AnaLomy of Lhe CenlLourlnary 1racL Cross Mlcroscoplc

1he kldneys
1he kldneys lle reLroperlLoneally ln Lhe posLerlor abdomen and are separaLed from Lhe surroundlng
renal fascla (CeroLas fascla) by perlnephrlc faL 1he renal vascular pedlcle enLers Lhe renal slnus Lhe
veln ls anLerlor Lo Lhe arLery and boLh are anLerlor Lo Lhe renal pelvls 1he renal arLery dlvldes [usL
ouLslde Lhe renal slnus lnLo anLerlor and posLerlor branches LhaL undergo furLher subdlvlslons wlLh
varlable exLenLs of dlsLrlbuLlon 1hey are end arLerles and Lhus resulL ln segmenLal lnfarcLlon when
occluded 1he venous LrlbuLarles anasLomose freely and usually draln lnLo one renal veln
1he 8enal arenchyma
1he renal parenchyma conslsLs of more Lhan 1 mllllon funcLlonlng unlLs (nephrons) and ls dlvlded lnLo a
perlpheral corLex conLalnlng secreLory elemenLs and a cenLral medulla conLalnlng excreLory elemenLs
1he nephron sLarLs as 8owmans capsule whlch surrounds Lhe glomerulus and leads Lo elongaLed
proxlmal and dlsLal convoluLed Lubules wlLh Lhe loop of Penle ln beLween endlng ln a collecLlng ducL
LhaL opens lnLo a mlnor callx aL Lhe Llp of a papllla
1he 8enal elvls Callces
1he renal pelvls and callces are wlLhln Lhe renal slnus and funcLlon as Lhe maln collecLlng reservolr 1he
pelvls whlch ls parLly exLrarenal and parLly lnLrarenal (buL occaslonally ls LoLally exLrarenal or
lnLrarenal) branches lnLo Lhree ma[or callces LhaL ln Lurn branch lnLo several mlnor callces 1hese callces
are dlrecLly relaLed Lo Lhe Llps of Lhe medullary pyramlds (Lhe paplllae) and acL as a recelvlng cup Lo Lhe
collecLlng Lubules 1he pelvlcallceal sysLem ls a hlghly muscular sLrucLure Lhe flbers run ln many
dlrecLlons and are dlrecLly conLlnuous from Lhe callces Lo Lhe pelvls allowlng synchronlzaLlon of
conLracLlle acLlvlLy
1he ureLer
1he ureLer connecLs Lhe renal pelvls Lo Lhe urlnary bladder lL ls a muscularlzed Lube lLs muscle flbers lle
ln an lrregular hellcal arrangemenL and funcLlon prlmarlly ln perlsLalLlc acLlvlLy ureLeral muscle flbers
are dlrecLly conLlnuous from Lhe renal pelvls cranlally Lo Lhe veslcal Lrlgone dlsLally
1he blood supply Lo Lhe renal pelvls and ureLers ls segmenLal arlslng from mulLlple sources lncludlng
Lhe renal gonadal and veslcal arLerles wlLh rlch subadvenLlLlal anasLomoses
1he 8ladder
1he bladder ls prlmarlly a reservolr wlLh a meshwork of muscle bundles LhaL noL only change from one
plane Lo anoLher buL also branch and [oln each oLher Lo consLlLuLe a synchronlzed organ lLs musculaLure
ls dlrecLly conLlnuous wlLh Lhe ureLhral musculaLure and Lhus funcLlons as an lnLernal ureLhral
sphlncLerlc mechanlsm ln splLe of Lhe lack of a Lrue clrcular sphlncLer
1he ureLers enLer Lhe bladder posLerolnferlorly Lhrough Lhe ureLeral hlaLus afLer a shorL lnLraveslcal
submucosal course Lhey open lnLo Lhe bladder and become conLlnuous wlLh Lhe Lrlgone whlch ls
superlmposed on Lhe bladder base Lhough deeply connecLed Lo lL
1he ureLhra
1he adulL female ureLhra ls abouL 4 cm long and ls muscular ln lLs proxlmal four flfLhs 1hls musculaLure
ls arranged ln an lnner longlLudlnal coaL LhaL ls conLlnuous wlLh Lhe lnner longlLudlnal flbers of Lhe
bladder and an ouLer clrcular coaL LhaL ls conLlnuous wlLh Lhe ouLer longlLudlnal coaL of Lhe bladder
1hese ouLer clrcular flbers comprlse Lhe sphlncLerlc mechanlsm 1he sLrlaLed exLernal sphlncLer
surrounds Lhe mlddle Lhlrd of Lhe ureLhra
ln Lhe male Lhe prosLaLlc ureLhra ls heavlly muscular and sphlncLerlc 1he membranous ureLhra ls wlLhln
Lhe urogenlLal dlaphragm and ls surrounded by Lhe sLrlaLed exLernal sphlncLer 1he penlle ureLhra ls
poorly muscularlzed and Lraverses Lhe corpus sponglosum Lo open aL Lhe Llp of Lhe glans
1he rosLaLe
1he prosLaLe surrounds Lhe proxlmal porLlon of Lhe male ureLhra lL ls a flbromuscular coneshaped
gland abouL 23 cm long and normally welghlng abouL 20 g ln Lhe adulL lL ls Lraversed from base Lo apex
by Lhe ureLhra and ls plerced posLerolaLerally by Lhe e[aculaLory ducLs from Lhe semlnal veslcles and vas
deferens LhaL converge Lo open aL Lhe verumonLanum (semlnal colllculus) on Lhe floor of Lhe ureLhra
1he prosLaLlc glandular elemenLs draln Lhrough abouL 12 palred excreLory ducLs LhaL open lnLo Lhe floor
of Lhe ureLhra above Lhe verumonLanum 1he prosLaLe ls surrounded by a Lhln capsule derlved from lLs
sLroma whlch ls rlch ln musculaLure and parL of Lhe ureLhral musculaLure and Lhe sphlncLerlc
mechanlsm A rlch venous plexus surrounds Lhe prosLaLe especlally anLerlorly and laLerally lLs
lymphaLlc dralnage ls lnLo Lhe hypogasLrlc sacral obLuraLor and exLernal lllac lymph nodes
1he 1esLls Lpldldymls vas
1he LesLls ls a palred organ surrounded by Lhe Lunlca albuglnea and subdlvlded lnLo numerous lobules by
flbrous sepLa 1he exLremely convoluLed semlnlferous Lubules gaLher Lo open lnLo Lhe reLe LesLls where
Lhey [oln Lhe efferenL ducL and draln lnLo Lhe epldldymls 1he epldldymls dralns lnLo Lhe vas deferens
whlch courses Lhrough Lhe lngulnal canal lnLo Lhe pelvls and ls [olned by Lhe ducL from Lhe semlnal
veslcle Lo form Lhe e[aculaLory ducL whlch opens before openlng lnLo Lhe prosLaLlc ureLhra on elLher
slde of Lhe verumonLanum
ArLerlal supply ls vla Lhe spermaLlc vas deferenLlal and exLernal cremasLerlc arLerles venous dralnage
ls Lhrough Lhe pamplnlform plexus whlch dralns lnLo Lhe lnLernal spermaLlc velns Lhe rlghL spermaLlc
veln [olns Lhe vena cava and Lhe lefL [olns Lhe renal veln
1esLlcular lymphaLlcs draln lnLo Lhe reLroperlLoneal lymph nodes Lhe rlghL prlmarlly lnLo Lhe
lnLeraorLocaval area Lhe lefL lnLo Lhe paraaorLlc area boLh [usL below Lhe renal vessels
hyslology of Lhe CenlLourlnary 1racL
1he kldneys
1he kldneys malnLaln and regulaLe homeosLasls of body flulds by glomerular fllLraLlon Lubular
reabsorpLlon and Lubular secreLlon
Clomerular lllLraLlon
1hls mechanlsm ls dependenL on glomerular caplllary arLerlal pressure mlnus plasma collold osmoLlc
pressure plus 8owmans capsular reslsLance 1he resulLanL glomerular fllLraLlon pressure (abouL 812
mm Pg) forces proLelnfree plasma Lhrough Lhe caplllary fllLerlng surface lnLo 8owmans capsule
normally abouL 130 mL of plasma ls fllLered every mlnuLe Lhrough Lhe renal clrculaLlon Lhe enLlre
volume of plasma reclrculaLes Lhrough Lhe kldney and ls sub[ecLed Lo Lhe fllLraLlon process once every
27 mlnuLes

