• The collecting system of the kidney is composed of several major and minor calyces

UROLOGY 2020 (Doc Barcenas ppt) that coalesce into the renal pelvis.
• The renal pelvis tapers into the ureteropelvic junction (UPJ) where it joins with the
•Study of surgical and medical diseases of the male and female urinary tract and male ureter.
reproductive organs.
•Kidneys, adrenal glands, ureters, urinary bladder, urethra, and the male reproductive organs ADRENALS
(testes, epididymis, vas deferens, seminal vesicles, prostate and penis)
• The adrenal glands lie superomedially to the kidneys within Gerota’s fascia.
SCOPE • The arterial supply of the adrenals derives from the inferior phrenic, aorta, and small
branches from the renal arteries.
I.Anatomy • The venous drainage on the left is mainly through the inferior phrenic vein and
II.Urologic Malignancies through
III.Trauma
IV.Emergencies URETERS
V.Infections
VI.Lower Urinary Tract Obstruction • The ureters are muscular structures that course anterior to the psoas muscles from
VII.Upper Urinary Tract Obstruction the renal pelvis to the bladder.
VIII.Pediatric Urology • The blood supply of the proximal ureter derives from the aorta and renal artery and
comes mainly from the medial direction.
I. Anatomy • The ureters enter the bladder laterally and pass through the bladder wall at an
oblique angle, which helps prevent reflux of urine during bladder filling. The ureters
Anatomic structures that fall under the purview of Genitourinary surgery are the adrenals, propel urine into the bladder via the ureteral orifices.
kidneys, ureters, bladder, prostate, seminal vesicles, urethra, vas deferens, penis, and • Mobilizing the distal ureter for anastomosis requires releasing its lateral attachments,
testes. which results in ischemia.
• Distal ureteral injuries are typically managed by anastomosing the proximal ureter to
Kidneys the bladder.
• The ureters course along the pelvic sidewall and pass under the uterine arteries in
• The kidneys are paired retroperitoneal organs that are invested in a fibro-fatty layer: women, making them vulnerable to injury during hysterectomy, especially in the
fascia of Zuckerkandl posteriorly and Gerota’s fascia anteriorly. context of pelvic bleeding.
• The renal arteries, are single vessels extending from the aorta that branch into
several segmental arteries before entering the renal URINARY BLADDER
• Right renal artery passes posterior to the vena cava and is significantly longer than
the left renal artery. • The urinary bladder is situated in the retropubic space in an extraperitoneal position.
• Occasionally, the kidney is supplied by a second renal artery, an accessory renal • A portion of the bladder dome is adjacent to the peritoneum, so ruptures at this point
artery, typically to the lower pole. can result in intraperitoneal urine leakage.
• Within the kidney, there is essentially no anastomotic arterial flow, so the kidneys are PROSTATE
prone to infarction when branch vessels are interrupted. • The prostate is in continuity with the bladder neck, and the urethra courses through
• Left renal vein passes anterior to the aorta and is much longer than the right renal it.
vein. • The prostate has a significant component of smooth muscle and can provide urinary
• Left vein is in continuity with the left gonadal vein, the left inferior adrenal vein, and a continence even in the absence of the external striated sphincter.
lumbar vein

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 • Puboprostatic ligaments connect the prostate to the pubic symphysis, and pelvic
fractures often result in proximal urethral injuries due to the traction that these
ligaments provide.
• Between the prostate and the rectum lies Denonvilliers’ fascia, which is the main
anatomic barrier that prevents prostate cancer from regularly penetrating into the
rectum
PENIS
• 3 main bodies – 2 corpora cavernosum, 1 corpora spongiosum
• The corpora cavernosum are the paired, cylinder-like structures that are the main
erectile bodies of the penis - innervated by the cavernosal nerves
• The corpus spongiosum is located on the ventrum of the penis. The corpus
spongiosum lacks a tough fascia similar to tunica albuginea and thus does not
exhibit the same rigidity during erection.
• The tip of the penis, called the glans, is in continuity with the corpus spongiosum.
• Surrounding all three bodies of the penis are the outer dartos fascia and the inner
Buck’s fascia.
• The dorsal nerves of the penis, which provide sensation to the penile skin, derive
from the pudendal nerves and, along with the dorsal penile arteries, travel along the
dorsum of the penis within Buck’s fascia.
SCROTUM AND TESTES
• The scrotum is a capacious structure that contains the testes and epididymes.
• Because of its dependent position, significant edema can develop when a patient is
fluid overloaded.
• Any significant bleeding will result in the accumulation of large hematomas.
• Beneath the internal fascia are the parietal and visceral layers of the tunica vaginalis,
between which hydroceles form.
• Noncompliant outer testis layer is the tunica albuginea.
• The blood supply enters the testis at the superior pole by way of the spermatic cord.
• The cord carries three separate sources of arterial blood flow—the testicular artery
that arises from the aorta below the renal artery, the cremasteric artery, and the
deferential artery.
• Interruption of one of the arteries during vasectomy or inguinal surgery will not result
in ischemia to the testis.
• Dilation of spermatic veins is called a varicocele and may be palpable when a patient
is standing or with Valsalva.
• They do not need to be treated unless they cause discomfort, are discovered on
infertility workup, or are found in children
• The testicular artery arises directly from the aorta; the deferential artery, which
supplies the vas deferens, arises from the internal iliac artery; and the cremasteric
artery, which supplies the cremaster musculature, arises from the external iliac
artery.
I.UROLOGIC MALIGNANCIES
• Bladder Cancer
• Testicular Cancer
• Kidney Cancer
• Prostate Cancer
Urothelial Tumors of the Urinary Bladder
• Transitional cell epithelium lines the urinary tract from the renal pelvis, ureter, urinary
bladder, and the proximal two-thirds of the urethra
• Tobacco Use Is the Most Frequent Risk Factor (50%in men and 40% in women),
followed by occupational exposure to various carcinogenic materials such as
automobile exhaust or industrial solvents.
• In the presence of a known bladder tumor, unilateral or bilateral hydronephrosis is an
ominous sign of locally advanced disease (at least muscle invasive bladder cancer)
• Patients who have disease invading into bladder muscle (T2), immediate (within 3
months of diagnosis) cystectomy with extended lymph node dissection is the best
chance for survival.
• Because upper tract recurrence is fairly common (up to 17% of patients with
carcinoma in situ), surveillance must be performed with RGPs or CT urograms.
• Patients are monitored for recurrence at 3-month intervals during the first year.
Detection of Urothelial Cancer
• Painless gross hematuria occurs in 85% of patients & requires a complete evaluation
that includes cystoscopy, urine cytology, CT scan, & a PSA.
• • Recurrent or significant hematuria (>3 RBC’s/HPF on 3 urinalysis, a single
urinalysis with >100 RBCs, or gross Hematuria) is associated with significant renal or
urologic lesion in 9.1%
• Patients with microscopic hematuria require a full evaluation, but low- risk patients do
not require repeat evaluations.
• High-risk individuals primarily are those with a smoking history & should be
evaluated every 6 months.
• •The level of suspicion for urogenital neoplasms in patients with isolated painless
hematuria and nondysmorphic RBCs increases with age.
• White light cystoscopy with random bladder biopsies is the gold standard for tumor
detection
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 Non-Muscle Invasive Bladder Ca
HISTORY AND STAGING
• Patients with non–muscle-invasive bladder cancer (confined to the bladder mucosa
• Low-grade papillary lesions are likely to recur in up to 60% of patients but invade in or submucosa) can be managed with TUR alone and adjuvant intravesical (instilled
less than 10% of cases. into the bladder) chemotherapy/ immunotherapy
• High-grade lesions also recur; invasion subsequent stage progression can occur in • Intravesical treatments are advised for patients with diffuse ClS,recurrent disease,
50% of tumors. >40% involvement of the bladder surface by tumor, or T1 disease.
• Muscle-invasive bladder cancer leads to death in a significant proportion of patients
despite aggressive therapy. Endoscopic Surgical Management

PATHOLOGY
• Malignant tumors are classified as low grade or high grade.
• The most important risk factor for progression is grade.
• Urothelial tumors exhibit polychronotropism, which is the tendency to recur over time
in new locations in the urothelial tract.
• As long as urothelium is present, continuous monitoring is required.
• TURBT is performed both to remove all visible tumors & to provide specimens for
pathologic examination to determine stage & grade.
• Repeat resection within 1 to 6 weeks is usually indicated in patients with high-grade
disease.
• Single-dose intravesical chemotherapy administered within 6 hours of resection
reduces recurrence of low-risk tumors.
• All suspicious lesions should be sampled, but “random” biopsies are not required in
low-risk patients.

-Tumors recur at the same site of resection in 20% to 40% of cases and they may progress
to invade the muscle layers of the bladder

Immunotherapy

• Intravesical BCG has higher efficacy than intravesical chemotherapy.

• BCG is the only agent shown to delay or reduce high-grade tumor
• progression.
• Standard therapy, is Bacillus Calmette-Guérin (BCG) in six weekly instillations,
followed by maintenance administrations for > 1 year
• BCG is contraindicated in the setting of a disrupted urothelium because of the risk of
intravasation & septic death.

Intravesical Chemotherapy

• Intravesical chemotherapy has a clear impact on tumor recurrence when immediately

instilled after TURBT & in the adjuvant setting
• In general, side effects of chemotherapy tend to be less common & less severe than
those for BCG, but BCG is more efficacious.

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Surveillance & Prevention

• Cystoscopy is the hallmark of surveillance. Usually every 3 months.

• Increased fluids, smoking cessation, & a low-fat diet are recommended.
• Stopping or never starting smoking is the best prevention for bladder cancer.
• There are no clear dietary or micronutrient programs to prevent primary bladder
cancer.
• BCG plus high-dose vitamins may prevent recurrent bladder cancer.

Muscle invasive bladder cancer

• In men, the prostate is removed with the bladder (Radical Cysto Prostatectomy).
• In women, the uterus, ovaries, and anterior wall of the vagina are removed with the
bladder (Anterior Pelvic Exenteration).
• Orthotopic neobladder has emerged as a popular urinary diversion for patients
without urethral involvement.
• Most common diversion is noncontinent, the ileal conduit

Neoadjuvant chemotherapy

• • Presurgical (or neoadjuvant) chemotherapy increases the cure rate by 5–15%,

• • In patients receiving three cycles of neoadjuvant MVAC followed by cystectomy
had a significantly better median (6.2 yea rs) and 5-year surviva l (57%) compared to
cystectomy alone (median survival 3.8 years; 5-year survival 42%).

