternity rates compared to normal
phrosis, scarring, or other evidence of anatomic abnormality. A controls. In contrast, men with bilateral cryptorchidism have
VCUG may also be performed if a child has recurrent infections up to a 50% rate of infertility.183 There is data to suggest that
despite empirical treatment. These guidelines do not address orchidopexy in the first year of life is associated with better
children older than 2 years of age but one can assume that simi- total sperm counts in adulthood.184 With regard to malignancy,
lar algorithms of treatment would be appropriate. untreated UDT has a fivefold increase risk of tumor develop-
There is now greater understanding that most children ment compared to the normal population. However, there is data
with UTIs, whether pyelonephritis or cystitis, have some ele- to suggest that prepubertal orchidopexy is protective and that
ment of bladder and/or bowel dysfunction as the major factor these boys only have a twofold greater risk.185
in the development of the infection. Thus, all children with
UTIs need to have a thorough assessment of daily bladder and
bowel habits. The latter may be difficult to ascertain in younger REFERENCES
children, but bowel dysfunction, even subclinical, may be the Entries highlighted in bright blue are key references.
most important factor in the development of UTIs. Behavioral
1. Schaeffer A, Matulewicz R, Klumpp D. Infections of the urinary
therapies such as regular and complete voiding in conjunction tract. In: Wein AJ, Kavoussi LR, Partin AW, et al, eds. Campbell-
with a bowel program should be considered the mainstay of the Walsh Urology. 11th ed. Philadelphia: Elsevier; 2016.
prevention of infections as opposed to prophylactic antibiotics. 2. Polackwich AS, Shoskes DA. Chronic prostatitis/chronic pel-
vic pain syndrome: a review of evaluation and therapy. Pros-
Prenatal Hydronephrosis tate Cancer Prostatic Dis. 2016;19(2):132-138.
Antenatal imaging will show hydronephrosis in nearly 1% of all 3. Link R, Rosen T. Cutaneous diseases of the external genitalia.
babies. Though the majority of children will have benign hydro- In: Wein AJ KL, Partin AW, et al, ed. Campbell-Walsh Urology.
nephrosis of no clinical significance, it may also be related to 11 ed. Philadelphia, Penn: Elsevier; 2016.
1778 4. Scales CD, Smith AC, Hanley JM, Saigal CS, Project UDiA. 25. Djavan B, Marberger M. A meta-analysis on the efficacy and
Prevalence of kidney stones in the United States. Eur Urol. tolerability of alpha1-adrenoceptor antagonists in patients
2012;62(1):160-165. with lower urinary tract symptoms suggestive of benign pros-
5. Pearle MS, Calhoun EA, Curhan GC, Project UDoA. Uro- tatic obstruction. Eur Urol. 1999;36(1):1-13.
logic diseases in America project: urolithiasis. J Urol. 26. Roehrborn CG, Boyle P, Nickel JC, Hoefner K, Andriole G,
2005;173(3):848-857. Investigators AAaAS. Efficacy and safety of a dual inhibitor
6. Scales CD, Curtis LH, Norris RD, et al. Changing gender of 5-alpha-reductase types 1 and 2 (dutasteride) in men with
prevalence of stone disease. J Urol. 2007;177(3):979-982. benign prostatic hyperplasia. Urology. 2002;60(3):434-441.
7. Taylor EN, Stampfer MJ, Curhan GC. Diabetes mellitus and 27. McConnell JD, Roehrborn CG, Bautista OM, et al. The long-
the risk of nephrolithiasis. Kidney Int. 2005;68(3):1230-1235. term effect of doxazosin, finasteride, and combination therapy
8. Taylor EN, Stampfer MJ, Curhan GC. Obesity, weight gain, on the clinical progression of benign prostatic hyperplasia.
and the risk of kidney stones. JAMA. 2005;293(4):455-462. N Engl J Med. 2003;349(25):2387-2398.
9. Heilberg IP. Treatment of patients with uric acid stones. 28. Roehrborn CG, Barkin J, Siami P, et al. Clinical outcomes
PART II

Urolithiasis. 2016;44(1):57-63. after combined therapy with dutasteride plus tamsulo-

10. Fulgham PF, Assimos DG, Pearle MS, Preminger GM. Clini- sin or either monotherapy in men with benign prostatic
cal effectiveness protocols for imaging in the management hyperplasia (BPH) by baseline characteristics: 4-year
of ureteral calculous disease: AUA technology assessment. results from the randomized, double-blind combination
J Urol. 2013;189(4):1203-1213. of Avodart and Tamsulosin (CombAT) trial. BJU Int.
SPECIFIC CONSIDERATIONS

11. Poletti PA, Platon A, Rutschmann OT, Schmidlin FR, Iselin 2011;107(6):946-954.
CE, Becker CD. Low-dose versus standard-dose CT protocol 29. McVary KT, Monnig W, Camps JL, Young JM, Tseng LJ,
in patients with clinically suspected renal colic. AJR Am J van den Ende G. Sildenafil citrate improves erectile function
Roentgenol. 2007;188(4):927-933. and urinary symptoms in men with erectile dysfunction and
12. Pearle MS, Goldfarb DS, Assimos DG, et al. Medical lower urinary tract symptoms associated with benign pros-
management of kidney stones: AUA guideline. J Urol. tatic hyperplasia: a randomized, double-blind trial. J Urol.
