UROLOGIC

EMERGENCIES

Clinic of General Urology, Oncological and Functional

Head: Prof. Piotr Radziszewski MD. Ph.D.
Types of urologic emergencies

Frequent:
• Renal Colic and Urinary Retention
• Severe Haematuria
Need of prompt surgery:
• Torsion of the testis
• Priapism
• Fournier’s Gangrene
Rare:
• Paraphimosis
 Renal colic

• Sudden ureteral obstruction

• Increase of pressure in the pelvocaliceal system

• Stretching of the pelvocaliceal system and renal

capsule

• Pain
 Renal colic

§ Severe, colic flank pain (radiates to the groin)

§ Painful percussion of the loin

§ Pain on palpation of the upper abdomen

§ Nausea

§ Haematuria – gross or microscopic

§ Increased temperature
Renal colic - differentiation

§ Cholecystitis
§ Appendicitis
§ Perforation of GI tract: stomach and duodenal
ulcer, diverticulae of large intestine
§ Pacreatitis
§ Adnexitis and Ectopic pregnancy
§ Pyelonephritis
§ Neuralgia, lumbalgia
 Renal colic - diagnosis
§ Temperature – simple diagnosis of infected
pyelonephritis
§ Ultrasound – noninvasive method confirming obstruction
in UT
§ Low Dose Non Contrast CT (NCCT) of abdominal and
pelvic cavity – gold standard in renal colic diagnosis,
localization, size and hardness of stone
§ Urine Examination: haematuria, leucocyturia
§ Plain x-ray (KUB) – rarely used, omits nonradiopaque
stones
§ Intravenous pyelography (IVP) - if doubts or surgery
considered; replaced by contrast CT
 Renal colic - NCCT
• Advantages:
- highest sensitivity
and specifity
- size
- localization
- density
• Disadvantages:
- insufficient
information on
pelvicalyceal
system; replaced by
contrast CT
 Renal colic - USG
• Advantages:
- noninvasive
- easy to perform
• Disadvantages:

- visualizes only stones

next to the kidney
and the bladder
- useless in middle
ureter
- undirect diagnosis of
renal colic –
dilatation of
pelvicalyceal system
 Renal colic - KUB
• Advantages:

• Disadvantages:
- same dose as NCCT
- no visualization of
anatomy
- stones can be
mistaken with
vessels
calcifications
 Renal colic - IVP
• Advantages:
- One shot IVP in
trauma surgery
- Rare in renal colic
• Disadvantages:

- if doubts or surgery
considered;
insufficient
information on
pelvicalyceal
system; replaced by
contrast CT
Renal colic – types of treatment
Small stone (<1cm), no infection – medical treatment

Large stone (>1cm), no infection – surgery

Any size, infection – Kidney decompression: Double J

stent or percutaneous nephrostomy + Antibiotics
 Renal colic – medical treatment
• Treating of severe pain:
• NSAID's (diclofenac, ketoprofen)
• Spasmolythic agent (papaverine, drotaverin) i.m. / i.v.
• MET (Medical Expulsion Therapy) - Tamsulozine or any α –
blocker – increases stone free rate
• Antibiotic prophylaxis in case of urine stasis
(fluorochinolone)
• Drink - as much as usual – 2-3L/day
• Move a lot
• Follow-up: USG every week if pyelocaliceal dilatation
disappears
• Maximum time of medical treatment of obstructing stone
is 6 weeks - SURGERY
• In case of FEVER (>38C) go to Emergency Department -
PYELONEPHRITIS
 Renal colic – Pylonephritis
§ Fluids iv.
§ Oxygen
§ Empirical antibiotics iv.
§ Infected urine diversion: PN or DJ catheter
§ Urine culture from infected urine
§ Targeted antibiotics iv.
§ Targeted antibiotics po. after normalization of body
temperature min 3 days without fever
§ Treatment of obstruction after normalization of
infection parameters
Renal colic – types of urine diversion
Percutaneous nephrostomy tube -
https://link.springer.com/chapter/10.1007/978-3-319-14821-2_4

VS.
Renal colic – types of urine diversion

Ureteral double J stent

 ACUTE URINARY RETENTION

Urinary retention is due to a blockage of the flow

of urine out of the body
CAUSES

• Benign prostatic hyperplasia

• Advanced forms of Prostate cancer
• Prostatitis
• Srticture of urethra
• Foreign bodies (stones)
• Clots
• After epidural anesthesia
 ACUTE URINARY RETENTION
SYMPTOMS:
§ Pain in lower abdomen (most common symptom in complete
urine retention)

§ Gross or microscopic haematuria

§ Acute and chronic renal failure
§ Altered voiding
§ Recurrent urinary tract infection (UTI)

§ Gynecologic or abdominal surgery

 ACUTE URINARY RETENTION
CATHETERISATION – FOLEY CATHETER
- lower urinary tract obstruction
- decompression of bladder 500ML/10MIN
- faster decompression = acute bleeding

PERCUTANEOUS NEPHROSTOMY vs. DJ

URETHERAL STENT
- upper urinary tract obstruction in:
- solitary kidney
- bilateral obstruction
 Haematuria
≥ 5 red blood cells (RBCs) per high-power field
3 positive specimens of urine obtained
during last week
§ gross (bloody, brownish, or meat-flush-
colored urine) or microscopic (no visible)

§ symptomatic or asymptomatic
§ transient or persistent
§ solitary or with associated comorbidities
 Gross Haematuria – urologic causes

• Acute cystitis – mostly woman

• Urothelial tumors: mostly bladder cancer
• Kidney Neoplasm
• Locally advanced Prostate cancer
• BPH
• Urinary stones
• Traumas of urinary system on any level
• Postoperative bleeding (NSS, TURP, TURT)
 Haematuria – diagnosis

§ CBC
§ Coagulogram: APTT, PT, INR
§ Urinalysis
§ Electrolytes
§ Blood urea nitrogen (BUN)
§ Creatinine
§ Blood Group in case of massive haemorrhage
§ Urine culture (UTI)
 Gross Haematuria – diagnosis

§ Renal and bladder ultrasonography

§ Spiral CT
§ Voiding cystourethrography
§ Radionuclide studies
§ Endoscopic studies: cystoscopy, ureterorenoscopy

§ IV urography rarely contributes additional information in

the evaluation of hematuria and results in unnecessary
exposure to ionizing radiation
 Gross Haematuria – diagnosis

§ Gross haematuria
 Gross Haematuria – diagnosis

§ Renal and bladder ultrasonography

Bladder Tumor
 Gross Haematuria – diagnosis

§ Endoscopic studies: cystoscopy

Bladder Tumor
 Gross Haematuria – diagnosis

§ Spiral CT

Kidney Tumor
 Gross Haematuria – treatment

Conservative management:
§ check blood morphology – transfusion if Hb < 7,0g/dl
§ Couvelaire catheter - bladder tamponade evacuation
§ 3-way catheter (Difour) continuous irrigation –
tamponade, clotting prevention
§ Cystoscopy
§ TURB - transurethral resection Bladder
§ TURP- transurethral resection Prostate
§ Electrocoagulation, if conservative management is not
successful in bleeding control
§ Embolisation of vessels in bleeding kidney tumor.
 Testicular torsion
l occurs in 17% of males

l bilateral in 40%
l torsion of the spermatic cord structures
l no the blood supply to the torsioned testicle

l urological emergency
l early diagnosis and treatment – the most important in
saving testicle and preserving fertility
l testicular viability decreases significantly after 6 hours
from the onset of symptoms

l fast surgical treatment may prevent further ischemic

damage to the testis.
 Testicular torsion
Intravaginal torsion:

• adolescents

• testis - increased weight after puberty

• cremasteric muscles contraction can rotate

the testicle

Extravaginal torsion:

• neonates

• tunica vaginalis isn't connected to the

gubernaculum

• spermatic cord + tunica vaginalis =

torsioned unit

http://paediatricem.blogspot.com/2015/05/testicular-torsion.html
 Testicular torsion
l Pain and tenderness of testicle

l Swollen testicle

l High position of testis

l Transverse location in scrotum

l Loss of the cremasteric reflex

l Negative Prehn sign (relief of pain with elevation of the

testicle) - predictor of torsion, not enough for diagnosis

l Enlargement and edema of the testicle and scrotum

l Scrotal erythema

l Nausea or vomiting

l Fever (rare)
 Testicular torsion - differentiation

§ Epididymitis, orchitis, epididymo-orchitis

§ Torsion of the appendices
§ Testis tumor
§ Testicular trauma – interview
§ Testicular infarction
§ Hydrocele
§ Scrotal edema
 Testicular torsion - case

• Sudden onset of severe pain of the

scrotum
• Age: < 30 years old
• The testis swollen, the scrotum red, tender
• Ultrasound: normal size epididymis,
enlarged testis, low blood flow in doppler
ultrasound

• But: if there is any doubt, operate the

testis
Testicular torsion - operation
Testicular torsion - operation
 Testicular torsion - treatment
➲ Manual detorsion if successful and confirmed by color
Doppler sonogram with complete resolution of
symptoms - definitive surgical fixation of both testes
➲ Detorsion must be accomplished within 6 hours

SURGERY
• Exploration of scrotum
• First detorsion
• Examination of the testis – check viability of testicles
• Excision if necrotic
• Fixation if viable – nonabsorbable sutures
• The opposite testis should always be fixated
 PRIAPISM

Painful erection lasting within 4-6 hours, despite the absence of both
physical and psychological stimulation
 PRIAPISM

Low-flow priapism (ischemic) - 80-90%

§ Painful
§ Pain may disappear with prolonged priapism
§ Rigid erection
§ Ischemic corpora (dark blood upon corporeal aspiration)
§ No evidence of trauma
High-flow priapism (nonischemic) 10-20%
§ Not painful
§ Episodic manner
§ Adequate arterial flow
§ Well-oxygenated corpora
§ Evidence of trauma: Blunt or penetrating injury to the penis or
perineum (straddle injury is usually the initiating event)
 PRIAPISM - Diagnosis

Lab studies
l Complete blood count (CBC): ↓RBC, ↑WBC, ↑PLT

l PT and APTT: coagulation abnormalities for surgical intervention

l Blood group: Exchange transfusion in sickle cell disease (SCD)

l Penile blood gas (PBG) measurement: differentiation between high- and low-
flow priapism
l Psychoactive medication testing: cause priapism

l Urine toxicology for medications may cause priapism

Imaging studies
l Penile duplex Doppler ultrasonography: identify and locate fistulas in
patients with high-flow priapism
l Pelvic angiography: confirm the fistula’s location
 PRIAPISM - Surgery
l Aspiration of blood from corpora cavernosa – repeat if necessary

l Irrigation of corpora cavernosa (0,9% saline solution)

l Injection of phenylefrine or epinephrine or methylene blue – 1ml/1mg of

epinephrine diluted with 9ml od 0,9% saline – inject 0,5ml and repeat after 15 min
if needed

l Distal shunts:

l Ebbehoj technique - transglandular-to–corpus cavernosal with scalpel

l Winter technique - transglandular-to–corpus cavernosal needle-core biopsy

l Unilateral shunt - standard

l Bilateral shunts - only if necessary (usually apparent after 10 min).

l Insertion of a penile prosthesis

 PRIAPISM - Surgery

Shigehara, Kazuyoshi & Namiki, Mikio. (2016). Clinical Management of Priapism: A

Review. The World Journal of Men's Health. 34. 1. 10.5534/wjmh.2016.34.1.1.
 Fournier gangrene

Polymicrobial necrotizing fasciitis of the perineal, perianal, or genital areas

Causative microorganisms:
l Streptococcal species
l Staphylococcal species
l Enterobacteriaceae
l Anaerobic organisms
l Fungi
Fournier gangrene
 Fournier gangrene - causes
Anorectal: Accidental, intentional, or surgical trauma:
• perianal, perirectal abscesses • blunt trauma
• anal fissures
• superficial soft-tissue injuries
• anal fistula
• colonic perforations • genital piercings
• anal intercourse • urethral instrumentation
Urogenital:
• prosthetic penile implants
• infection in the bulbourethral glands
• urethral injury • intramuscular injections

• iatrogenic injury secondary to urethral • rectal foreign body

stricture manipulation
Gynecological:
• epididymitis
• orchitis • septic abortions
• lower urinary tract infection (eg. in • Bartholin gland abscesses
patients with long-term indwelling
urethral catheters) • hysterectomy
Dermatologic:
• episiotomy
• hidradenitis suppurativa
• ulceration
 Fournier gangrene - comorbidities

l Diabetes mellitus - 60%

l Morbid obesity
l Alcoholism
l Cirrhosis
l Age
l Vascular disease of the pelvis
l Malignancy (acute leukemia)
l Systemic lupus erythematosus
l Crohn disease
l HIV infection
l Malnutrition
 Fournier gangrene

Antibiotic and Antifungal Therapy: iv

Surgical Diagnosis and Debridement: perineal fascial compartment opening

Excising necrotic tissue

Reconstruction: skin grafts

Hyperbaric Oxygen Therapy : support

URINARY
INCONTINENCE

Tomasz Piecha MD, PhD

Department of General, Oncological and
Functional Urology
Medical University of Warsaw
Contents

GENERAL INFORMATION
PATHOPHYSIOLOGY AND DIAGNOSTICS
TREATMENT
STRESS URINARY INCONTINENCE
URGENCY URINARY INCONTINENCE (UUI)
MIXED URINARY INCONTINENCE (MUI)
What does urinary incontinence mean?