Partial Cystectomy

• Limited to patients with a solitary lesion in which radical cystectomy is otherwise

contraindicated & a sufficient margin can be obtained.
• Partial cystectomy can be curative in other tumor types including squamous cell
carcinoma & adenocarcinoma.
• Restricted to primary solitary lesions unsuitable for removal by transurethral
resection and to residual tumor at repeat resection 2 months later.
• The tumor must also lie at a site that allows 2cm of normal tissue around it to be
removed.
• Bladder must have adequate capacity and compliance to be functional after removal
of part of its wall.

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Radical Cystectomy • Scrotal ultrasonography is extremely accurate in identifying solid intratesticular lesions,
with greater than 95% sensitivity and specificity.
• Designed to remove the bladder, pelvic peritoneum, prostate, and seminal vesicles in
men and the urethra, uterus, broad ligaments, and anterior third of the vaginal wall in
women.
• • In both sexes, pelvic lymphadenectomy is an integral part of the operation.
• • Some form of urinary diversion must be created.

Metastatic Disease

• Overall response rates of >50% have been reported using combinations such as
methotrexate, vinblastine, doxorubicin， and cisplatin (MVAC); gemcitabine and cisplatin
(GC); or gemcitabine, paclitaxel, and cisplatin (GPC)

Management of Bladder Cancer

Non-muscle-invasive disease- Endoscopic removal, usually with intravesical therapy

Muscle-invasive disease- Cystectomy 士 systemic chemotherapy (before or after surgery)

TESTICULAR TUMORS
Tumor Markers
• Primary germ cell tumors (GCTs) of the test is arising by the malignant
• Initial studies must include tumor markers,including α- fetoprotein (AFP), β-human
transformation of primordial germ cells constitute 95% of all testicular neoplasms
chorionic gonadotropin (BHCG), and lactate dehydrogenase (LDH).
• Testicular cancer is the most common solid malignancy in men age 15 to 35 years
• Elevated tumor markers are found almost exclusively in non-seminomatous germ cell
(1-1.5% of all cancers in men).
tumors
• A painless testicular mass is pathognomonic for a testicular malignancy
• 10% of patients with localized seminomas and 25% with metastatic seminomas will
• A major risk for the development of testicular cancer is cryptorchidism (49/100,000
have a modest rise in β-human chorionic gonadotropin.
(0.05%) to 12/1,075 (1%).
• AFP concentration is increased only in patients with nonseminoma GCT.
• Abdominal cryptorchid testes are at a higher risk than inguinal cryptorchid testes.
• The presence of an increased AFP level in a patient whose tumor shows only
• An isochromosome of the short arm of chromosome12 [i (1 2p)] is pathognomonic for
seminoma, the patient should be treated for nonseminomatous GCT
GCT
• LDH levels are less specific than AFP or hCG but are increased in 50-60% patients
• After orchiectomy, a computed tomography (CT) scan of the chest, abdomen, and
with metastatic nonseminoma and in up to 80% of patients with advanced
pelvis is generally performed
seminoma.
• Serum tumour markers, both before, and 5-7 days after orchiectomy (AFP and hCG)
• Testicular cancer is the most common solid tumor in men between the ages of 20 and 35
and LDH.
years.
• Increased serum AFP and hCG concentrations decay according to first -order
• Careful history, physical examination, and serum tumor markers (hCG, AFP, and LDH) are
kinetiιs; the half-life is 24-36 h for hCG and 5-7 days for AFP.
helpful in establishing the correct diagnosis.
• AFP and hCG should be assayed serially during and after treatment.

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 • The reappearance of hCG and/or AFP or the failure of these markers to decline
according to the predicted half-life is an indicator of persistent or recurrent tumor.
Radical Inguinal Orchiectomy
• Patients suspected of having a testicular neoplasm should undergo a radical inguinal
orchiectomy with removal of the tumor-bearing testis and spermatic cord to the level
of the internal inguinal ring.
• A trans scrotal orchiectomy or biopsy is contraindicated
• Radical orchiectomy establishes the histologic diagnosis and primary T stage,
provides important prognostic information from the tumor histology, and is curative in
80% to 85% and 70% to 80% of CS I seminoma and CS I NSGCT
Clinical Staging
• Predictable pattern of spread from the primary tumor to retroperitoneal lymph nodes
& then to distant metastatic sites.
• The primary “landing zone” for left-sided tumors is the paraaortic & left renal hilar
lymph nodes, & for right-sided tumors it is the interaortocaval & paracaval lymph
nodes.
• Chest radiography & CT are acceptable staging modalities in the absence of
retroperitoneal lymphadenopathy or elevated serum tumor marker level
Non Seminomatous GCT
• Over 80% of patients with clinical stage IA nonseminoma are cured with orchiectomy
alone, surveillance is the preferred treatment option.
• Patients with limited, ipsilateral retroperitoneal adenopathy <2cm in largest diameter
and normal levels of AFP and hCG can be treated with either a modified bilateral
nerve-sparing RPLND or chemotherapy
Seminoma
• Inguinal orchiectomy followed by immediate retroperitoneal radiation therapy or
surveillance with treatment at relapse both result in cure in nearly 100% of patients
with stage 1 seminoma
• Generally, nonbulky retroperitoneal disease (stage IIA and small IIB) is treated with
retroperitoneal radiation therapy.
• Approximately 90% of patients achieve relapse-free survival with retroperitoneal
masses < 3 cm in diameter
• In bulkier disease， initial chemotherapy is preferred for all stage IIC and some
stage IIB patients
GCT
• Regardless of histology, all patients with stage IIC and stage III and most with stage
IIB GCT are treated with chemotherapy.
• Combination chemotherapy programs based on cisplatin at doses of 100 mg/m2 plus
etoposide at doses of 500 mg/m2 per cycle cure 70-80% of such patients, with or
without bleomycin
MALIGNANT TUMOR OF THE KIDNEYS
RENAL CELL CARCINOMA
• Renal cell carcinoma (RCC) is a malignancy of the renal epithelium that can arise
from any component of the nephron
• Notable features include resistance to cytotoxic agents, infrequent responses to
biologic response modifiers such as interleukin (IL) 2, robust activity to
antiangiogenesis targeted agents, and a variable clinical course for patients with
metastatic disease, including anecdotal reports of spontaneous regression.
• Renal tumors are usually solid, but they also can be cystic
• Many environmental factors have been investigated as possible contributing causes;
the strongest association is with cigarette smoking
• The most common sites of metastasis are the retroperitoneal lymph nodes and
lungs, but liver, bone, and brain also are common sites of spread
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 • Patients should undergo testing for the presence of metastatic disease including
chest CT, bone scan, and liver function tests.
• Hematuria, Abdominal pain or flank mass
• Widespread use of radiologic cross-sectional imaging procedures (CT, ultrasound,
MRI) contributes to earlier detection, including incidental renal masses detected
during evaluation for other medical conditions.
• Standard evaluation of patients with suspected renal cell tumors includes a CT scan
of the abdomen and pelvis, chest radiograph, urine analysis, and urine cytology
• Up to 10% of RCC invades the lumen of the renal vein or vena cava.
• Thrombus below the level of the liver can be managed with cross-clamping above
and below the thrombus and extraction from a cavotomy at the insertion of the renal
vein
• For thrombus above the hepatic veins, a multidisciplinary approach with either
venous or cardiopulmonary bypass is necessary

Advanced Renal Cell Carcinoma

• Metastatic renal cell carcinoma is refractory to chemotherapy

• Cytokine therapy with IL-2 or interferon α (IFN-α) produces regression in 10-20% of
patients
• Antiangiogenic therapy – Sunitinib, Pazopanib and axitinib as first line therapy;
• Temsirolimus and everolimus, show activity in patients with untreated poor prognosis
tumors and insunitinib/sorafenib-refractory tumors.

Palliative Surgery in Advanced Renal Cell Carcinoma

• In patients with advanced RCC, cytoreductive nephrectomy may help alleviate

symptoms related to the primary tumor (e.g., intractable pain, hematuria) or
paraneoplastic manifestations.

• Resection of metastatic lesions (often in combination with radiation or systemic

therapy) is sometimes performed for relief of symptoms or to prevent life- threatening
or disabling sequelae.

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BOSNIAK CLASSIFICATION SYSTEM
• based on septations, calcifications, and enhancement, is used to assess the
likelihood of malignancy in Renal Cysts
Category I lesions are uncomplicated, simple, benign cysts of the kidney that are
straightforward to diagnose on ultrasonography, CT, or MRI. No treatment is necessary.
• Bilateral involvement can be synchronous or asynchronous and is found in 2% to 4%
of sporadic RCCs, more common in patients with von Hippel-Lindau disease.
• Multicentricity, which is found in 10% to 20% of cases, is more common in
association with papillary histology and familial RCC
• Clear cell RCC accounts for 70% to 80% of all RCCs, arise from the epithelial cells of
the proximal tubules and usually show chromosome 3p deletions

Category II lesions are minimally complex cysts that are generally benign but have some
radiologic findings that cause concern.These lesions include septated cysts, cysts with
calcium in the wall or septum, infected cysts, & hyperdense (high-density) cysts.This
category has now been subdivided to differentiate category II lesions that do not require
surveillance from category IIF lesions that mandate surveillance.The risk of malignancy for
category IIF renal cysts is 5% to 10%, & these lesions should be observed with periodic
renal imaging.

Category III lesions are more complex renal cysts that cannot be confidently distinguished
from malignant neoplasms.The radiographic features include thickened irregular or smooth
walls or septa in which measurable enhancement can be observed. Surgical exploration is
usually indicated in healthy patients. About 50% of these lesions are malignant; the
remainder prove to be benign multiloculated, hemorrhagic, or densely calcified cysts.

Category IV lesions have large cystic components; irregular, shaggy margins; &, most
important, solid enhancing portions that provide a definitive diagnosis of malignancy.
Category IV lesions are almost invariably cystic RCCs that, if localized, require surgical
treatment.
Staging
Radiologic Evaluation of Renal Mass
• Abnormal liver function test results, elevated serum alkaline phosphatase or LDH
• A dedicated (thin-slice) renal CT scan remains the single most important levels or ESR, hypercalcemia, and significant anemia point to the probability of
radiographic test for delineating the nature of a renal mass. advanced disease.
• CT Urography is necessary to take full advantage of the contrast enhancement • The radiographic staging of RCC - high-quality abdominal CT scan and a routine
characteristics of highly vascular renal parenchymal tumors chest radiograph
• Any renal mass that enhances with intravenous administration of contrast material on
CT by more than 15 Hounsfield units (HU) should be considered an RCC until
proved otherwise

Pathology

• Most sporadic RCCs are unilateral and unifocal.