2014;192(2):316-324. 2007;177(3):1071-1077.
13. Hubner WA, Irby P, Stoller ML. Natural history and current 30. Wang C. Phosphodiesterase-5 inhibitors and benign prostatic
concepts for the treatment of small ureteral calculi. Eur Urol. hyperplasia. Curr Opin Urol. 2010;20(1):49-54.
1993;24(2):172-176. 31. Wasson JH, Reda DJ, Bruskewitz RC, Elinson J, Keller AM,
14. Miller OF, Kane CJ. Time to stone passage for observed Henderson WG. A comparison of transurethral surgery with
ureteral calculi: a guide for patient education. J Urol. 1999;162 watchful waiting for moderate symptoms of benign prostatic
(3 Pt 1):688-690; discussion 690-681. hyperplasia. The Veterans Affairs Cooperative Study Group
15. Assimos D, Krambeck A, Miller NL, et al. Surgical on Transurethral Resection of the Prostate. N Engl J Med.
management of stones: American Urological Associa- 1995;332(2):75-79.
tion/Endourological Society guideline, PART I. J Urol. 32. Montorsi F, Naspro R, Salonia A, et al. Holmium laser enu-
2016;196(4):1153-1160. cleation versus transurethral resection of the prostate: results
16. Assimos D, Krambeck A, Miller NL, et al. Surgical from a 2-center, prospective, randomized trial in patients with
management of stones: American Urological Associa- obstructive benign prostatic hyperplasia. J Urol. 2004;172
tion/Endourological Society guideline, PART II. J Urol. (5 pt 1):1926-1929.
2016;196(4):1161-1169. 33. Tan AH, Gilling PJ, Kennett KM, Frampton C, Westenberg
17. Lu Z, Dong Z, Ding H, Wang H, Ma B, Wang Z. Tamsulosin AM, Fraundorfer MR. A randomized trial comparing holmium
for ureteral stones: a systematic review and meta-analysis of laser enucleation of the prostate with transurethral resection
a randomized controlled trial. Urol Int. 2012;89(1):107-115. of the prostate for the treatment of bladder outlet obstruction
18. Albala DM, Assimos DG, Clayman RV, et al. Lower pole I: a secondary to benign prostatic hyperplasia in large glands
prospective randomized trial of extracorporeal shock wave lith- (40 to 200 grams). J Urol. 2003;170(4 Pt 1):1270-1274.
otripsy and percutaneous nephrostolithotomy for lower pole 34. Elzayat EA, Elhilali MM. Holmium laser enucleation
nephrolithiasis-initial results. J Urol. 2001;166(6):2072-2080. of the prostate (HoLEP): long-term results, reoperation
19. Ozturk U, Sener NC, Goktug HN, Nalbant I, Gucuk A, rate, and possible impact of the learning curve. Eur Urol.
Imamoglu MA. Comparison of percutaneous nephroli- 2007;52(5):1465-1471.
thotomy, shock wave lithotripsy, and retrograde intrarenal 35. Anger JT, Buckley JC, Santucci RA, Elliott SP, Saigal CS,
surgery for lower pole renal calculi 10-20 mm. Urol Int. Urologic Diseases in America P. Trends in stricture management
2013;91(3):345-349. among male Medicare beneficiaries: underuse of urethro-
20. Egan KB. The epidemiology of benign prostatic hyperplasia plasty? Urology. 2011;77(2):481-485.
associated with lower urinary tract symptoms: prevalence and 36. Fenton AS, Morey AF, Aviles R, Garcia CR. Anterior ure-
incident rates. Urol Clin North Am. 2016;43(3):289-297. thral strictures: etiology and characteristics. Urology.
21. Barry MJ, Fowler FJ, O’Leary MP, et al. The American 2005;65(6):1055-1058.
Urological Association symptom index for benign prostatic 37. Nuss GR, Granieri MA, Zhao LC, Thum DJ, Gonzalez CM.
hyperplasia. The Measurement Committee of the American Presenting symptoms of anterior urethral stricture disease: a
Urological Association. J Urol. 1992;148(5):1549-1557; disease specific, patient reported questionnaire to measure
discussion 1564. outcomes. J Urol. 2012;187(2):559-562.
22. O’Leary M. The importance of standardisation and validation 38. Bertrand LA, Warren GJ, Voelzke BB, et al. Lower urinary
of symptom scores and quality of life: the urologist’s point of tract pain and anterior urethral stricture disease: prevalence and
view. Eur Urol. 1997;32(suppl 2):48-49. effects of urethral reconstruction. J Urol. 2015;193(1):184-189.
23. McVary KT, Roehrborn CG, Avins AL, et al. Update on AUA 39. Pal DK, Kumar S, Ghosh B. Direct visual internal urethrotomy:
guideline on the management of benign prostatic hyperplasia. is it a durable treatment option? Urol Ann. 2017;9(1):18-22.
J Urol. 2011;185(5):1793-1803. 40. Hudak SJ, Atkinson TH, Morey AF. Repeat transurethral
24. Nickel JC, Herschorn S, Corcos J, et al. Canadian guidelines manipulation of bulbar urethral strictures is associated with
for the management of benign prostatic hyperplasia. Can J increased stricture complexity and prolonged disease dura-
Urol. 2005;12(3):2677-2683. tion. J Urol. 2012;187(5):1691-1695.