1ubular 8eabsorpLlon
AbouL 99 of Lhe fllLered volume ls reabsorbed Lhrough Lhe Lubules LogeLher wlLh all Lhe valuable
consLlLuenLs of Lhe fllLraLe (chlorldes glucose sodlum poLasslum calclum and amlno aclds) urea urlc
acld phosphaLes and sulfaLes are also reabsorbed Lo varylng degrees 1he process of reabsorpLlon ls a
comblnaLlon of acLlve and passlve LransporL mechanlsms 8eabsorpLlon of waLer and elecLrolyLes ls
under Lhe conLrol of adrenal plLulLary and paraLhyrold hormones
1ubular SecreLlon
1ubular secreLlon helps (1) Lo ellmlnaLe cerLaln subsLances and Lhus malnLaln Lhelr plasma levels and (2)
Lo exchange valuable lons from Lhe fllLraLe for less deslrable lons ln Lhe plasma (eg a sodlum lon from
Lhe urlne for a hydrogen lon ln Lhe plasma) lallure of adequaLe secreLory funcLlon leads Lo Lhe acldosls
commonly encounLered ln chronlc renal dlsease
1he ureLeropelvlcallceal SysLem
1hls sysLem ls one conLlnuous Lubular sLrucLure wlLh a syncyLlal Lype of smooLh musculaLure LhaL ls
lmpercepLlbly ln moLlon from one segmenL Lo Lhe oLher Waves of perlsLalLlc conLracLlons sLarL from Lhe
callces and are propagaLed along Lhe smooLh muscle cells Lo Lhe renal pelvls AL normal urlne flow raLes
many of Lhese conLracLlon waves are LermlnaLed aL Lhe ureLeropelvlc [uncLlon however some are
LransmlLLed Lo Lhe ureLer and down Loward Lhe urlnary bladder 1hese perlsLalLlc waves occur aL a raLe
of abouL 38/mln lnvolve a 2cm Lo 3cm segmenL aL a Llme and usually proceed aL Lhe veloclLy of 3
cm/s lrequency ampllLude and veloclLy are lnfluenced by urlne ouLpuL and flow raLe ln a sLaLe of
dluresls Lhere may be a 11 relaLlonshlp beLween callceal conLracLlons and ureLeral conLracLlons
ureLeral fllllng ls prlmarlly passlve and occurs by recepLlon of a bolus of urlne from a renal pelvls
conLracLlon 1he ureLeropelvlc [uncLlon closes afLer passlng a bolus of urlne prevenLlng backpressure
and backflow of urlne lnLo Lhe renal pelvls secondary Lo Lhe elevaLed ureLeral conLracLlon pressure A
conLracLlon rlng forms ln Lhe proxlmal ureLer and as lL mlgraLes down Lhe ureLer lL pushes Lhe bolus of
urlne anLegrade ln sLaLes of dluresls Lhe slze of Lhe bolus lncreases and Lhe pressure ln Lhe bolus may
be greaLer Lhan Lhe pressure ln Lhe conLracLlon rlng ahead of lL ln Lhls case Lhe ureLeral walls cannoL
coapL and urlne ls LransporLed as an unlnLerrupLed column of fluld
1he ureLeroveslcal !uncLlon
1he ureLeroveslcal [uncLlon allows flow of urlne from Lhe ureLer Lo Lhe bladder and aL Lhe same Llme
prevenLs reLrograde flow 1he conLlnulLy and Lhe speclflc muscular arrangemenL of Lhe lnLraveslcal
ureLer and Lhe Lrlgone provlde a muscularly acLlve valvular mechanlsm LhaL can efflclenLly adapL lLself Lo
Lhe varlable phases of bladder acLlvlLy durlng fllllng and voldlng
1he normal resLlng pressure of Lhe ureLeroveslcal [uncLlon (1013 cm P2C) ls greaLer Lhan Lhe more
cephalad ureLeral resLlng pressure (03 cm P2C) rogresslve bladder fllllng leads Lo flrm occluslon of
Lhe lnLraveslcal ureLer agalnsL reLrograde urlne flow and Lo lncreased reslsLance Lo anLegrade flow
resulLlng from Lrlgonal sLreLchlng uurlng voldlng Lrlgonal conLracLlon compleLely seals Lhe lnLraveslcal
ureLer agalnsL any anLegrade or reLrograde flow of urlne
1he urlnary 8ladder
1he urlnary bladder funcLlons prlmarlly as a reservolr LhaL can accommodaLe varlable volumes wlLhouL
lncreaslng lLs lnLralumlnal pressure When Lhe bladder reaches full capaclLy Lhe deLrusor muscle
volunLarlly conLracLs followlng relaxaLlon of Lhe exLernal sphlncLer and malnLalns lLs conLracLlon unLll
Lhe bladder ls compleLely empLy lunnellng of Lhe bladder ouLleL wlLh progresslve downward movemenL
of Lhe dome ensures compleLe empLylng
1he veslcal sphlncLerlc mechanlsm ls prlmarlly a smooLh muscle sphlncLer ln Lhe bladder neck and male
prosLaLlc ureLhra and ln Lhe proxlmal four flfLhs of Lhe female ureLhra 1here ls no purely clrcular
sphlncLerlc enLlLy buL Lhere are abundanL clrcularly orlenLed smooLh muscle flbers LhaL are dlrecLly
conLlnuous wlLh Lhe ouLer coaL of Lhe deLrusor muscles 1he sphlncLer has an abundance of alpha
recepLors LhaL respond Lo sympaLheLlc neural lnpuL from Lhe pelvlc nerve Lo malnLaln ureLhral closure
arasympaLheLlc lnpuL from Lhe pelvlc nerve faclllLaLes bladder conLracLure and voldlng
1here ls a volunLary sLrlaLed muscle sphlncLer LhaL ls parL of Lhe urogenlLal dlaphragm and surrounds Lhe
mld ureLhra ln Lhe female and Lhe membranous ureLhra ln Lhe male lL responds Lo somaLlc neural lnpuL
from Lhe pudendal nerve lL ls essenLlal for conLlnence when Lhe lnLernal sphlncLer ls nonfuncLlonal lLs
paLhologlc lrrlLablllLy or spasLlclLy can lead Lo obsLrucLlve manlfesLaLlons
lnLroducLlon
CenlLourlnary LracL anomalles consLlLuLe abouL one Lhlrd of all congenlLal abnormallLles and occur ln
over 10 of Lhe populaLlon 1he severlLy varles from leslons lncompaLlble wlLh llfe Lo lnslgnlflcanL
flndlngs deLecLed durlng dlagnosLlc sLudles for unrelaLed reasons 1he anaLomlc abnormallLles are ofLen
noL lnLrlnslcally harmful yeL Lhey may predlspose Lo lnfecLlon sLone formaLlon or chronlc renal fallure
8enal Anomalles
8llaLeral absence of Lhe kldneys ls rare and ls assoclaLed wlLh ollgohydramnlos oLLer facles and
pulmonary hypoplasla lL occurs more ofLen ln males and resulLs ln deaLh shorLly afLer blrLh unllaLeral
renal agenesls ls seen more ofLen buL ls noL usually assoclaLed wlLh lllness 8enal agenesls ls LhoughL Lo
be due Lo boLh lack of a ureLeral bud and lack of subsequenL developmenL of Lhe meLanephrlc blasLema
1he Lrlgone ls absenL on Lhe affecLed slde 8ecause adrenal gland developmenL ls unrelaLed Lo kldney
developmenL boLh adrenals are usually presenL ln Lhe normal poslLlon 8arely more Lhan Lwo kldneys
are seen a condlLlon clearly dlsslmllar Lo ureLeral dupllcaLlon as descrlbed laLer
Abnormal ascenL of Lhe meLanephros leads Lo an ecLoplc kldney whlch may be unllaLeral or bllaLeral
Lumbar pelvlc and Lhe less common Lhoraclc and crossed ecLoplc varleLles are seen LcLoplc kldneys are
assoclaLed wlLh genlLal anomalles ln 1020 of cases luslon abnormallLles are also assoclaLed wlLh
fallure of normal ascenL and lnclude fused pelvlc kldneys and horseshoe kldneys (Lhe mosL common)
whlch are Lyplcally fused aL Lhe lower poles lnLravenous urography Lyplcally esLabllshes Lhe dlagnosls
1he relaLlonshlp of Lhe kldneys Lo Lhe psoas muscles ls abnormal lnsLead of an obllque orlenLaLlon wlLh
Lhe medlal border of Lhe kldney parallel Lo Lhe psoas muscle Lhe kldneys are verLlcal and Lhe medlal
border lnLersecLs and crosses Lhe psoas muscle Porseshoe kldneys have an elevaLed lncldence of
veslcoureLeral reflux and are aL lncreased rlsk of ureLeropelvlc [uncLlon obsLrucLlon 1he laLLer may be
relaLed Lo a hlgh ureLeral lnserLlon ln Lhe renal pelvls crosslng of Lhe ureLer over Lhe lsLhmus or
compresslon by one of many anomalous arLerles lallure of roLaLlon durlng ascenL resulLs ln
malroLaLed kldneys and ls rarely slgnlflcanL
olycysLlc kldneys
arenchymal anomalles lnclude a varleLy of cysLlc and dysplasLlc leslons olycysLlc kldney dlsease ls
heredlLary and bllaLeral 1he auLosomal recesslve polycysLlc kldney dlsease (A8ku) prevlously called
lnfanLlle ku has numerous small cysLs LhaL arlse only from Lhe collecLlng ducLs and resulL ln bllaLeral
symmeLrlcal enlargemenL of Lhe kldneys 1he auLosomal domlnanL Auku prevlously called adulL ku
has cysLs arlslng from all areas of Lhe nephron whlch are usually larger and more varlable ln slze Lhan
Lhe A8ku cysLs A8ku occurs ln 1 ln 40000 blrLhs and may be deLecLed ln uLero by Lhe presence of
enlarged hyperechogenlc kldneys and ollgohydramnlos lnfanLs usually dle of resplraLory fallure raLher
Lhan renal problems however Lhe 1year survlval probablllLy afLer Lhe flrsL monLh ls over 83 1hese
chlldren have decllnlng renal funcLlon as well as severe hyperLenslon and hepaLlc perlporLal flbrosls wlLh
porLal hyperLenslon leadlng Lo hypersplenlsm and esophageal varlces
1he genes muLaLed ln Auku may lnclude Lhe ku1 gene (locaLed on chromosome 16p133) ln 83 of
paLlenLs or Lhe ku2 gene (on chromosome 4q2123) ln 12 Lo 13 of paLlenLs 1hese genes code for
Lhe polycysLln1 and polycysLln2 proLelns respecLlvely Auku occurs ln 1 ln 1000 lndlvlduals and ls a
ma[or cause of endsLage renal dlsease ln adulLs CysLs may also be presenL ln Lhe llver pancreas and
spleen and cerebral arLerlal aneurysms may occur 8enal cysLlc enlargemenL exerLs pressure on normal
parenchyma leadlng Lo lLs gradual desLrucLlon and glomerulosclerosls
1he dlagnosls ls ofLen made durlng a workup for hyperLenslon or uremla dlscovered ln Lhe Lhlrd Lo slxLh
decades PemaLurla wlLh or wlLhouL flank paln ls a common flndlng An lnLravenous urogram reveals Lhe
enlarged kldneys wlLh marked elongaLlon of Lhe callces whlch are compressed by large cysLs
ulLrasonography or C1 scan readlly makes Lhe dlagnosls
Surgery ls rarely warranLed 1herapy ls medlcal and ulLlmaLely lncludes dlalysls 1he medlan age for
reachlng endsLage renal dlsease ls 34 years ln ku1 and 74 years ln ku2 8enal LransplanLaLlon ls ofLen
lndlcaLed Lhough poLenLlal famlly donors musL be carefully screened Lo deLermlne wheLher Lhey have
Lhe same dlsorder 1he leadlng cause of deaLh ln Auku ls cardlovascular dlsease whlch may relaLe Lo
early unLreaLed hyperLenslon
Medullary Sponge kldney
Medullary sponge kldney resulLs from collecLlng Lubular ecLasla (see secLlon on olycysLlc kldneys) and
ls assoclaLed wlLh recurrenL urollLhlasls and an lncreased lncldence of lnfecLlon ln 30 of paLlenLs 1he
leslon ls ofLen bllaLeral and may lnvolve all of Lhe callces lnLravenous urograms reveal dllaLed collecLlng
Lubules as a blush ln Lhe renal papllla Mlcroscoplc hemaLurla ls common Speclflc anLlbloLlcs should
be glven for documenLed lnfecLlons and prophylacLlc Lherapy for renal sLones should be recommended
on Lhe basls of meLabollc sLone evaluaLlon
Slmple 8enal CysLs
Slmple renal cysLs are common (approxlmaLely 30 afLer age 30) and are LhoughL Lo arlse from Lubular
dllaLlon 1hey may be sollLary or bllaLeral and mulLlple 1hey rarely have paLhologlc slgnlflcance excepL
ln Lhe dlfferenLlaLlon from solld renal masses (See Lhe secLlon on 8enal Adenocarclnoma (8enal Cell
Carclnoma))
MulLlcysLlc uysplasLlc kldney
MulLlcysLlc dysplasLlc kldney ls a congenlLal abnormallLy conslsLlng of macroscoplc cysLs of varlable slzes
compresslng dysplasLlc renal parenchyma lL ls usually assoclaLed wlLh an aLreLlc proxlmal ureLer 1he
dlsorder occurs ln abouL 1 ln 3000 llve blrLhs and ls frequenLly noLed on prenaLal ulLrasound 8arely lL
may occur bllaLerally and ls assoclaLed wlLh ollgohydramnlos and renal fallure lL may be dlsLlngulshed
from oLher causes of hydronephrosls by Lhe absence of any renal funcLlon on renal scan 1here ls an
lncreased lncldence of conLralaLeral ureLeropelvlc [uncLlon obsLrucLlon (310) and reflux (1843)
elLher of whlch lncreases Lhe paLlenLs rlsk of subsequenL chronlc renal lnsufflclency
1he chance of developlng a mallgnancy ln mulLlcysLlc dysplasLlc kldney appears Lo be no greaLer Lhan 1
ln 2000 1here may also be an lncreased lncldence of hyperLenslon 1hese Lwo facLors consLlLuLe a
raLlonale for LreaLmenL by nephrecLomy Powever conservaLlve managemenL wlLh rouLlne ulLrasound
examlnaLlons aL lnLervals of 6 Lo 12 monLhs ls reasonable pracLlce slnce abouL half lnvoluLe wlLhln 3
years
8enal vascular AbnormallLles
MulLlple renal arLerles occur ln 13 Lo 20 of paLlenLs and are slgnlflcanL only when Lhey cause
ureLeropelvlc [uncLlon obsLrucLlon CongenlLal renal arLery aneurysms are lnfrequenL Lhey are
dlfferenLlaLed from acqulred leslons by Lhelr locaLlon aL Lhe blfurcaLlon of Lhe maln renal arLery or aL a
dlsLal branch polnL 1he leslons are usually asympLomaLlc buL Lhey can cause hyperLenslon 1hey
requlre surglcal LreaLmenL only lf hyperLenslon ls unconLrolled lf Lhey are lncompleLely calclfled or lf
Lhey have a dlameLer of more Lhan 23 cm CongenlLal arLerlovenous flsLulas are rare buL may resulL ln
hemaLurla hyperLenslon or cardlac fallure necesslLaLlng operaLlve LreaLmenL
8enal elvls Anomalles
ureLeropelvlc [uncLlon obsLrucLlon ls Lhe mosL common cause of anLenaLal hydronephrosls 1he
condlLlon may be assoclaLed wlLh compresslon by anomalous renal arLerles or lnLrlnslc sLenosls of Lhe
[uncLlon 1he dlagnosls ls noL uncommonly made when gross hemaLurla follows mlnor Lrauma 8enal
ulLrasound provldes a safe screenlng Lechnlque ln paLlenLs suspecLed of havlng ureLeropelvlc [uncLlon
obsLrucLlon ulureLlc renal scan may conflrm Lhe dlagnosls and suggesL funcLlonal slgnlflcance
lnLravenous pyelogram or reLrograde pyelography may furLher deflne Lhe anaLomy 8llaLerallLy ls noL
uncommon and Lhe condlLlon requlres surglcal repalr lf sympLomaLlc or severe ercuLaneous lnclslon
of Lhe obsLrucLlon wlLh shorLLerm sLenLlng has been successful ln adulLs SympLoms lnclude
lnLermlLLenL flank paln parLlcularly wlLh orally lnduced dluresls
Cooper CS eL al AnLenaLal hydronephrosls evaluaLlon and ouLcome Curr urol 8ep 20023131 Mlu
12084203
PaLeboer n Cllnlcal managemenL of polycysLlc kldney dlsease Clln Med 20033309 Mlu 14703027
Wlnyard ChlLLy L uysplasLlc and polycysLlc kldneys dlagnosls assoclaLlons and managemenL renaL
ulagn 200121924 Mlu 11746143