Urinary incontinence every involuntary leakage of urine

Lower urinary tract is composed of the bladder and urethra, which are connected to a
complex system of neural innervation and musculofascial support. Normal function involve
storing urine at low intravesical pressure and expelling urine at socially appropriate and
convenient time.
Stress urinary incontinence (SUI) - involuntary loss of urine with physical exertion
(i.e., walking, straining, exercise) or with sneezing/coughing or other activities with a
rise in intra-abdominal pressure (Valsalva maneuver).
Urgency urinary incontinence (UUI) - involuntary urine loss associated with urgency.
Mixed urinary incontinence (MUI) - involuntary urine loss associated with urgency and
is also associated with effort, physical exertion, sneezing, or coughing.
Urinary incontinence epidemiology in
women
World-wide prevalence of urinary incontinence - between 25% and 40%
Rates are age-dependent
Approx. 10% of women experience at least weekly incontinence episodes
Increase of prevalence is being observed

Stress urinary incontinence 10-25% of general population (50% of UI)

Urgency urinary incontinence 3-10% of general population
Mixed urinary incontinence 5-20%
Urinary incontinence epidemiology in
men
World-wide prevalence of urinary incontinence - between 11% and 34%
Urgency urinary incontinence 6-27% (40-80% of UI)
Stress urinary incontinence 1-3% (<10% of UI)
Mainly patients after radical prostatectomy or transurethral resection of prostat
(TURP)
Mixed urinary incontinence 3-13% (10-30% of UI)

Post void dribbling up to 46% of males >40 yrs

Leak of urine remaining in the urethra after urination
 Urinary incontinence risk factors
Females Males
Age Age
• most important is time from menopause • Stongest independent risk factor for UI development in men
• change in incontinence type that tends to occur with aging, with a shift away from SUI
toward MUI and UUI noted in most studies

Pregnancy and postpartum Post-radical prostatectomy or post-TURP status

• prevalence of SUI during pregnancy approx. 40%
• 3 months postpartum SUI approx. 30%
• development of UI during pregnancy = greater likelihood of developing UI later in life
Aspects of delivery Medical conditions
• history of vaginal birth of a large baby is associated with an increased likelihood for • Neurologic diseases
developing UI
• Lower risk after casarean delivery

Parity
• single pregnancy and subsequent delivery significantly increase a woman s risk for UI in
later life, with an OR of approximately 1.5.

Race/ethnicity
• Caucasian women have greater chance for developing UI

Hormonal treatment
• oral estrogen treatment with or without progestogens is associated with the
development of UI

Obesity
• BMI ≥30 = more than double risk of UI

Diet
• association between caffeine intake and symptoms of UUI, MUI or OAB
• No association with SUI
Medical conditions
• Diabetes
• Depression
Causes of triansent incontinence
DIAPPERS
Delerium

Infection (urinary tract infection)

Atrophic vaginitis/urethritis

Psychological (e.g., severe depression, neurosis)

Pharmacologic

Excess urine production

Restricted mobility

Stool impaction
 Stress urinary
incontinence -
pathophysiology
Causes:
1. Urethral hypermobility due to pelvic
floor dysfunction
• Dysfunction of support of bladder
and urethra
2. Intrinsic urethral sphincter deficiency
• Dysfunction of sphincter
contractility

Increase of intraabdominal pressure and

subsequent increase of pressure inside
bladder is higher than pressure inside
urethra = leak
Stress urinary incontinence signs and
symptoms
urine leakage triggered by coughing, sneezing, laughing, lifting, exercising,
straining

usually worse standing than supine

small to moderate volumes of urine

infrequent nocturnal leakage

little post-void residual

Urinary incontinence - diagnosis
Screening questions or questionnaries
Suggesting for SUI - wetting during cough, sneezing, big efforts

Suggesting for UUI - Urgency, frequency, nocturia

Questionnaries: QUID or 3IQ potential to discriminate UI type in women

History
Identify contributing medical factors

OB/Gyn history

Bowel history Cough test observation of leakage during cough

Medications

Surgical history

Bladder diary
At least 3-day diary

Requires literacy and significant amount of time and work by patient

Physical exam
Cough test

Q-tip test

Pad test
Q-tip test observation of cotton swab angle in relaxation and during
Gynecological examination valsalva maneouver. Positive fo urethral hypermobility if angle ≥ 30°

Post-void residual, urinalysis.

DO NOT PERFORM ROUTINELY URODYNAMIC EXAMINATION IN UNCOMPLICATED SUI

Stress urinary incontinence Stamey
grading
Grade 1 loss of urine with sudden increases of abdominal pressure: e.g.
coughing, sneezing or laughing.

Grade 2 - loss of urine with lesser degrees of stress: e.g. walking or standing
up.

Grade 3 - loss of urine without any relation to physical activity or position,

e.g. while lying in bed.
Stress urinary incontinence - therapy
Conservative management I line of treatment
In clinical practice, it is the convention that non-surgical therapies are tried first
because they usually carry the least risk of harm.
Proper treatment of associated conditions and adjustment of patient medications
Treatment of constipation there is association between UI and constipations, but
no data that constipation treatment improves UI
Lifestyle intervention
Moderate exercise is associated with lower rates of UI in middle-aged or older women
Encurage to weight loss it improves symptoms of SUI in women
Bahavioural and physical therapy
Pelvic floor muscle training (PFMT) improves pelvic floor function, improving urethral
stability. It may be used to prevent SUI eg. during pregnancy
Possible use of biofeedback in physical therapy
Physican should offer supervisded PFMT for at least 3 months as I line therapy to all
women with SUI
Stress urinary incontinence - therapy
Pharmacological treatment
Dulexetine
inhibits the presynaptic re-uptake of neurotransmitters, serotonin and norepinephrine
increase in pudendal motor neurones stimulation, with subsequent increase of the resting
tone and contraction strength of the urethral striated sphincter.
improvement in SUI symptoms compared to placebo
high incidence of adverse events: nausea and vomiting (40% or more of patients), dry
mouth, constipation, dizziness, insomnia, somnolence and fatigue
Duloxetine can be administered in selected SUI patients, if contrindications for surgery
exist

Vaginal oestrogens
Vaginal estrogens but not systemic estrogens, improve UI symptoms in post-menopausal
women
Systemic estrogen therapy (hormone replace therapy) using equine conjugated estrogens
may worse UI symptoms or increase risk of developing UI.
Stress urinary incontinence - therapy
Surgical treatment is currently the basis of SUI therapy.
Mid-urethral slings (MUS)
Most commonly used ced f SUI
Support for hypermobile urethra
Possible use of autologous sling (mainly from rectus muscle fascia) or non-
autologous slings (artificial)
Non-autologous slings should be made from monofilament, non-absorbable
material, typically polypropylene, and constructed as a 1-2 cm wide mesh with a
relatively large pore size
Transobturator route (TOT) or retropubic route
Success rate >95% with long-lasting effect
Complications
Pain
De novo OAB
Tape erosion
Urinary retention
Stress urinary incontinence - therapy
Other surgical treatment techniques:
Colposuspension both laparoscopic or open
Burch colposuspension more popular
Marshall Marchetti Krantz (MMK) urethropexy less popular

Bulking agents
intra or periurethral injection of an agent able to solidify under the submucosa or around
the urethra,
Cure rate 25-73%
Worse effectiveness than MUS or suspension surgery

Artificial urinary sphincter (AUS)

Best solution to treat SUI in men
Insufficient evidence to suport the use of AUS in females, but it can improve UI in women
with intrinsic sphincter deficiency
 Urgency urinary
incontinence -
pathophysiology
Inappropriate contraction of detrusor
muscle during bladder filling

• Idiopathic
• Realted to ageing (unclear
mechanism)
• Decreased cortical inhibition (CVA,
Parkinson s disease, Alzheimer
disease, SM etc.)
• Bladder irritation (UTI, bladder
cancer, bladder stone)
Urgency urinary incontinence signs and
symptoms
Frequent voiding with little or no warning

Moderate or large volume (bladder emtying)

Equal frequency during day and night

Decreased perineal sensation and sphincter control

Intact sacral reflex

Urodynamic study

Overactive bladder - condition

where there is a frequent
feeling of needing to urinate to
a degree that it negatively
affects a person's life. If there
is loss of bladder control = urge
incontinence.

Cystometry anf pressure-flow

study
Enables observation of
bladder function during
storage and micturition
phase
Spontaneous contrasctions of detrusor muscle
(arrows) If pathological contraction
of detrusor musce is
observed = detrusor
overactivity
Urgency urinary incontinence - therapy
Pharmacological therapy
Anticholinergics first choice in drug treatment of OAB and UUI
5 types of muscarinic postganglionic parasympathetic receptors inbody
M2 and M3 subtype in bladder contraction as well as salivary gland and
intestine
Side effects include dry mouth, drowsiness, constipation, tachycardia, blurred
vision; is contraindicated in glaucoma
Patient may increase fluid intake due to dry mouth and influence the effect on
frequency
Solifenacin, tolterodin, oxybutynin, trospium

Beta-3 adrenergic receptor agonist

Mirabegron
Beta-3 adrenoceptors are the predominant beta receptors expressed in the smooth muscle
cells of the detrusor and their stimulation is thought to induce detrusor relaxation
Side effects: hypertension, dry mouth, constipation

Possible combination treatment

Urgency urinary incontinence - therapy
III line treatment
Botulinum toxin
Onabotulinum A injection
Injection of botulinum toxin A directly to detrusor muscle can effectively reduce detrusor
overactivity
Detrusor underactivity will develop
Patients may need clean intermittent catheterization

Sacral neuromodulation
Implantation od electrodes into S3 foramen.
Inhibition of efferent impulses in pelvic plexus
No risk of underactive detrusor development
More invasive than botulinum injection
Urgency urinary incontinence surgical
treatment
Augmentation cystoplasty
Augmentation of intestine to bladder

Urinary diversion
Ureteroileostomy
Continent pouch
Orthotopic intestinal bladder

ONLY FOR SEVERE CASES AND ONLY IN SPECIALIZED CENTRES

Mixed urinery incontinence

Involuntary leakage associated with Stress Urinary Incontinence and Urgency

Urinary Incontinence

Treat dominant component first!

 Serious social problem

Stress UI and Urge UI

Take home Urgency (with/without UI) pharmacotherapy

surgery
message
Stress UI excercises surgery (drugs if surgery
is contraindicated)
General management of the
neuropathic patient

Prof. Piotr Radziszewski

Department of Urology
Medical University of Warsaw
Poland
 PATHOPHYSIOLOGY OF LUTD
Madersbacher classification system with typical
neurological lesions

Heavy lines symbolize overactivity, thin lines underactive or acontractile and green
lines normal function of the relevant structure
 Neurogenic bladder management
Key points

Kidney
Pressure
Residual
Continence
Focus on both :
Outflow region
Bladder
Acute Spinal Cord Lesion

Spinal shock phase

The bladder is able to store urine,

but unable to void.
The patient is at risk for kidney
failure unless the bladder is not
emptied adequately.
Acute Spinal Cord Lesion
Neuro-Urological Aims
Prevention of early complications as a
prerequisite for successful rehabilitation
of lower urinary tract function

Prevention of
bladder overdistension
urinary tract infections
stone formation
urethral injury
Acute Spinal Cord Lesion

Securing of bladder emptying

Intermittent catheterisation
Suprapubic catheter
Transurethral indwelling catheter
Spontaneous voiding rarely
adequate
Acute Spinal Cord Lesion
Intermittent Catheterization
Prerequisites
patient does no require intensive care
patient does no require acute surgery
regular diuresis at maximum
of 2000 ml per day
catheterisation every 4-6 hours possible
An acute syndrome of excessive, uncontrolled sympathetic output
Potentially serious consequences, including death
Occurs in patients with spinal cord injury ( level T6 or above )
Ca ed b pinal refle mechani m ha remain in ac de pi e he pa ien inj r
Pathophysiology of AD Noxious stimulus below the level
of spinal lesion produces an afferent
impulse that generates a generalized
sympathetic response
Results in vasoconstriction below
the neurologic level (if > T6,
involves the splanchnic vascular
bed) enough to cause elevated B/P
Normally descending central
inhibitory pathways would respond
to the rise in B/P, would modulate
sympathetic response
SCI prevents such signals from
descending to the sympathetic chain
Excessive parasympathetic output
causes vasodilation above the SCI
Clinical Features of AD

Presenting symptoms
• Bilateral, pounding headache
• Sweating above the level of the SCI, nasal congestion, malaise, nausea, blurred vision

Signs
• Flushed, sweating above the SCI
• Cool, pale skin below the SCI

Main finding
• elevated B/P, systolics at 250-300, diastolics 200-220
• Remembering resting B/P declines for SCI patients often to range 90/60. Therefore 120/80
might be considered elevated
• Reflex bradycardia, but tachycardia also seen

Differential diagnosis
• Migraine and cluster headache
• essential hypertension
• posterior fossa turmours
• pheochromocytoma
• toxemia of pregnancy
 There is no universal treatment algorithm for
every single neurogenic disease related LUT
dysfunction

•Function restoration

•Status-quo preservation

•KPRC

•Quality of life
Intermittent Catheterization

is the cornerstone of modern neurogenic bladder management

 Intermittent Catheterization
1. Sterile (clean) technique
using sterile materials, non-touch
technique of catheterization

is the method of choice

2. Hygienic (clean) technique - CIC

with re-usable catheters-low income countries
Clean Intermittent catheterization (CIC)

Type of catheters:

12-14 Fr

Auto-lubricated vs. non lubricated plus jelly

Cleaning at home (antiseptic solutions, microwaving)

Number of CIC /day: 1-6

A Ca he er in lips ick si e ma
enhance the acceptance for IC

17
Intermittent Catheterisation
What is the best technique,
what are the best materials?
No best technique, no best material, both depend
greatly on the patients individual anatomic, social
and economic possibilities
Wyndaele et al., ICI 2005
No controlled studies comparing different techniques
and materials

Infection rate with sterile disposable catheters lower

than with reused catheters
E Hudson & RI Murahata
Spinal Cord (2005) 43, 611-614 18
(Self-)Intermittent Catheterisation

The aims of IC / SIC are to empty the bladder

regularely and to achieve continence.

IC / SIC has been proved to be effective and safe

in the long-term treatment of bladder emptying
IC is also the prerequisite for other treatment
modalities, e.g. bladder augmentation,
continent diversion
Clean Intermittent catheterization (CIC)

Positive aspects:
Adequate protection of the upper urinary tract
50-100% of continence (with additional measures)

Negative aspects:
Symptomatic UTI ( 2/year in 30% of patients in CIC)
Urethral trauma (20% of patients)
Dependent upon patients s manual dexterity
Intermittent catheterisation
Suprapubic continent stoma

Mitrofanoff, Monti
with or without closure
of the bladder neck

especially for obese

women in wheelchair,
unable to perform IC
transurethrally
21
 Triggered reflex voiding

Pontine micturition
center
Indication: Patients with spinal cord
lesions after the period of spinal shock

Spinal
cord
Stimulating the sacral micturition
reflex:
Suprapubic tapping
C
Ad Thigh scratching
Bladder Penile or scrotal squeezing
Anal or rectal stimulation
Triggered reflex voiding: caveats

Triggered reflex voiding depends upon the

activation of a non-physiological reflex

Severe DSD with high detrusor pressures must be

ruled out

Regular follow-up is mandatory

Bladder Expression by
Crede or Valsalva Manoevre
Problem:
During expression manoeuvres compression of the
membranous urethra on its way through the pelvic
floor musculature

High intravesical pressures can be created and

cause vesico uretero - renal reflux
Should be replaced by intermittent catheterization
24
Urethral indwelling catheter

Chronic urethral catheterization should be avoided !!!