 41. Pipitone N, Vaglio A, Salvarani C. Retroperitoneal fibrosis. 62. Wirth GJ, Peter R, Poletti PA, Iselin CE. Advances in the man- 1779
Best Pract Res Clin Rheumatol. 2012;26(4):439-448. agement of blunt traumatic bladder rupture: experience with
42. Cronin CG, Lohan DG, Blake MA, Roche C, McCarthy P, 36 cases. BJU Int. 2010;106(9):1344-1349.
Murphy JM. Retroperitoneal fibrosis: a review of clini- 63. Inaba K, McKenney M, Munera F, et al. Cystogram follow-up
cal features and imaging findings. AJR Am J Roentgenol. in the management of traumatic bladder disruption. J Trauma.
2008;191(2):423-431. 2006;60(1):23-28.
43. Li KP, Zhu J, Zhang JL, Huang F. Idiopathic retroperitoneal 64. Elgammal MA. Straddle injuries to the bulbar urethra:
fibrosis (RPF): clinical features of 61 cases and literature management and outcome in 53 patients. Int Braz J Urol.
review. Clin Rheumatol. 2011;30(5):601-605. 2009;35(4):450-458.
44. Elsamra SE, Leavitt DA, Motato HA, et al. Stenting for malig- 65. Mouraviev VB, Coburn M, Santucci RA. The treatment of
nant ureteral obstruction: Tandem, metal or metal-mesh stents. posterior urethral disruption associated with pelvic fractures:

CHAPTER 40 UROLOGY
Int J Urol. 2015;22(7):629-636. comparative experience of early realignment versus delayed
45. Lopez-Huertas HL, Polcari AJ, Acosta-Miranda A, Turk urethroplasty. J Urol. 2005;173(3):873-876.
TM. Metallic ureteral stents: a cost-effective method of 66. Koraitim MM. Effect of early realignment on length and
managing benign upper tract obstruction. J Endourol. delayed repair of postpelvic fracture urethral injury. Urology.
2010;24(3):483-485. 2012;79(4):912-915.
46. Taylor ER, Benson AD, Schwartz BF. Cost analysis of metal- 67. Morey AF, Brandes S, Dugi DD, 3rd, et al. Urotrauma: AUA
lic ureteral stents with 12 months of follow-up. J Endourol. guideline. J Urol. 2014;192(2):327-335.
2012;26(7):917-921. 68. Nasser TA, Mostafa T. Delayed surgical repair of penile frac-
47. Baumgarten AS, Hakky TS, Carrion RE, Lockhart JL, Spiess ture under local anesthesia. J Sex Med. 2008;5(10):2464-2469.
PE. A single-institution experience with metallic ureteral 69. el-Assmy A, el-Tholoth HS, Mohsen T, Ibrahiem el HI. Does
stents: a cost-effective method of managing deficiencies in timing of presentation of penile fracture affect outcome of
ureteral drainage. Int Braz J Urol. 2014;40(2):225-231. surgical intervention? Urology. 2011;77(6):1388-1391.
48. McAninch JW. Genitourinary trauma. World J Urol. 70. Buckley JC, McAninch JW. Use of ultrasonography for the
1999;17(2):65. diagnosis of testicular injuries in blunt scrotal trauma. J Urol.
49. Breyer BN, McAninch JW, Elliott SP, Master VA. Minimally 2006;175(1):175-178.
invasive endovascular techniques to treat acute renal hemor- 71. Fitzpatrick JM, Desgrandchamps F, Adjali K, et al. Man-
rhage. J Urol. 2008;179(6):2248-2252; discussion 2253. agement of acute urinary retention: a worldwide survey
50. Hotaling JM, Sorensen MD, Smith TG 3rd, Rivara FP, of 6074 men with benign prostatic hyperplasia. BJU Int.
Wessells H, Voelzke BB. Analysis of diagnostic angiography 2012;109(1):88-95.
and angioembolization in the acute management of renal trauma 72. Fitzpatrick JM, Kirby RS. Management of acute urinary reten-
using a national data set. J Urol. 2011;185(4):1316-1320. tion. BJU Int. 2006;97(suppl 2):16-20; discussion 21-12.
51. Moore EE, Shackford SR, Pachter HL, et al. Organ injury 73. Zeif HJ, Subramonian K. Alpha blockers prior to removal of
scaling: spleen, liver, and kidney. J Trauma. 1989;29(12): a catheter for acute urinary retention in adult men. Cochrane
1664-1666. Database Syst Rev. 2009(4):Cd006744.
52. Anselmo da Costa I, Amend B, Stenzl A, Bedke J. Contem- 74. Ringdahl E, Teague L. Testicular torsion. Am Fam Physician.
porary management of acute kidney trauma. Journal of Acute 2006;74(10):1739-1743.
Disease. 2016;5(1):29-36. 75. Srinivasan A, Cinman N, Feber KM, Gitlin J, Palmer LS.
53. Jansen JO, Inaba K, Resnick S, et al. Selective non-operative History and physical examination findings predictive of tes-
management of abdominal gunshot wounds: survey of prac- ticular torsion: an attempt to promote clinical diagnosis by
tise. Injury. 2013;44(5):639-644. house staff. J Pediatr Urol. 2011;7(4):470-474.