ureLeral Anomalles
CongenlLal CbsLrucLlon of Lhe ureLer
CongenlLal obsLrucLlon of Lhe ureLer may be due Lo ureLeroveslcal and ureLeropelvlc [uncLlon
obsLrucLlon or Lo neurologlc deflclLs such as sacral agenesls or myelomenlngocele luncLlonal ureLeral
obsLrucLlonalso known as prlmary obsLrucLlve megaureLerls noL uncommon SympLoms are renal
paln durlng dluresls or resulLlng from pyelonephrlLls LxcreLory urograms deplcL dllaLlon above Lhe
obsLrucLlon veslcoureLeral reflux ls uncommonly assoclaLed wlLh megaureLer Mllder forms wlLhouL
sympLoms or slgnlflcanL hydronephrosls are Lhe rule and do noL requlre LreaLmenL lf renal funcLlon ls
normal When LreaLmenL ls necessary lL conslsLs of dlvlslon of Lhe ureLer proxlmal Lo Lhe obsLrucLlon
and relmplanLaLlon of Lhe ureLer lnLo Lhe bladder ofLen lnvolvlng ureLeral Laperlng or pllcaLlon
uupllcaLlon of ureLers
8lfurcaLlon of Lhe ureLeral bud before lL lnLeracLs wlLh Lhe meLanephrlc blasLema resulLs ln lncompleLe
ureLeral dupllcaLlon commonly ln Lhe mld or upper ureLer A second ureLeral bud from Lhe meLanephrlc
ducL leads Lo compleLe ureLeral dupllcaLlon (llgure 384 rlghL kldney) dralnlng one kldney 1hls
represenLs Lhe mosL common ureLeral anomaly occurrlng ln 1 ln 123 people lL occurs Lwlce as ofLen ln
females 1he presence of more Lhan Lwo ureLers on each slde ls noL common buL bllaLerallLy of ureLeral
dupllcaLlon occurs ln 40 usually all of Lhe dupllcaLed ureLers enLer Lhe bladder Lhe ureLer dralnlng
Lhe upper pole of Lhe kldney enLers closesL Lo Lhe bladder neck (due Lo lLs laLer reabsorpLlon lnLo Lhe
bladder) 8ecause of Lhls relaLlonshlp Lhe ureLer dralnlng Lhe lower pole ofLen has a shorL lnLramural
Lunnel and an lnadequaLe surroundlng musculaLure and ls Lhus prone Lo veslcoureLeral reflux 1he
ureLer dralnlng Lhe upper pole may be ecLoplc (because of lLs laLe absorpLlon) and Lhus empLy lnLo Lhe
bladder neck ureLhra or genlLal sLrucLures (vaglna or vesLlbule ln Lhe female and semlnal veslcle or vas
deferens ln Lhe male llgure 384 lefL kldney) 1he ureLer dralnlng Lhe upper pole ls prone Lo
obsLrucLlon and may be assoclaLed wlLh a ureLerocele whlch ls a common cause of obsLrucLlon
uupllcaLlon becomes slgnlflcanL when hydronephrosls or pyelonephrlLls occurs 1he dlagnosls ls made
by lnLravenous urography ureLeral relmplanLaLlon Lo prevenL recurrenL lnfecLlon ls necessary ln some
cases An anasLomosls beLween Lhe upper pole renal pelvls and Lhe lower pole ureLer or a low
ureLeroureLerosLomy are alLernaLlves ln selecLed cases 1he upper pole of Lhe kldney and lLs ureLer may
requlre removal lf obsLrucLlon ls severe and renal funcLlon of LhaL segmenL ls poor
llgure 384




uupllcaLlon of ureLers and ecLoplc ureLeral orlflce CompleLe dupllcaLlon wlLh obsLrucLlon Lo one ureLer
wlLh ecLoplc orlflce on lefL 1he ureLer wlLh Lhe ecLoplc openlng always dralns Lhe upper pole of Lhe
kldney