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Partial Nephrectomy

• Nephron sparing surgery should be considered in all patients, as those patients

undergoing a radical nephrectomy are at risk for future chronic kidney disease
• the risk of contralateral RCC is 2% to 3% in most series,
• a partial nephrectomy may prevent the future need for dialysis in case of a
contralateral kidney tumor
• Situations in which radical nephrectomy would render the patient anephric or at high
risk for ultimate need of dialysis bilateral synchronous RCC, to preserve as much
functioning renal tissue as possible
• A functioning renal remnant of at least 20% of one kidney is necessary to avoid end-
stage renal failure
• Local recurrence after PN ranged from 3% to 5%,
• PN is now standard of care for the management of clinical T1 renal masses in the
presence of a normal contralateral kidney

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 • Patients who undergo nephron-sparing surgery for RCC may be left with a relatively
small amount of renal tissue and are at risk for development of long-term renal
functional impairment from hyperfiltration renal injury
Radical Nephrectomy
• RN encompasses early ligation of the renal artery and vein, removal of the kidney
with primary dissection external to the Gerota fascia, excision of the ipsilateral
adrenal gland, and performance of a complete regional lymphadenectomy from the
crus of the diaphragm to the aortic bifurcation
• For large tumors, particularly on the right side where the liver makes exposure of the
tumor more difficult, a thoracoabdominal approach is very helpful
PROSTATE CANCER
• 1 in 6 men will eventually be diagnosed with the disease,
• Prostate Cancer remains the 2nd leading cause of cancer deaths in men,
• only 1 man in 30 with prostate cancer will die of his disease.
• Current estimates are that 40% of early-onset and 5– 10% of all prostate cancers are
hereditary
• African-American males have both a higher incidence of prostate cancer and larger
tumors and more worrisome histologic features than white males
• Need to pursue a diagnosis of prostate cancer is based on symptoms, an abnormal
DRE or, a change in or an elevated serum PSA
• The AUA - routine screening for men 55 to 69 years of age.
• Patients of African American descent or with a family history of prostate cancer
should be considered for screening at an earlier age (as early as 40).
• Men with abnormal DRE or PSA elevation have an indication for prostate biopsy to
determine the presence of the disease
• Direct visualization by transrectal ultrasound (TRUS) or magnetic resonance imaging
(MRI) assures that all areas of the gland are sampled
• • Contemporary schemas advise 12-core biopsy that includes sampling from the
peripheral zone as well as a lesion-directed palpable nodule or suspicious image
guided sampling.
• • 75-80% occurs in the peripheral zone, 15-25% in the transition zone.
• • Men with an abnormal PSA and negative biopsy are advised to undergo a repeat
biopsy.
Diagnostic Modalities
• Digital Rectal examination
• Prostate Specific Antigen
• PSA Derivatives and Molecular Forms
– Volume-Based PSA Parameters.
– Prostate-Specific Antigen Velocity.
– Free Prostate-Specific Antigen
Digital Rectal Examination
• • Cancers 0ccur in the peripheral zone and may be palpated on DRE
• • Carcinomas are characteristically hard, nodular, and irregular. 20-25% of
• men with an abnormal DRE have cancer
• • Risk of prostate cancer among men with abnormalities on DRE - use PSA and DRE
together for prostate cancer detection
• • PSA improves the positive predictive value of DRE for cancer when DRE and PSA
are used in prostate cancer screening, detection rates are higher with PSA than with
DRE and highest with both tests together
PSA
• The presence of prostate disease (prostate cancer, benign prostatic hyperplasia
[BPH], and prostatitis) is the most important factor affecting serum PSA levels.
• PSA is produced by both nonmalignant and malignant epithelial cells and is prostate-
specific and not prostate cancer-specific.
• The level of PSA in blood is strongly associated with the risk and outcome of
prostate cancer
• Use of PSA increases the detection of prostate cancers that are more likely to be
organ-confined when compared with detection without PSA
• Future risk of prostate cancer and the chance of finding cancer on a prostate biopsy
increase incrementally with the serum PSA level
• AUA recommends shared decision-making considering PSA based screening for
men age 55-69. Outside this age range， PSA-based
• screening as a routine test was not recommended based on the available evidence.
Key Points: PSA
• Most prostate cancer arises as clinically nonpalpable (stage T1c) disease with PSA
between 2.5 & 10 ng/mL
• The serum half-life of PSA, calculated after removal of all prostate tissue, is 2 to 3
days.
• Finasteride & Dutasteride used for treatment of BPH have been shown to lower PSA
levels by an average of 50%.
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 • The role for % PSA is more applicable to PSA levels less than 10 ng/mL because the
positive predictive rate of total PSA greater than 10 to 20 ng/mL has been
demonstrated to be as high as 80%.
• The combination of DRE & serum PSA is the most useful first- line test for assessing
the risk that prostate cancer is present.
• The presence of prostate disease (prostate cancer, BPH, & prostatitis) is the most
important factor affecting serum levels of PSA.
• PSA increases detection rates of prostate cancer & leads to the detection of prostate
cancers that are more likely to be confined
Prostate Cancer
• Prostate cancer is graded according to the Gleason scoring system. A primary and
secondary score are assigned based on the most common and second most
common histologic patterns.
• Gleason score, preoperative PSA level, and DRE are used to estimate the likelihood
of whether the cancer is localized, locally advanced, or metastatic.
• Prostate cancer with a high Gleason score (8 to 10) or a high PSA level (>20) is
much more likely to have spread, often at a micrometastatic level
• Prostate Cancer
Key Points: Conservative Management
Staging
• Most common site of spread of prostate cancer is the pelvic lymph nodes and bone.
• Radionuclide bone scans (bone scintigraphy) are used to evaluate spread to
osseous sites
• This test is sensitive but relatively nonspecific because areas of increased uptake
are not always related to metastatic disease
• True-positive bone scans are uncommon when the PSA is < 1 0 ng/ mL unless the
tumor is high grade
• TRUS is the imaging technique most frequently used to assess the primarγ tumor,
but its chief use is directing prostate biopsies
• MRI performed with an endorectal coil is superior to CT to detect cancer in the
prostate and to assess local disease extent.
• T 1 -weighted MRI produces a high signal in the periprostatic fat, periprostatic
venous plexus， perivesicular tissues, lymph nodes， and bone marrow.
• T2-weighted MRI demonstrates the internal architecture of the prostate and seminal
vesicles.
• MRI is also useful for the planning of surgery and radiation therapy.
• Multiple treatment options include radical prostatectomy (retropubic, perineal, or
robotic-assisted laparoscopic approaches), brachytherapy, and external-beam
radiation therapy
• For high-risk disease, either non–nerve-sparing surgery or external-beam radiation
therapy plus androgen deprivation may be performed
• Active surveillance has emerged as a safe and viable option for men with anticipated
survival of <10 years, low Gleason score (6), early-stage disease (cT1c), and small
volume disease as determined by biopsy.
• Patients should be monitored closely with digital rectal exam, PSA testing, and
repeat biopsy at 1 to 2 years to assess the possible progression of disease.
• Reserved for men with a life expectancy of less than 10 years & a low-grade prostate
cancer.
• Patients with clinically localized prostate cancer managed with watchful waiting have
significantly higher rates of local cancer progression, metastases, & death from
prostate cancer than do those treated initially with radical prostatectomy
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Radical Prostatectomy
• Radical prostatectomy, still remains the gold standard
• Hormone therapy and chemotherapy are never curative, and not all cancer cells can
be eradicated consistently by radiation or other physical forms of energy.
• Offers the possibility of cure with minimal collateral damage to surrounding tissues.
• Provides a more accurate tumor staging by pathologic examination of the surgical
specimen.
• Treatment failure is more readily identified.
• Risk for erectile dysfunction and urinary incontinence.
• PSA should become undetectable in the blood within 6 weeks.
• PSA remains or becomes detectable after radical prostatectomy; the patient is
considered to have persistent disease.
• PSA failure is usually defined as a value greater than 0.1 or 0.2 ng/mL
Radiation Therapy
• External beam radiotherapy uses gamma radiation beams directed at the prostate &
surrounding tissues through multiple fields.
• Patients with a high PSA level, high Gleason score, or large-volume tumor benefit
from androgen- deprivation therapy in conjunction with radiotherapy.
• Cancer control after radiation therapy has been defined by various criteria, including
a decline in PSA to <0.5 or 1 ng/m L, or “non rising” PSA values, and a negative
biopsy of the prostate 2 years after completion of treatment.
• The current standard definition of biochemical failure (the Phoenix definition) is a rise
in PSA by >2 ng/mL higher than the lowest PSA achieved
• Brachytherapy - radioactive seeds or needles are implanted directly into the prostate
gland to deliver a high dose of radiation to the tumor while possibly sparing the
bladder & the rectum.
• Adjuvant radiotherapy shortly after surgery is most likely to benefit patients with
positive surgical margins or extracapsular tumor extension without seminal vesicle
invasion or lymph node involvement.
Primary Hormone Therapy
• Primary androgen-deprivation therapy may be appropriate for older men, those with
significant medical comorbidities precluding the use of curative therapy, & those who
do not wish to undergo curative therapy.
• Hormone therapy is never curative
• Bilateral orchiectomy or luteinizing hormone–releasing hormone analogs.
• Antiandrogens produce less sexual dysfunction & osteoporosis but have a greater
risk for adverse cardiovascular complications.
Prevention
• Prostate Cancer Prevention Trial (PCPT), 5ARI finasteride, showed a 25% (95%
confidence interval 19–31%) reduction in prevalence of prostate cancer
• Reduction by Dutasteride of Prostate Cancer Events (REDUCE) trial, a 23%
reduction in the 4-year period prevalence was observed (p = .001).
• Selenium and Vitamin E Cancer Prevention Trial (SELECT), which enrolled African-
American men age ≥50 years and others age ≥55 years, showed no difference in
cancer incidence in patients
UROLOGIC TRAUMA
KIDNEY TRAUMA
• More common during blunt trauma, accounting for 90% of injuries to the kidney.
• Any patient with a major deceleration injury, shock, or gross hematuria should
undergo radiographic imaging of the kidneys.
• All patients with penetrating injuries to the flank or abdomen must undergo imaging
unless unstable and requiring immediate exploration.
• Blunt traumatic injuries usually can be managed conservatively, while penetrating
renal injuries usually require exploration
• All grade V vascular injuries should be considered for immediate exploration
• If immediate operative exploration for other injuries is required, renal injury staging
can be performed while in the operating room.
• If concern exists over renal injury or the presence of a retroperitoneal hematoma, a
single-shot, 10-minute delayed intravenous pyelogram (IVP) (2 mL/kg contrast)
is useful at assessing the presence of two functional kidneys and extent of injury
ETIOLOGY
• Motor vehicle accidents, falls from heights, and assaults contribute to the majority of
blunt renal trauma.
• Direct transmission of kinetic energy and rapid deceleration forces places the
kidneys at risk.
• The most important information to obtain in the history of the injury is the extent of
deceleration involved in high-velocity impact trauma.
• Penetrating renal injuries most often come from gunshot and stab wounds
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HEMATURIA CT SCAN
• The best indicators of significant urinary system injury include the presence of • Findings on CT that raise suspicion for major injury are
microscopic (>5 RBCs/HPF or positive dipstick finding) or gross hematuria
(1) medial hematoma, suggesting vascular injury;
and hypotension (systolic blood pressure <90 mm Hg).
(2) medial urinary extravasation, suggesting renal pelvis or UPJ avulsion injury; and
(3) lack of contrast enhancement of the parenchyma, suggesting arterial injury.