Risks:
Urethral lesions
Upper urinary tract deterioration
Frequent UTI
Stone formation
Supra-pubic indwelling catheter

Indication: when CIC is not possible

Provides a reasonable protection of

upper urinary tract whenever a close
follow-up is possible

Risks
Bladder cancer
Urine loss through the urethra
 NDO & Normal Sphincter
Key points:
• Continence
• Pressure
• Residual /monitoring/

Therapy:
1.Behavioural modifications+anticholinergics
2.Botulinum toxin injections
3.Neuromodulation with implantable devices
4.Bladder surgery
 Behavioural methods

• Scheduled voiding
• Consecutive voids
• Increased interval
• Drinking habits
• Toilet accessibility
• Patient’s mobility
• Keeping voiding diary
They always should be combined with pharmacotherapy
There are no RCT demonstrating beh. met. efficacy in NDO
 Differences between
NDO and OAB pharmacotherapy
OAB
• Urgency NDO
• Frequency • Pressure
• Incontinence • Phasic +terminal overactivity
• Incontinence
• No influence on PVR
• PVR of secondary importance
 Anticholinergics in NDO
which one to choose?
• Limited data about anticholinergics in neurogenic
patients
• Mainly „old” drugs (trospium, propantheline,
oxybutynine, limited data for tolterodine and
solifenacine)
• Realistically it would be illogical to think that the
„new” genereation drugs are not effective
• Usually maximum doses should be used
• Anticholinergics combination therapy is
sometimes neccessary
Extended release (ER) oral oxybutynin

Ditropan XL

10 SCI patients
Dose escalating (10-30 mg/day)

6
4
0

10 mg 20mg 30 mg Daily dose

Oxybutynin ER decreased incontinence and frequency and increased MCC

Doses higher than the standard (10 mg) are required
No serious side effects

O Leary, et al, J Spinal Cord Med 2003

 Solifenacin in MS patients

30 MS patients
Dose escalating study (5mg up to 10 mg)

Baseline 8 weeks p
Frequency 11.7 9.5 0.0001
Voided volume 121 155 0.0001
Incontinence/day 1.3 0.2 0.36
Pads/day 2.0 1.0 0.01

17 patients preferred 10 mg
2 patients withdraw due to side effects

Van Rey and Heesakkers EAU meeting Paris 2006 (abstract 1103)
 Efficacy and compliance with combination
of two anticholinergic drugs
Before After Before After
ml
12 8,6 368
7,5 326
400 297
10 7

8 300
6 141
200 125 123
2
4 1,3
0,6 100
2
0 0
Tol + Oxy Trosp + Tol Trosp + Oxy Tol + Oxy Trosp + Tol Trosp + Oxy

Incontinence episodes Bladder capacity

25 % reported side effects,

7 % drop out rate
Tolterodine: 8 mg (4 mg)
Oxybutynin: 30 mg (15 mg)
Trospium: 45 mg (90 mg)
Amend et al, Eur Urol, 2008
 When we should introduce
BTX therapy in NDO?
• After one failure with anticholinergics
• After multiple failures
• As the treatment of choice:
– Small bladders
– Non-compliant bladders
– High pressure bladders
– In all „complicated” cases
– In all cases
Indications for Botulinum Toxin-A
injections in the detrusor

1) Patients on CIC who maintain high DLPP or incontinence

despite adequate antimuscarinic therapy

2) Patients that develop severe side-effects with antimuscarinic

drugs

3) Exclude patients with poor pulmonary reserve

4) Exclude myasthenia gravis

5) Exclude BoNT/A administration for other reasons in the last

3 months
 How to inject BoNT-A in the human bladder

Rigid or flexible cystoscope

Flexible needle
Bladder filled at half capacity
1ml at each injection site (30 in total)

Dose are not interchangeable

Botox (onabotulinumtoxinA): 200-300 UI
Dysport (abobotulinumtoxinA): 500-750 UI
Xeomin (incobotulinumtoxinA): ????
PBO vs 200 U or 300 U OnabotA (Botox) in
NDO
Time (days) until patient-requested retreatment
360
295 295

270

180
Request was
92
90 allowed after
the 1st 12 weeks
(84 days)
0
PBO 200 U 300 U

Cruz F et al, Eur Urol, 2011

PBO vs 200 U or 300 U OnabotA (Botox) in NDO

Main adverse events (%)

PBO 200 U 300 U

UTI 40 56 64
Urinary
3 20 32
retention
de novo
12 30 42
CIC

Urinary retention and de novo CIC mainly in MS patients

Cruz F et al, Eur Urol, 2011
AbobotA (Dysport), 500 U vs 750 U in
SCI patients in CIC

Grise et al, Eur Urol, 2010

Mean Dose of Anticholinergics
Before & After BTX

Reitz A et al. Euro Urol. 45: 510-15, 2004

 What are the treatment limitations?
• Bladder capacity (<100ml)
• Bladder hypertrophy due to obstruction
(simoultaneous bladder and sphincter/prostate
injections)
• Bladder compliance (<10)
 Neuromodulation for NDO

Referal centers only

Two main types of implantable devices
Interstim-efficacy: 69%
/not suitable for complete lesion/
Finetech-Brindley /SARS+SDAF/: efficacy 78%

Possibility of combined treatment for NDO and DSD

 Neurostimulation and neuromodulation
• For complete lesion patients
/Finetech-Brindley/

• Alternatives to SDAF-SPARSI
/no good data yet/
SACRAL ANTERIOR ROOT NEUROSTIMULATION
(PLUS DORSAL ROOT SECTION)

440 patients, 6,6 years follow-up

Continence rate: 83%
UTI rate: drop from 6.3 to 1.2 per year
Kidney function remained stable
Surgical complications: 2,5%
Late surgical repair: 7.7%

17 years of experience with the Brindley technique

Kutzenberger, Domurath and Sauerwein, Art. Organs, 2005
 Sacral Neuromodulation
for Neurogenic LUT
Dysfunction
Results not satisfactory
J.M. Guys et al. 2004
J. Urol 172, 1673
but the difference with the control group was
not significant (n = 26 , 16 )
a larger multicenter study is warranted
E. Chartier-Kastler et al. 2000
J. Urol. 164, 1476
treatment options in selected patients with
spinal cord lesions. 45
SACRAL AFFERENT NEUROMODULATION

Sacral Nerve Neuromodulation

Improvements in frequency and incontinence between 43-68%
(1,2)

Posterior Tibial Nerve Stimulation

MCC improvement > 50% in half of MS (3) Parkinson (4) disease

Dorsal Penile/Clitoral Stimulation

(1): Wallace et al, Am j Obst Gynecol, 2007

(2): van Rey and Heesakkers, Urologia Internationalis
(3): Kabay et al, Urology, 2008
(4): Kabay et al, Neurology and Urodynamics, 2009
 Modern reconstructive surgery would
not be possible without
• intermittent
catheterisation
• Improvement of
appliances
• Improvement of
surgical techniques
and intensive care
management
Catheterizable continent diversion
Incontinent diversion-Bricker
 Indications for augmentation
cystoplasty/diversion
• Poor bladder compliance and hydronephrosis
• Presence of hydronephrosis, a decrease of kidney function
• Contracted bladder and incontinence
• Chronic interstitial cystitis causes bladder pain
• Frequent pyelonephritis in neurogenic patients
• Before /during/ kidney transplantation
• Intractable detrusor overactivity and incontinence
refractory to treatment

• Limited routine performance in neurologically intact

patients by acute morbidity and potential for long term
metabolic and bowel-related complications and the need of
CIC
 High risk SCI Patients
• Complete neurological lesion
• Cervical SCI with quadriplegia
• Prolonged indwelling catheter
• High detrusor leak-point pressure
• Presence of DESD and AD
• Large residual urine
• Presence of vesicoureteral reflux

• Diversion (e.g.Bricker) may be justified in a subcategory

of patients with “end-stage” bladders combined with
severe sphincteric damage or pelvic pain.
Contraindication for enterocystoplasty
in NVD
• Elevated creatinine (>2.5mg%) Creatinine
clearence<10ml/min
• Severely damaged or incompetent urethra
• Low abdominal straining ability and poor hand
function for catheterization
• Severe intestinal dysfunction and diarrhea
• Low social status and far to reach medical
resources
 Complications

• Metabolic and electrolyte disorders

Metabolic acidosis and hyperchloremia in 80%
• Stone formation
On staples and suture material
Chronic bacteriuria
Mucus retention
• Perforation
Chronic overdistension

• Malignancy in 4,5% after 32 (22-52) years, associated with coexisting

carcinogenic stimuli ( smoking, immunosuppressants)
– Husmann DA & Rathburn SR J Pediatr Urol 2008
• Re-operations for perforation, bladder stones and bowel obstruction
– Austin JC Curr Opin Urol 2008
• Vit B 12 deficiency
– Yearly assessment
– In pediatric patients starting 5y after surgery
– Rosenbaum DH et al. J Urol 2008
Complications of enterocystoplasty
• Ureteral reimplantation stenosis 9-16%
• Continence 27- 65%
• Need for clean intermittent catheterization 8-
44%
• Stone formation
• Impairment of bone formation &
mineralization
 Bladder autoaygmentation
Detrusor myotomy=creation of diverticulum

•The idea: excising a thick segment

of muscle from the dome of the
bladder, leaving only the mucosal
membrane in place. Bladder
pressure gradually dilates the
demuscularized area resulting in
bladder augmentation.
•The area around the
detrusorectomy can be protected
using the omentum or a striated
muscle (rectusabdominus muscle)
to prevent perforation and retraction
•Most of the published studies
 Continent urinary reservoir
• Indicated in quadriplegics with less good hand
function
• Women who cannot perform CISC
• Severe urethral incompetence and incontinence
after repeat surgical procedures
• Patient with a severely damaged or scarred
urethra
• Different techniques possible
(Kock, Mainz, Camey, Studer etc.)
• Cystectomy is mandatory
Contracted bladder with a non-
functioning urethra
 Continent cystostomy
• Indicated for patients with a fair bladder
compliance but a damaged urethra and
incontinence
• Closed the bladder outlet and augmented
with anti-incontinence ileum or cecum with
appendix
• Avoid excessive intestinal surgery and prevent
the need of ureteral reimplantation
Mitrofanoff catheterizable stoma

Kersenty 2008; de Jong 2008

Vesicostomy
 Non continent diversions
• End stage bladders
• Tetraplegic patients
• Motor handicap that prevents other modes of micturition

• Bladder should be removed during the procedure because of the risk of

later complications at this site
• Ileal conduit urinary diversion has the best long-term results for non-
continent diversion, if the following pre- and perioperative precautions
are taken :
- Pre-operative location of the stoma, with wheelchair test, if necessary
- Utilization of a short intestinal segment (10 cm maximum).
- Minimal dissection of the ureters

• Cutaneous ureterostomy shouldn’t be usedfor non continent urinary

diversion in adult patients because of the rate of long term
complications
ICI 2009
Chartier-Castler 2002
 Final conclusions NDO without
obstruction
• For patients with complete lesion it is advisable to
proceed promptly for more radical and definitive
treatment options (surgery, neuromodulations)

• Yearly check-up of kidney functions and post-void residual

is advisable

• Worsening of incontinence, recurrent urinary tract

infections, increased post void residual, hydronephrosis
should trigger the detailed examination of the lower
urinary tract for worsening of existing pathology or
appearance of the new one.
 NDO & Underactive Sphincter
Key points:
• Continence /stress and urge/
• Residual /monitoring/

Therapy:
Therapy for NDO as described
Therapy for stress incontinence:
1.Behavioral therapy,physiotherapy and pharmacotherapy
2.Use of external and internal appliances
2.Minimally invasive surgery
 Stress incontinence surgery and NDO
• the cause of stress incontinence is sphincter
denervation
• urethral hypermobility may be or may be not
present
Key factors for decision taking
• NDO severity
• Disability status
• Outflow obstruction
• Stress incontinence surgery could worsen detrusor overactivity
• Sometimes it is better to have patient with minimal stress
incontinence, than to face the stress incontinence surgery
complications.
 Conservative therapy
Perineal musles electrostimulation
Bifeedback
Behavioural modification
External appliances
Males

Condom catheter

Females

VIVA Reliance Femsoft

No studies in neurogenic patients
Pharmacotherapy for stress incontinence
• a-agonists
No studies in neurogenic
• Tricyclic antidepressants patients
• Duloxetine

Surgery for stress incontinence

AUS-gold standard
bladder neck slings
injectables
micro-balloons
mid-urethral slings
CIC willingness a pre-requisite for surgery
 TVT
secure
Mini Arc

Needleless
 Male slings ?

Argus
InVance

Retropubic
suspension

Remeex system
 Bulking agents
• variety of substances
• tissue compatibility, migration, durability and safety.
• the ideal urethral bulking agent has not yet been identified.
• the exact mechanism on continence has not been defined
• success 36-69%; dry 4-20%
• cost effectivness?
• significantly better objective outcome in the surgical groups
• no evidence that one bulking agent has advantage over any other
• there are no available data comparing urethral bulking agents with non-
surgical treatments or with other minimal access surgical techniques
Cochrane review (Keegan , 2007) ; Corcos 2005; Maher, 2005)
AUS is still the gold standard

durability and complications

Lai et al J Urol 2007; 177:1021-1025

 Final conclusions NDO and sphincter weaknes
• Patients with complete lesion should be managed
accordingly to their disability status and kidney functions.
More radical treatment options are advisable.

• Follow up of a patient should again observe the ICI

guidelines for specific neuropathy.

• Patients after the surgery for stress incontinence should

be checked at least yearly for post-void residual and
should have performed urodynamics.