54. Dugi DD 3rd, Morey AF, Gupta A, Nuss GR, Sheu GL, Pruitt 76. Pogorelic Z, Mustapic K, Jukic M, et al. Management of acute
JH. American Association for the Surgery of Trauma grade 4 scrotum in children: a 25-year single center experience on 558
renal injury substratification into grades 4a (low risk) and 4b pediatric patients. Can J Urol. 2016;23(6):8594-8601.
(high risk). J Urol. 2010;183(2):592-597. 77. Norton KS, Johnson LW, Perry T, Perry KH, Sehon JK, Zibari
55. McClung CD, Hotaling JM, Wang J, Wessells H, Voelzke BB. GB. Management of Fournier’s gangrene: an eleven year ret-
Contemporary trends in the immediate surgical management rospective analysis of early recognition, diagnosis, and treat-
of renal trauma using a national database. J Trauma Acute ment. Am Surg. 2002;68(8):709-713.
Care Surg. 2013;75(4):602-606. 78. Oguz A, Gümüs M, Turkoglu A, et al. Fournier’s gangrene:
56. Atala A, Miller FB, Richardson JD, Bauer B, Harty J, Amin a summary of 10 years of clinical experience. In: Int Surg.
M. Preliminary vascular control for renal trauma. Surg Gyne- 2015;100:934-941.
col Obstet. 1991;172(5):386-390. 79. Sherman J, Solliday M, Paraiso E, Becker J, Mydlo JH. Early
57. Elliott SP, McAninch JW. Ureteral injuries from external CT findings of Fournier’s gangrene in a healthy male. Clin
violence: the 25-year experience at San Francisco General Imaging. 1998;22(6):425-427.
Hospital. J Urol. 2003;170(4 Pt 1):1213-1216. 80. Rosen DR, Brown ME, Cologne KG, Ault GT, Strumwasser
58. Elliott SP, McAninch JW. Ureteral injuries: external and iat- AM. Long-term follow-up of Fournier’s Gangrene in a tertiary
rogenic. Urol Clin North Am. 2006;33(1):55-66, vi. care center. J Surg Res. 2016;206(1):175-181.
59. Mauck RJ, Hudak SJ, Terlecki RP, Morey AF. Central role of 81. Ozkan OF, Koksal N, Altinli E, et al. Fournier’s gangrene cur-
Boari bladder flap and downward nephropexy in upper ure- rent approaches. Int Wound J. 2016;13(5):713-716.
teral reconstruction. J Urol. 2011;186(4):1345-1349. 82. Montague DK, Jarow J, Broderick GA, et al. American Uro-
60. Morey AF, Iverson AJ, Swan A, et al. Bladder rupture after logical Association guideline on the management of priapism.
blunt trauma: guidelines for diagnostic imaging. J Trauma. J Urol. 2003;170(4 Pt 1):1318-1324.
2001;51(4):683-686. 83. Anele UA, Le BV, Resar LMS, Burnett AL. How I treat pria-
61. Quagliano PV, Delair SM, Malhotra AK. Diagnosis of blunt pism. Blood. 2015;125(23):3551-3558.
bladder injury: A prospective comparative study of com- 84. Burnett AL, Sharlip ID. Standard operating procedures for
puted tomography cystography and conventional retrograde priapism. J Sex Med. 2013;10(1):180-194.
cystography. J Trauma. 2006;61(2):410-421; discussion 85. Mackway-Jones K, Teece S. Ice, pins, or sugar to reduce para-
421-412. phimosis. Emerg Med J. 2004;21(1):77-78.
1780 86. Pohlman GD, Phillips JM, Wilcox DT. Simple method 104. Che M, Tamboli P, Ro JY, et al. Bilateral testicular germ cell
of paraphimosis reduction revisited: point of technique tumors: twenty-year experience at M. D. Anderson Cancer
and review of the literature. J Pediatr Urol. 2013;9(1): Center. Cancer. 2002;95(6):1228-1233.
104-107. 105. Powles TB, Bhardwa J, Shamash J, Mandalia S, Oliver T.
87. Ubee SS, McGlynn L, Fordham M. Emphysematous pyelone- The changing presentation of germ cell tumours of the testis
phritis. BJU Int. 2011;107(9):1474-1478. between 1983 and 2002. BJU Int. 2005;95(9):1197-1200.
88. Lu YC, Hong JH, Chiang BJ, et al. Recommended initial 106. Capelouto CC, Clark PE, Ransil BJ, Loughlin KR. A review
antimicrobial therapy for emphysematous pyelonephritis: of scrotal violation in testicular cancer: is adjuvant local ther-
51 cases and 14-year-experience of a tertiary referral center. apy necessary? J Urol. 1995;153(3 Pt 2):981-985.
Medicine (Baltimore). 2016;95(21):e3573. 107. Donohue JP, Zachary JM, Maynard BR. Distribution of
89. Misgar RA, Mubarik I, Wani AI, Bashir MI, Ramzan M, nodal metastases in nonseminomatous testis cancer. J Urol.
Laway BA. Emphysematous pyelonephritis: a 10-year 1982;128(2):315-320.
experience with 26 cases. Indian J Endocrinol Metab. 108. Pont J, Holtl W, Kosak D, et al. Risk-adapted treatment choice
PART II

2016;20(4):475-480. in stage I nonseminomatous testicular germ cell cancer by

90. Lu YC, Chiang BJ, Pong YH, et al. Predictors of failure of regarding vascular invasion in the primary tumor: a prospec-
conservative treatment among patients with emphysematous tive trial. J Clin Oncol. 1990;8(1):16-20.
pyelonephritis. BMC Infect Dis. 2014;14:418. 109. Divrik RT, Akdogan B, Ozen H, Zorlu F. Outcomes of sur-
91. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2018. CA veillance protocol of clinical stage I nonseminomatous germ
SPECIFIC CONSIDERATIONS

Cancer J Clin. 2018;68(1):7-30. cell tumors-is shift to risk adapted policy justified? J Urol.