LcLoplc ureLeral Crlflce
ureLeral ecLopla can occur ln Lhe absence of dupllcaLlon and draln lnLo any of Lhe abnormal poslLlons
menLloned prevlously lf Lhe orlflce lles proxlmal Lo Lhe exLernal urlnary sphlncLer no lnconLlnence
ensues buL veslcoureLeral reflux ls common ln conLradlsLlncLlon Lo Lhe female Lhe ecLoplc orlflce ln Lhe
male never lles dlsLal Lo Lhe exLernal sphlncLer maklng lnconLlnence an exLremely rare presenLaLlon
Should Lhe ecLoplc orlflce ln Lhe female draln lnLo Lhe vaglna or aL Lhe vesLlbule Lhere may be
conLlnuous leakage of urlne aparL from voldlng MosL ecLoplc orlflces lnvolve Lhe ureLer dralnlng Lhe
upper pole of a dupllcaLed sysLem and mosL are observed ln females PydroureLeronephrosls of Lhe
lnvolved segmenL frequenLly occurs due Lo ureLeral obsLrucLlon as lL Lraverses Lhe muscle of Lhe bladder
neck
An ecLoplc orlflce may be seen beslde Lhe ureLhral orlflce or ln Lhe roof of Lhe vaglna on endoscopy
8enal ulLrasound or lnLravenous urograms ofLen demonsLraLes hydroureLeronephrosls of Lhe upper
renal segmenL CysLography may show reflux lnLo Lhe ecLoplc orlflce buL may requlre cycllc voldlng flrsL
Lo decompress Lhe obsLrucLed segmenL wlLh bladder neck relaxaLlon and subsequenLly Lo permlL reflux
ln Lhe rare case when Lhere ls slgnlflcanL upper pole renal funcLlon Lhe ureLer can be dlvlded and
relmplanLed lnLo Lhe bladder or lower pole ureLer usually however hemlnephroureLerecLomy ls
necessary
ureLerocele
A ureLerocele ls a balloonlng of Lhe dlsLal submucosal ureLer lnLo Lhe bladder 1hls sLrucLure commonly
has a plnpolnL orlflce and Lherefore leads Lo hydroureLeronephrosls lf large enough lL may obsLrucL Lhe
veslcal neck or Lhe conLralaLeral ureLer lL ls mosL common ln females wlLh ureLeral dupllcaLlon and
always lnvolves Lhe ureLer dralnlng Lhe upper renal pole
MosL ureLeroceles are now deLecLed by prenaLal ulLrasound SympLoms are usually Lhose of
pyelonephrlLls or obsLrucLlon lnLravenous urograms may show a negaLlve shadow ln Lhe bladder casL by
Lhe ureLerocele 1he ureLer and renal callces may be normal or may reveal marked dllaLlon or no
excreLory funcLlon aL all A cysLogram may show reflux lnLo Lhe lpsllaLeral lower pole ureLer
1reaLmenL of ureLeroceles depends on mulLlple facLors lncludlng Lhe presence or absence of reflux ln
any or all of Lhe ureLers as well as wheLher or noL Lhe ureLerocele ls compleLely conLalned wlLhln Lhe
bladder (lnLraveslcal/orLhoLoplc) or lf a porLlon ls aL Lhe bladder neck or ureLhra (exLraveslcal/ecLoplc) A
slmple meLhod of esLabllshlng dralnage lnvolves cysLoscopy and puncLure of Lhe ureLerocele AssoclaLed
reflux lf presenL can be managed wlLh prophylacLlc anLlbloLlcs unLll Lhe chlld has grown larger aL whlch
Llme a Lechnlcally easler ureLeral relmplanL may be performed wlLh a decompressed ureLer ln Lhe
relaLlvely uncommon slLuaLlon when Lhere ls no assoclaLed reflux an upper pole hemlnephrecLomy ls
consldered Mlnlmally obsLrucLlve ureLeroceles wlLhln Lhe bladder ln adulLs do noL requlre LreaLmenL
Cooper CS eL al LongLerm followup of endoscoplc lnclslon of ureLeroceles lnLraveslcal versus
exLraveslcal ! urol 20001641097 Mlu 10938731
lreLz C eL al LongLerm ouLcome analysls of SLarr pllcaLlon for prlmary obsLrucLlve megaureLers ! urol
2004172703 Mlu 13247766

veslcoureLeral 8eflux
1he maln funcLlon of Lhe ureLeroveslcal [uncLlon ls Lo permlL free dralnage of Lhe ureLer and
slmulLaneously prevenL urlne from refluxlng back from Lhe bladder AnaLomlcally Lhe ureLeroveslcal
[uncLlon ls well equlpped for Lhls funcLlon because Lhe ureLeral musculaLure conLlnues unlnLerrupLed
lnLo Lhe base of Lhe bladder Lo form Lhe superflclal Lrlgone AddlLlonally Lhe Lermlnal 4 Lo 3 cm of ureLer
are surrounded by a musculofasclal sheaLh (Waldeyers sheaLh) LhaL follows Lhe ureLer Lhrough Lhe
ureLeral hlaLus and conLlnues ln Lhe base of Lhe bladder as Lhe deep Lrlgone (llgure 383)
llgure 383




veslcoureLeral reflux 1he lengLh and flxaLlon of Lhe lnLraveslcal ureLer and Lhe appearance of Lhe
ureLeral orlflce depend on Lhe muscular developmenL and efflclency of Lhe lower ureLer and lLs Lrlgone
A normal sLrucLures 8 ModeraLe muscular deflclency C Marked deflclency resulLs ln a golf hole
dlsLorLlon of Lhe submucosal ureLer


ulrecL conLlnulLy beLween Lhe ureLer and Lhe Lrlgone offers an efflclenL muscularly acLlve valvular
funcLlon Any sLreLch of Lhe Lrlgone (wlLh bladder fllllng) or any Lrlgonal conLracLlon (wlLh voldlng) leads
Lo flrm occluslon of Lhe lnLraveslcal ureLer Lhus lncreaslng reslsLance Lo flow from above downward and
seallng Lhe lnLraveslcal ureLer agalnsL reLrograde flow (llgure 386)
llgure 386




normal ureLeroLrlgonal complex A Slde vlew of ureLeroveslcal [uncLlon 1he Waldeyer muscular sheaLh
lnvesLs Lhe [uxLaveslcal ureLer and conLlnues downward as Lhe deep Lrlgone whlch exLends Lo Lhe
bladder neck 1he ureLeral musculaLure becomes Lhe superflclal Lrlgone whlch exLends Lo Lhe
verumonLanum ln Lhe male and sLops [usL shorL of Lhe exLernal meaLus ln Lhe female 8 Waldeyers
sheaLh ls connecLed by a few flbers Lo Lhe deLrusor muscle ln Lhe ureLeral hlaLus 1hls muscular sheaLh
lnferlor Lo Lhe ureLeral orlflces becomes Lhe deep Lrlgone 1he musculaLure of Lhe ureLers conLlnues
downward as Lhe superflclal Lrlgone (AdapLed from 1anagho LA ugh 8C8 1he anaLomy and funcLlon
of Lhe ureLeroveslcal [uncLlon 8r ! urol 196333131 8eproduced wlLh permlsslon of 8lackwell
ubllshlng LLd)

LLlology ClasslflcaLlon
veslcoureLeral reflux may be classlfled as prlmary reflux due Lo developmenLal ureLeroLrlgonal weakness
or assoclaLed wlLh ureLeral anomalles such as ecLoplc orlflce or ureLerocele and secondary reflux due Lo
bladder ouLleL or ureLhral obsLrucLlon neuropaLhlc dysfuncLlon laLrogenlc causes and lnflammaLlon
especlally speclflc lnfecLlon (eg Luberculosls) rlmary reflux ls assoclaLed wlLh some degree of
congenlLal muscular deflclency ln Lhe Lrlgone and Lermlnal ureLer
8eflux ls assoclaLed wlLh an lncreased lncldence of pyelonephrlLls and renal damage lL also allows
bacLerla free access from Lhe bladder Lo Lhe kldney
8eflux ls Lhe mosL common cause of pyelonephrlLls and ls found ln 30 Lo 30 of chlldren presenLlng
wlLh urlnary LracL lnfecLlon lL ls presenL ln over 73 of paLlenLs wlLh radlologlc evldence of chronlc
pyelonephrlLls and ls responslble for endsLage renal dlsease ln a large percenLage of paLlenLs requlrlng
chronlc dlalysls or renal LransplanLaLlon
ln prlmary reflux Lhe chlld (on average beLween 2 and 3 years of age) usually presenLs wlLh sympLoms
of pyelonephrlLls or cysLlLls vague abdomlnal paln ls noL uncommon 8enal paln and paln wlLh voldlng
are relaLlvely uncommon Cn rare occaslons Lhe paLlenL may presenL wlLh advanced renal fallure wlLh
bllaLeral renal parenchymal damage SlgnlflcanL reflux and lLs sequelae are more common ln females
and are usually deLecLed afLer a urlnary LracL lnfecLlon AbouL one Lhlrd of Lhe slbllngs of a chlld wlLh
reflux wlll also have reflux and one half of Lhe chlldren of a moLher wlLh reflux wlll also have reflux
ln secondary reflux manlfesLaLlons of Lhe prlmary dlsease (neuropaLhlc obsLrucLlve eLc) are usually Lhe
presenLlng sympLoms
Cllnlcal llndlngs
SympLoms and Slgns
WlLh acuLe pyelonephrlLls fever chllls and cosLoverLebral angle Lenderness may be presenL Chlldren
usually do noL have renal paln buL may complaln of vague abdomlnal paln Cccaslonally dayLlme
frequency lnconLlnence or enuresls may be caused by lnfecLlon assoclaLed wlLh reflux ln cases of
obsLrucLlon or neuropaLhlc deflclL a palpable hydronephroLlc kldney or a dlsLended bladder may be
found 1he dlagnosls may be eluslve ln lnfanLs who presenL wlLh llldeflned sympLoms
LaboraLory llndlngs
urlnalysls usually reveals evldence of lnfecLlon (pyurla and bacLerlurla) urlne culLures are mandaLory
when lnfecLlon ls suspecLed 8enal funcLlon LesLs may be abnormal lf reflux and lnfecLlon have caused
renal scarrlng
lmaglng SLudles
1he mosL useful sLudy for concluslve dlagnosls of reflux conLlnues Lo be voldlng cysLoureLhrography
(llgure 387) 1hls sLudy demonsLraLes Lhe grade of reflux as well as Lhe ureLhral anaLomy 8adlonucllde
voldlng sLudles are exLremely senslLlve aL deLecLlng reflux buL do noL demonsLraLe Lhe anaLomlc deLall
seen wlLh a voldlng cysLoureLhrogram 8adlonucllde voldlng sLudles are ofLen performed as followup
afLer an lnlLlal voldlng cysLoureLhrogram because Lhey offer Lhe advanLage of decreased radlaLlon
exposure
llgure 387