• If overactivity is worsening (despite staging the

overactivity treatment) one must consider urethrolysis,
even if this would make the patient incontinent again.
 NDO & Overactive Sphincter
Key points:
• Kidney
• Pressure
• Continence
• Residual CIC is the gold standard
Therapy
Therapy for NDO as described
Therapy for obstruction:
1.Physical maneouvers, pharmacotherapy ( minimally effective)
2.Catheterization (indwelling, intermittent)
2.Botulinum toxin injections (for both NDO and sphincteric overactivity)
3.Neuromodulations (for both NDO and sphincteric overactivity)
4.Sphincterotomy
5.Intraurethral stents
Pharmacotherapy for overactive sphincter?

a-blockers 3 C
Phenoxybenzamin 4 NR
Baclofen 4 C
Benzodiazepins 4 C
Dantrium 4 C
Botulinum toxin 2 B
Nitric oxide donors-
under evaluation
 Alpha 1A-blockers may improve bladder
emptying by decreasing urethral pressure
Effect of Tamsulosin in MUP
0

All Tam
Tam 0.4

Tam 0.8
Placebo
Mean change in MUP (cm H2O) -2
-4
-6
-8
-10
-12
-14
-16
-18
-20 **
RCT Open-label
Abrams et al.,J Urol., 03
4 weeks 1 year

Indications:
Decrease resistance of a normal/slightly overactive sphincter to
facilitate emptying (to avoid CIC)
BoNT/A injections in the urethral sphincter

n = 68 100-200 U Before treat After treat p value

Retention requiring catheterization 41 7

Postvoid residual urine volume (ml) 240 88 0.01
Maximal voiding pressure (cm H2O) 81 52 0.01
Maximal cystometric capacity (ml) 198 241 ns
Stress Urinary incontinence 2 3

Smith et al, Urology. 2005

 Sphincterotomy

Indication: Patients with severe DSD, unable for CIC and

with severe autonomic dysreflexia

Complications: Low success rate (32%)

Bleeding, recurrent UTI
Incomplete sphincter section
Urethral stricture formation
Permanent incontinence
Pan D et al, J Urol, 2009
 Final conclusions NDO and overactive
sphincter
• the worse case scenario, which most often leads to
chronic kidney failure
• the treatment goal is the preservation of kidney function ,
while the quality of life issues are of secondary
importance
• follow-up should be performed accordingly to the ICI
guidelines and additionally PVR, kidney function and
bladder functions (urodynamics or video urodynamics)
should be performed yearly or when a deterioration of
incontinence or kidney functions is observed.
 Bladder Underactivity & Sphincter
Over, Under, Normo activity
Key points:
• Continence
• Residual CIC is the gold standard

Therapy for baldder underactivity:

1.Physical maneouvers, pharmacotherapy ( minimally effective,
dangerous)
2.Catheterization (indwelling, intermittent)
3.Electrotherapy (minimally effective)
Incomplete lesions only
4.Pharmacotherapy (minimally efective)-
Cholinergics not able to induce / increase detrusor contractions,
but seem to increase the detrusor muscle-tone
5.Surgery (latissimus dorsi plasty)-selected centers
 Indwelling suprapubic catheterisation for
long term management ?

Nomura S, Ishido T, Teranishi J,

Makiyama K.
Urol Int. 2000; 65 (4): 185-9
Long-term analysis of suprapubic
cystostomy drainage in patients with
neurogenic bladder

Conclusion:
Continuous cystostomy drainage is not considered
to be ideal for bladder emptying, however some
patients may benefit.
80
ICI 2013
ICI 2013
 Take-home messages

Protect upper urinary tract

Detect and manage poor bladder

emptying

Prevent high bladder pressures

Improve urinary continence

Improve quality of life

GENITOURINARY (GU) TRAUMA
e-learning course

Department of Urology
Warsaw Medical University
Head and Chair : Prof. dr hab. n med. Piotr Radziszewski
 INCIDENCE
 10 % OF POLYTRAUMA AFFECT GU SYSTEM

 1-2% OCCUR AS ISOLATED GU TRAUMA

 KIDNEY - MOST COMMON : CA 50% OF GU

TRAUMA
 RENAL TRAUMA: INCIDENCE
 MOST COMMON GU TRAUMA

 > 50% UNDER 50 YEARS OLD

 MALE : FEMALE = 3-4 : 1

 RENAL TRAUMA: ETIOLOGY
 BLUNT 80 - 90 %: fall, direct blow,
traffic accidents (with deceleration),
associated intra-abdominal injuries in
25%
 PENETRATING : 77-100% with associated
intra-abdominal injuries
 GUNSHOT
 RENAL TRAUMA: RISK FACTORS
 Age: children more prone -
- weak muscles & rib cage,
- relatively large kidneys,
- thin retroperitoneal fat
 Congenital abnormalities: e.g. hydronephrosis,
horseshoe kidney
 Pathological conditions: e.g. Wilms and other
tumors
 RENAL TRAUMA: STAGING
Grade 1: renal contusion, subcapsular haematoma
Grade 2: minor injury = renal parenchymal laceration < 1
cm deep, not extending to cortico-medullary junction
(CMJ)
Grade 3: parenchymal laceration >1 cm deep, extension
to CMJ, no communication with collecting system
Grade 4: laceration with extension to collecting system,
segmental vascular injury with loss of its function
Grade 5: renal pedicle avulsion (major vascular injury) or
shattered kidney
According to American Association for Surgery of Trauma
 RENAL TRAUMA: DIAGNOSIS
 History: mechanism, associated pathology
-flank pain, tenderness
 Physical: abdomen - palpable mass + related
to associated injuries
 Stable / shock (RR, HR)
 Blood & urinalysis: haematuria (gross or
micro)
 RENAL TRAUMA: HAEMATURIA
DOES NOT CORRELATE WITH SEVERITY
OF INJURY !!!
 does not occur in 0,5-25% of renal trauma
 does not occur in 20->50% of severe injuries
of renal pedicle or ureter
 clinical course of gross haematuria -
indicative of damage
 RENAL TRAUMA:
RADIOLOGICAL EVALUATION
 US - all suspected renal injuries:
initial staging, monitoring, selection
 Further: CT/spiral CT /IVP -
ALL :
children, penetrating injuries, shock, gross
haematuria
 NO - adult , blunt injury, no shock,
microhaematuria as only 0,25 % major injuries
will be missed
 RENAL TRAUMA: CT vs IVP

 evaluation of associated injuries & renal pedicle

 evaluation of non functioning (IVP) kidney
 precise evaluation of
– renal fragments
– extravasation (urinoma)
– haematoma
 Angiography - rarely, only when planning vascular
surgery or embolization
Grade IV
Grade V UPJ tear
Motorbike accident
 RENAL TRAUMA: TREATMENT
 AIM : maximal preservation of tissue & function
 DEPENDING ON: type, grade, associated
injuries, evolution, shock
CONSERVATIVE >80%
 ENDOUROLOGIC
 SURGICAL EARLY & LATE
RENAL TRAUMA: CONSERVATIVE TREATMENT
WHO ? STABLE ! HOW ?
– BLUNT – BED REST UNTIL
HAEMATURIA
 GRADE 1-3 RESOLVES
 OFTEN GRADE 4
– RR, HR
– PENETRATING – US EVALUATION OF
 ONLY ISOLATED !!! HAEMATOMA
 GRADE 1,2 – BLOOD
 NOT GRADE >2: OFTEN
– FOLLOW UP: US - 6 & 12,
ASSOCIATED INJURIES,
IN 25% DELAYED IVP-12 WEEKS
BLEEDING - 75% REQ.. – BP for at least 12
SURGERY MONTHS
RENAL TRAUMA: ENDOUROLOGIC TREATMENT

WHO ? HOW ?
– BLUNT GRADE 4 – PERCUTANEOUS
– PERSISTENT NEPHROSTOMY
EXTRAVASATION – JJ STENT
(UP TO 75% RESOLVE – DRAINAGE
SPONTANEOUSLY) – ANTIBIOTIC
– URINOMA
RENAL TRAUMA: EARLY SURGICAL TREATMENT
 WHO ?
– SHOCK / UNSTABLE
– MOST PENETRATING / GUNSHOT
– GRADE 5
– EXPANDING/PULSATILE HAEMATOMA
– GRADE 3,4 + LAPAROTOMY FOR OTHER
INJURIES
– GRADE 4 + >25% OF NON VITAL RENAL TISSUE
 RENAL TRAUMA: LATE SURGICAL TREATMENT

 WHY ?
– LATE HEMORRHAGE
– UNSTABLE
– PERSISTENT EXTRAVASATION
– COMPLICATIONS
 RENAL TRAUMA: SURGICAL OPTIONS

 Parenchymal, collecting system, vascular

repair
 Debridement
 Omental wrapping
 Drainage: external, JJ stent
 Nephrectomy
 RENAL TRAUMA: COMPLICATIONS
 Late bleeding
 Abscess
 Pseudocyst formation
 Hypertension - vascular: arterial thrombosis, AV fistula
- detached fragments
- Page kidney
 Hydronephrosis
 Kidney atrophy
 Death
 URETERIC TRAUMA:
ETIOLOGY
 IATROGENIC
– ureteroscopy
– gynaecologic surgery
– pelvic, retropeitoneoscopic,
laparoscopic surgery
 EXTERNAL
– penetrating 80%, mainly
gunshot, rarely stab
– blunt: deceleration injury in
children - UPJ rupture
Ureteral trauma
 URETERIC TRAUMA:
DIAGNOSIS
Difficult & delayed!!!!
 History: surgery, injury
 Signs & symptoms: flank pain, fistula (wound, vagina,
skin), peritonitis, fever, sepsis, mild uremia,
haematuria (40-80%), anuria/oliguria (bilateral/solitary
anatomical /functional kidney)
 IVP: extravasation, dilated collection system, non-
functioning kidney
 CT, US: urinoma, abscess, haematoma
 Ante/retrograde pyelography
 URETERIC TRAUMA - TREATMENT
 Early diagnosis (5-7 days) - early surgical repair or
curative JJ stent/nephrostomy - if not avulsion
 Late diagnosis (>10-14 days) or infected: JJ stent or
nehrostomy for 6 weeks, radiological evaluation (IVP,
pyelography) - cured or delayed surgery
 Surgical options: always drain +JJ stent/nephrostomy
– upper ureter: end-to-end anastomosis,ileal
repair,transureteroureterostomy, autotransplantation
– mid& lower ureter: ureterocystoneostomy with/without
psoas hitch/Boari flap
End to end
anastomosis
Psoas hitch
Boari flap
Psoas hitch Boari flap
the use of intestine
 URETERIC TRAUMA:
COMPLICATIONS
 Stricture &
hydronephrosis
 Urinoma
 Abscess, sepsis
 Fistula
 Loss of kidney
BLADDER TRAUMA -ETIOLOGY
BLUNT - 85%, mainly traffic accidents
– contusion
– intraperitoneal rupture: full bladder, intoxicated
– extraperitoneal rupture :pelvic fracture
 PENETRATING: almost always assoc. injuries
 IATROGENIC: TUR-BT, CIC
 SPONTANEOUS: underlying pathology: tumor
90% associated with pelvic fractures, 10%
of p.f. will be associated with bladder injury.
 BLADDER TRAUMA -DIAGNOSIS
 Signs & symptoms: haematuria (95% gross),
anuria / oliguria, peritonitis - intraperitoneal,
suprapubic pain - extraperitoneal rupture
 Empty bladder
 Cystography 300ml 25% contrast: empty, 100
& 200-300 ml, postvoid, two projections (AP +
lat/obl)
 CT cystography if CT performed
 IVP mandatory for associated GU trauma
INTRAPERITONEAL BLADDER RUPTURE: MECHANISM AND CYSTOGRAPHY
EXTRAPERITONEAL BLADDER RUPTURE: MECHANISM AND CYSTOGRAPHY
BLADDER TRAUMA -TREATMENT
 SURGICAL REPAIR AS A RULE
– BLADDER SUTURING, DRAINAGE,
CATHETER/SPT 10 DAYS
 Conservative - small extraperitoneal ruptures,
not bladder neck, no laparotomy for other
reasons :mainly iatrogenic – TUR-BT
– catheter 10 days, cystography
BLADDER TRAUMA -COMPLICATIONS

 Pelvic abscess
 Persistent leakage
 MALE URETHRAL TRAUMA: ETIOLOGY,
CLASSIFICATION
 Degree: Complete, partial, contusions
 Blunt:
– anterior (bulbar, penile) - straddle injury: urethra
compressed against lower pubic arch
– posterior (membranous, prostatic) - pelvic fracture in
90%, usually membranous urethra disrupted
above&below urogenital diaphragm. 10-20% bladder
trauma.
 Iatrogenic, penetrating, sex, external violence
 MALE URETHRAL TRAUMA :DIAGNOSIS

 Blood at external meatus

 Urinary retention: full bladder, inability to void
 Anterior:
– butterfly ecchymosis limited by Colles fascia if
Buck’s fascia ruptured (penis only if not)
– Anterior abdominal wall if Colles fascia ruptured
 Posterior: „high riding prostate” on DRE
(elevated by haematoma)
HAEMATOMA: ANTERIOR URETHRAL INJURY
HAEMATOMA: POSTERIOR URETHRAL INJURY – HIGH RIDING PROSTATE
MALE URETHRAL TRAUMA:DIAGNOSIS
 Retrograde urethrography : 10-25 ml 25-30%
contrast , F14 Foley catheter introduced to
the urethra and occluded with 2ml saline in
balloon
 NO DIAGNOSTIC CATHETERIZATION !!!!
partial to complete - incontinence/impotence,
infection
Posterior
posterior
MALE URETHRAL TRAUMA:TREATMENT

 LOCATION anterior vs posterior

 DEGREE contusion, partial vs complete
 ASSOCIATED INJURIES
– life threatening
– urinary tract : bladder
ANTERIOR URETHRAL TRAUMA: TREATMENT

 CONTUSION, PARTIAL
– catheter/SPT (no if voids)
– repeated 2 weekly urethrography until healed
 COMPLETE
– SPT
– emergency repair if fresh eg.cut (anastomosis +
hematoma drainage)
– delayed 3-6 months repair (anastomosis/patch)
 POSTERIOR URETHRAL TRAUMA:
TREATMENT

 SPT !!!!
 PARTIAL : as anterior
 COMPLETE
– delayed anastomosis at 3-6 months
– early anastomosis 5-10 days: bleeding stopped
-fibrosis not started. Large distraction difficult to
handle later
URETHRAL TRAUMA:COMPLICATIONS
 Urethral stricture (anterior, posterior 50-90%)
- internal urethrotomy
- urethroplasty if scar is long & dense
 Impotence (posterior): mainly due to pelvic
trauma (30%) early railroading increases to
50%
 Urinary incontinence
 Urethral diverticulum
 FEMALE URETHRAL TRAUMA
 Rare
 Etiology: pelvic fractures, vaginal injuries
 Bladder injuries associated in 2/3 cases
 Treatment: SPT + delayed repair at 3-6 months
 Complication: incontinence
 PENILE TRAUMA
 PENETRATING  BLUNT
(potentially infected) – contusion = haematoma -
– tunica albuginea conservative
rupture - emergency – fracture = tunica albuginea
surgery rupture -surgery
– degloving - grafts – dislocation (empty sleeve -
– amputation skin ruptured in coronal
-microsurgery groove) - surgery
complete/partial & – strangulation - foreign body
total/subtotal around - emergency removal of
FB
Foreign body
directly
after
removal
of
foreign
body
 SCROTAL & TESTICULAR TRAUMA
 Penetrating (potentially infected )& blunt
 US: haematoma - always emergency surgery =
haematoma evacuation, drainage,
debridement, tunica albuginea repair (testicular
rupture)
 Why ? haematoma > increased intrascrotal
pressure > edema > ischemic testicular
atrophy + risk of infection
 UWAGA!