92. American Joint Committee on Cancer. Urinary bladder. In: 2006;176(4 pt 1):1424-1429; discussion 1429-1430.
Edge SB, Byrd DR, Compton CC, Fritz AG, L. GF, Trotti A, 110. Oliver RT, Mead GM, Rustin GJ, et al. Randomized trial
eds. AJCC Cancer Staging Handbook: From the AJCC of carboplatin versus radiotherapy for stage I seminoma:
Cancer Staging Manual. 7th ed. New York: Springer-Verlag; mature results on relapse and contralateral testis cancer rates
2010:569-577. in MRC TE19/EORTC 30982 study (ISRCTN27163214).
93. Sylvester RJ, van der Meijden AP, Oosterlinck W, J Clin Oncol. 2011;29(8):957-962.
et al. Predicting recurrence and progression in individual 111. Hartmann M, Siener R, Krege S, et al. [Results of the ran-
patients with stage Ta T1 bladder cancer using EORTC domised phase III study of the German Testicular Cancer
risk tables: a combined analysis of 2596 patients from Study Group. Retroperitoneal lymphadenectomy versus
seven EORTC trials. Eur Urol. 2006;49(3):466-465; one cycle BEP as adjuvant therapy for non-seminomatous
discussion 475-467. testicular tumours in clinical stage I.] Der Urologe Ausg A.
94. Babjuk M, Bohle A, Burger M, et al. EAU guidelines on 2009;48(5):523-528.
non–muscle-invasive urothelial carcinoma of the bladder: 112. N H, AM N, M K, et al. SEER Cancer Statistics Review, 1975-
update 2016. Eur Urol. 2017;71(3):447-461. 2014, National Cancer Institute. Bethesda, MD. Available at:
95. Lamm DL, Blumenstein BA, Crissman JD, et al. Maintenance https://seer.cancer.gov/csr/1975_2014/, based on November
bacillus Calmette-Guerin immunotherapy for recurrent TA, 2016 SEER data submission, posted to the SEER web site.
T1 and carcinoma in situ transitional cell carcinoma of the 2017. Accessed August 9, 2018.
bladder: a randomized Southwest Oncology Group Study. 113. Luz MA, Kotb AF, Aldousari S, et al. Retroperitoneal lymph
J Urol. 2000;163(4):1124-1129. node dissection for residual masses after chemotherapy in
96. Fernandez-Gomez J, Solsona E, Unda M, et al. Prognostic nonseminomatous germ cell testicular tumor. World J Surg
factors in patients with non–muscle-invasive bladder cancer Oncol. 2010;8:97.
treated with bacillus Calmette-Guerin: multivariate analysis 114. Pearce SM, Golan S, Gorin MA, et al. Safety and early onco-
of data from four randomized CUETO trials (see comment). logic effectiveness of primary robotic retroperitoneal lymph
Eur Urol. 2008;53(5):992-1001. node dissection for nonseminomatous germ cell testicular
97. Fernandez-Gomez J, Madero R, Solsona E, et al. The EORTC cancer. Eur Urol. 2017;71(3):476-482.
tables overestimate the risk of recurrence and progression in 115. Frank I, Blute ML, Cheville JC, Lohse CM, Weaver

patients with non–muscle-invasive bladder cancer treated with AL, Zincke H. Solid renal tumors: an analysis of patho-
bacillus Calmette–Guérin: external validation of the EORTC logical features related to tumor size. J Urol. 2003;170
risk tables. Eur Urol. 2011;60(3):423-430. (6 pt 1):2217-2220.
98. Chang SS, Bochner BH, Chou R, et al. Treatment of non- 116. Richard PO, Jewett MA, Tanguay S, et al. Safety, reliability
metastatic muscle-invasive bladder cancer: AUA/ASCO/ and accuracy of small renal tumour biopsies: results from a
ASTRO/SUO guideline. J Urol. 2017;198(3):552-559. multi-institution registry. BJU Int. 2017;119(4):543-549.
99. Shabsigh A, Korets R, Vora KC, et al. Defining early morbid- 117. Richard PO, Jewett MA, Bhatt JR, et al. Renal tumor biopsy
ity of radical cystectomy for patients with bladder cancer for small renal masses: a single-center 13-year experience.
using a standardized reporting methodology. Eur Urol. Eur Urol. 2015;68(6):1007-1013.
2009;55(1):164-174. 118. Marconi L, Dabestani S, Lam TB, et al. Systematic review
100. Johnson SC, Smith ZL, Golan S, Rodriguez JF, 3rd, Smith and meta-analysis of diagnostic accuracy of percutaneous
ND, Steinberg GD. Temporal trends in perioperative morbid- renal tumour biopsy. Eur Urol. 2016;69(4):660-673.
ity for radical cystectomy using the National Surgical Quality 119. Lane BR, Kattan MW. Prognostic models and algorithms
Improvement Program database. Urol Oncol. 2017;35(11):659 in renal cell carcinoma. Urol Clin North Am. 2008;35(4):
e613-659 e619. 613-625; vii.