voldlng cysLoureLhrogram showlng LoLal (grade lv) lefL veslcoureLeral reflux

8adlolsoLoplc renal scannlng provldes accuraLe dlfferenLlal renal funcLlon daLa and deLecLlon of renal
scars ulLrasound can provlde accuraLe measuremenL of renal slze and may demonsLraLe Lhe presence
of renal scarrlng and ureLeral or callceal dllaLlon ln many cases Lhere may be no abnormallLy vlslble ln
Lhe upper urlnary LracL or only mlld dlsLal ureLeral dllaLaLlon may be seen
urodynamlc ConslderaLlons
A slgnlflcanL number of chlldren wlLh dysfuncLlonal voldlng presenL wlLh urlnary LracL lnfecLlons and are
subsequenLly found Lo have reflux 1hese chlldren conLracL Lhe bladder agalnsL a closed exLernal
sphlncLer LlevaLed voldlng pressures assoclaLed wlLh dysfuncLlonal voldlng may lncrease renal damage
wlLh an assoclaLed urlnary LracL lnfecLlon and may also lessen Lhe chance for elLher sponLaneous or
surglcal resoluLlon of reflux When Lhe hlsLory suggesLs Lhe posslblllLy of voldlng dysfuncLlon
(lnconLlnence frequency urgency) urodynamlc sLudles are conducLed Lo evaluaLe Lhe voldlng
dynamlcs 1reaLmenL of voldlng dysfuncLlon may resulL ln resoluLlon of Lhe reflux
1reaLmenL
AlLhough some chlldren wlLh lower grades of reflux may noL requlre anLlbloLlcs LradlLlonally any chlld
wlLh reflux was malnLalned on prophylacLlc anLlbloLlcs Lo aLLempL Lo decrease Lhe lncldence of urlnary
LracL lnfecLlons Several recenL sLudles suggesL LhaL Lhe pracLlce of dally anLlbloLlc prophylaxls ln all
chlldren wlLh reflux may be of llmlLed beneflL ln prevenLlng urlnary LracL lnfecLlon rompL LreaLmenL of
pyelonephrlLls prevenLs renal scar formaLlon lacLors causlng secondary refluxsuch as dysfuncLlonal
voldlng or obsLrucLlonshould be correcLed
ln many chlldren reflux resolves wlLh Llme 8eflux ls graded as seen on voldlng cysLoureLhrography as
follows
Crade l ConLrasL enLers ureLer
Crade ll ConLrasL enLers Lhe renal collecLlng sysLem
Crade lll SllghL dllaLlon of Lhe callces or ureLer
Crades lv and v rogresslvely lncreased amounLs of callceal dllaLlon and ureLeral dllaLlon or LorLuoslLy
8eflux mosL llkely Lo resolve ls of lower grade or deLecLed aL a younger age Cver 70 of chlldren wlLh
grades l ll or unllaLeral grade lll reflux wlll have resoluLlon wlLhln 3 years 8esoluLlon ln chlldren wlLh
grade v or bllaLeral grade lv reflux can be anLlclpaLed ln less Lhan 10 of cases CLher facLors LhaL
appear Lo negaLlvely affecL Lhe chance for reflux resoluLlon lnclude early reflux durlng bladder fllllng
presenLaLlon wlLh a febrlle urlnary LracL lnfecLlon renal scars and voldlng dysfuncLlon
ln obsLrucLlve secondary reflux (eg posLerlor ureLhral valves) release of obsLrucLlon may cure reflux
Cccaslonally surglcal relmplanLaLlon ls sLlll requlred ln neuropaLhlc reflux lnLermlLLenL caLheLerlzaLlon
for conLrol of lnfecLlon may allow reLurn of valvular compeLence Powever many cases requlre bladder
augmenLaLlon for a noncompllanL bladder and ureLeral relmplanLaLlon ln reflux assoclaLed wlLh ecLoplc
orlflces dupllcaLlon wlLh ureLerocele and oLher congenlLal malformaLlons relmplanLaLlon ls generally
requlred
1he alm of surgery ls Lo correcL Lhe reflux 1hls ls accompllshed by Lhe creaLlon of a longer submucosal
Lunnel for Lhe ureLer WlLh bladder fllllng and lncreased pressure Lhe ureLer ls compressed beLween Lhe
mucosa and underlylng deLrusor muscle 1hls flap valve prevenLs reflux of urlne 1he necessary lengLh of
Lhe Lunnel Lo sLop reflux depends on Lhe dlameLer of Lhe ureLer wlLh a 31 lengLhLodlameLer raLlo
belng ldeal Cne of Lhree meLhods ls used ln mosL cases (1) ln suprahlaLal repalr (ollLanoLeadbeLLer
procedure) a new ureLeral hlaLus ls developed abouL 23 cm above Lhe orlglnal one and Lhe ureLer
afLer passlng Lhrough a submucosal Lunnells suLured Lo Lhe cuL edge of Lhe Lrlgone aL Lhe level of Lhe
orlglnal orlflce (2) ln Lhe crossLrlgonal repalr (Cohen procedure) Lhe orlglnal hlaLus ls malnLalned and
Lhe ureLer ls advanced Lhrough a submucosal Lunnel exLendlng across Lhe Lrlgone Lo Lhe conLralaLeral
bladder wall (3) A LoLally exLraveslcal ureLeral advancemenL procedure (exLraveslcal ureLeroplasLy)
achleves resulLs slmllar Lo Lhose achleved wlLh Lhe lnLraveslcal meLhods wlLh a shorLer hosplLal sLay and
shorLer convalescence
ln[ecLlons of subureLerlc bulklng agenLs have also been used Lo lncrease submucosal supporL of Lhe
ureLer WlLh proper placemenL beneaLh Lhe ureLeral orlflce under endoscoplc vlslon Lhese ln[ecLlons acL
Lo bolsLer Lhe deflclenL anLlreflux mechanlsm Concern regardlng laLe sequelae of 1eflon ln[ecLlons (eg
parLlcle mlgraLlon) has prevenLed use of Lhls approach ln Lhe unlLed SLaLes CurrenLly hyaluronlc
acld/dexLranomer (nASPA/ux) gel (ueflux) ls Lhe only luAapproved maLerlal for endoscoplc ln[ecLlon Lo
manage veslcoureLeral reflux ln chlldren ShorLLerm success ln sLopplng reflux wlLh Lhe ln[ecLlon
Lechnlques appears Lo be around 73 1he longLerm success raLes wlLh agenLs oLher Lhan 1eflon
remaln Lo be deLermlned
rognosls
1he longLerm prognosls ls excellenL for paLlenLs wlLh mlld Lo moderaLe reflux successfully LreaLed wlLh
anLlbloLlc prophylaxls 1here are few lnsLances of recurrenL lnfecLlon or renal lnsufflclency aLlenLs wlLh
more slgnlflcanL reflux or perslsLenL urlnary LracL lnfecLlons may beneflL from subureLerlc ln[ecLlon or
surglcal relmplanLaLlon Lhe success raLe ls approxlmaLely 93 wlLh Lhe open surglcal Lechnlque
(cessaLlon of reflux clearance of renal lnfecLlon and absence of obsLrucLlon) unforLunaLely for
paLlenLs wlLh advanced dlsease (lrreverslble ureLeral decompensaLlon and severe bllaLeral scars) Lhe
prognosls ls less favorable 1hese paLlenLs accounL for a slgnlflcanL proporLlon of paLlenLs wlLh endsLage
renal dlsease who ulLlmaLely requlre chronlc dlalysls renal LransplanLaLlon or boLh
AusLln !C Cooper CS veslcoureLeral reflux surglcal approaches urol Clln norLh Am 200431343
Mlu 13313064
Cooper CS AusLln !C veslcoureLeral reflux who beneflLs from surgery? urol Clln norLh Am 200431333
Mlu 13313063
Cooper CS eL al 1he ouLcome of sLopplng prophylacLlc anLlbloLlcs ln older chlldren wlLh veslcoureLeral
reflux ! urol 2000163269 Mlu 10604374
Llder !S eL al edlaLrlc veslcoureLeral 8eflux Culdellnes anel summary reporL on Lhe managemenL of
prlmary veslcoureLeral reflux ln chlldren ! urol 19971371846 Mlu 9112344
Carln LP eL al Cllnlcal slgnlflcance of prlmary veslcoureLeral reflux and urlnary anLlbloLlc prophylaxls
afLer acuLe pyelonephrlLls a mulLlcenLer randomlzed conLrolled sLudy edlaLrlcs 2006117626 Mlu
16310640
!odal u eL al lnfecLlon paLLern ln chlldren wlLh veslcoureLeral reflux randomly allocaLed Lo operaLlon or
longLerm anLlbacLerlal prophylaxls Lhe lnLernaLlonal reflux sLudy ln chlldren ! urol 19921481630
Mlu 1433381
knudson M! eL al redlcLlve facLors of early sponLaneous resoluLlon ln chlldren wlLh veslcoureLeral
reflux ! urol 20071781684 Mlu 17707023