URETERAL INJURIES

• Any penetrating trauma involving the retroperitoneum should undergo evaluation with
intraoperative inspection, IVP, or CT urogram.
• A retrograde pyelogram (RGP) is the most sensitive test for ureteral injury, and a
stent can be placed if a partial transection is observed.
• The ureter also is frequently injured intraoperatively.
• Endoscopic procedures such as ureteroscopy also can lead to ureteral injury such as
perforation and avulsion.

IMAGING STUDIES

• Contrast-enhanced computed tomography (CT) is the gold standard for

genitourinary imaging in renal trauma
• CT provides the most definitive staging information:
• Parenchymal lacerations are clearly defined;
• extravasation of contrast-enhanced urine can easily be detected;
• associated injuries to the bowel, pancreas, liver, spleen, and other organs can be
identified;
• and the degree of retroperitoneal bleeding can be assessed by the size and
dimensions of the retroperitoneal hematoma

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URINARY BLADDER
• The most common associated injury is pelvic fracture, which is associated with 83%
to 95% of bladder injuries
• Sudden force applied to a full bladder may result in a rapid rise in intravesical
pressures and lead to rupture without pelvic fracture.
• Obstetric and gynecologic complications are the most common causes of bladder
injuries during open surgery
• CLINICAL SX INCLUDES Pronounced nonspecific symptoms such as suprapubic
pain combined with inability to void.
• Physical signs include suprapubic tenderness, lower abdominal bruising, muscle
guarding and rigidity, and diminished bowel sounds.
• Immediate catheterization should be performed when blunt bladder rupture is
suspected because the most reliable indicator is gross hematuria, which is present in
nearly all cases
Key Points: Clinical Indicators of Bladder Injury
• Suprapubic pain or tenderness
• Free intraperitoneal fluid on CT or ultrasound examination
• Inability to void or low urine output
• Clots in urine or clots noted in bladder on CT
• Enlarged scrotum with ecchymosis
• Abdominal distention or ileus
URINARY BLADDER INJURIES
• Diagnosis should be entertained for any lower abdominal or pelvic trauma. Nearly all
patients present with gross hematuria
• Radiographic evaluation begins with either a fluoroscopic or CT cystogram.
• A preset amount can be instilled, which is typically approximately 300 to 400 mL in
adults. The bladder can be filled under gravity by raising the Foley catheter to 15 cm
above the pubic ramus. The contrast material should be allowed to fill to the natural
capacity of the bladder.
• It is important to have a post drainage film to assess for persistent contrast, which
may indicate a rupture.
• Extraperitoneal bladder injuries can typically be managed with catheter drainage for
7 to 10 days.
• If intraoperative exploration is to occur for other injuries, repair can be performed at
that time
• Intraperitoneal bladder injuries should be explored immediately and repaired.
• All penetrating or intraperitoneal injuries resulting from external trauma should be
managed by immediate operative repair
RADIOGRAPHIC IMAGING
• After blunt external trauma the absolute indication for immediate cystography is
gross hematuria associated with pelvic fracture — approximately 29% of patients
presenting with this combination of findings have bladder rupture
• Retrograde or stress cystography is nearly 100% accurate for bladder injury if
performed appropriately.
• A dense, flame-shaped collection of contrast material in the pelvis is characteristic of
extraperitoneal extravasation
• Intraperitoneal extravasation is identified when contrast material outlines loops of
bowel and/or the lower lateral portion of the peritoneal cavity.
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URETHRA
URETHRAL INJURIES
• Urethral injuries can be divided by anterior (penile and bulbar urethra) and posterior
(membranous and prostatic) location.
• Any patient with blunt pelvic trauma, blood present at the urethral meatus, hematuria,
inability to void, or perineal hematoma should be considered to have a urethral injury
until proven otherwise.
• Typically occur in conjunction with multisystem trauma from vehicular accidents,
falls, or industrial accidents.
• Fracture of the anterior pelvic ring or pubic diastasis are almost always present when
urethral disruption is encountered, and a greater degree of displacement has been
correlated to a higher risk of urethral injury
• “Straddle fractures” involving all four pubic rami and fractures resulting in
both vertical and rotational pelvic instability are associated with the highest
risk of urologic injury
• Anterior injuries often are related to blunt straddle injuries and penetrating trauma.
• Posterior urethral injuries usually result from pelvic crush injuries and shearing forces
causing a prostatomembranous disruption.
DIAGNOSIS
• Urethral disruption is heralded by the triad of blood at the meatus, inability to urinate,
and palpably full bladder.
• Females may also develop proximal urethral avulsion injuries; they present with
vulvar edema and blood at the vaginal introitus
• Retrograde urethrography (RUG).
• Patient in an oblique position and a 12F catheter placed in the urethral meatus.
• 30 mL of contrast is instilled while an x-ray is obtained during filling.
• Direct inspection by urethroscopy is suggested in lieu of urethrography in females
with suspected urethral injury
INITIAL MANAGEMENT
• Contusions & incomplete injuries can be treated with urethral catheter diversion
alone.
• Incomplete urethral tears are best treated by stenting with a urethral catheter.
• When the urethral catheter is removed after 4 to 6 weeks, it is imperative to retain a
suprapubic catheter because many patients will, despite realignment, develop
posterior urethral stenosis
• Immediate suprapubic tube placement remains the standard of care in men with
posterior urethral injuries.
ANTERIOR URETHRAL INJURIES
• The majority occur after straddle injury and involve the bulbar urethra, which is
susceptible to compressive injury because of its fixed location beneath the pubis
• Clinical signs of anterior urethral injuries include blood at the meatus, perineal
hematoma, gross hematuria, and urinary retention.
STRICTURE FORMATION
• After injury, allow adequate time for healing and provide for drainage of urine away
from the site.
• Strictures occur in the spongy urethra because the urethral lining itself is very thin
and easily injured.
• This allows an irreversible diffuse fibrous reaction in the vascular tissue of the corpus
spongiosum, the spaces of which become filled during urination.
• The contraction of this scar produces the stricture.
TESTIS
TESTICULAR INJURIES
• Testicular injury most commonly occurs with blunt injuries when the testicle is forcibly
compressed against the thigh or pubic bone with enough force to rupture the tunica
albuginea.
• Ultrasound is the preferred modality for staging the extent of injury.
• Blunt injury (usually the result of assault, sports-related events, and motor vehicle
accidents) can result in rupture of the tunica albuginea, contusion, hematoma,
dislocation, or torsion of the testis
• Penetrating injuries due to firearms, explosions, or impalement
DIAGNOSIS
• Most patients complain of exquisite scrotal pain and nausea.
• Swelling and ecchymosis are variable, and the degree of hematoma may not
correlate with the severity of testicular injury; absence does not entirely rule out
testicular rupture, and contusion without fracture can present as significant bleeding.
• Concomitant urethral injury should be suspected and evaluated when examination
reveals blood at the meatus or if the mechanism of injury or hematuria suggests this
possibility
 • Ultrasonography can be helpful to assess the integrity and vascularity of the testis in
equivocal cases
• Ultrasound findings suggestive of testicular fracture include a heterogeneous echo
pattern of the testicular parenchyma and disruption of the tunica albuginea
• Ultrasonography may assist in detection of testicular fracture or hematoma; a normal
or equivocal ultrasound study should not delay surgical exploration when PE findings
suggest testicular damage; definitive diagnosis is often made in the operating room
MANAGEMENT
• Early exploration and repair of testicular injury is associated with increased testicular
salvage, reduced convalescence and disability, faster return to normal activities, and
preservation of fertility and hormonal function
• The goal of surgery is to salvage as much parenchyma as possible and to avoid
delayed complications such as ischemic atrophy or abscess formation.
• A ruptured tunica albuginea can be repaired primarily, and nonviable parenchyma
may need to be débrided.
• Penetrating trauma, immediate exploration is recommended for accurate staging and
repair.
• Testicular salvage rates exceed 90% with exploration and repair within 3 days of
injury versus orchiectomy rates threefold to eightfold higher with conservative
management and delayed surgery
• Testicular salvage rates with conservative management are as low as 33%, with
delayed orchiectomy rates between 21% and 55%
PENIS
• Buck’s fascia is disrupted, swelling and ecchymosis can be noted throughout the
perineum ("butterfly sign").
• DX AND IMAGING:
• Intraoperative flexible cystoscopy is now performed routinely just before catheter
placement at the time of penile exploration when urethral injury is suspected
• The typical history and clinical presentation of fractured penis usually make
adjunctive imaging studies unnecessary
MANAGEMENT
• Exploration by a circumcising (degloving) incision and repair of the defect offers the
best chance at avoiding permanent ED and penile deformity while also minimizing
the risk of infection.
• A retrograde urethrogram should be performed to rule out urethral injury at the time
of surgery.
• A Foley catheter is left in place for several days after surgery.
GUNSHOT AND PENETRATING INJURIES
• Treatment principles include immediate exploration, copious irrigation, excision of
foreign matter, antibiotic prophylaxis, and surgical closure.
• Retrograde urethrography should be considered in any patient with penetrating injury
to the penis, especially with high-velocity missile injuries, blood at the meatus, or
difficulty voiding and when the trajectory of the bullet was near the urethra
• Urethral injuries due to penetrating trauma should be closed primarily by use of
standard urethroplasty principles whenever possible
UROLOGIC EMERGENCIES
• Acute Urinary Retention
• Testicular Torsion
• Fournier’s Gangrene
• Priapism
• Paraphimosis
• Emphysematous Pyelonephritis
ACUTE URINARY RETENTION
• It most commonly occurs in men with benign prostatic enlargement (BPE).
• Other chronic causes of poor bladder emptying, such as diabetic neuropathy,
urethral stricture, multiple sclerosis, or Parkinson’s disease, can result in episodes of
complete urinary retention, often when the bladder becomes overdistended.
VESICAL PAIN
• Vesical pain is usually produced either by overdistention of the bladder as a result of
acute urinary retention
• Patients with slowly progressive urinary obstruction and bladder distention (e.g.,
diabetics with a flaccid neurogenic bladder) frequently have no pain at all despite
residual urine volumes over 1L
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INCONTINENCE
• Urgency incontinence is the precipitous loss of urine preceded by a strong urge to
void. Commonly observed in advanced bladder outlet obstruction with secondary
loss of bladder compliance.
• Overflow urinary incontinence, is secondary to advanced urinary retention and high
residual urine volumes. In these patients, the bladder is chronically distended and
never empties completely. Urine may dribble out in small amounts as the bladder
overflows.
SEPSIS
• When associated with urinary obstruction, fever and chills may portend septicemia
and necessitate emergency treatment to relieve obstruction.
PHYSICAL EXAMINATION
• Percussion is better than palpation for diagnosing a distended bladder.
• The examiner begins by percussing immediately above the symphysis pubis and
continuing cephalad until there is a change in pitch from dull to resonant
MANAGEMENT
• Treatment should include placement of a urethral catheter as quickly as possible.
• A common mistake is to use a smaller catheter to bypass the enlarged prostate.
• A larger (18F to 20F) catheter is less flexible and is more likely to push into the
bladder rather than curl in the prostatic urethra.
• A urinalysis should be checked because a poorly emptying bladder is prone to
infection.
• Renal function also should be assessed for those in AUR by checking the creatinine
level.
• An elevated creatinine level suggests that AUR has resulted in renal dysfunction,
and these patients are at risk for post obstructive diuresis.
POST OBSTRUCTIVE DIURESIS
• Fluid and electrolytes must be replaced if the urine output exceeds 200 mL/h,
especially if hemodynamic instability or electrolyte imbalances are seen.
• 0.5 mL of 0.45 normal saline for every 1 mL of urine output above 200 mL in 1 hour
TESTICULAR TORSION
• Usually in neonates or adolescent males.
• The blood supply to the testicle is compromised due to twisting of the spermatic cord
within the tunica vaginalis, resulting in ischemia to the epididymis and the testis.
• Risk factors for torsion include undescended testis, testicular tumor, and a “bell-
clapper” deformity—poor gubernacular fixation of the testicles to the scrotal wall.
• Sudden onset of pain at a distinct point in time, with subsequent swelling.
• PE may demonstrate a swollen, asymmetric scrotum with a tender, high-riding
testicle.
• The diagnosis is made by clinical history and examination, but can be supported by a
Doppler ultrasound, which typically shows decreased intratesticular blood flow
relative to the contralateral testis.
• MANAGEMENT: More than 80% of testes can be salvaged if surgery is performed
within 6 hours; this rate decreases to <20% as time lapses beyond 12 hours
Key Points: Testicular Torsion
• The anatomic abnormality predisposing to torsion of the spermatic cord is the bell-
clapper deformity & occurs in about 12% of males.
• Findings most suggestive of spermatic cord torsion include puberty, absent
cremasteric reflex, short duration (<6 hours) of pain, & reduced or absent blood flow
&/or a visible spermatic cord twist on ultrasound imaging.
• Intrascrotal fixation of the testis must be performed bilaterally because a contralateral
bell-clapper deformity usually exists & may lead to metachronous torsion.
FOURNIER’S GANGRENE
• Necrotizing fasciitis of the male genitalia and perineum that can be rapidly
progressing and fatal if not treated promptly. The mortality rate has been reported to
be as high as 30% to 40%.
• Risk factors for Fournier’s gangrene include urethral strictures, perirectal abscesses,
poor perineal hygiene, diabetes, cancer, human immunodeficiency virus (HIV), and
other immunocompromised states.
• The infection spreads along the dartos, Scarpa’s, and Colles’ fascias.
• Clinical signs include fevers, perineal and scrotal pain, and associated indurated
tissue.
• The diagnosis is largely made on clinical suspicion, and significantly less often made
on laboratory or radiographic findings.
• Classically, the patient describes pain out of proportion to the physical findings.
• In the genital region, most cases of FG are caused by mixed bacterial flora, which
include gram-positive, gram-negative, and anaerobic bacteria.
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 • The hallmark of FG is a rapid progression from the signs and symptoms of cellulitis MANAGEMENT
to blister formation and foul-smelling necrotic lesions
• Initial management can include oral agents such as pseudoephedrine or baclofen,
• Diagnosis of FG is a surgical emergency as progression from genitalia to perineum
but more aggressive measures usually are necessary to achieve rapid
to abdominal wall may occur extremely rapidly (often within hours)
detumescence.
• Skin may also have a grayish cast or fetid odor uncharacteristic of uncomplicated
• Insertion of a large-gauge needle (18-gauge) into the lateral aspect of one corporal
genital cellulitis
body allows thorough aspiration and irrigation of both corporal bodies because of
MANAGEMENT widely communicating channels.
• Injection of phenylephrine (up to 200 mg in 20 mL normal saline) into the corporal
• Prompt débridement of nonviable tissue and broad spectrum antibiotics are bodies may be required.
necessary to prevent further spread
• A surgical shunt is sometimes necessary to resolve the episode.
• Because the testes have a separate blood supply, they are usually not threatened
• Distal shunts should be performed first, because they can be done quickly in the
and do not need to be removed.
emergency room with a True-Cut needle (Winter shunt).
• They may be tucked subcutaneously into the thigh ("thigh pouch") to ease
• If this fails, an operative distal shunt can be performed (Al-Ghorab).
postoperative management.
• Proximal shunts such as Grayhack (corporal-saphenous vein) or Quackel (proximal
• Patients frequently require return trips to the operating room for further débridement. cavernosumspongiosum) shunts may be required in refractory cases.
PRIAPISM