Niniejsza prezentacja jest chroniona prawem autorskim i jest właśnością

intelektualną Kliniki Urologii Ogólnej, Onkologicznej i Czynnościowej
Warszawskiego Uniwersytetu Medycznego.
Autorzy nie zezwalają na jej rozpowszechnianie, bez udzielenia uprzedniej zgody.
 Anatomy
Prostate is a gland
which forms part of
the male genitalia
• is closely linked to
the urinary tract
• is not a part of
lower urinary tract

https://www.earthslab.com/anatomy/verumontanumseminal-colliculus/
 4 zones:
peripheral, transitional, medial,
anterior
 Transitional zone – 5% of the
normal prostate,
area of BPH development
 Peripheral zone - 75% of the normal medial
prostate, usually the area of the
cancer development
 Prostate excretion - 5ml (15-25% of peripheral
ejaculate volume) contains glucose,
citric acid, polyamides,
prostaglandins, PSA – to liquefy
sperm
The Prostatic Gland

Zones:
1. medial (central)
2. peripheral
3. anterior
4. transitional
 Acini are formed by:
• secretory cells
• a basement membrane

 The supporting tissue

is formed by:
• muscle fibres
• fibroblasts
• endothelial tissue
Netter's Atlas Of Human Anatomy (5th Ed.)
under the influence

 Testosterone

 Estrogens

 Growth factors

The basement membrane is not affected by this activity

 Androgen regulation in man
LHRH
pituitary
gland

LH

adrenal
gland

Testosterone

testis
5 reductase converts
T =>DHT
SHGB T
plasma
membrane

DHT
DHT

Nuclear envelope

DHT DHT
 THE MOST COMMON CANCER IN MALES
30% of men > 50yr
90% of men > 90 yr. on autopsy
 INCREASING INCIDENCE
▪ life expectancy increases
▪ detection rate increases: screening, PSA
 ANDROGEN DEPENDENT
 Siegel R, Miller K, Jemal A
Cancer Statistics, 2019 CA CANCER J CLIN
Siegel at al. Cancer Statistics, 2020; Ca CANCER J CLIN 2020
http://onkologia.org.pl/wp content/uploads/Nowotwory_2017.pdf
Siegel R, Miller K, Jemal ACancer Statistics, 2019 CA CANCER J CLIN
A.D. Lamb et al. Pre-malignant Disease in the Prostate in R.C. Fitzgerald (ed.), Pre-Invasive Disease: Pathogenesis and Clinical Management 2011
75% peripheral , 20% transition & 5% central zone

Multifocal : average 2,4 foci per surgical specimen

 98% adenocarcinoma

 Spread:

▪ local: capsule, SV, bladder, rectum, pelvic wall

▪ distant: bones (95%), lymph nodes (obturator 1st)

 PSA, DRE, TRUS
 Biopsy
▪ Random: TRUS guided,
▪ Targeted: mpMRI fusion or TRUS hypoechogenic
▪ Formal (to confirm diagnosis)
 Pathological examination: Gleason sum/score,
 mp MRI stageing
 Bone scan – PSA >20ng/ml or predominant GG ≥4
 Early PCa – no specific symptoms!!!!
 LUTS – due to concomitant BPH/prostatitis

 Locally advanced PCa – haematuria, incontinence,

dilation of upper urinary tract, lower limb oedema

 Distant metastases – bone symptoms

(pain, pathological fractures)
 Palpation of the prostate:

▪ Volume (size), each lobe

▪ Presence of the prostatic fossa
▪ Mobility of rectal mucosa
▪ Presence of induration
▪ Presence of the nodule
▪ Presence of infiltration
early
prostate
cancer
causes
no pain
 PSA. A substance produced by the prostate that may be found in
an increased amount in the blood of men who have prostate
cancer, benign prostatic hyperplasia, or infection or
inflammation of the prostate.
TAUS TRUS
 Describes the appearance of the cancerous prostate tissue
Gleason Sum
▪ sum of the 2 Gleason grades (range 1-5) assigned to the
2 most prevalent glandular patterns of the tumor cells
▪ ranges from 2-10
▪ modified: includes most malignant grade

Gleason 1 Gleason 5
 T1 – no palpable tumour
▪ T1a, b – incidental finding in
specimen from resection
▪ T1c – detected in biopsy (elevated
PSA)
 T2 – palpable tumour, organ
confined
 T3 – tumour extends beyond
prostatic capsule
(ECE, SV+)
 T4 – fixed, invading
adjacent structures
Localized disease Locally advanced disease
Case courtesy of Dr Angel Donato, Radiopaedia.org, rID: 59151
 Age
 Life expectancy
 Clinical staging (PSA, DRE, nodes, Gleason):
▪ localized / locally advanced / metastatic
 Patient choice
 Symptoms
 PSA< 10ng/mL
 Gleason <7
 Biopsy: small volume cancer no more than 1-2 cores

 Follow up !!!
 PSA every 6 months
 Biopsy every 1 to 2 years
 WW => death from
competing causes

Active Delayed radical

Surveillance treatment

Disease progression
Death from PCa
 Treatment-free survival

62%
 With curative intent (radical prostatectomy, RT, brachy)
▪ Life expentancy >10-15 years
▪ Localized and locally advanced

 Palliative (hormonal, RT, WaWa)

▪ Life expentancy <10 years
▪ Not suitable for agressive treatment
▪ Patient’s choice
 Aims - cancer control,
 Lifespan > 15 (10) years
 Suitable - low comorbidity
 Retropubic, perineal, laparoscopic approach
 Most reliable staging
 Significant complications:
▪ UI (3-10%),
▪ ED (30-100%),
▪ anastomotic stricture,
▪ thromboembolic complications
 Cross-
Section of
Prostate
Urethra

Neurovascular
Prostate
Bundles

Rectum
 ca 74-78 Gy over 6 weeks-conformal (individually CT based
dose):
 IMRT: intrensity modulated rtx 81 Gy
 Proton beam rtx 91 Gy (too expensive)
 Results as good as after radical prostatectomy
 Lifespan 10-15 yr.
 Not suitable for surgery
 No reliable staging

 Complications: cystitis & proctitis, ED, UI

 1966 - DES w raku stercza 1977 - agoniści LH-
Charles B. Huggins RH
Andrew Schally

14-4-11
1966 - Charles B. Huggins 1977- Andrew V. Schally
for their discoveries
systemic approach to concerning the peptide
treat prostate cancer hormone production of
the brain
Nature can refuse to speak but
she cannot give a wrong answer.
 The effect of estrogens and androgen injection on serum phosphatases in metastatic carcinoma of the
prostate. Cancer Res 1941
The effect of castration on advanced carcinoma of the prostate gland. Arch Surg 1941

600
Fast and durable suppression of
500
testosterone
Testosterone (ng/dl)

Charles Huggins
1901–1997 400
1966 Nobel Prize
300

200

days after castration

100

0
-14 0 1 3 7 14 21 28 29 31 35 56 57 59
 Irreversible
 cheap
 LHRH LHRH
Pituitary agonist
gland

LH

adrenals

Testosteron
LHRH -Mechanism of action
testis
Testosterone T

T
 Antiandrogenes = antagonists of T receptors
▪ steroid (cyproterone acetate) - serum T changed
▪ non steroid (flutamide, nilutamide, bicalutamide) - serum T
not changed - libido & erections saved
 Castration
▪ surgical - irreversible, cheap, compliance not required, fastest
▪ pharmacological - LH-RH analogues (goserelin, leuprolid,
buserelin, triptorelin) - reversible, requires compliance
MAB – maximal androgen blockade
castration

Maximal
Androgen
Blockade
Antyandrogen
 erectile dysfunction (impotence),
 infertility
 low sex drive
 changes in hair growth
 fatigue
 depression
 hot flushes
 reduced bone substance (increasing the risk of
osteoporosis) and muscle mass
 UROLITHIASIS
Tom asz Piecha MD PhD
Departm ent of General , Oncol ogical and Functional Urol ogy
Medical University of Warsaw
Contents
DEFINITIONS

UROLITHIASIS
Epidemiology
Risk factors
Pathophysiology of stone disease
Classifications of stones
Diagnostics
Treatment
Metabolic evaluation
Prophylaxis

RENAL COLIC
Symptoms
Complicated renal colic
Diagnostics
Treatment

BLADDER STONES
Epidemiology and classification
Symptoms
Diagnostics
Treatment

31.03.2020
DEFINITIONS
◦ UROLITHIASIS
◦ presence of calculi (stones) in urinary tract: pelvocaliceal system of kidney, ureter,
bladder or urethra

◦ RENAL COLIC
◦ type of abdominal pain caused by streaching of renal capsule and pelvocaliceal
system subsequent to urine obstruction mainly due to stone. Typically pain is located
in lumbar area and radiate to lower abdomen, external genitalia and lower
extremity
UROLITHIASIS - EPIDEMIOLOGY
◦ LIFE-LONG RISK OF UROLITHIASIS - 1-15%

◦ PREVALENCE
◦ EUROPE 5-9%
◦ NORTH AMERICA 7-13%
◦ ASIA 1-5%

◦ INCREASE OF UROLITHIASIS INCIDENCE DURING LAST DECADES

CHRONIC DEHYDRATION

GENDER
Males are more prone to develop urolithiasis; male: female ratio = 1,5-3:1
UROLITHIASIS
Androgens cause increase and estrogens decrease in urine oxalate levels

RACE/ETHNICITY
RISK FACTORS
Stones are most common among caucasian race and least common among black
race

AGE
Peak incidence between 30 and 60 years
Among women second peak aftter menopause

CLIMATE, GEOGRAPHICS AND ENVIRONMENTAL FACTOR

More prevalent in dry and warm climate
Global Warming icrease of mean temperature by 0,5-1 C may lead to increase of
The recurrence risk is
urolithiasis prevalence by 5-15% basically determined by
High temperatures at work (eg. Ironworks) causes increase in urolithiasis development
Emotional stress and sedentary lifestyle is risk factor of urolithiasis
the disease or disorder
OTHER DISEASES
causing the stone
Obesity, diabetes mellitus and metabolic syndrome
formation
Hypertension possible relation to urolithiasi
◦ Physiological concentration of oxalate salts in urine exceeds 4
times saturation concentration but inhibitors of crystalisation
ensure metastability of solution
◦ Normally phenomenon of nucleation occurs small stones
crystalize and dissolve spontaneously
◦ In case of lack of inhibitors or presence of promoters small crystals
can aggergate in bigger structures
◦ Promoting factors:
◦ Oxidative stress UROLITHIASIS -
◦ Angiogenic disfunction of Bowman capsule PATHOPHYSIOLOGY
◦ Local inflammatory state
◦ Inhibitors:
◦ Nonorganic pirophosphate
◦ Citrates
◦ Magnesium ions
◦ Polyanionic macromolecules
◦ Glycoproteins mainly Tamm-Horsfall protein
◦ Uropontin
 General factors

UROLITHIASIS
Early onset of urolithiasis (especially children and teenagers)
Familial stone formation
Brushite-containing stones (CaHPO4.2H2O)

INDIVIDUAL RISK
Uric acid and urate-containing stones
Infection stones
Solitary kidney (the kidney itself does not particularly increase the risk of stone formation, but prevention of stone recurrence is
of more importance)
Diseases associated with stone formation
Hyperparathyroidism
Metabolic syndrome
◦ 50% of Nephrocalcinosis
Polycystic kidney disease (PKD)
patients Gastrointestinal diseases (i.e. jejuno-ileal bypass, intestinal resection, Crohn s disease, malabsorptive conditions, enteric
develop only hyperoxaluria after urinary diversion) and bariatric surgery

one Increased levels of vitamin D

Sarcoidosis
incidence of Spinal cord injury, neurogenic bladder
urolithiasis. Genetically determined stone formation
Cystinuria (type A, B and AB)
Primary hyperoxaluria (PH)
Renal tubular acidosis (RTA) type I

◦ 10% of 2,8-Dihydroxyadeninuria
Xanthinuria
patients = Lesch-Nyhan syndrome
high risk stone Cystic fibrosis
Drug-induced stone formation
formers Anatomical abnormalities associated with stone formation
Medullary sponge kidney (tubular ectasia)
Ureteropelvic junction (UPJ) obstruction
Calyceal diverticulum, calyceal cyst
◦ Risk factors of Ureteral stricture
recurrence Vesico-uretero-renal reflux
Horseshoe kidney
Ureterocele
Environmental factors
High ambient temperatures
Chronic lead and cadmium exposure
UROLITHIASIS CLASSIFICATION
◦ Stone classification by aetiology • Non-infection Stones
• Calcium oxalate – 75% of stones
• Calcium phosphate
• Uric acid
• Infection stones
• Magnesium ammonium phosphate
• Carbonate apatite
• Ammonium urate
• Genetic causes
• Cystine
• Xanthine
• 2,8-Dihydroxyadenine
• Drug stones
UROLITHIASIS -
CLASSIFICATION

Classification by chemical
structure
UROLITHIASIS CLASSIFICATION
◦ Classification by X-ray characteristic

◦ Other
◦ Stone size
◦ Stone location
UROLITHIASIS DIAGNOSTICS
◦ Medical history
◦ Mainly previous episodes and other diseases
◦ LUTS present in bladder stone
◦ Physical examination
◦ In patient without renal colic without any signs
◦ Labs
◦ Basic lab tests urinalysis, CBC, creatinin,
UROLITHIASIS DIAGNOSTICS
◦ IMAGINING – MOST IMPORTANT IN UROLITHIASIS DIAGNOSTICS
◦ Ultrasound cheap, widely avaiable, no radiation
◦ Can identify stone in pelvocaliceal system, pelvo-ureteral junction, distal ureter
◦ Ureteral stone mostly associated with dilatation of pelvocaliceal system (hydronephrosis)