8ladder Anomalles
Anomalles of Lhe bladder are lnfrequenL and lnclude Lhe followlng (1) agenesls or compleLe absence
whlch resulLs ln a perslsLenL cloaca (2) bladder dupllcaLlon whlch may be compleLe wlLh separaLe
ureLeral openlngs dralned by dupllcaLed ureLhras or lncompleLe wlLh a sepLum or hourglass deformlLy
and (3) urachal anomalles whlch ln Lhe mosL severe forms appear as a paLenL openlng aL Lhe umblllcus
and are usually assoclaLed wlLh some form of bladder ouLleL obsLrucLlon ln less severe forms a urachal
dlverLlculum may be presenL aL Lhe dome of Lhe bladder or a urachal cysL along Lhe course of Lhe
parLlally obllLeraLed urachus 1hese laLLer condlLlons may cause abdomlnal paln and umblllcal or bladder
lnfecLlon requlrlng surglcal LreaLmenL Cccaslonally adenocarclnoma develops ln a urachal remnanL (see
secLlon on 1umors of Lhe 8ladder)
lallure of cloacal dlvlslon resulLs ln a perslsLenL cloaca lncompleLe dlvlslon ls more frequenL (Lhough sLlll
rare) and resulLs ln a recLoveslcal recLoureLhral or recLovesLlbular flsLula (usually wlLh lmperforaLe anus
or anal aLresla)
LxsLrophy of Lhe 8ladder
LxsLrophy of Lhe bladder ls Lhe mosL severe bladder anomalyLhe resulL of a compleLe venLral defecL of
Lhe urogenlLal slnus and Lhe overlylng lnferlor abdomlnal wall musculaLure and lnLegumenL 1he lower
cenLral porLlon ls devold of skln and muscle 1he anLerlor bladder wall ls absenL and Lhe posLerlor wall ls
conLlguous wlLh surroundlng skln urlne dralns onLo Lhe abdomlnal wall Lhe raml of Lhe publc bones are
wldely separaLed and Lhe open pelvlc rlng may affecL galL ln males Lhe penls ls shorLened and Lhe
ureLhra ls eplspadlac 1he exposed bladder mucosa Lends Lo be chronlcally lnflamed
CurrenLly Lhe favored LreaLmenL ls bladder salvage whlch lncludes closure of Lhe bladder ln Lhe
newborn perlod ureLhral closure and penlle reconsLrucLlon have also been advocaLed aL Lhe Llme of Lhe
lnlLlal bladder closure ureLeral obsLrucLlon or veslcoureLeral reflux may develop and requlre ureLeral
relmplanLaLlon 1he closed bladder may have a small capaclLy and lnconLlnence ls ofLen a compllcaLlon
aLlenLs frequenLly requlre mulLlple operaLlons lncludlng bladder augmenLaLlon and bladder neck
reconsLrucLlon Cood resulLs have been observed ln more Lhan half of all paLlenLs LreaLed wlLh
preservaLlon of renal funcLlon and conLlnence
Cooper CS eL al edlaLrlc reconsLrucLlve surgery Curr Cpln urol 200010193 Mlu 10838896
rune 8elly Syndrome
rune belly syndrome conslsLs of a Lrlad of abnormallLles deflclenL abdomlnal wall musculaLure
bllaLeral crypLorchldlsm and varlable amounLs of dllaLlon of Lhe urogenlLal LracL 1he cause ls noL
known AlmosL all chlldren wlLh prune belly syndrome have reflux 1he lncldence of evenLual renal
fallure ls 23 Lo 30 8lsk facLors for renal fallure lnclude bllaLeral abnormal kldneys on ulLrasound or
renal scan a serum creaLlnlne LhaL never falls below 07 mg/dL and cllnlcal pyelonephrlLls 1hese
chlldren are managed wlLh prophylacLlc anLlbloLlcs and frequenL urlne culLures followed by prompL
LreaLmenL of any urlnary LracL lnfecLlons AbdomlnoplasLy may be performed Lo help correcL Lhe
abdomlnal wall defecL
noh P eL al rognosLlc facLors of renal fallure ln chlldren wlLh prune belly syndrome ! urol
19991621399 Mlu 10492223
CongenlLal neuroveslcal uysfuncLlon
CongenlLal neuroveslcal dysfuncLlon frequenLly accompanles a posLerlor myelomenlngocele or sacral
agenesls wlLh assoclaLed splnal abnormallLles 8oLh condlLlons may resulL ln lnconLlnence and recurrenL
urlnary lnfecLlon wlLh laLe sequelae (ureLeral reflux pyelonephrlLls and renal fallure) 1hese chlldren
requlre frequenL evaluaLlon of Lhelr kldneys and kldney funcLlon because hlgh bladder sLorage pressures
may harm Lhe kldneys
enlle ureLhral Anomalles
Pypospadlas
Pypospadlas resulLs from fallure of fuslon of Lhe ureLhral folds on Lhe undersurface of Lhe genlLal
Lubercle 1he ureLhral meaLus ls venLrally dlsplaced on Lhe glans on Lhe shafL of Lhe penls or more
proxlmal aL Lhe level of Lhe scroLum or perlneum WlLh more proxlmal dlsplacemenL chordee (venLral
curvaLure of Lhe penlle shafL) frequenLly occurs and requlres LreaLmenL or lL precludes sLralghL
erecLlons and normal lnLercourse (llgure 388) 1he mldscroLal hypospadlac penls may resemble female
exLernal genlLalla wlLh an enlarged cllLorls and labla Sexual asslgnmenL ln Lhese laLLer lnfanLs requlres
hormonal and chromosomal analysls
llgure 388




Pypospadlas penoscroLal Lype 8edundanL dorsal foreskln LhaL ls deflclenL venLrally venLral chordee