• Priapism is a persistent erection for greater than 4 hours unrelated to sexual

stimulation.
• The most common type—low-flow/ischemic priapism—is a medical emergency.
• On examination, the penis is very tender, and both cavernosal bodies will be rigid
while the glans will be flaccid. Priapism is essentially a compartment syndrome.
• With prolonged erection (priapism), the sustained decrease in arterial inflow
ultimately causes tissue hypoxia, acidosis, and edema and results in long-term
fibrosis and impotence, and sometimes frank necrosis.
• Persistent painful erection
• Corporal bodies are firm but glans are not

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PARAPHIMOSIS
• When foreskin is retracted for prolonged periods, constriction of the glans penis may
ensue.
• Delay can be catastrophic as penile necrosis may occur due to ischemia
• It is useful to apply firm pressure to the edematous distal penis for several minutes.
Although painful, this reduction in penile edema can be the key to success.
• With the fingers pulling the constricting band distally, the thumbs can push the glans
penis back into normal location.
• If the foreskin cannot be manually reduced, surgical intervention is required
EMPHYSEMATOUS PYELONEPHRITIS
• Emphysematous pyelonephritis is a life-threatening infection that results from
complicated pyelonephritis by gas-producing organisms.
• It is an acute necrotizing infection of the kidney that occurs predominantly in diabetic
patients.
• Patients frequently present with sepsis and ketoacidosis.
• Escherichia coli appears to be the most frequent organism responsible for this
infection.
• Usual clinical presentation is severe, acute pyelonephritis
• Almost all patients display the classic triad of fever, vomiting, and flank pain.
• Pneumaturia is absent unless the infection involves the collecting system.
DIAGNOSIS
• CT is the imaging procedure of choice in defining the extent of the emphysematous
process and guiding management
• Absence of fluid in CT images or the presence of streaky or mottled gas with or
without bubbly and loculated gas appears to be associated with rapid destruction of
renal parenchyma and a 50% to 60% mortality rate
MANAGEMENT
• Those with gas confined to the parenchyma frequently can be managed
conservatively with placement of a nephrostomy tube to allow drainage of purulent
material.
• Patients with extensive involvement of the perirenal tissue may not respond to
conservative management, and strong consideration should be given to expeditious
nephrectomy, particularly if the patient is displaying signs of sepsis.
• Emphysematous pyelonephritis is a surgical emergency.
• Most patients are septic, and fluid resuscitation and broad-spectrum antimicrobial
therapy are essential.
• If the affected kidney is nonfunctioning and not obstructed, nephrectomy should be
performed.
• If a kidney is obstructed, catheter drainage must be instituted. If the patient’s
condition improves, nephrectomy may be deferred pending a complete urologic
evaluation.
UROLOGIC INFECTIONS
• Cystitis
• Pyelonephritis
• Prostatitis
• Epididymo-orchitis
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CYSTITIS
• Bacterial cystitis is acute in onset.
• The typical symptoms of cystitis are dysuria， urinary frequency, and urgency.
• Nocturia, hesitancy, suprapubic discomfort， and gross hematuria are often noted
as well
• Among women presenting with dysuria, the probability of bacterial cystitis is ∼50%.
• This figure rises to >90% if four criteria are fulfilled: dysuria and frequency without
vaginal discharge or irritation
PYELONEPHRITIS
• In women a urinalysis that is positive for pyuria, bacteriuria, or hematuria, or a
combination, should provide sufficient documentation of UTI and a urine culture
may be omitted
TREATMENT
• Approximately 90% of women are asymptomatic within 72 hours after
initiating antimicrobial therapy
• UTIs in most men should be considered complicated until proven otherwise
• Approximately 50% of men with UTIs have a significant abnormality
• 3-day therapy is the preferred regimen for uncomplicated cystitis in women
• 3-day therapy has been associated with cure rates similar to longer courses
of therapy
• 7-day therapy is the preferred regimen in complicated cystitis in men

• Bacterial infection of the kidney that usually manifests itself by fever and flank
tenderness.
• Pyelonephritis is one of the most common diseases of the kidney and is defined as
inflammation affecting the tubules, interstitium, and renal pelvis
• Attributed to ascending bacteria along the path of the ureters.
• The fever of pyelonephritis typically exhibits a high spiking "picket-fence" pattern and
resolves over 72 h of therapy
• Pyelonephritis can also be complicated by intraparenchymal abscess formation;
should be suspected when a patient has continued fever and/or bacteremia despite
antibacterial therapy.
• Pyelonephritis can result in renal scarring that is accelerated in the setting of urinary
obstruction.
• Emphysematous pyelonephritis is a particularly severe form of the disease that is
associated with the production of gas in renal and perinephric tissues and occurs
almost exclusively in diabetic patients. Mortality rates - 30%
• Xanthogranulomatous pyelonephritis occurs when chronic urinary obstruction (often
DIAGNOSIS by staghorn calculi) ，together with chronic infection， leads to suppurative
destruction of renal tissue
• Urinalysis - leukocyte esterase is a marker of inflammation, and nitrites are
• ACUTE PYELONEPHRITIS- On physical examination there often is tenderness to
formed from bacterial reduction of nitrates.
deep palpation in the costovertebral angle.
• Risk factors include female gender, urinary instrumentation, urinary obstruction,
diabetes, and neurologic bladder dysfunction.