◦ Plain abdominal X-ray KUB (kidney, ureter, bladder)

◦ Classic procedure
◦ Can identify only radiopaque Stones

◦ Intravenous urography (IVU)

◦ Classic study with use of contrast medium.
◦ After contrast medium injection a series of X-rays are taken
◦ Can locate stone
◦ Can define upper urinary tracet architecture
◦ Delay of contrast output suggest failure of kidney function

◦ Computed tomography (CT)

◦ Golden standard of stone imagining
◦ All stone types except INDINAVIR stones are visible
◦ With use of contrast, CT-IVU can be done
◦ Best definitione of upper urinary tract archoteture
◦ In renal colic non-contrast-enhanced computed tomography (NCCT) is golden standard of emergency diagnostics
◦ Biggest radiation dose
UROLITHIASIS TREATMENT

Observation Medical expulsion therapy (MET)

Is an option in asymptomatic lower pole kidney
stone in comorbid patients
Pharmacological treatment in renal colic due to
stone in ureter, in patients that don t need active
treatment
Stones that are likely to be expelled ( 6 mm in
diameter)
Usage of drugs that provide ureter musculature
relaxation
Alpha-adernolytics e.g. Tamsulosin 0,4 mg 1x1 p.o.
(other drugs have smaller therapeutic potential)
Need for systematic observation of patients, as
well as discontinuation of treatment and
qualification for active forms of therapy in case of
inefficiency or complications: fever, recurrent pain,
or renal function deterioration

31.03.2020
UROLITHIASIS TREATMENT
◦ Extracorporeal shock wave lithotripsy (ESWL)
◦ Lithotripsy is the result of the interaction of the focused mechanical wave (infrasound) generated by the lithotriptor
◦ Pressure changes (up to 40 MPa), shear stress and cawitation cause accumulation of damage and subsequently stone disintegration
◦ Efficiency 30-80%

◦ Indications:
◦ radiopaque stone
◦ <20mm (in kidney)
◦ ureter (all sizes)
◦ <1000 HU in CT stones >1000 HU are less likely to disintegrate with ESWL

◦ Contrindications:
◦ PREGNANCY
◦ Symptomatic UTI (untreated)
◦ Aortic or renal vessel aneurysm
◦ Coagulation disorders (untreated)
◦ Stricture of urinary tract below stone

◦ Complications:
◦ Haematuria
◦ Kidney and pararenal heamtomas
◦ Stein strasse stone fragments that block ureter and cause renal colic
◦ Urinary tract infection
UROLITHIASIS TREATMENT
◦ URSL URETERORENOSCOPIC LITHOTRIPSY
◦ Endoscopic procedure done through urethra, bladder and ureter under direct visual control. Performed with
ureterorenoscope
◦ During procedure, the stone is fragmented mainly with holmium laser and then removed with special forceps or
baskets
◦ fURSL (flexible ureterorenoscopic lithotripsy; other name RIRS retrograde intrarenal surgery) is the procedure
performer with ureterofiberoscope (flexible instrument), that can access stones in kidney pelvis and calices
◦ Often need to put JJ stent inside ureter post URSL
◦ Efficiency up to 84-90%
◦ Indications
◦ For fURSL kidney stones <2cm in inefficiency or contrindications for ESWL (in specialized stones centres possible treatemt for
stones >2cm)
◦ For URSL (rigid instrument)
◦ Ureteral Stones >10 mm
◦ Ureteral Stones <10 mm if other treatment modalities are inefficient or unacceptable
◦ Complications:
◦ Ureter trauma
◦ Ureter stricture
◦ Haematuria
UROLITHIASIS TREATMENT
◦ PCNL Percutaneous nephrolitotomy
◦ Minimally-invasive procedure to remove stones from the kidney by a small puncture wound (up to about 1 cm) through the skin
◦ PCNL consist of 2 stages:
◦ 1. creating percutaneous nephrostomy (puncture through calix foramen to renal pelvis) – most important stage
◦ 2. dilatation of tract and stone removal
◦ During procedure, the stone is fragmented mainly with sonotrode (ultrasonic machining, welding and mixing device) or holmium laser and
then removed with special forceps, baskets or suction device.
◦ Efficiency success rate up to 94%

◦ Indications:
◦ Renal stone >20 mm
◦ Renal stone <20 mm when other methods are ineffective or unacceptable

◦ Contrindications:
◦ Untreated UTI
◦ Untreated coagulation disorders
◦ Pregnancy
◦ Renal tumour
◦ Morbid obesity or severe skeletal deformities

◦ Complications:
◦ Fever
◦ Hemorrhage and/or need of blood transfusion
◦ Thoracic complications (atelectasis, hydrothorax)
◦ Sepsis
◦ Adjacent organ injuries (bowel, liver, spleen)
◦ Urinoma
UROLITHIASIS TREATMENT
◦ Laparoscopic and open surgery

◦ Nowadays 1-3% of stones are treated with open or laparoscopic methods

◦ Used techniques both laparoscopic and open

◦ Ureterolithotomy for ureteral stones

◦ Pyelolithotomy for stones in renal pelvis
◦ Nephropyelolithotomy for stones in renal pelvis and calices

◦ Complication rate is higher than for endoscopic methods each case should be discussed individually.
UROLITHIASIS METABOLIC EVALUATION
INDICATIONS FOR METABOLIC EVALUATION IN UROLITHIASIS

Recurrent urolithiasis
◦ 50% of first-time stone formers will
Stong familial history of urolithiasis
have recurrence during 10 years
Intestinal disorders (esp. chronic diarrheal diseases)

History of patological fractures

◦ Underlying contidions that
increase risk of urolithiasis should Osteoporosis
be diagnosed Infection Stones

Gout

◦ In high risk patients metabolic General conditions that indicate poor tolerance of further symptomatic
evaluation should be performed urolithiasis
Single anatomical or functional kidney

Anatomical disorders of urinary tract

◦ Indications for metabolic
Renal insufficiency
evaluation is listed in table
Cystine, strivute or uric acid stones

Urolithiasis in childhood
UROLITHIASIS METABOLIC EVALUATION
◦ Comprehensive metabolic panel
◦ 14 blood tests that evaluate function of liver, kidneys and parathyroids, as well as glucose metabolism and electolytes
concentrastion
◦ Fasting glucose, calcium, sodium, potassium, chloride, bicarbonate, albumin, totoal protein, bilirubin, blood urea nitrogen
(BUN), creatinine, alkaline phosphatase (ALP), alanine aminotransferase (ALT), aspartate aminotransferase (AST)

◦ Parathormone (hyperparathyroidism)
◦ Urinalysis
◦ 24-hour urine collection
◦ 2-3 times because of changes due to diet (but fasting and calcium-load urine is no longer performer except selected
cases)
◦ Total volume, calcium oxalate supersaturation, urine calcium, urine oxalate, urine citrate, calcium phosphate
supersaturation, uric acid supersaturation, urinary uric acid, urine magnesium, urinary cystine, 24-hour urine pH

◦ Stone composition
◦ X-ray diffraction
◦ Infrared spectroscopy
UROLITHIASIS GENERAL PROPHYLAXIS
GENERAL PROPHYLAXIS MEASURES
FLUID INTAKE Fluid amount 2,5-3 l/d
Circadian drinking
Neutral pH beverages
Diuresis >2-2,5 l/d
Specific urine weight <1010 g/l
NUTRITIONAL ADVICE Balanced diet
Rich in vegetables and fibre
Calcium content 1-1,2 g/d
Limited NaCl content 4-5 g/d
Limited animal protein content 0,8-1,0 g/kg/d
LIFESTYLE ADVICE Retain normal BMI range
Adequate physical activity
Balancing of excessive fluid loss
UROLITHIASIS - PROPHYLAXIS

◦ After metabolic evaluation:

◦ In concomitant diseases treat concomitant disease eg. Hyperparathyroidism

◦ For certain conditions possible pharmacological prophylaxis

◦ Possible specific dietary advice

RENAL COLIC - SYMPTOMS
◦ Flank pain typically unrelenting, excruciating pain that can radiate to the lower abdomen and testicles
or labia on the affected side
◦ Pain is secondary to stretching of collecting system and renal capsule. Streching is caused by increase of intrarenal
pressure due to urine output obstruction.
◦ Obstruction may be caused by stone in pelvoureteral junction or ureter
◦ No obstruction = no symptoms (stones in calices, renal pevis or staghorn)
◦ Pain is often wavy aggrevated by ureteral muscle contraction on the level of stone, after relaxation the pain can
relieve

◦ often associated with nausea or vomiting

◦ common autonomic innervation of kidneys and intestines
◦ connected with paralytic subileus
RENAL COLIC COMPLICATED RENAL COLIC

◦ INDICATIONS FOR ADMISSION TO HOSPITAL AND INVASIVE TREATMENT

◦ FEVER – RISK OF UROSEPSIS

UROLOGICAL
◦ SINGLE FUNCTIONAL OR ANATOMICAL KIDNEY (ACUTE RENAL FAILURE) EMERGENCY
◦ NO CONSERVATIVE TREATMENT AVAIABLE DUE TO WOMITING
◦ RECURRENT RENAL COLIC
◦ UROLITHIASIS NON SUGGESTING SPONTANEOUS EXPULSION (STONE >6 MM)
RENAL COLIC COMPLICATED RENAL COLIC

◦ In case of fever (risk of urosepsis) or acute kidney injury

◦ Kidney drainage
◦ JJ stent insertion
◦ Percutaneous nephrostomy
◦ Empiric antibiotic treatment

◦ In case of recurrent colic, severe womiting or stone >6 mm

◦ URSL
◦ Kidney drainage
RENAL COLIC - DIAGNOSTICS
◦ Medical history
◦ Onset of symptoms
◦ Previous stone-related events and treatment
◦ Fever
◦ Lower urinary tract symptoms
◦ Concomitant diseases
◦ Drugs
◦ Allergies

◦ Physical examination
◦ Goldflam sign (Costovertebral angle tenderness, Murphy s punch sign)
◦ medical test in which pain is elicited by percussion of the area of the back overlying the kidney
◦ tapping produce pressure wave, that streches renal capsule and collecting system and generates pain
◦ Positive in: renal colic, pyelonephritis, perirenal inflammation

◦ Labs
◦ CBC, Urinalysis, creatinine
◦ In complicated colic coagulation test, CRP, electolytes
RENAL COLIC - DIAGNOSTICS
◦ Diagnostic imagining
◦ Ultrasound examination
◦ Primary diagnostic tool
◦ sensitivity of 45% and specificity of 94% for ureteral stones and a sensitivity of 45% and specificity of 88% for renal stones
◦ Dilatation of renal collecting system most probably due to obstruction

◦ Non-contrast-enhanced computed tomography

◦ GOLDEN STANDARD
◦ can detect uric acid and xanthine stones, which are radiolucent on plain films, but not indinavir stones
◦ radiation risk can be reduced by low-dose CT
◦ allows for rapid 3D data acquisition including information on stone size and density, skin-to-stone distance and surrounding
anatomy

◦ KUB X-ray
◦ If no CT available
◦ Can differentiate radiopaque and radiolucent Stones (most common uric acid)

◦ Intravenous urography
◦ Has been replaced by NCCT in renal colic
RENAL COLIC - TREATMENT
◦ PAIN RELIEF diagnostics can not delay pain relief
◦ According to WHO analgesic lader
◦ Level I NSIAD s, paracetamol, metamizole
◦ Better analgesic efficacy than opioids in renal colic
◦ First choice metamizole and paracetamol In analgesic refractory pain
◦ Depending on cardiovascular risk factors diclofenac, ibuprofen
consider renal decompression
◦ Level II weak opioids eg. Tramadol
(drainage) or ureteral stone
◦ Level III strong opioids
◦ Intravenous lidocaine conflicting results
removal

◦ Antispasmodics
◦ Ex juvantibus treatment
◦ Available data do not show significant benefit

◦ MET
◦ May be used in distal ureter stones >5 mm
BLADDER STONES EPIDEMIOLOGY AND CLASSIFICATION

◦ 5% of all urinary stones

◦ Can be classified as

◦ Primary (endemic)
◦ Mostly children in areas with poor hydration, recurrent diarrhoea and a diet deficient in animal protein

◦ Secondary
◦ Bladder outlet obstruction (BOO) – benign prostate enlargement – cause of 45-78% bladder stones
◦ Chronic bacteriuria
◦ Neurogenic bladder obstruction
◦ Foreign bodies
◦ Bladder augmentation
◦ Urinary diversion

◦ Migratory
◦ those which have passed from the upper urinary tract
BLADDER STONES - SYMPTOMS

◦ Urinary frequency
◦ Heamaturia
◦ Dysuria
◦ Suprapubic pain
BLADDER STONES - DIAGNOSTICS
◦ Medical history
◦ Onset of symptoms
◦ Previous stone-related events and treatment
◦ Lower urinary tract symptoms
◦ Concomitant diseases
◦ Drugs
◦ Allergies

◦ Physical examination
◦ Basic evaluation
◦ Examination of external genitalia, peripheral nervous system (including digital rectal examination, peri-anal tone and
sensation in men)
◦ ULTRASOUND
◦ sensitivity and specificity of 20-83% and 98-100%,
BLADDER
◦ Assessment of prostate volume and post-void residua STONES -
DIAGNOSTICS
◦ KUB X-ray
◦ sensitivity of 21%-78%
◦ stones >2 cm are more likely to be radiopaque ALWAYS DIAGNOSE AND
TREAT UNDERLYING
CONDITION
◦ Computer tomography
◦ higher sensitivity for detecting bladder stones than
US or X-Ray in adults

◦ Cystoscopy
◦ higher sensitivity for detecting bladder stones than
US or X-Ray in adults
BLADDER STONES - TREATMENT
◦ Secondary Stones are unlikely to pass spontaneously and are mostly symptomatic require treatment
◦ Transurethral cystolithotripsy
◦ Highly effective
◦ Can be combined with transurethral resection of prostate (TURP)

◦ Suprapubic cystolithotomy
◦ Open procedur for big Stones
◦ associated with a need for catheterisation and longer hospital stay in both adults and children compared to all other
stone removal modalities

