Documente Academic
Documente Profesional
Documente Cultură
: R3
Contents
1
4
5
Department of Surgery
VGHTC
Contents
urolithiasis
urologic trauma
8
9
urologic oncology
Department of Surgery
VGHTC
VGHTC
Urologic Anatomy
for the general
surgeon
Department of Surgery
VGHTC
UROLOGIC ANATOMY
Upper Abdomen and Retroperitoneum
Department of Surgery
VGHTC
UROLOGIC ANATOMY
the surrounding organs:
Right
Left
Posterior
12th rib
psoas muscle
11th~12th rib
psoas muscle,
Anterior
Department of Surgery
VGHTC
UROLOGIC ANATOMY
Department of Surgery
VGHTC
UROLOGIC ANATOMY
URETER
Department of Surgery
VGHTC
UROLOGIC ANATOMY
Ureter
blood supply
The calyces, pelvis, and upper ureter: renal arteries
The lower ureter: common and internal iliac, internal
spermatic, and vesical arteries
UROLOGIC ANATOMY
Pelvic Anatomy: Bladder, Prostate,
and Seminal Vesicles
Department of Surgery
VGHTC
UROLOGIC ANATOMY
BLADDER
Capacity: ~500 mL
Cephalad: urachus, a fibrous remnant of the cloaca
Superior: covered by peritoneal reflection
Inferior: attached to the pubic bone by puboprostatic ligaments /
pubovesical ligaments
Artery:
hypogastric a.(internal iliac a.)superior, middle, and inferior vesical arteries
vaginal and uterine a.
Vein:
vesicle plexus internal iliac v.
Lymphatics:
The bulk of the lymphatic drainage external iliac LN
Anterior, lateral drainage obturator, internal iliac node
Base, trigone internal, common iliac groups
UROLOGIC ANATOMY
Pelvic Anatomy: Bladder, Prostate,
and Seminal Vesicles
Department of Surgery
VGHTC
UROLOGIC ANATOMY
PROSTATE
Weight:~20 g
Anterior: puboprostatic ligament
Inferiorly: urogenital diaphragm
Posterior: Denonvilliers' fascia x2 layers rectum
Zonal anatomy
peripheral zone
central zone
transitional zone
anterior segment(anterior fibromuscular stroma)
preprostatic sphincteric zone
*BPH develops from the median or lateral lobes, posterior lobe is
prone to cancerous formation.
VGHTC
UROLOGIC ANATOMY
PROSTATE
Artery:
inferior vesical a.
internal pudendal a.
middle rectal (hemorrhoidal) a.
Vein:
periprostatic plexus, which has connections with the deep
dorsal vein of the penis and the internal iliac
(hypogastric) veins
VGHTC
UROLOGIC ANATOMY
Groin, Genitalia, and Perineum
Department of Surgery
VGHTC
UROLOGIC ANATOMY
Male urethra
20 cm
four anatomic sections
Prostatic urethra
Membranous urethra
Bulbous urethra
penile urethra.