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 RENAL ABSCESS

• Pyelonephritis can develop into an abscess that can be located within the renal
parenchyma (renal abscess) or between the capsule and Gerota’s fascia
(perinephric abscess).
• Any patient who is not properly responding to antibiotic therapy after 72 hours
should undergo CT imaging to rule out an abscess or obstruction.
• Treatment consists of broad-spectrum IV antibiotics and percutaneous drainage.
LAB DX

• Urinalysis usually reveals numerous WBCs, often in clumps, and bacterial rods or
chains of cocci.
• The presence of large amounts of granular or leukocyte casts in the urinary sediment
is suggestive of acute pyelonephritis.
Renal Ultrasonography and Computed Tomography

• Evaluate patients initially for complicated UTIs or factors or to reevaluate patients

who do not respond after 72 hours of therapy.
• Ultrasonography and CT show renal enlargement, hypoechoic or attenuated
parenchyma, and a compressed collecting system
MNGT

• Fluoroquinolones are the first-line therapy for acute uncomplicated pyelonephritis

• Combinations of a ß-Iactam and a ß-Iactamase inhibitor or imipenem-cilastatin can
be used in patients with more complicated histories, previous episodes of
pyelonephritis, or recent urinary tract manipulations;
• In general，the treatment of such patients should be guided by urine culture results.

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PREVENTION

• Antimicrobial prophylaxis
• Antimicrobial prophylaxis can be given continuously (daily, weekly) for longer periods
of time (3-6 months), or as a single post-coital dose.
PROSTATITIS

ACUTE PROSTATITIS

• Acute prostatitis is a bacterial infection in the prostate gland

• Patients present with fever, dysuria, and perineal or back discomfort.
CHRONIC PROSTATITIS
• A DRE may indicate an indurated and tender gland.
• Patients require a 4- to 6-week course of antibiotic therapy, typically a
fluoroquinolone.
• Those who continue to have no improvement after 48 hours should be considered for
imaging to rule out a prostatic abscess.
• Chronic prostatitis presents with continued lower urinary tract symptoms and pelvic
pain.
• Chronic prostatitis may be bacterial or nonbacterial, which can be distinguished by
culturing pre- and post-prostatic massage urine.
• The bacterial form is a frequent cause of recurrent urinary tract infections in men
and can be treated with a prolonged course of antibiotics.
• Chronic nonbacterial prostatitis does not respond to antibiotics or most other
medications.
• Biofeedback, physical therapy, and other non–prostate-specific treatments may be
effective in the treatment of this challenging clinical entity

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Lower Urinary Tract Culture Technique
• The two-glass pre- and post-massage test is a simple, useful screen for inflammation
and infection of the lower urinary tract in patients presenting with chronic prostatitis.
PROSTATIC MASSAGE
• Evidence for a role of repetitive prostatic massage as an adjunct in the management
of chronic prostatitis is at most “soft” but could be considered as part of multimodal
therapy in selected patients.
• Frequent ejaculation may achieve the same function as prostatic massage.
EPIDIDYMO-ORCHITIS
• Result of bacterial infection originating in the urinary tract
• Unilateral painful swelling of the epididymis and/or testis, often with fever.
• The scrotum may be erythematous on the side of involvement. The white blood cell
(WBC) count often is elevated.
• An ultrasound may provide supporting evidence such as increased blood flow to the
epididymis. A reactive hydrocele may be present.
• Intratesticular infection can result in ischemic orchitis, and reduced testicular blood
flow can be seen on ultrasound.
ORCHITIS
• Most cases of orchitis, particularly bacterial, occur secondary to local spread of an
ipsilateral epididymitis and are referred to as epididymo-orchitis.
• UTIs are usually the underlying source in boys and elderly men.
• In young sexually active men, sexually transmitted diseases are often responsible
DIAGNOSIS
• History discloses a recent onset of testicular pain, often associated with abdominal
discomfort, nausea, and vomiting.
• These symptoms may be preceded by symptoms of parotitis in boys or young men
(Viral – Mumps), by UTIs in boys or elderly men, or alternatively by symptoms of a
sexually transmitted disease in sexually active men.
P/E
• The skin of the involved hemiscrotum is erythematous and edematous, and the testis
is quite tender to palpation or can be associated with a transilluminating hydrocele.
• The patient should be clinically assessed for prostatitis and urethritis.
MNGT
• General principles of therapy include bed rest, scrotal support, hydration,
antipyretics, anti-inflammatory agents, and analgesics.
• Antibiotic therapy (specific for UTI, prostatitis, or sexually transmitted diseases)
should be employed for infectious orchitis and is ideally based on culture and
sensitivity testing but may be based on microscopic or Gram stain results
• Treatment is with oral antibiotics.
• Hospitalization and parenteral antibiotics are required if the patient has high fevers or
significantly elevated WBC or is hemodynamic unstable
• Tunica albuginea is non-compliant – elevated pressures can result in ischemic
necrosis of the parenchyma
• Antimicrobials should be selected on the empirical basis
• in young, sexually active men, C. trachomatis is usually causative,
• In older men, with BPH or other micturition disturbances, the most common
uropathogens are involved
• Fluoroquinolones, preferably those with activity against C. trachomatis (e.g. ofloxacin
and levofloxacin), should be the drugs of first choice, because of their broad
antibacterial spectra and their favorable penetration into the tissues of the urogenital
tract.
• If C. trachomatis has been detected as an etiological agent, treatment could also be
continued with doxycycline, 200 mg/day, for at least 2 weeks.
OBSTRUCTIVE UROPATHY
• Hydronephrosis is the dilation of the renal pelvis or calyces.
• Obstructive uropathy refers to the functional or anatomic obstruction of urinary flow
at any level of the urinary tract.
• Obstructive nephropathy is present when the obstruction causes functional or
anatomic renal damage.
SYMPTOM
• Pain secondary to stretching of the urinary collecting system.
• The pain produced by ureteral obstruction is typically colicky in nature.
• Hematuria in adults, should be regarded as a symptom of urologic malignancy
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CLINICAL IMPLICATIONS
• Hallmark of partial or complete upper urinary tract obstruction is
hydroureteronephrosis (HN), with the ureteral dilation extending to the level of the
obstruction
• In the acute setting, the degree of HN does not necessarily correlate with the degree
of obstruction, as it may take time for severe HN to develop
• Serum creatinine may be elevated, but the contralateral kidney will compensate so
serum chemistries may not indicate renal impairment
• Partial obstruction may result in permanent loss of function on the affected side if not
POST-OBSTRUCTIVE DIURESIS
alleviated within several weeks (4 weeks).
• Complete occlusion can cause permanent dysfunction within 2 weeks
DX IMAGING
• Renal ultrasonography is a mainstay in the evaluation of suspected urinary tract
obstruction.
• Renal parenchymal thickness can be measured readily, and cortical thinning may be
indicative of chronic obstruction.
• The renal pelvis and calyces can be imaged, and dilatation is readily identifiable.
• Excretory Urogram
• Acute urinary obstruction may be inferred from the functional abnormality of a
delayed nephrogram and pyelogram on the affected side or sides.
• Delayed images may then ultimately reveal the anatomic level of obstruction and
LOWER URINARY TRACT OBSTRUCTION
perhaps causation.
• Nuclear Renography
• It provides a functional assessment without exposure to iodinated contrast material.
• The glomerular agent technetium (Tc) 99m DTPA and the tubular agent 99mTc-
MAG3 are most commonly used in the evaluation of obstruction BPH
• Unenhanced CT is the most sensitive method of detecting urinary tract stones and is
currently the preferred imaging modality for evaluating most patients with suspected
renal colic
HYPERTENSION
• Hypertension can be precipitated by ureteral obstruction and is a well-recognized
sequela of BUO or obstruction of a solitary kidney.
• Patients with BUO are typically volume overloaded.
• Renin activation and resultant angiotensin II generation have been demonstrated in
animal models of UUO and may be the mechanism by which new-onset
hypertension occurs in this setting
RENAL DRAINAGE
• Minimally invasive endourologic and interventional radiologic techniques allow
prompt drainage of the obstructed kidney.
• DJ Stenting or Percutaneous Tube Nephrostomy
• These measures may allow temporary drainage until a definitive procedure is
performed.
• Following the relief of urinary tract obstruction, a period of significant polyuria may
ensue.
• Urine outputs of 200 mL/hr or greater may be encountered.
• Mainly after relief of BUO or obstruction of a solitary kidney
• Mainly physiologic
• Patients susceptible to this phenomenon typically have signs of fluid overload
including edema, congestive heart failure, or hypertension
• Subjects in whom BUO or UUO in a solitary kidney is relieved should be monitored
for a post obstructive diuresis.
• Serum electrolytes, magnesium, blood urea nitrogen (BUN), and creatinine should
be checked daily
• Benign Prostatic Hyperplasia
• Urethral Stricture
• Symptoms, arising from lower urinary tract dysfunction, are subdivided into:
• obstructive symptoms (urinary hesitancy, straining， weak stream, terminal dribbling,
prolonged voiding， incomplete emptying) and
• irritative Symptoms (urinary frequency， urgency， nocturia, urge incontinence,
small voided volumes)
• Benign prostatic hyperplasia (BPH) is a pathologic process that contributes to lower
urinary tract symptoms (LUTS) in aging men.
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 • Prostatic hyperplasia increases urethral resistance, resulting in compensatory
changes in bladder function.
• Obstruction-induced changes in detrusor function, compounded by age related
changes in both bladder and nervous system function, lead to urinary frequency,
urgency, and nocturia, the most bothersome BPH-related complaints.
• The size of the prostate does not correlate with the degree of obstruction.
• Medical treatment of BPH is usually the first step.
• α-Blockers act on α receptors in the smooth muscle of the prostate and decrease its
tone.
• 5α-Reductase inhibitors, which block the conversion of testosterone to the more
potent Z, shrink the prostate over several months.
• Transurethral resection of the prostate is the mainstay of endoscopic surgical BPH
treatment.
• When the prostate is very enlarged (>100 g), open surgical procedures can be used.
• Suprapubic (simple) prostatectomy involves enucleation of the majority of the
prostate, but the capsule is left so there is minimal effect on continence and erectile
function.
IRRITATIVE SX – Frequency, urgency, nocturia
OBSTRUCTIVE SX- weak stream. intermittency, straining, incomplete emptying URETHRAL STRICTURE