101. Balar AV. Immune checkpoint blockade in metastatic urothe- 120. Kanao K, Mizuno R, Kikuchi E, et al. Preoperative prog-
lial cancer. J Clin Oncol. 2017;35(19):2109-2112. nostic nomogram (probability table) for renal cell carcinoma
102. Godwin JL, Hoffman-Censits J, Plimack E. Recent devel- based on TNM classification. J Urol. 2009;181(2):480-485;
opments in the treatment of advanced bladder cancer. Urol discussion 485.
Oncol. 2018;36(3):109-114. 121. Krejci KG, Blute ML, Cheville JC, Sebo TJ, Lohse CM,
103. Znaor A, Lortet-Tieulent J, Jemal A, Bray F. International Zincke H. Nephron-sparing surgery for renal cell carcinoma:
variations and trends in testicular cancer incidence and mor- clinicopathologic features predictive of patient outcome.
tality. Eur Urol. 2014;65(6):1095-1106. Urology. 2003;62(4):641-646.
 122. Mekhail TM, Abou-Jawde RM, Boumerhi G, et al. Validation events in asymptomatic and minimally symptomatic, che- 1781
and extension of the Memorial Sloan-Kettering prognos- motherapy-naive patients with metastatic castration-resistant
tic factors model for survival in patients with previously prostate cancer (PREVAIL): results from a randomised, phase
untreated metastatic renal cell carcinoma. J Clin Oncol. 3 trial. Lancet Oncol. 2015;16(5):509-521.
2005;23(4):832-841. 142. Sternberg CN, de Bono JS, Chi KN, et al. Improved outcomes
123. Smith ZL. Current status of minimally invasive surgery for in elderly patients with metastatic castration-resistant prostate
renal cell carcinoma. Curr Urol Rep. 2016;17(6):43. cancer treated with the androgen receptor inhibitor enzalu-
124. Kunkle DA, Uzzo RG. Cryoablation or radiofrequency
tamide: results from the phase III AFFIRM trial. Ann Oncol.
ablation of the small renal mass : a meta-analysis. Cancer. 2014;25(2):429-434.
2008;113(10):2671-2680. 143. Dalbagni G, Zhang ZF, Lacombe L, Herr HW. Male ure-
125. Clayman RV, Kavoussi LR, Soper NJ, et al. Laparoscopic thral carcinoma: analysis of treatment outcome. Urology.

CHAPTER 40 UROLOGY
nephrectomy: initial case report. J Urol. 1991;146(2):278-282. 1999;53(6):1126-1132.
126. Motzer RJ, Jonasch E, Agarwal N, et al. Kidney cancer, ver- 144. Swartz MA, Porter MP, Lin DW, Weiss NS. Incidence of
sion 2.2017, NCCN clinical practice guidelines in oncology. primary urethral carcinoma in the United States. Urology.
J Natl Compr Canc Netw. 2017;15(6):804-834. 2006;68(6):1164-1168.
127. Abaza R. Initial series of robotic radical nephrectomy with vena 145. Cupp MR, Malek RS, Goellner JR, Espy MJ, Smith TF.
caval tumor thrombectomy. Eur Urol. 2011;59(4):652-656. Detection of human papillomavirus DNA in primary squa-
128. Gill IS, Metcalfe C, Abreu A, et al. Robotic level III infe- mous cell carcinoma of the male urethra. Urology. 1996;48(4):
rior vena cava tumor thrombectomy: initial series. J Urol. 551-555.
2015;194(4):929-938. 146. Dinney CP, Johnson DE, Swanson DA, Babaian RJ, von
129. Schroder FH, Hugosson J, Roobol MJ, et al. Screening and Eschenbach AC. Therapy and prognosis for male ante-
prostate cancer mortality: results of the European Ran- rior urethral carcinoma: an update. Urology. 1994;43(4):
domised Study of Screening for Prostate Cancer (ERSPC) 506-514.
at 13 years of follow-up. Lancet. 2014;384(9959):2027-2035. 147. Gofrit ON, Pode D, Pizov G, Zorn KC, Katz R, Shapiro A.
130. Moyer VA, Force USPST. Screening for prostate cancer: U.S. Prostatic urothelial carcinoma: is transurethral prostatectomy
Preventive Services Task Force recommendation statement. necessary before bacillus Calmette-Guerin immunotherapy?
Ann Intern Med. 2012;157(2):120-134. BJU Int. 2009;103(7):905-908.
131. Carter HB, Albertsen PC, Barry MJ, et al. Early detection 148. Gakis G, Witjes JA, Comperat E, et al. EAU guidelines on
of prostate cancer: AUA Guideline. J Urol. 2013;190(2): primary urethral carcinoma. Eur Urol. 2013;64(5):823-830.
419-426. 149. Gakis G, Morgan TM, Daneshmand S, et al. Impact of
132. Gleason DF, Mellinger GT. Prediction of prognosis for pros- perioperative chemotherapy on survival in patients with
tatic adenocarcinoma by combined histological grading and advanced primary urethral cancer: results of the international
clinical staging. J Urol. 1974;111(1):58-64. collaboration on primary urethral carcinoma. Ann Oncol.