ln hypospadlas wlLh Lhe meaLus poslLloned proxlmal Lo Lhe corona Lhe prepuce ls abnormalnoL
formlng a compleLe cyllnder due Lo a venLral defecL Clrcumclslon should noL be done ln Lhese paLlenLs
as Lhe prepuce can be used laLer ln surglcal repalr
1he degree of hypospadlas dlcLaLes Lhe need for repalr lf Lhe openlng ls glandular or coronal (83 of
paLlenLs) Lhe penls ls usually funcLlonal boLh for mlcLurlLlon and procreaLlon and repalr ls done
prlmarlly for cosmeLlc reasons Cpenlngs LhaL are more proxlmal on Lhe shafL requlre correcLlon Lo allow
voldlng whlle sLandlng normal erecLlon and proper sperm deposlLlon durlng lnLercourse Surglcal
plasLlc repalr of hypospadlas ls currenLly accompllshed by a varleLy of hlghly successful onesLage
operaLlons and ls rouLlnely performed beLween 6 and 18 monLhs of age 1he mosL common
compllcaLlons of hypospadlas surgery lnclude meaLal sLenosls and flsLula formaLlon however lmproved
Lechnlques have decreased Lhe lncldence of Lhese compllcaLlons
Lplspadlas
Lplspadlas ls a rare congenlLal anomaly LhaL ls commonly assoclaLed wlLh bladder exsLrophy When lL
occurs alone lL ls consldered a mllder degree of Lhe exsLrophy complex
1he ureLhra opens on Lhe dorsum of Lhe penls wlLh deflclenL corpus sponglosum and loosely aLLached
corpora cavernosa lf Lhe defecL ls exLenslve lL may exLend Lo Lhe bladder neck causlng lnconLlnence
because of deflclenL sphlncLer muscles 1he publc bones are separaLed as ln exsLrophy Marked
dorslflexlon of Lhe penls ls usually presenL
1reaLmenL conslsLs of correcLlon of penlle curvaLure reconsLrucLlon of Lhe ureLhra and reconsLrucLlon
of Lhe bladder neck ln lnconLlnenL paLlenLs
ureLhral SLrlcLures
CongenlLal ureLhral sLrlcLures are rare buL when presenL are mosL common ln Lhe fossa navlcularls ([usL
proxlmal Lo Lhe meaLus) and ln Lhe bulbomembranous ureLhra Commonly Lhese sLrlcLures are Lhln
dlaphragms LhaL may respond Lo slmple dllaLlon or Lo dlrecL vlslon lnLernal ureLhroLomy 8arely ls open
surglcal repalr necessary CongenlLal ureLhral sLrlcLures ln glrls and meaLal sLenosls ln boys are
uncommon When Lhe laLLer does occur lL appears Lo be acqulred as lL ls seen only ln clrcumclsed boys
ureLhral ulverLlculum
ln males ureLhral dlverLlcula are nearly always ln Lhe pendulous or bulbous ureLhra 1hey are ofLen
assoclaLed wlLh an obsLrucLlve flap of Lhe ureLhral mucosa (anLerlor ureLhral valve) LhoughL Lo
represenL lncompleLe closure of Lhe ureLhral folds 1reaLmenL by endoscoplc unrooflng ls usually
successful Lhough mosL dlverLlcula are small and requlre no Lherapy ln females Lhey occur ln adulL llfe
and are usually manlfesLed by lrrlLaLlve sympLoms and recurrenL lnfecLlon 1he cause ls unknown buL
Lhe dlsorder ls mosL llkely congenlLal 1reaLmenL ls usually by Lransvaglnal exclslon ulverLlcula may
occaslonally harbor sLones or Lumors
osLerlor ureLhral valves
osLerlor ureLhral valves are Lhe mosL common obsLrucLlve ureLhral leslon ln newborn and lnfanL males
and Lhe mosL common cause of endsLage renal dlsease ln boys 1hey conslsL of obsLrucLlve folds of
mucosa whlch orlglnaLe aL or are aLLached aL some polnL Lo Lhe verumonLanum ln Lhe prosLaLlc ureLhra
1he embryologlc derlvaLlon ls lndeflnlLe 1hey are parLlally obsLrucLlve and Lhus lead Lo varlable degrees
of backpressure damage Lo Lhe urlnary bladder and upper urlnary LracL ullaLlon and obsLrucLlon of Lhe
prosLaLlc ureLhra are always presenL SponLaneous urlnary asclLes from Lhe kldneys ls ofLen seen ln
neonaLes 1hls clears when Lhe obsLrucLlon ls relleved
AbouL one Lhlrd of chlldren wlLh posLerlor ureLhral valves are now dlagnosed by prenaLal ulLrasound
AnoLher one Lhlrd are dlagnosed ln Lhe flrsL year of llfe wlLh Lhe remalnlng Lhlrd presenLlng laLer
Cllnlcal manlfesLaLlons conslsL of dlfflculL voldlng a weak urlnary sLream and a mldllne lower abdomlnal
mass LhaL represenLs a dlsLended bladder ln some cases Lhe kldneys are palpable and Lhe chlld may
have slgns and sympLoms of uremla and acldosls urlnary lnconLlnence and urlnary LracL lnfecLlon may
occur LaboraLory flndlngs lnclude elevaLed serum urea nlLrogen and creaLlnlne and evldence of urlnary
lnfecLlon ulLrasound shows evldence of bladder Lhlckenlng and LrabeculaLlon hydroureLer and
hydronephrosls uemonsLraLlon of ureLhral valves on a voldlng cysLoureLhrogram esLabllshes Lhe
dlagnosls as does endoscoplc ldenLlflcaLlon of valves up Lo 70 of chlldren wlLh valves may have
veslcoureLeral reflux
1reaLmenL conslsLs of desLrucLlon of Lhe valves by endoscoplc lnclslon ln a premaLure lnfanL wlLh a
small ureLhra prohlblLlng LransureLhral resecLlon a Lemporary cuLaneous veslcosLomy may be requlred
Lo provlde dralnage and lmprove lmpalred kldney funcLlon
1he prognosls depends on Lhe orlglnal degree of kldney damage and Lhe success of efforLs Lo prevenL or
LreaL lnfecLlon 8aLes of chronlc renal fallure or endsLage renal dlsease range from 23 Lo 67 of boys
wlLh valves oor prognosLlc facLors lnclude Lhe presence of bllaLeral reflux or an elevaLed nadlr serum
creaLlnlne ln Lhe flrsL year of llfe Many of Lhese chlldren have delayed developmenL of urlnary
conLlnence due Lo bladder changes and lmpalred urlnary concenLraLlon
Crady 8W eL al CompleLe repalr of exsLrophy ! urol 1999 1621413 Mlu 10492227
Snodgrass W Snodgrass Lechnlque for hypospadlas repalr 8r ! urol (lnL) 200393683 Mlu 13703110
?llnen L AlaPouhala M WlksLrm S rognosLlc facLors of posLerlor ureLhral valves and Lhe role of
anLenaLal deLecLlon edlaLr nephrol 200420874

ScroLal 1esLlcular Anomalles
1esLlcular 1orslon
neonaLal LesLlcular Lorslon (exLravaglnal Lorslon) ls an exLremely rare condlLlon 1he enLlre LesLlcle and
Lhe Lunlca vaglnalls are LwlsLed no Lrlgger mechanlsm assoclaLed wlLh Lhe Lorslon has been ldenLlfled
AlLhough Lhe vasL ma[orlLy are necroLlc and nonsalvageable several sLudles have reporLed salvage of
LesLlcular Llssue when Lorslon ls deLecLed lmmedlaLely followlng blrLh Any scroLal swelllng ln Lhe
neonaLe requlres close followup lnLravaglnal LesLlcular Lorslon ln adolescenLs ls descrlbed laLer ln Lhls
chapLer
Cooper CS eL al 8llaLeral neonaLal LesLlcular Lorslon Clln edlaLr 199736633 Mlu 9391740
ScroLal Leslons
CongenlLal scroLal leslons lnclude hypoplasla of Lhe scroLum (unllaLeral or bllaLeral) ln assoclaLlon wlLh
crypLorchldlsm and blfld scroLum wlLh exLenslve hypospadlas Mldllne lncluslon cysLs may also occur
CrypLorchldlsm
LLlology ClasslflcaLlon
1rue undescended LesLlcles sLop along Lhe normal paLh of descenL lnLo Lhe scroLum 1hey may remaln ln
Lhe abdomlnal cavlLy (leasL common) ln Lhe lngulnal canal (canallcular) or [usL ouLslde Lhe exLernal rlng
(suprascroLal mosL common) 1esLes may also pass Lhrough Lhe exLernal rlng and Lhen be locaLed
ecLoplcally mosL commonly ln a superflclal lngulnal pouch 1he lncldence of undescended LesLlcles
lncreases from 3 Lo 3 ln fullLerm lnfanLs Lo 30 ln premaLure lnfanLs MosL undescended LesLlcles
descend wlLhln Lhe flrsL 6 monLhs of llfe and by 1 year of age Lhe prevalence ls 1 1he lefL LesLlcle ls
affecLed more ofLen and 1 Lo 2 of chlldren wlLh crypLorchldlsm wlll have boLh LesLlcles affecLed
1wenLy percenL of boys who presenL wlLh crypLorchldlsm have one nonpalpable LesLls Cf nonpalpable
LesLes 20 are lnLraabdomlnal 40 are canallcular scroLal or ecLoplc LesLes and 40 are aLrophlc or
absenL
Cllnlcal llndlngs
1he dlagnosls of crypLorchldlsm relles on physlcal examlnaLlon Absence of an ldenLlflable LesLlcle wlLh
ulLrasound compuLed Lomography or magneLlc resonance lmaglng does noL prove LesLlcular agenesls
and Lherefore does noL alLer Lhe need for surglcal exploraLlon 1esLlcular examlnaLlon ln Lhe lnfanL and
young chlld requlres Lwo hands wlLh Lhe flrsL hand belng swepL from Lhe anLerlor lllac splne along Lhe
lngulnal canal Lo genLly express any reLalned LesLlcular Llssue lnLo Lhe scroLum whlch ls palpaLed wlLh
Lhe oLher hand A Lrue undescended or ecLoplc lngulnal LesLls may sllp or pop under Lhe examlners
flngers 1o dlsLlngulsh a reLracLlle LesLlcle Lhe LesLlcle ls broughL lnLo Lhe scroLal poslLlon holdlng lL ln
place for a mlnuLe Lo faLlgue Lhe cremasLer muscle AfLer Lhls a reLracLlle LesLlcle remalns ln Lhe
scroLum whereas an ecLoplc or undescended LesLls lmmedlaLely snaps back ouL of Lhe scroLum lf a
LesLls cannoL be palpaLed ln Lhe lngulnal canal or Lhe scroLum or ln Lhe Lyplcal ecLoplc slLes evaluaLlon
for a nonpalpable LesLls musL be performed
A chlld wlLh bllaLeral nonpalpable LesLes should undergo hormonal evaluaLlon for LesLlcular absence
LlevaLlons ln luLelnlzlng hormone (LP) and folllclesLlmulaLlng hormone (lSP) and absence of deLecLable
mullerlanlnhlblLlng subsLance suggesL LesLlcular absence 1esLlcular absence ls conflrmed by a negaLlve
human chorlonlc gonadoLropln (hCC) sLlmulaLlon LesL 1he hCC sLlmulaLlon LesL ls performed by Lhe
admlnlsLraLlon of lnLramuscular hCC (2000 lu/day for 34 days) 8alsed gonadoLropln levels (lSP and
LP) and a lack of a LesLosLerone rlse from hCC lndlcaLe bllaLeral absenL LesLes and a formal surglcal
exploraLlon ls unnecessary When one or boLh componenLs are lacklng or Lhere ls deLecLable mullerlan
lnhlblLlng subsLance surglcal exploraLlon ls warranLed
Surglcal 1herapy
1reaLmenL of Lhe undescended LesLlcle offers Lhe posslblllLy of lmproved ferLlllLy correcLlon of paLenL
processus vaglnalls prevenLlon of LesLls Lorslon and lmprovemenL ln body lmage 1here ls conLroversy
wheLher orchldopexy decreases Lhe rlsk of mallgnancy buL placemenL of an undescended LesLlcle ln Lhe
scroLum asslsLs physlcal examlnaLlon of Lhe LesLls PlsLologlc changes relaLed Lo lnferLlllLy occur ln Lhe
undescended LesLlcle as young as 1 year of age and sponLaneous descenL rarely occurs afLer 6 monLhs
of age maklng Lhls Lhe opLlmal Llme for surglcal correcLlon
AlmosL 90 of undescended LesLes have an assoclaLed paLenL processus vaglnalls whlch predlsposes Lo
formaLlon of a hydrocele or hernla CcculL lngulnal hernla ln paLlenLs wlLh unLreaLed undescended LesLls
can presenL aL any Llme wlLh Lhe Lyplcal sympLoms or compllcaLlons lncludlng lncarceraLlon
rlor Lo any surglcal lnLervenLlon Lhe paLlenL ls reexamlned whlle under anesLhesla because on occaslon
a reLracLlle LesLlcle descends under anesLhesla or a prevlously nonpalpable LesLlcle becomes palpable
lor a palpable LesLlcle an open lngulnal approach ls performed lor Lhe nonpalpable LesLlcle ln a chlld a
laparoscoplc approach ls preferred buL an open lngulnal approach may be performed
CuLcomes
Success raLes followlng orchldopexy are 74 for Lhe abdomlnal LesLls 87 for canallcular and 92 for
Lhose dlsLal Lo Lhe exLernal rlng 1he mosL slgnlflcanL compllcaLlon ls LesLlcular aLrophy whlch occurs ln
1 Lo 2 of cases of orchldopexy whlle compleLe devascularlzaLlon of Lhe LesLls ls rare aLernlLy raLes
have been reporLed aL 63 90 and 93 ln men wlLh bllaLeral crypLorchldlsm unllaLeral
crypLorchldlsm and normally descended LesLlcles respecLlvely lf only one LesLls ls undescended Lhe
sperm counL ls subnormal ln 23 Lo 33 paLlenLs and serum lSP concenLraLlon ls sllghLly elevaLed
1hese abnormallLles suggesL LhaL boLh LesLes are abnormal perhaps congenlLally alLhough only one falls
Lo descend lf boLh LesLes are undescended sperm counL usually ls severely subnormal and serum
LesLosLerone may be reduced
AlLernaLlve 1herapy
Pormonal Lherapy ls an opLlon ln Lhe LreaLmenL of crypLorchldlsm because Lhe condlLlon may be relaLed
Lo hypogonadoLroplc hypogonadlsm hCC ls Lhe only hormone approved for use ln Lhe LreaLmenL of
crypLorchldlsm ln Lhe unlLed SLaLes Slde effecLs of hCC LreaLmenL lnclude enlargemenL of Lhe penls
growLh of publc halr lncreased LesLlcular slze and aggresslve behavlor durlng admlnlsLraLlon 1he
llkellhood of success wlLh hormonal Lherapy ls greaLesL for Lhe mosL dlsLal undescended LesLes or for
LesLes LhaL have been prevlously descended Some suggesL LhaL hormonal Lherapy ls effecLlve only for
reLracLlle and noL Lruly undescended LesLes AlLhough hormonal Lherapy may noL be effecLlve ln
achlevlng LesLlcular descenL lL may lmprove ferLlllLy ln crypLorchld boys
PuLcheson !C eL al 1he anaLomlcal approach Lo lngulnal orchlopexy ! urol 20001641702 Mlu
11023733
Lee MM eL al MeasuremenLs of serum mullerlan lnhlblLlng subsLance ln Lhe evaluaLlon of chlldren wlLh
nonpalpable gonads n Lngl ! Med 19973361480 Mlu 9134766
Lee A eL al lerLlllLy afLer bllaLeral crypLorchldlsm LvaluaLlon by paLernlLy hormone and semen daLa
Pormone 8es 20013328 Mlu 11423739