female urethra
4 cm
lies below the pubic symphysis
anterior to the vagina
voluntary external urinary sphincter:
lies within the urogenital diaphragm
Department of Surgery
VGHTC
UROLOGIC ANATOMY
Spermatic cord, contains:
vas deferens
internal and external spermatic arteries,
artery of the vas
spermatic vein
Lymphatics
Nerves
epididymis
1~3 seminiferous tubules rete testis in the mediastinum 12~
20 efferent ductules head of the epididymis single coiled
duct of the epididymis
testis
4 3 2.5 cm in diameter
Tunica albuginea, connects with the lobules within the testis
visceral tunica vaginalis serous tunica vaginalis
Department of Surgery
VGHTC
VGHTC
endoscopic urologic
surgery
Department of Surgery
VGHTC
Endoscopic
urologic surgery
Cystoscopy/cystourethroscopy(CUS)
rigid or flexible
adult
17Fr diagnostic rigid scopes
24 to 26 Fr operating resectoscopes
Department of Surgery
VGHTC
Endoscopic
urologic surgery
Optical urethrotome: urethral stricture
incision
Electroresectoscope
cutting loop
Green Light laser
Holmium laser
bipolar resection system
Ellik evacuator
Continuous bladder irrigation (CBI)
Department of Surgery
VGHTC
Endoscopic
urologic surgery
Department of Surgery
VGHTC
VGHTC
Urologic Infectious
Disease
Department of Surgery
VGHTC
Urologic infectious
disease
Emphysematous Infection
DM
Emphysematous pyelonephritis
fulminant infection involving the renal parenchyma progress
to involve the perinephric space
most common causative agent: E.coli
percutaneous drainage
urgent nephrectomy: delay if improving with medical
treatment
Emphysematous pyelitis
gas within the renal collecting system but not within the
parenchyma
Department of Surgery
VGHTC
Urologic infectious
disease
Department of Surgery
VGHTC
Urologic infectious
disease
Emphysematous cystitis
gas-forming infection involving the bladder wall
urinary catheter drainage
VGHTC
Urologic infectious
disease
Xanthogranulomatous Pyelonephritis
foamy, lipid-laden, macrophage infiltrate in the renal
parenchyma
chronic bacterial infection, usually in the presence of
stones and chronic obstruction
poorly functioning kidney
fistulization to the flank or adjacent organs
drainage often are unproductive, Nephrectomy is
usually indicated
cooling off period for active infection
risk of iatrogenic adjacent organ injury is high
the renal vessels cannot be individually dissected
Department of Surgery
VGHTC
Urologic infectious
disease
Epididymitis, Epididymo-Orchitis, Without
and With abscess
infected through ascending infection from the urinary
tract down the vas deferens into the scrotum
DDx:
testicular torsion
incarcerated inguinal hernia
testicular tumor with necrosis and inflammation
Scrotal ultrasound
abscess: surgical drainage +/- orchiectomy
testicular ischemia: exploration +/- orchiectomy
Department of Surgery
VGHTC
Urologic infectious
disease
Fourniers Gangrene
Necrotizing soft tissue infections of the genitalia
scrotal and genital pain, swelling, discoloration or
frank necrosis, crepitus, foul-smelling discharge
broad-spectrum antibiotic, supportive care, urgent
surgical debridement
separate the parietal tunica vaginalis of the testes
from the overlying necrotic dartos and skin and
preserve the tunical compartment intact
If the penile skin is necrotic, it can be dbrided down
to but not through the Bucks fascial layer
urinary tract source: urethral stricture with perforation
Foley
meshed STSG for the scrotum and nonmeshed thick
STSG for the penile shaft
Department of Surgery
VGHTC
Urologic infectious
disease
Department of Surgery
VGHTC
Urologic infectious
disease
Genitourinary Fungal Infections
diabetics, immunocompromised patients
extensive nosocomial and antibiotic exposure
invasive fungal infections of the bladder or
kidneys may be life-threatening
antifungal bladder irrigation
fungus balls in the renal colleting
system:direct irrigation or endoscopic removal
Department of Surgery
VGHTC
Urologic infectious
disease
Genitourinary Tuberculous Infections
Urine cultures from the first morning void
Upper urinary tract tuberculosis infection
may cause ureteral strictures, result in silent
obstruction and renal loss
Tuberculous epididymitis
chronic epididymitis results in cutaneous
fistula formation
test for an immunocompromised state,
including HIV
Department of Surgery
VGHTC
VGHTC
Voiding Dysfunction,
BOO, BPH, and
Incontinence
Department of Surgery
VGHTC
Voiding dysfunction
Postoperative Acute Urinary Retention