◦ Percutaneous cystolithotripsy
◦ Mostly used in children
SUPPLEMENTARY READINGS

◦ https://radiopaedia.org/
◦ https://uroweb.org/guideline/bladder-stones/
◦ https://uroweb.org/guideline/urolithiasis/
Urooncology
Renal cell carcinoma
 Age: 60-70yo
 Sex: 1,5:1 (M:F)
 Risk factors: smoking, obesity, hypertension, diabetes
 Von Hippel-Lindau disease (VHL) – mutation of tumor
suppressor gene on chromosome 3p25.3
 Histological diagnosis:
 Clear-cell RCC (ccRCC) 80-90%

 Papillary RCC (pRCC) 10-15%

 Chromophobe (chRCC) 4-5%

 Renal medullary cancer (RMC) <0.5 %

 Other
Clinical manifestations
 About 70% - incidental US finidings

 The classic triad: flank pain, hematuria, and flank mass –

uncommon (<10%)

 Paraneoplastic manifestations:
 Hypercalcaemia
 Polycythaemia
 Hypertension
 Amyloidosis
Ultrasound
CT
IVP
 http://webpathology.com/
Case contributed by: Liang Cheng, MD, Dept. of Pathology, Indiana University
School of Medicine, Indianapolis.

chRCC
 ccRCC

http://www.urology-textbook.com/renal-cell-carcinoma.html
 ccRCC

https://www.oncotherapynetwork.com/renal-cell-carcinoma/
 https://www.umassmed.edu/urology/clinica

https://uroweb.org/guideline/renal-cell-carcinoma/
 Renal cell carcinoma – treatment
localised tumor
 Surgery
 Radical nephrectomy

 Partial nephrectomy (nephron-sparing surgery – NSS)

 Imperative – solitary kidney, bilateral tumors
 Elective – whenever feasible – generally
recommended for <7 cm tumors

 Laparoscopic radical nephrectomy

if partial nephrectomy is not possible and/or not beneficial – large tumor, tumor of
afunctional kidney

 Laparoscopic partial nephrectomy

in centers with laparoscopic experience

 Focal treatment (cryoablation, radiofrequency ablation)

http://www.urology.com.sg/kidney-health/kidney-cancer/
 Renal cell carcinoma – treatment
locally-advanced tumor

Surgery
Radical nephrectomy (NSS?) +/- lymphadenectomy +/- thrombectomy
+/- cavotomy
Check: https://www.youtube.com/watch?v=xC50mVH2RSE

http://www.scielo.br/scielo.php?script=sci_arttext&pid=

https://uroweb.org/guideline/renal-cell-carcinoma/
 Renal cell carcinoma – treatment
metastatic tumor

 Chemotherapy
 Ineffective in RCC (exception – medullary ca, collecting duct ca)

 Immunotherapy
 PD1-PD1L /CTLA-4 checkpoint inhibitors (pembrolizumab, nivolumab /
ipilimumab,
 CTLA-4 checkpoint inhibitors (ipilimumab)

 Anti-VEGF /Tyrosine kinase multi-target inhibitors (aksytynib, sunitynib,

pazopanib, cabozantinib)
 Interferon – α (?)
Benign kidney tumors

Angiomyolipoma

Oncocytoma

Fibroma

Lipoma

Angioma

Mixed tumors
oncocytoma

https://radiopaedia.org/cases/renal-oncocytoma-gross-pathology-2
angiomyolipoma

https://www.auanet.org/education/auaunive

https://healthjade.net/angiomyolipoma/
Upper tract urothelial carcinoma (UTUC)

 transitional cell carcinoma, TCC

 Renal pelvis/calyx/ureter/
 5-10% all TCC tumor (~95% bladder tumors)
 Hematuria !
Imaging

 IVP
 ureteropielography
 US
 ureterorenoscopy
 CT urography

Department archives
Department archives
Department archives
Treatment
 Depending on grading and staging – risk
grouping
 Nephroureterectomy – open/laparoscopic – for
high risk UTUC
 Kidney-sparing approach including endoscopic
treatment – low risk UTUC
 Adjuvant treatment
 BCG / mitomycin instillations via nephrostomy tube
(?)
 Systemic chemotherapy for metastatic TCC
 UTUC dx + UTUC sin + invasive bladder ca ??

https://www.ncbi.nlm.nih.gov/pubmed/17591588
 Renal cyst
 Simple renal cyst: treat when
symptomatic
 Puncture: cytology + fluid
culture
 Obliterative drug instillation

 Bosniak categories:
https://radiologykey.com/renal-cystic-disease-2/

https://radiologykey.com/renal-cystic-disease-2/
Department archives
Department archives
Department archives
Department archives
Department archives
Department archives
Department archives
Department archives
Department archives
 Bladder cancer

 Seventh most commonly diagnosed cancer in the male population;

drops to eleventh when both genders are considered
 Sex: 4:1 – M:F
 Ris factors: smoking, occupational exposure occurs mainly in
industrial plants, which process paint, dye, metal and petroleum
products
 Clinical presentation:
 Painless hematuria!

 Other lower urinary tract symptoms (urgency, frequency)

 Histological variants
 Transitional cell carcinoma, urothelial carcinoma
(carcinoma urotheliale), TCC >90%
 carcinoma in situ, CIS
 Squamous/glandular/trophoblastic differentiation
 Other rare variants
 70% non-muscle-invasive; 30% muscle-invasive
US

Department archives
http://learningradiology.com/archives05/
Department archives
 Cystocopy – rigid vs flexible

https://www.ncbi.nlm.nih.gov/books/NBK660

https://www.healthdirect.gov.au/surgery/rigid-cystoscopy-male
 What’s inside?

https://www.livescience.com/34701-bladder-cancer-symptoms-treatment.html

https://uroweb.org/guideline/non-musc
https://uroweb.org/guideline/non-muscle-invasive-bladder-cancer/#5
TURBT – transurethral resection
of bladder tumour
 Resection and pathological
assesment :
 Grading (G)
 Staging (T) = depth of
invasion

https://www.roswellpark.org/cancer/bladder/treatment/surgery/turbt
 Bladder cancer –TNM

https://uroweb.org/guideline/non-muscle-invasive-bladder-cancer/#5
http://atlasgeneticsoncology.org/Tumors/Images/bladd_1.gif
Department archives
Department archives
Department archives
Treatment
 Non-muscle-invasive bladder cancer (NMIBC)
TURT
 Follow-up - cystoscopy, US /
…(+ mitomycin instillations)
 High risk NMIBC (TaHG, T1HG, cis)
TURT + adjuvant
 (+ mitomycin instillations + BCG instillations )
 Early cystectomy
 Muscle-invasive bladder cancer (MIBC)
 Radical cystectomy (+neoadjuvant/adjvant chemotherapy)
 Metastatic BC

GC = gemcitabine plus cisplatin;

GFR = glomular f iltration rate;
HD-MVAC = (high-dose)
methotrexate, vinblastine,
adriamycin plus cisplatin; PCG =
paclitaxel, cisplatin, gemcitabine;
PS = performance status

https://uroweb.org/guideline/bl
 Urinary diversion
 ureterocutaneostomy
 ureterosigmoideostomy
 Brickers conduit

transileal ureterocutaneostomy
 orthotopic neobladder

https://my.clevelandclinic.org/health/treatments/12546-urinary-reconst
Indiana Pouch

Colostomy Urostomy
 Prostate cancer

 Depending on location: no1(some European countries) or

no2 (worldwide)
 Well-established risk factors: : increasing age, ethnic origin,
genetic predisposition
 No preventive measures

 Major health concern:

- Increasing proportion of elderly men
- Overdiagnosis
- Overtreatment
Prostate cancer - TNM

https://uroweb.org/guideline/pro
 Prostate cancer – how to establish an early diagnosis?

• „Screening” tools = PSA + DRE

• Biopsy indication = positive PSA or
DRE
• PSA - individualised risk-adapted
strategy !

• When planning biopsy, (which when

performed based on transrectal
ultrasound is basically systematic
only) – should we perform any other
imaging to improve performance of
biopsy with targeted cores?

multiparametric MRI aids decision on biopsy as

well as improve its performance
 Prostate cancer – when to mpMRI?

https://uroweb.org/guideline/pro

= if you think of biopsy, always consider MRI first. If first biopsy was
negative and you still feel pt can have cancer – always perform MRI
https://cancerimagingjournal.biomedcentral.com/articles/10.1186/s40644-016-0068-2
 Screening for prostate cancer – dangers
Overtreatment = treating prostate cancer in patients who will suffer
from treatment complications but are unlikely to benefit from prostatę
cancer therapy because will probably die due to different reason.

Examples:
-Prostatectomy in 90yo man with several comorbidities and low risk
organ-confined prostate cancer
-Prostatectomy in 70yo man with highest CVD risk category with
multiple comorbidities and intermediate risk organ-confined prostate
cancer with life expectancy of 5 years*

* prostatectomy can be considered in individuals with life expectance

>10 years
 Screening for prostate cancer – dangers
Overdiagnosis = diagnosing the patient with prostate cancer which
may lead to overtreatment and result in unnecessary patient anxiety

Examples:

- Performing PSA test in unsymptomatic 85-year-old man in whom

prostatectomy would not be considered

https://uroweb.org/guideline/prostate-cancer/
 Prostate biopsy
• Decision on indications based on PSA, DRE and mpMRI
• Tru-cut – provides histopathology not cytology
• TRUS can aim targeted biopsy, but lesions are poorly visible thus
biopsy is performer systematically
• For targeted biopsies prebiopsy MRI imaging is utilized - check
https://www.youtube.com/watch?v=qLuhBK3L9l8

• Biopsy outcomes:
- Presence and amount of cancerous tissue
- Type of cancer
- Grading (Gleason score)

https://www.researchgate.net/figure/MRI-US-fusion-target-and-random-re-biopsy-2-MRI-lesions-with-a-PIRAD
 After biopsy – stratify and decide what to do

https://uroweb.org/guideline/prostate-cancer/
 Prostate cancer
– treatment for organ-confined disease

• Active survaillance
• Watchfull waiting
• Surgery
• Radiotherapy
• Clinical trials: focal therapy, cryotherapy, HIFU
(high intensity focused ultrasound)
 Prostate cancer
Active survaillance (AS) vs watchfull waiting (WW)
• AS might be defined as observation of potentially treatable low-risk
disease. When progression is observed, observation turns into active
treatment.
• WW is abandon of radical treatment in patients who are unlikely to
benefit from it. WW protocol focuses on treatment of complications
that appear as disease progresses
https://uroweb.org/gu
 Prostate cancer
Surgical treatment
• Radical prostatectomy
(RP) +/-
lymphadenectomy (based
on risk group and
preoperative % risk of
lymph nodes positivity)
• Retropubic/
laparoscopic/ robot-
assisted
• Stress incontinence and
erectile dysfunction –
most common adverse
effects of RP
https://basicmedicalkey.com/radical-prostatectomy/
 Prostate cancer
Surgical treatment

https://www.researchgate.net/figure/Operative-specimen-b-Whole-mount-section-of-th
 Prostate cancer
Radiotherapeutic treatment
• external-beam radiation therapy (EBRT):
-intensity-modulated radiation therapy (IMRT)
-volumetric arc external-beam radiotherapy (VMAT)
• brachytherapy (BT)
• +/- adjuvant androgen deprivation therapy (ADT)
• Combined EBRT + BT

• In patients after RP with adverse pathologic features – positive

margins and/or extracapsular extension and/or seminal vesicle
involvement (post RP specimen) – adjuvant (immediate) RTx or
salvage RTx (performed when biochemical recurrence is detected)
 Prostate cancer
Follow-up

https://uroweb.org/guideline/prostate-cancer/
 Prostate cancer
Metastatic disease treatment
• Androgen deprivation can be achieved by either
suppressing the secretion of testicular androgens or
inhibiting the action of circulating androgens at the
level of their receptor.
• GnRH agonists and GnRH antagonists suppres the
secretion of testosterone = pharmacological
castration
• Chronic exposure to GnRH agonists results in the
down-regulation of GnRH-receptors, suppressing
LH and FSH secretion and therefore testosterone
production. A castration level is usually obtained
within 2 to 4 weeks.
• Initially transient rise in LH and FSH leads to 'flare-
up' phenomenon, which starts two to three days after
administration and lasts for about one week.

https://uroweb.org/guideline/prostate-cancer/ https://erc.bioscientifica.com/view
 Prostate cancer
„Flare up” phenomenon
• After GnRH agonists only

• increased bone pain,

• acute bladder outlet obstruction,
• obstructive renal failure,
• spinal cord compression,
cardiovascular death due to
hypercoagulation status

• Treatment = temporary treatment

with antiandrogens to suppres
excessive testosterone

https://uroweb.org/guideline/prostate-cancer/

https://europepmc.org/article/med/24756149
 Prostate cancer
Metastatic disease treatment

GnRH antagonists
cetrorelix, ganirelix, abarelix, degarelix

GnRH agonists
leuprorelin, buserelin, nafarelin, histrelin, goserelin, deslorelin

Antiandrogens
Flutamide, bicalutamide, nilutamide

Novel drugs (castration resistant Pca; a-priori mPCa treatment?)

Enzalutamide, abiraterone, docetaxel
 Testicular cancer
Histological classification

Germ cell tumors ~95% (40-50% seminoma)

World Health Organization (WHO) 2016 pathological classification:

1.Germ cell tumours

2.Derived from germ cell neoplasia in situ (GCNIS)
3.Germ cell tumours unrelated to GCNIS
4.Sex cord/stromal tumours
5.Miscellaneous non-specific stromal tumours
 Testicular cancer

Most common neoplasm in young males

Risk factors
•testicular dysgenesis syndrome: cryptorchidism, hypospadia, decreased
spermatogenesis evidenced by sub- or infertility
•familial history of testicular tumours among first-grade relatives
•presence of a contralateral tumour or GCNIS

75-80% of seminoma patients, and about 60% of non-seminomatous

germ cell tumour patients have stage I disease at diagnosis
 Testicular cancer
Diagnostic evaluation

Physical examination – detection (self examination!)

US – diagnosis
CT/MRI – N and M staging

Pre-operative serum tumour markers – diagnosis+ prognosis

Serum tumour markers after orchidectomy – prognosis
AFP+ B-HCG +LDH (miRNA?)