133. Epstein JI, Zelefsky MJ, Sjoberg DD, et al. A contemporary 2015;26(8):1754-1759.
prostate cancer grading system: a validated alternative to the 150. Kent M, Zinman L, Girshovich L, Sands J, Vanni A. Com-
gleason score. Eur Urol. 2016;69(3):428-435. bined chemoradiation as primary treatment for invasive male
134. Hamdy FC, Donovan JL, Lane JA, et al. 10-year outcomes urethral cancer. J Urol. 2015;193(2):532-537.
after monitoring, surgery, or radiotherapy for localized 151. Dayyani F, Pettaway CA, Kamat AM, Munsell MF, Sircar K,
prostate cancer. N Engl J Med. 2016;375(15):1415-1424. Pagliaro LC. Retrospective analysis of survival outcomes and
135. Chung MS, Lee SH. Current status of active surveillance in the role of cisplatin-based chemotherapy in patients with ure-
prostate cancer. Investig Clin Urol. 2016;57(1):14-20. thral carcinomas referred to medical oncologists. Urol Oncol.
136. Wiegel T, Bartkowiak D, Bottke D, et al. Adjuvant radiother- 2013;31(7):1171-1177.
apy versus wait-and-see after radical prostatectomy: 10-year 152. Aguilar-Navarro S, Navarrete-Reyes AP, Grados-Chavarria
follow-up of the ARO 96-02/AUO AP 09/95 trial. Eur Urol. BH, Garcia-Lara JM, Amieva H, Avila-Funes JA. The sever-
2014;66(2):243-250. ity of urinary incontinence decreases health-related quality of
137. Thompson IM, Tangen CM, Paradelo J, et al. Adjuvant life among community-dwelling elderly. J Gerontol A Biol Sci
radiotherapy for pathological T3N0M0 prostate cancer Med Sci. 2012;67(11):1266-1271.
significantly reduces risk of metastases and improves sur- 153. Bettez M, Tu le M, Carlson K, et al. 2012 update: guidelines
vival: long-term followup of a randomized clinical trial. for adult urinary incontinence collaborative consensus docu-
J Urol. 2009;181(3):956-962. ment for the Canadian urological association. Can Urol Assoc
138. Pound CR, Partin AW, Eisenberger MA, Chan DW, Pear- J. 2012;6(5):354-363.
son JD, Walsh PC. Natural history of progression after 154. Tennstedt SL, Chiu GR, Link CL, Litman HJ, Kusek JW,
PSA elevation following radical prostatectomy. JAMA. McKinlay JB. The effects of severity of urine leakage on qual-
1999;281(17):1591-1597. ity of life in Hispanic, white, and black men and women: the
139. Ryan CJ, Smith MR, Fizazi K, et al. Abiraterone acetate plus Boston community health survey. Urology. 2010;75(1):27-33.
prednisone versus placebo plus prednisone in chemother- 155. Ramage-Morin PL, Gilmour H. Urinary incontinence and
apy-naive men with metastatic castration-resistant prostate loneliness in Canadian seniors. Health Rep. 2013;24(10):
cancer (COU-AA-302): final overall survival analysis of a 3-10.
randomised, double-blind, placebo-controlled phase 3 study. 156. Brown JS, Vittinghoff E, Wyman JF, et al. Urinary inconti-
Lancet Oncol. 2015;16(2):152-160. nence: does it increase risk for falls and fractures? Study of
140. Logothetis CJ, Basch E, Molina A, et al. Effect of abiraterone Osteoporotic Fractures Research Group. J Am Geriatr Soc.
acetate and prednisone compared with placebo and predni- 2000;48(7):721-725.
sone on pain control and skeletal-related events in patients 157. Abrams P, Cardozo L, Fall M, et al. The standardisation of
with metastatic castration-resistant prostate cancer: explor- terminology in lower urinary tract function: report from the
atory analysis of data from the COU-AA-301 randomised standardisation sub-committee of the International Conti-
trial. Lancet Oncol. 2012;13(12):1210-1217. nence Society. Urology. 2003;61(1):37-49.
141. Loriot Y, Miller K, Sternberg CN, et al. Effect of enzalutamide 158. Dumoulin C, Hunter KF, Moore K, et al. Conservative
on health-related quality of life, pain, and skeletal-related management for female urinary incontinence and pelvic
1782 organ prolapse review 2013: Summary of the 5th Interna- double-blind placebo-controlled trials and the postmarket-
tional Consultation on Incontinence. Neurourol Urodyn. ing safety database. Int J Clin Pract. 2010;64(2):240-255.
2016;35(1):15-20. 173. Baltaci S, Aydos K, Kosar A, Anafarta K. Treating erectile
159. Chapple C, Khullar V, Gabriel Z, Dooley JA. The effects of dysfunction with a vacuum tumescence device: a retro-
antimuscarinic treatments in overactive bladder: a systematic spective analysis of acceptance and satisfaction. Br J Urol.
review and meta-analysis. Eur Urol. 2005;48(1):5-26. 1995;76(6):757-760.
160. Chapple CR, Cardozo L, Nitti VW, Siddiqui E, Michel MC. 174. Ganem JP, Lucey DT, Janosko EO, Carson CC. Unusual
Mirabegron in overactive bladder: a review of efficacy, safety, complications of the vacuum erection device. Urology.
and tolerability. Neurourol Urodyn. 2014;33(1):17-30. 1998;51(4):627-631.