Cause:
Immobility
Narcosis
anticholinergic side effects of anesthetic agents
underlying subclinical bladder outlet obstruction,
local pain and spasm (typical after hemorrhoid or groin hernia
surgery)
transient prostatic swelling following coronary bypass surgery
or other procedures requiring cardiopulmonary bypass
Treatment:
Catheterization voiding trial second catheterization +
indwelling Foley catheter for 1 or more days
alpha blocker
adequate analgesics
urodynamic studies
cystoscopy
Department of Surgery
VGHTC
Voiding dysfunction
Urinary Incontinence
Urgency incontinence
loss of urine associated with an urge to void
overactive bladder / detrusor instability
anticholinergic / antimuscarinic
SE: dry mouth, constipation, confusion
Contraindication: narrow-angle glaucoma
Stress incontinence
loss of urine with movement, straining, or increase in
abdominal pressure
multiple vaginal deliveries, psot radical prostatectomy
pelvic floor exercises, sling, artificial urinary sphincter
Department of Surgery
VGHTC
Voiding dysfunction
Overflow incontinence
loss of urine when the bladder becomes full and
there is an inability to empty volitionally
palpate the full bladder, measurement of postvoid
residual by ultrasound or catheter drainage
the cause of the bladder distention: obstructive
versus detrusor dysfunction
Mixed incontinence
Department of Surgery
VGHTC
Voiding dysfunction
Neurourology and Voiding
Dysfunction of the Neurologically
Impaired
cerebral dysfunction: uninhibited detrusor
function
cervical cord lesions: detrusor-sphincter
dyssynergia (DESD)
lower lumbar / sacral lesions: bladder
flaccidity and impaired emptying
Department of Surgery
VGHTC
Voiding dysfunction
Benign Prostatic Hyperplasia and
Bladder Outlet and Urethral
Obstruction
LUTS (lower urinary tract symptoms)
little correlation between the measured
volume of the prostate and degree of
symptomatology that results
watchful waiting
Department of Surgery
VGHTC
Voiding dysfunction
Department of Surgery
VGHTC
Voiding dysfunction
medical therapy
-adrenergic blocking agents
orthostatic side effects
5-alpha-reductase inhibitors
minimally invasive
standard surgical intervention
laser procedures
TURP
open simple prostatectomy
Department of Surgery
VGHTC
VGHTC
Department of Surgery
VGHTC
Male Infertility
Infertility affects 15% ~ 20% of couples
Male factor: 50% of these cases.
Hx:
potential gonadotoxic exposure
urologic and sexually transmitted infections
trauma and prior surgery involving the pelvis, groin, and
genitalia
family history of infertility
PE:
Masculinization
meatal location
testicular size
presence and normalcy of the
epididymis and vas deferens
Varicocele
DRE
Department of Surgery
VGHTC
Male Infertility
Semen analysis
semen volume
consistency
sperm concentration
sperm total count
percentage motility
quality of sperm movement
sperm morphology
presence of RBC/WBC/bacteria
FSH
LH
testosterone
free testosterone
prolactin
Department of Surgery
VGHTC
Male Infertility
azoospermia: complete absence of sperm from
the semen
lack of sperm production
normal semen volume
elevated serum follicle-stimulating hormone (FSH) level
varicocele
antisperm antibodies
genital duct infection with pyospermia causing sperm dysfunction
gonadotoxic exposure
Department of Surgery
VGHTC
Male Sexual
Dysfunction
40% of men at 40y/o and 70% of
men at 70y/o
erectile dysfunction can be an early
indication of significant
atherosclerotic vascular disease
Department of Surgery
VGHTC
VGHTC
Urolithiasis
Department of Surgery
VGHTC
Urolithiasis
Risk factors
20~50y/o, males, Caucasians and Asians
family history of stone disease
Low fluid intake (<1200ml/day)
High animal protein intake
Low activity levels
Chronic UTI
primary hyperparathyroidism
Sarcoidosis
Familial renal tubular acidosis
hyperoxaluria
cystinuria
inflammatory bowel disease
short gut syndrome
medullary sponge kidney
Department of Surgery
VGHTC
Urolithiasis
Symptoms
acute onset pain, hematuria, and possibly
nausea, vomiting, and ileus.
Image:
KUB: 90% of stones are radio-opacity
Ultrasound: hydronephrosis
non-contrast CT: the stone and the dilated
collecting system proximal to it
Department of Surgery
VGHTC
Urolithiasis
Acute episodes: obstruction /
infection
Hydration
Analgesics
Decompressed urgently if with infection
retrograde ureteral stent insertion
percutaneous nephrostomy insertion
Ureteroscopic lithotripsy is contraindicated.