DIAGNOSIS
• Uroflowmetry can identify those with normal flow rates who are unlikely to benefit
from treatment, and bladder ultrasound can identify those with high postvoid
residuals who may need intervention.
OPEN PROSTATECTOMY
• Considered when the obstructive tissue is estimated to weigh more than 75 g.
• If sizable bladder diverticula justify removal, suprapubic prostatectomy and
diverticulectomy should be performed Concurrently
• Large bladder calculi that are not amenable to easy transurethral fragmentation
may also be removed during the open procedure.
• Considered when a patient presents with ankylosis of the hip or other orthopedic
conditions that prevent proper positioning for TURP.
• In men with recurrent or complex urethral conditions, such as urethral stricture or
previous hypospadias repair, to avoid the urethral trauma associated with TURP.
• Inguinal hernia with an enlarged prostate suggests an open procedure, because
the hernia may be repaired via the same lower abdominal incision
• Anterior urethral disease, or a scarring process involving the spongy erectile tissue of
the corpus spongiosum (spongiofibrosis)
• Posterior urethral stricture is an obliterative process in the posterior urethra that has
resulted in fibrosis and is generally the effect of distraction in that area caused by
either trauma or radical prostatectomy
DILATION
• Urethral dilation is the oldest and simplest treatment of urethral stricture disease, and
for the patient with an epithelial stricture without spongiofibrosis, it may be curative.
• The goal of this treatment, a concept that is frequently forgotten, is to stretch the scar
without producing more scarring.
• The least traumatic method to stretch the urethra is to use soft techniques over
multiple treatment sessions.
INTERNAL URETHROTOMY
• Internal urethrotomy refers to any procedure that opens the stricture by incising it
transurethrally.

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 • The urethrotomy procedure involves incision through the scar to healthy tissue to
allow the scar to expand (release of scar contracture) and the lumen to heal
enlarged.
• Many surgeons have learned to perform internal urethrotomy by making a single
incision at the 12-o’clock position.
EXCISION AND REANASTOMOSIS
• The most dependable technique of anterior urethral reconstruction is the
complete excision of the area of fibrosis, with a primary reanastomosis of the
normal ends of the anterior urethra
PELVIC FRACTURE URETHRAL INJURIES
• Pelvic fracture urethral injuries are the result of blunt pelvic trauma and
accompany about 10% of pelvic fracture injuries.
• In these patients, the placement of an aligning catheter may allow the urethra
to heal virtually unscarred or with an easily managed stenosis.
• When the patient is successful in relaxing to void and the cystogram outlines
the posterior urethra, a simultaneous retrograde urethrogram nicely outlines
the length of the injury defect.
• Primary anastomosis is the goal in all these patients until it is proved
impossible to perform.
• The classic reconstruction consists of a spatulated anastomosis of the
proximal anterior urethra to the apical prostatic urethra.
UPPER URINARY TRACT OBSTRUCTION
• Hallmark of partial or complete upper urinary tract obstruction is
hydroureteronephrosis (HN), with the ureteral dilation extending to the level of the
obstruction
• In the acute setting, the degree of HN does not necessarily correlate with the degree
of obstruction, as it may take time for severe HN to develop
• Serum creatinine may be elevated, but the contralateral kidney will compensate so
serum chemistries may not indicate renal impairment
• Partial obstruction may result in permanent loss of function on the affected side if not
alleviated within several weeks.
• Complete occlusion can cause permanent dysfunction within 2 weeks
• Urolithiasis
• Retroperitoneal Fibrosis
UROLITHIASIS
• Urinary calculi may occur anywhere in the urinary tract.
• Asymptomatic in the renal pelvis or bladder, but they are a very common cause of
symptomatic ureteral obstruction.
• Smaller stones (up to 6 mm) may cause severe symptoms, such as flank pain and
nausea, but typically pass without intervention.
• α-Blockers, which relax the distal ureter, may be given to reduce renal colic.
• Calculi ≥7 mm are more likely to become impacted or to have a prolonged passage
through the ureter
• Intervention at the time of presentation is preferred for larger stones (except in cases
where the calculus is in the very distal ureter) due to the likelihood of repeat
emergency room visits for severe symptoms.
• Calcium oxalate stones are most common (75%); next, are calcium phosphate (
15%)， uric acid (8%)，struvite (1 %)，and cystine (<1%) stones
• CT scans will demonstrate all calculi except those composed of crystalline-excreted
indinavir
• Noncontrast CT scans have become the study of choice to evaluate for urolithiasis.
• Obstructing stones often are temporized with stent placement, which allows proximal
collecting system decompression.
• When urinary infection coexists with an obstructing stone, a stent can be placed, but
a PCN is preferable if the patient demonstrates any instability
• Definitive treatment of renal or ureteral calculi (lithotripsy) is through ureteroscopy,
percutaneous nephrostolithotomy (PCNL), or extracorporeal shock wave lithotripsy
(ESWL)
• Patients with recurrent stones will benefit from examination of stone composition and
24-hour urine metabolic workup to determine the underlying etiology.
• Better hydration is useful for all etiologies
• Most patients will benefit from alkalization of the urine (e.g., potassium citrate)
•
Key Points: Physicochemistry
• Urine must be supersaturated for stones to form.
• Urinary calcium and oxalate are equal contributors to urinary saturation of calcium
oxalate.
• Common calcium stones may originate from subepithelial plaques composed of
calcium apatite that serve as an anchor on which calcium oxalate stones can grow.
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 • The noncrystalline component of stones is matrix, which is composed of a
combination of mucoproteins, proteins, carbohydrates, and urinary inhibitors.
Key Points: Fluid Recommendations

• Patients should be strongly encouraged to consume enough fluids to produce 2 L of

urine per day.
• Water hardness is unlikely to play a significant role in recurrence risk.
• Carbonated water may confer some protective benefit.
• Soda flavored with phosphoric acid may increase stone risk, whereas those with
citric acid may decrease risk.
• Citrus juices (particularly lemon and orange juices) may be a useful adjunct to stone
prevention.
Key Points: Dietary Recommendations

• Randomized studies have confirmed the advantage of a diet with reduced animal
protein (meat) intake.
• A diet high in fruits and vegetables imparts a reduced risk of stone formation than do
those diets high in animal protein.
• Randomized trials have demonstrated a benefit of dietary sodium restriction in both
normal volunteers and stone formers.
Key Points: Role of Dietary Calcium

• Dietary calcium restriction actually increases stone recurrence risk.

• Calcium supplementation is likely safest when taken with meals.
• Calcium citrate appears to be a more “stone-friendly” calcium supplement due to the
additional inhibitor action of citrate.
Key Points: Abbreviated Protocol
for Low-Risk Single Stone Formers

• A complete medical history should be obtained from all stone formers.

• Patients should be screened for medical diseases that predispose to calculi.
• Serum metabolic panel and urinalysis are obtained.
• Urine microscopy for crystals may provide clues to diagnosis.
• Stone analysis may improve the accuracy of further evaluation.
• Basic radiography (plain films) screen for remaining calculi.

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Key Points: Extensive Diagnostic Evaluation
• A complete metabolic evaluation may be obtained as an outpatient.
• Calcium fast/load tests can discriminate between the various forms of hypercalciuria.
• Routine performance of calcium fast/load tests is not required to complete a
metabolic evaluation.
• Potassium citrate can effectively alter the urinary milieu in patients with
hyperuricosuria by decreasing the supersaturation of uric acid and calcium oxalate.
Key Points: Infection Calculi (Struvite)
• Women produce more infection calculi than men.
• The urine pH is usually greater than 6.5 and 7.0.
• Urea-splitting organisms are frequent.
• Infection calculi are the most likely to produce staghorn stones.
• Struvite calculi are best managed with surgical removal rather than chemical
dissolution.
• Recurrent infections (and therefore recurrent calculi) may be avoided with the
use of antibiotic prophylaxis.
Key Points: Oxalate Avoidance

• Avoidance of excess dietary oxalate loading is reasonable and intuitive.

• Vitamin C in large doses may increase the risk of stone recurrence. Doses should
probably be limited to 2 g/day.

Key Points: Use of Stone Analysis to Determine Metabolic Abnormalities

• Stone analysis may obviate the need for a complete metabolic evaluation.
• Stone composition can direct metabolic investigation.
Key Points: Uric Acid–Based Calculi

• Hyperuricosuria may be associated with pure uric acid calculi or calcium oxalate
calculi.
• Patients with gout may be predisposed to uric acid stones.
• Dietary indiscretion (purine gluttony) should always be suspected.
Reversible and Irreversible Injury
Key Points: Hyperuricosuric Calcium Oxalate Nephrolithiasis
• Reversible Changes
• Patients with hyperuricosuria should be instructed to decrease dietary purine intake.
Mild tubular necrosis
• Allopurinol can decrease uric acid production and may be ideal for those patients
with a history of gout. Casts and red blood cells in tubular lumen