Biopsy (contralateral testis, suspicion of neoplasia in situ)

 Testicular cancer
treatment
Radical orchiectomy + chemotherapy (BEP/EP)/ Retroperitoneal Lymph
Node Dissection (RLND)/ survaillance (low risk prognostic groups)

https://www.frontiersin.org/articles/1

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1464-410X.2009.08434.x
 Learn more

Oncology guidelines
https://uroweb.org/individual-guidelines/oncology-guidelines/
https://www.auanet.org/guidelines
https://www.nccn.org/professionals/physician_gls/default.aspx

Procedures
RALP https://www.youtube.com/watch?v=56Jav9AolC0
Laparoscopic RN https://www.youtube.com/watch?v=zNaBE53glfA
Laparoscopic NSS https://www.youtube.com/watch?v=eDOgxZ3PfOg
Laparoscopic RC https://www.youtube.com/watch?v=6V-I_aPRMp0
TURT
https://www.youtube.com/watch?v=7Rhsb5m3OSY&list=PLD1ZssA5i8
Endoscopic treatment of UTUC
https://www.youtube.com/watch?v=3V0lAphFdzc
 BPH
Benign Prostatic Hyperplasia

Department of General, Onkological and Functional Urology

Medical University of Warsaw
Sylwia Bender, MD
Lower urinary tract symptoms (LUTS)
• Prevalent, bother and impair QoL symptoms:
- Storage
- Voiding
- Post- micturition

• LUTS  Bladder outlet obstruction (BOO) Benign prostatic

enlargement (BPE) Benign prostatic hyperplasia (BPH)

• OAB/ detrusor overactivity, detrusor underactivity/ underactive

bladder, structural or functional abnormalities of the urinary tract,
prostatic inflammation, nocturia
Male LUTS- most common related conditions:

• AUR= Acute Retention of Urine- painful, palpable or percussible

bladder, when the patient is unable to pass any urine;

• Chronic retention of urine- non- painful bladder, wich remains

palpable or percussible after the patient has passed urine; such
patients may be incontinent
Male LUTS- most common related conditions:

• BOO= Bladder outlet obstruction – the generic term for

obstruction during voiding and is characterised by increasing
detrusor pressure and reduced urine flow rate; diagnosed by
values of flow- rate and detrusor pressure

• BPO= Benign prostatic obstruction- form of BOO, may be

diagnosed when the cause of outlet obstructio is known to be
BPE

• BPH= Benign prostatic hyperplasia- typical histological pattern,

which defines the disease
Male LUTS- most common related conditions:

• DO= detrusor overactivity- urodynamic observation

characterised by involuntary detrusor contractions during the
filling phase which may be spontaneous or provoked

• OAB= overactive bladder syndrome- urine urgency, with or

without urgency urinary incontinence, usually with increased
daytime frequency and nocturia, if there is no proven infection
or other obvious pathology
Diagnostic evaluation:
• Medical history:
- Symptoms
- ED
- relevent comorbidities,
- neurological diseases,
- current medication
- lifestyle habits,
- emotional and psychological factors,
- urological/ surgical history,
Diagnostic evaluation:
• Symptom score questionnaires
(Self- completed validated symptom questionnaire):
- The International Prostate Symptom Score (IPSS)
- The International Consultation on Incontinence uestionnaire
(ICIQ-MLUTS)
- Danish Prostate Symptom Score (DAN-PSS)
• Voiding diaries
• International Index for Erectile Function (IIEF)
IPSS
IPSS- QoL
Quality of Life scale
Voiding diary
IIEF
Physical examination
• Suprapubic area
• External genitalia:
- Urethral discharge
- Meatal stenosis
- Phimosis
- Penile cancer
• Perineum
• Digital rectal examination (DRE)
• Lower limbs
Laboratory tests:
• Urinalysis (dipstick or sediment) to exclude:
- urinary tract infections (UTI),
- microhaematuria,
- diabetes mellitus ( glycosuria, proteinuria)

• Prostate- specific antigen (PSA)

Laboratory tests:
• Renal function measurement:
- serum creatinine,
- estimated glomerulal filtration rate (eGFR)

Hydronephrosis, renal insufficiency and urinary retention are

more prevalent in patients with signs and symptoms of BPO.
Post- void residual urine (PVR)
• Assessed by:
- Transabdominal ultrasonography
- Bladder scan
- Catheterisation

• Treshold:
- 150 ml
Uroflowmetry=urinary flow rate
• Non- invasive urodynamic test
• Key parameters: maximal flow (Qmax) and flow pattern
• Minimal voided volume to perform study is 150 ml
• Useful to monitoring treatment outcomes and correlating
symtoms with objective findings
Uroflowmetry equipment
Uroflowmetry
Normal Q max
18- 25 ml/s
Imaging of the prostate
• Can be performer by:
- Transabdominal ultrasound (TAUS)daily practice

- Transrectal ultrasound (TRUS) daily practice

- Computed tomography (CT)

- Magnetic resonance imaging (MRI)

TRUS vs TAUS
• Transrectal US is superior to transabdominal volume
measurement
Upper urinary tract ultrasound
Urethrocystoscopy

For patients with LUTS and history of:

-Microscopic or gross haematuria
-Urethral stricture
-Bladder cancer
Urodynamics
Male LUTS urodynamic techniques = filling cystometry + pressure flow studies (PFS)
BPH management- conservative treatment
• Watchful waiting (WW)- option for men with non- bothersome LUTS
• Behavioural and dietary modifications:
 reduction of fluid intake at night or when going out in public
 avoiding consumption of caffeine or alcohol
 use of relaxed and double- voiding techniques
 urethral milking to prevent post- micturition dribble
bladder training to increase bladder capacity and the time between voids
 treatment of constipation
BPH management- phytotherapy
• Herbal drug preparations are made of: roots, seeds, pollen, bark or fruits
• Mono- or combination preparations
• The most widely used plants:
- Cucurbita pepo (pumpkin seeds)
- Hypoxis rooperi (South Africa star grass)
- Pygeum africanum (bark of the African plum tree)
- Secale cereale (rye pollen)
- Serenoa repens (Sabal serrulata; saw palmetto)
- Urtica dioica (roots of the stinging nettle)
BPH management- phytotherapy
Effects:
-anti- inflammatory
-anti- androgenic
-oestrogenic
- decrease sexual hormone binding globulin
-inhibit aromatase, lipoxygenase, growth factor- stimulated
proliferation of prostatic cells, α-adrenoceptors, 5 α-reductase,
muscarinic cholinoceptors, dihydropyridine receptors, vaniloid
receptors
-neutralise free radicals
BPH management- phytotherapy
No phytotherapeutic agent has been shown to :
-reduce prostate size
-BOO reduction
-decrease in desease progression
AE:
- gastrointestinal complaints
BPH management- pharmacological treatment

α1-adrenoceptor antagonists (α1-blockers )

[alfuzosin, doxazosin, silodosin, tamsulosin, terazosin,
naftopidil]
-inhibit the effect of endogenously released noradrenaline on
smooth muscle cells in the prostate
-reduce prostate tone and BOO
-reduce IPSS (30-40%)
-increase Qmax (20-25%)
-reduce storage and voiding LUTS
-more efficacious in patients with smaller prostates (< 40ml)
BPH management- pharmacological treatment
α1-adrenoceptor antagonists (α1-blockers )
[alfuzosin, doxazosin, silodosin, tamsulosin, terazosin,
naftopidil]
-they do not reduce prostate size and do not prevent AUR
- most frequent adverse events [AE]:
•asthenia
•dizziness
•hypotension (orthostatic)
•intra- operative floppy iris syndrome (IFIS) affecting cataract
surgery
•retrograde ejaculation, decrease or absence of seminal fluid
 BPH management- pharmacological treatment

5α- reductase inhibitors

[dutasteride, finasteride]
- testosteron enzyme 5α- reductase (nuclear- bound steroid) dihydrotestosterone
-induces apoptosis of prostate epithelial cells
-decrease in circulating PSA level about 50% after 6-12 month of treatment
-reduces risk of AUR and need for surgery
-effective at prostate volume > 40 ml
-after 2-4 years treatment:
•prostate size reduction of about 18- 28%
•increases Qmax by 1,5- 2,0 ml/s
•IPSS improvement by 15- 30%
BPH management- pharmacological treatment
5α- reductase inhibitors
[dutasteride, finasteride]
-AE:
•reduces libido
•erectile dysfunction (ED)
•ejaculation disorders:
retrograde ejaculation
ejaculation failure
decrease in semen volume
•gynaecomastia (with breast or nipple tenderness) 1-2%
BPH management- pharmacological treatment

phosphodiesterase 5 inhibitors (PDE5Is)

tadalafil (5 mg once daily)
•increase intracellular cyclic guanosine monophosphate  reducing smooth
muscle tone of the detrusor, prostate and urethra
•chronic treatment increase blood perfusion and oxygenation in lower urinary
tract
•recomended for the treatment of LUTS and ED
•reduce IPSS, storage and voiding LUTS
•improve QoL
•improve IIEF, but not Qmax
•AE: flushing, headache, dyspepsia
BPH management- pharmacological treatment

muscarinic receptor antagonists

[fesoterodine, oxybutynin, propiverine, solifenacin, tolterodine,
trospium]
•detrusor is innervated by parasympathetic nerves whose main
neurotransmiter is acetylocholinę, which stimulates muscarinic receptors on
the smooth muscle cells
•improve urgency, urgent urinary incontinence and reduce daytime
frequency
•increased PVR after therapy, but not AUR
•AE:
-dry mouth
-constipation
BPH management- pharmacological treatment

beta-3 agonist
[mirabegron]
•predominant beta receptors expressed in the smooth muscle cells of the
detrusor
their stimulation to induce detrusor relaxation
•reduces micturition frequency, urgency and urgent urinary incontinence
•improves voided volume and nocturia
•does not change Qmax and PVR
AE:
- hypertension
- headache
BPH management- pharmacological treatment
Combination therapies
α1-blockers + 5α-reductase inhibitors

α1-blockers + muscarinic receptor antagonists

BPH management- surgical treatment

TUIP- transurethral incision of the prostate

- minimally invasive surgical treatment of LUTS
-incising the bladder outlet without tissue removal
-prostate volume < 30 ml, without a middle lobe
-no TUR- syndrome
-risk of bleeding requiring transfusion is negligible
- retrograde ejaculation rate lower compared to TURP
BPH management- surgical treatment
TURP- transurethral resection of prostate

-cornerstone of LUTS/BPO surgical treatment

-removing tissue from the transition zone of the gland
-using monopolar (M-TURP) or bipolar energy (B-TURP)
-prostate volume 30- 80 ml
-significant reduction in IPSS, QoL scale and PVR
-improvement Qmax
BPH management- surgical treatment
TURP- complications:
-clot retention 4,9%
-AUR 4,5%
-UTI 4,1%
-bleeding requiring transfusion 2%
-TUR- syndrome 0,8% (M-TURP)
-retrograde ejaculation 65%
-ED 6,5 %
-urinary incontinence 2%
-bladder neck contracture 5%, urethral stricture 4%
BPH management- surgical treatment
B-TUVP = bipolar transurethral vaporisation of the prostate
•bipolar electrode + high- frequency generator to create a plasma
effect able to vaporise prostatic tissue
•displays thinner coagulation zones (B-TUVP < 2mm vs M-TUVP
10mm)
•better haemostatic efficiency  shorter catheterisation 
shorter hospitalisation times
•less irritative side-effects
•less stress urinary incontinence
•B-TUVP and TURP have similar short term efficacy
BPH management- surgical treatment
Open prostatectomy (OP)
-for substantially enlarged glands (> 80- 100 ml)
-adenomas enucleation:
•using the index finger
•through the bladder (Freyer’s procedure)
•through the anterior prostatic capsule (Millin procedure)
-reduces LUTS (63-86%)
-improves QoL (60- 87%)
-increases Q max (375% !!!)
-reduces PVR (86-98%)
BPH management- surgical treatment
Open prostatectomy (OP)- complications:
-bleeding requiring transfusion (7- 14%)
-transient urinary incontinence (10%)
-bladder neck contracture (6%)
-urethral stricture (6%)
-mortality (<0,25%)
BPH management- surgical treatment
Laser treatment of the prostate
Holmium laser enucleation (HoLEP) and holmium laser resection of the
prostate :
-efficacy comparable with TURP and OP
-shorter catherisation time and hospitalisation stay (vs TURP)
-reduced blood loss and fewer blood transfusions (vs TURP)
-longer operation time (vs TURP)
-complications are comparable with TURP
-safely performed in patients using anticoagulant and/or antiplatelet
medications
-did not negatively affect on erectile function
BPH management- surgical treatment
532 nm („Greenlight”) laser vaporisation of the prostate (PVP)
•the potassium- titanyl- phosphate 80 W (KTP) and the lithium triborate 120W and 180 W
(LBO) lasers – wavelength of 532 nm
•laser Energy is absorber by haemoglobin, but not by water
•vaporisation=
-immediate removal of prostatic tissue
-relief of BPO
-reduction of LUTS
-efficacy and complication comparable with TURP
-lower risk of capsule perforation
-significantly lower transfusion requirements
-shorter catheterisation time
-shorter duration of hospital stay
BPH management- surgical treatment
Thulium:yttrium-aluminium-garnet laser (Tm:YAG)
-wavelength 1,940 - 2,013 nm
-continuous wave mode
-front-fire applications
-Different applications:
•vaporisation (ThuVAP)
•vaporesection (ThuVARP)
•vapoenucleation (ThuVEP), laser assisted anatomical enucleation
(ThuLEP)
-high intra- operative safety (even with large prostates, anticoagulation or
bleeding disorders)
BPH management- surgical treatment
Diode laser treatment of the prostate:
-vaporisation and enucleation
BPH management- surgical treatment
Prostatic stents
-permanent stents are biocompatible- allowing for epithelialisation
-temporary stents do not epithelialise; may be biostable or biodebradable
-alternative to an indwelling catheter
-primary treatment option in patients without significant comorbidities
-relative improvement in symptoms and Qmax
-AE: misplacement, migration, poor tolerability,
-AE: exacerbation of LUTS, encrustation
-AE: perineal pain or bladder storage symptoms
BPH management- surgical treatment
Prostatic urethral lift (PUL)
-novel minimally invasive approach under local or general anaesthesia
- encroaching lateral lobes are compressed by small permanent suture-
based implants delivered under cystoscopic guidance (Urolift®)
-opening of the prostatic urethra that leaves a continuous anterior channel
through the prostatic fossa ranging from the bladder neck to the
verumontanum
BPH management- surgical treatment
Summary
Questions?