Department of Surgery
VGHTC
Urolithiasis
Treatment
Watchful waiting pilots
Extracorporeal lithotripsy (ESWL)
Intracorporeal techniques
Ureteroscopic stone manipulation
Flexible ureteroscopy and laser treatment
Percutaneous nephrolithotomy (PCNL)
VGHTC
VGHTC
Urologic Trauma
Department of Surgery
VGHTC
Urologic trauma
Urologic injury
10% of penetrating abdominal trauma cases
variable percentage of blunt abdominal
trauma cases
Renal injuries
1.4% to 3.25% of all trauma patients
4% to 8% of penetrating trauma patients
Department of Surgery
VGHTC
Urologic trauma
Department of Surgery
VGHTC
Urologic trauma
Renal Injuries
Imaging :CT scan
Treatment
Grade 1 ~ 3:routinely managed nonoperatively
Grade 4:controversial
hemodynamic
Interventional radiology options
Department of Surgery
VGHTC
Urologic trauma
Ureteral Injuries
Treatment
penetrating injuries / blunt avulsion: best managed by
surgical repair
Ureteral contusions:
prophylactic stenting to reduce progressive edema, occlusion, and
ischemia and postinjury extravasation
VGHTC
Urologic trauma
Bladder Injuries
Gross hematuria
Penetrating injuries with laparotomy planned:
direct inspection of the injury site intraoperatively
Blunt trauma
stress cystogram to distinguish intraperitoneal from extraperitoneal
injury
Extraperitoneal rupture
pelvic fracture tearing and shear forces related to injury to the pelvic
ring
catheter drainage alone
repair may be necessary when failure of catheter management
Intraperitoneal rupture
sudden compression of the bladder by impact to the lower anterior
abdominal wall --> laceration of the bladder dome
exploration and repair
Department of Surgery
VGHTC
Urologic trauma
Department of Surgery
VGHTC
Urologic trauma
exploration of the bladder:
Department of Surgery
VGHTC
Urologic trauma
Urethral Injuries
suspicion of urethral injury
blood per the urethra or blood at the urethral meatus
following blunt trauma
pelvic fracture
straddle injury with perineal impact
penetrating trauma
severe pubic diastasis
marked vertical shear pelvic fracture
Department of Surgery
VGHTC
Urologic trauma
Treatment
primary immediate goal: provide urinary bladder
drainage suprapubic catheter
early catheter realignment for posterior urethral
disruption
delay repair
Department of Surgery
VGHTC
Urologic trauma
Genital Injuries
Early exploration and repair
Penile injuries
VGHTC
VGHTC
Nontraumatic
Urologic Emergencies
Department of Surgery
VGHTC
Testicular Torsion
congenital deformity: bell clapper deformity
able to rotate freely on its spermatic cord pedicle
progressive edema and venous and arterial occlusion
testicular infarction
VGHTC
Testicular Torsion
Department of Surgery
VGHTC
Testicular Torsion
Best results: detorsion within 4 hours of the onset
of pain
8 ~ 12 hours: testicular viability and function
decreases significantly
Ultrasound: within 1 hour after presentation
VGHTC
Etiology:
Department of Surgery
VGHTC
VGHTC
Priapism
Definition:
Prolonged and often painful erection in the absence
of a sexual stimulus, lasting > 4~6h
may resolve spontaneously but, if it persists longer
than 2 to 3 hours, measures should be taken
Etiology:
Department of Surgery
VGHTC
Priapism
Low-flow priapism
Due to veno-occlusion, typical of sickle cell
patients
More common than high-flow priapism
sludging of blood in the corpora cavernosa results
in the accumulation of dark thick material
Ischaemic priapism > 4h: emergency intervention
Aspiration of blood from corpora:50ml portions
using a 18~20 gauge butterfly needle
Intracavernosal injection of 1 -adrenergic
agonist
medical treatment of the sickle crisis :
rehydration, oxygenation, analgesia, and
haematological input (consider exchange
transfusion).