161. van Kerrebroeck PE, van Voskuilen AC, Heesakkers JP, et al. 175. Guay AT, Perez JB, Velasquez E, Newton RA, Jacobson JP.
Results of sacral neuromodulation therapy for urinary voiding Clinical experience with intraurethral alprostadil (MUSE) in
dysfunction: outcomes of a prospective, worldwide clinical the treatment of men with erectile dysfunction. A retrospec-
study. J Urol. 2007;178(5):2029-2034. tive study. Medicated urethral system for erection. Eur Urol.
PART II

162. Burton C, Sajja A, Latthe PM. Effectiveness of percutane- 2000;38(6):671-676.

ous posterior tibial nerve stimulation for overactive bladder: 176. Fulgham PF, Cochran JS, Denman JL, et al. Disappointing
a systematic review and meta-analysis. Neurourol Urodyn. initial results with transurethral alprostadil for erectile dys-
2012;31(8):1206-1216. function in a urology practice setting. J Urol. 1998;160
163. Rovner E, Kennelly M, Schulte-Baukloh H, Zhou J, Haag- (6 pt 1):2041-2046.
SPECIFIC CONSIDERATIONS

Molkenteller C, Dasgupta P. Urodynamic results and clinical 177. Rajpurkar A, Dhabuwala CB. Comparison of satisfaction
outcomes with intradetrusor injections of onabotulinum- rates and erectile function in patients treated with silde-
toxinA in a randomized, placebo-controlled dose-finding nafil, intracavernous prostaglandin E1 and penile implant
study in idiopathic overactive bladder. Neurourol Urodyn. surgery for erectile dysfunction in urology practice. J Urol.
2011;30(4):556-562. 2003;170(1):159-163.
164. Johannes CB, Araujo AB, Feldman HA, Derby CA, Kleinman 178. Kaefer M, Diamond D, Hendren WH, et al. The incidence of
KP, McKinlay JB. Incidence of erectile dysfunction in men 40 intersexuality in children with cryptorchidism and hypospa-
to 69 years old: longitudinal results from the Massachusetts dias: stratification based on gonadal palpability and meatal
male aging study. J Urol. 2000;163(2):460-463. position. J Urol. 1999;162(3 pt 2):1003-1006; discussion
165. Corona G, Lee DM, Forti G, et al. Age-related changes in gen- 1006-1007.
eral and sexual health in middle-aged and older men: results 179. Keays MA, Dave S. Current hypospadias management: Diag-
from the European Male Ageing Study (EMAS). J Sex Med. nosis, surgical management, and long-term patient-centred
2010;7(4 Pt 1):1362-1380. outcomes. Can Urol Assoc J. 2017;11(1-2 suppl 1):S48-S53.
166. Lue TF. Erectile dysfunction. N Engl J Med. 2000;342(24): 180. Preda I, Jodal U, Sixt R, Stokland E, Hansson S. Normal
1802-1813. dimercaptosuccinic acid scintigraphy makes voiding cystoure-
167. Francis ME, Kusek JW, Nyberg LM, Eggers PW. The con- thrography unnecessary after urinary tract infection. J Pediatr.
tribution of common medical conditions and drug exposures 2007;151(6):581-584, 584.e581.
to erectile dysfunction in adult males. J Urol. 2007;178(2): 181. Roberts KB. Urinary tract infection: clinical practice guide-
591-596; discussion 596. line for the diagnosis and management of the initial UTI
168. Yafi FA, Jenkins L, Albersen M, et al. Erectile dysfunction. in febrile infants and children 2 to 24 months. Pediatrics.
Nat Rev Dis Primers. 2016;2:16003. 2011;128(3):595-610.
169. McCabe MP, Althof SE. A systematic review of the psycho- 182. Bilgutay AN, Roth DR, Gonzales ET, Jr., et al. Posterior
social outcomes associated with erectile dysfunction: does the urethral valves: risk factors for progression to renal failure.
impact of erectile dysfunction extend beyond a man’s inability J Pediatr Urol. 2016;12(3):179 e171-e177.
to have sex? J Sex Med. 2014;11(2):347-363. 183. Lee PA. Fertility after cryptorchidism: epidemiology and
170. The process of care model for evaluation and treatment of other outcome studies. Urology. 2005;66(2):427-431.
erectile dysfunction. The Process of Care Consensus Panel. 184. Feyles F, Peiretti V, Mussa A, et al. Improved sperm count and
Int J Impot Res. 1999;11(2):59-70; discussion 70-54. motility in young men surgically treated for cryptorchidism in
171. Yuan J, Zhang R, Yang Z, et al. Comparative effective- the first year of life. Eur J Pediatr Surg. 2014;24(5):376-380.
ness and safety of oral phosphodiesterase type 5 inhibitors 185. Pettersson A, Richiardi L, Nordenskjold A, Kaijser M, Akre O.
for erectile dysfunction: a systematic review and network Age at surgery for undescended testis and risk of testicular
meta-analysis. Eur Urol. 2013;63(5):902-912. cancer. N Engl J Med. 2007;356(18):1835-1841.
172. Giuliano F, Jackson G, Montorsi F, Martin-Morales

A, Raillard P. Safety of sildenafil citrate: review of 67