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Vacuolar changes of tubular lumen
Mild interstitial edema and hemorrhage
• Irreversible Changes Resulting in Loss of Renal Tissue
Disruption of nephrons
Extensive interstitial edema
Large hematomas of cortex and medulla
Rupture and occlusion of veins and arteries
Fracture of glomerular and peritubular capillaries
RETROPERITONEAL FIBROSIS
• Process resulting in encasement of the ureters, along with the great vessels, in a
dense fibrotic mass
• Many patients present in acute renal failure, and imaging demonstrates medially
displaced ureters with a homogeneous, plaque-like mass in the retroperitoneum.
• Bilateral ureteral stent or PCN placement provides temporary relief of the
obstruction.
• Corticosteroids may be given to reverse the inflammatory process, but surgical
ureterolysis still usually is required to free the ureters from retroperitoneal
encasement.
• They are brought into the peritoneum and wrapped in omentum to prevent re-
entrapment.
• Rare
• fibrotic and inflammatory mass envelops and potentially obstructs retroperitoneal
structures, including either or both ureters.
• appears as a fibrous, whitish plaque that encases the aorta, inferior vena cava, and
their major branches, and also the ureters, other retroperitoneal structures, and, at
times, intraperitoneal structures including the gastrointestinal tract.
• An underlying malignancy should always be considered, because one is reported to
be present in 8% to 10% of such cases
• Patients usually have nonspecific symptoms, which may include back, abdominal, or
flank pain, weight loss, anorexia, and malaise.
• Signs can be similarly nonspecific and include hypertension (in 50%), fever, and
lower extremity edema.
• The classic radiologic findings included medial deviation of extrinsically compressed
ureters with hydronephrosis.
• Hydronephrosis is typically demonstrated on ultrasonography, and there may also be
a smooth, well demarcated, hypoechoic or isoechoic mass anterior to the lumbar or
sacral spine
• Retrograde pyelography typically demonstrates hydronephrosis, with medially
deviated and segmentally narrowed ureters without filling defects
• CT typically reveals a well demarcated retroperitoneal mass, isodense with muscle
on unenhanced studies
• MRI allows superior soft tissue discrimination and can more accurately distinguish
the plaque from the great vessels than unenhanced CT.
TREATMENT
• If there is evidence of obstructive uropathy at presentation, therapy should be first
directed at its correction.
• This may be accomplished with internalized ureteral stents, but percutaneous
nephrostomy may be necessary if stenting is not possible or ineffective.
• Biopsy to exclude malignancy should be performed next. This can be attempted
percutaneously with CT, MRI, or ultrasound guidance.
• The administration of corticosteroids has been used for primary therapy.
• prednisolone administered at an oral dose of 60 mg on alternate days for 2 months,
tapered to 5 mg daily over the next 2 months, dose maintained for 2 years
• Ureterolysis is undertaken if medical therapy fails or if the patient is not a candidate
for medical therapy.
• The ureter may be displaced to a lateral position, brought to an intraperitoneal
location by closing the peritoneum behind it, or wrapped within a sleeve of omentum.
• Ureteral stents can generally be removed 6 to 8 weeks after ureterolysis
PEDIATRIC UROLOGY
1. Ureteropelvic Junction Obstruction
2. Vesicoureteral Reflux
3. Ureteroceles
4. Posterior Urethral Valve
URETEROPELVIC JUNCTION OBSTRUCTION
• UPJ obstruction is the most common cause of significant dilation of the collecting
system in the fetal kidney - 48% of all dilation of the collecting system
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 • UPJ obstruction occurs in neonates due to an adynamic or stenotic segment of
proximal ureter.
• This impairs flow of urine into the ureter, particularly during times of high flow, and
causes dilatation of the collecting system.
• Abnormal lower pole (i.e., accessory) renal arteries may be a secondary cause of
UPJ obstruction by kinking the proximal ureter.
• Seen during childhood and adolescence.
• More commonly in boys
Etiology – Intrinsic
• Typical finding on pyeloplasty is a narrowed segment of the ureter at the UPJ that is
probe patent.
• Result of an interruption in the development of the circular musculature of the UPJ or
an alteration of collagen fibers and composition between and around the muscle
cells.
• The muscle fibers become widely separated and attenuated, leading to a functional
discontinuity of the muscular contractions and ultimately to insufficient emptying.
Etiology – Extrinsic
• An aberrant, accessory, or early-branching lower-pole vessel is the most common
cause of extrinsic UPJ obstruction.
• These vessels pass anteriorly to the UPJ or proximal ureter and contribute to
mechanical obstruction.
• This a major cause of UPJ obstruction in adults.
Presentation and Diagnostic Studies
• Most infants are asymptomatic.
• In the older child, episodic flank or upper abdominal pain, sometimes associated with
nausea and vomiting due to intermittent UPJ obstruction, is a prominent symptom
• Radiographic studies should be performed to determinine both the anatomic site and
the functional significance of an obstruction.
• Excretory urographic findings include delay in function associated with a dilated
pelvicalyceal system
• If the ureter is visualized, it should be of normal caliber
• CT scans provide detailed anatomic and functional information to aid in diagnosis of
UPJ obstruction.
• In neonates and infants, the diagnosis of UPJ obstruction has generally been
suggested either by routine performance of maternal ultrasonography or by the
finding of a flank mass.
• Renal ultrasonography is usually the first radiographic study performed.
• Ideally, ultrasonography should be able to visualize dilatation of the collecting system
to help differentiate UPJ obstruction from multicystic kidney and determine the level
of obstruction.
Diagnostic Studies
• Diuretic renography remains a commonly used study for diagnosing both UPJ and
ureteral obstruction because it provides quantitative data regarding differential renal
function and obstruction, even in hydronephrotic renal units.
• Nuclear scans (mercaptoacetyltriglycine or 99mTc diethylene-triamine-penta-acetic
acid) have replaced the IVP as the diagnostic modality of choice.
• Delayed clearance of contrast or radiotracer implies obstruction.
• Retrograde pyelography retains a role for confirmation of the diagnosis and for
demonstration of the exact site and nature of obstruction before repair.
Indications and Options
for Intervention
• the presence of symptoms associated with the obstruction,
• impairment of overall renal function or progressive impairment of ipsilateral function,
• development of stones or infection, or, causal hypertension.
• Primary goal of intervention is relief of symptoms and preservation or improvement of
renal function
MNGT
• Patients with infections or impaired renal function require repair to improve drainage.
• Open dismembered pyeloplasty is considered the gold standard approach,
especially in infants.
• In older children or adults, laparoscopic or robotic approaches for pyeloplasty can
expedite convalescence and diminish postoperative pain.
DISMEMBERED PYELOPLASTY
• The principal reasons for the universal acceptance of the dismembered pyeloplasty
are
• (1) broad applicability, including preservation of lower pole or crossing vessels,
• (2) excision of the pathologic UPJ and appropriate repositioning, and
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 • (3) successful reduction pyeloplasty. Etiology

• Reflux is considered primary if the main reason for it is a fundamental deficiency in

the function of the UVJ antireflux mechanism while remaining factors (bladder and
VESICOURETERAL REFLUX
ureter) remain normal or relatively noncontributory.
• Vesicoureteral reflux (VUR) represents the retrograde flow of urine from the bladder • Secondary reflux, then, implies reflux caused by overwhelming the normal function of
to the upper urinary tract. the UVJ. Bladder dysfunction of a congenital, acquired, or behavioral nature is often
• Its clinical challenges arise from the fact that it is usually asymptomatic. When it is the root cause of secondary reflux.
not, it is responsible for pyelonephritic scarring and can be associated with Radiologic Investigation
congenital renal dysmorphism
• Vesicoureteral reflux (VUR) is the second most common cause of hydronephrosis • Radiographic investigation for VUR has generally been directed to children younger
after UPJ obstruction. than 5 years old, all children with a febrile UTI, and any male with a UTI regardless of
• Up to two thirds of infants presenting with urinary tract infections have VUR. age or fever, unless sexually active.
• Primary reflux is a congenital anomaly caused by insufficient intramural tunneling of
the distal ureter
• The prevalence of reflux was estimated to be approximately 30% for children with
UTI and 17% without infection.
• Reflux may be present in up to 70% of infants who present with UTI
• The incidence of VUR associated with UPJO ranges from 9% to 18%
• High-grade reflux being five times more likely to be associated with UPJO than lower
grades of reflux

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ASSOCIATED ANOMALIES AND CONDITIONS pregnancy.
• The conservative approach includes watchful waiting, intermittent or continuous antibiotic
1. Ureteropelvic Junction Obstruction
prophylaxis, and bladder rehabilitation in those with LUTD.
2. Ureteral Duplication
• Circumcision during early infancy may be considered as part of the conservative approach,
3. Bladder Diverticulum
because it is effective in reducing the risk of infection in normal children.
4. Renal Anomalies
Ureteral Duplication
URETEROCELES
• VUR is the most common abnormality associated with complete ureteral
• A ureterocele is a cystic dilation of the terminal ureter thought to result from a
duplications. The embryologic origin of the duplicated ureter supports the
persistent membrane between the ureteral bud and the urogenital sinus.
observation that reflux occurs most commonly into the lower pole.
• Most patients will have associated genitourinary anomalies such as duplicated
Renal Anomalies collecting systems or an ectopic ureteral location.
• Patients may have hydronephrosis and pyelonephritis.
• The cardinal renal anomalies associated with reflux are multicystic dysplastic kidney • A large, prolapsing ureterocele can cause bladder outlet obstruction
(MCDK) and renal agenesis, and the presence of either condition mandates a • Diagnosis can be confirmed with cystoscopy, VCUG, or IVP.
VCUG.
• Patients with a functioning renal moiety can undergo endoscopic incision of the
Principles of Management ureterocele.
• A ureterocele in a nonfunctioning duplicated system may require a heminephrectomy
• Almost 80% of low-grade and half of grade reflux will resolve spontaneously. to avoid infections.
• The classic approach has been to offer daily low-dose prophylactic antibiotic • Ureteroceles may be seen to represent a version of the ectopic ureter with a cystic
suppression of infections as the first line of treatment under the principle that every dilation of the distal aspect of the ureter that is located either within the bladder or
case of reflux should be offered time to resolve spontaneously, despite grade. spanning the bladder neck and urethra.
• Essential tenants of reflux management as follows:
1. Spontaneous resolution of reflux is very common.
2. High-grade reflux is less likely to resolve spontaneously.
3. Sterile reflux is benign.
4. Extended use of prophylactic antibiotics is benign.
5. Success of (open) surgical correction is very high.
Conservative therapy EAU 2015
The objective of conservative therapy is prevention of febrile UTI. It is based on the
understanding that:
• VUR resolves spontaneously, mostly in young patients with low-grade reflux. However,
spontaneous resolution is low for bilateral high-grade reflux.
• VUR does not damage the kidney when patients are free of infection and have normal LUT
function.
• There is no evidence that small scars can cause hypertension, renal insufficiency or
problems during

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POSTERIOR URETHRAL VALVES

• Posterior urethral valves can be a particularly damaging cause

• of bilateral hydronephrosis in a newborn boy.
• The “valves,” which are tissue folds located in the prostatic urethra, cause bladder
outlet obstruction.
• Diagnosis is established with a VCUG, which may show poor bladder emptying and
a dilated posterior urethra.
• A Foley catheter should be placed in the bladder to decompress the urinary system
in the hopes of facilitating recovery of renal function.
• Treatment involves cystoscopic ablation or resection of the valve.
• Type I. In the most common type, there is a ridge lying on the floor of the urethra,
continuous with the verumontanum, which takes an anterior course and divides into
two forklike processes in the region of the bulbomembranous junction.
• Type II valve as arising from the verumontanum and extending along the posterior
urethral wall toward the bladder neck.
• Type III valves as a membrane lying transversely across the urethra with a small
perforation near its center
VALVE ABLATION

• After successful initial bladder drainage and when the patient’s medical condition has
stabilized, the next step is to permanently destroy the valves.
Cutaneous Vesicostomy

• If the infant is too small to instrument safely for valve ablation, then a cutaneous
vesicostomy can be performed as a temporary measure

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