Department of Surgery
VGHTC
Priapism
High-flow priapism
after penile or perineal trauma
fistula develops between a central corporal
artery and the vascular space within the
corpus cavernosum
Aspiration: arterial appearance and arterial
blood gas parameters
cool bath / icepack
embolization of the internal pudendal artery
Department of Surgery
VGHTC
VGHTC
Urologic Oncology
Department of Surgery
VGHTC
urologic oncology
Renal Tumor
Diagnosis
solid renal tumors > 3 cm: 65% ~ 75% represent renal cell carcinomas
Bx prior to surgical extirpation is reserved
DDx:
lymphoma
minimally fat-containing angiomyolipoma,
Sarcoma
pseudotumor
hypercalcemia
anemia
Stauffer's syndrome(Nonmetastatic hepatic dysfunction)
ESR elevation
*cytokine
*Hepatic function normalizes after nephrectomy: 60% to 70%
VGHTC
urologic oncology
Department of Surgery
VGHTC
urologic oncology
Histologic Classification
Conventional
Clear cell
Granular
Mixed
Chromophilic/papillary
Type1
Type2
Chromophobic
Collecting duct
Medullary cell
Unclassified
*Sarcomatoid variants of almost all the histologic subtypes
Department of Surgery
VGHTC
urologic oncology
Partial nephrectomy
small, well-encapsulated, superficial, exophytic, polar lesion
positive margin and local recurrence rate: acceptable range < 5%
Radical nephrectomy
multiple tumors, large central tumor, postoperative hemorrhage,
necrosis, or loss of collecting system integrity
Department of Surgery
VGHTC
urologic oncology
Urothelial Cancer: Upper and Lower
Tract
Risk factors:
age
Tobacco smoking
chemical exposures:
aniline dyes
aromatic amine compounds
rubber, leather, dye and petroleum workers
Cyclophosphamide
VGHTC
urologic oncology
Bladder cancer
TCC: 90%
consider upper tract imaging
long-term recurrence rate: 50%
SCC: 5% ~ 10%
schistosomal infection
chronic inflammatory
smoking
Adenocarcinoma: 1% ~ 2%
urachal in origin, typically seen at the upper bladder
dome
history of bladder exstrophy
evaluation of the GI system to ensure that the tumor has
not arisen from another organ system
Department of Surgery
VGHTC
urologic oncology
Symptoms:
Dx:
Urine cytology / bladder wash cytology
Department of Surgery
VGHTC
urologic oncology
Treatment:
TURBt
BCG intravesical immunotherapy: initial + maintenance
Intravesical Chemotherapy: Mitomycin C
immediately following standard TUR
Radical cystectomy: muscle-invasive bladder cancer
+/- neoadjuvant chemotherapy
male: cystoprostatectomy
female: cystohysterectomy
+/- urethrectomy
urinary diversion
ileal conduit
cutaneous catheterizable reservoirs
orthotopic bladder substitution / neobladder:
Studer pouch
Chemotherapy: MVAC or GC
Department of Surgery
VGHTC
urologic oncology
Upper tract TCC
Treatment:
Surgical resection
+/- neoadjuvant chemotherapy
Nephroureterectomy, including ureteral orifice
Department of Surgery
VGHTC
urologic oncology
Prostate Cancer
Adenocarcinomas(95%)
Dx:
Asymptomatic
DRE, PSA, discovered incidentally during radical
cystectomy or TURP
Risk factors:
family history : Y chromosome
advancing age
African American heritage
Department of Surgery
VGHTC
urologic oncology
Prostate Cancer
Screening for prostate cancer: PSA and DRE
recommended by the American Cancer Society
and American Urologic Association
in all men older than 50 years
with elevated risk factors: 40 / 45 years
PSA
normal-range
50 y/o: 2.5ng/mL
60 y/o 3.5ng/mL
percentage of free PSA
VGHTC
urologic oncology
Prostate Cancer
Dx:
TRUS Bx
Gleason score: two highest and most prominent
grades observed
CT scan: lymph nodes metastasis
Bone scan: bone metastasis
Department of Surgery
VGHTC
urologic oncology
Prostate Cancer
Tx:
localized disease
advanced disease
androgen ablation therapy
Department of Surgery
VGHTC
urologic oncology
Penile, Urethral, and Other Genital
Malignancies
Penile cancer
Uncommon
SCC
chronic phimosis and local infection: HPV
circumcision, distal penectomy, or radical
penectomy +/- inguinal lymphadenectomy
Urethral cancer
women > men
TCC
partial or total urethrectomy
Department of Surgery
VGHTC
VGHTC