CbsLrucLlve uropaLhy
CbsLrucLlon ls one of Lhe mosL lmporLanL abnormallLles of Lhe urlnary LracL slnce lL evenLually leads Lo
decompensaLlon of Lhe muscular condulLs and reservolrs backpressure and aLrophy of renal
parenchyma lL also lnvlLes lnfecLlon and sLone formaLlon whlch cause addlLlonal damage and can
ulLlmaLely end ln compleLe unllaLeral or bllaLeral desLrucLlon of Lhe kldneys
8oLh Lhe level and Lhe degree of obsLrucLlon are lmporLanL Lo an undersLandlng of Lhe paLhologlc
consequences Any obsLrucLlon aL or dlsLal Lo Lhe bladder neck may lead Lo backpressure affecLlng boLh
kldneys CbsLrucLlon aL or proxlmal Lo Lhe ureLeral orlflce leads Lo unllaLeral damage unless Lhe leslon
lnvolves boLh ureLers slmulLaneously CompleLe obsLrucLlon leads Lo rapld decompensaLlon of Lhe
sysLem proxlmal Lo Lhe slLe of obsLrucLlon arLlal obsLrucLlon leads Lo gradual progresslve muscular
hyperLrophy followed by dllaLlon decompensaLlon and hydronephroLlc changes
LLlology
Acqulred urlnary LracL obsLrucLlon may be due Lo lnflammaLory or LraumaLlc ureLhral sLrlcLures bladder
ouLleL obsLrucLlon (benlgn prosLaLlc hyperplasla or cancer of Lhe prosLaLe) veslcal Lumors neuropaLhlc
bladder exLrlnslc ureLeral compresslon (Lumor reLroperlLoneal flbrosls or enlarged lymph nodes)
ureLeral or pelvlc sLones ureLeral sLrlcLures or ureLeral or pelvlc Lumors
aLhogenesls
8egardless of lLs cause acqulred obsLrucLlon leads Lo slmllar changes ln Lhe urlnary LracL whlch vary
dependlng on Lhe severlLy and duraLlon of obsLrucLlon
ureLhral Changes
roxlmal Lo Lhe obsLrucLlon Lhe ureLhra dllaLes and balloons A ureLhral dlverLlculum may develop and
dllaLlon and gaplng of Lhe prosLaLlc ureLhra and e[aculaLory ducLs may occur
veslcal Changes
Larly deLrusor and Lrlgonal Lhlckenlng and hyperLrophy compensaLe for Lhe ouLleL obsLrucLlon allowlng
compleLe bladder empLylng 1hls change leads Lo progresslve developmenL of bladder LrabeculaLlon
cellules saccules and flnally dlverLlcula SubsequenLly bladder decompensaLlon occurs and ls
characLerlzed by Lhe above changes plus lncompleLe bladder empLylng (le posLvold resldual urlne)
1rlgonal hyperLrophy leads Lo secondary ureLeral obsLrucLlon owlng Lo lncreased reslsLance Lo flow
Lhrough Lhe lnLraveslcal ureLer WlLh deLrusor decompensaLlon and resldual urlne accumulaLlon Lhere ls
sLreLchlng of Lhe hyperLrophled Lrlgone whlch appreclably lncreases ureLeral obsLrucLlon 1hls ls Lhe
mechanlsm of backpressure on Lhe kldney ln Lhe presence of veslcal ouLleL obsLrucLlon (whlle Lhe
ureLeroveslcal [uncLlon malnLalns lLs compeLence) CaLheLer dralnage of Lhe bladder relleves Lrlgonal
sLreLch and lmproves dralnage from Lhe upper LracL
A very laLe change wlLh perslsLenL obsLrucLlon (more frequenLly encounLered wlLh neuropaLhlc
dysfuncLlon) ls decompensaLlon of Lhe ureLeroveslcal [uncLlon leadlng Lo reflux 8eflux aggravaLes Lhe
backpressure effecL on Lhe upper LracL by LransmlLLlng abnormally hlgh lnLraveslcal pressures and
favors Lhe onseL or perslsLence of urlnary LracL lnfecLlon
ureLeral Changes
1he flrsL change noLed ls a gradual lncrease ln ureLeral dlsLenLlon 1hls lncreases ureLeral callber and
sLlmulaLes hyperacLlve ureLeral conLracLlon and ureLeral muscular hyperLrophy 8ecause Lhe ureLeral
musculaLure runs ln an lrregular hellcal paLLern sLreLchlng of lLs muscular elemenLs leads Lo lengLhenlng
as well as wldenlng causlng Lhe dllaLed ureLer Lo assume a LorLuous serplglnous course weavlng back
and forLh across Lhe relaLlvely sLralghL course of Lhe ureLeral vessels whlch are unaffecLed by Lhe
ureLeral obsLrucLlon 1hls ls Lhe sLarL of ureLeral decompensaLlon where LorLuoslLy and dllaLlon become
apparenL 1hese changes progress unLll Lhe ureLer becomes aLonlc wlLh lnfrequenL lneffecLlve or
compleLely absenL perlsLalsls
elvlcallceal Changes
1he renal pelvls and callces sub[ecLed Lo lncreased volumes of reLalned urlne dlsLend 1he pelvls shows
evldence flrsL of hyperacLlvlLy and hyperLrophy and Lhen of progresslve dllaLlon and aLony 1he callces
show slmllar changes Lo a varlable degree dependlng on wheLher Lhe renal pelvls ls lnLrarenal or
exLrarenal ln Lhe laLLer callceal dllaLlon may be mlnlmal ln splLe of marked pelvlc dllaLlon ln Lhe
lnLrarenal pelvls callceal dllaLlon and renal parenchymal damage are maxlmal 1he successlve phases
seen wlLh obsLrucLlon are roundlng of Lhe fornlces followed by flaLLenlng of Lhe paplllae and flnally
clubblng of Lhe mlnor callces
8enal arenchymal Changes
WlLh conLlnued pelvlcallceal dlsLenLlon Lhere ls parenchymal compresslon agalnsL Lhe renal capsule
and more lmporLanLly compresslon of Lhe arcuaLe vessels resulLs ln a marked drop ln renal blood flow
leadlng Lo parenchymal lschemlc aLrophy WlLh lncreased lnLrapelvlc pressure Lhere ls progresslve
dllaLlon of Lhe collecLlng and dlsLal Lubules wlLh compresslon and aLrophy of Lubular cells
Cllnlcal llndlngs
SympLoms and Slgns
1he flndlngs vary accordlng Lo Lhe slLe of obsLrucLlon
lnfraveslcal CbsLrucLlon
lnfraveslcal obsLrucLlon (eg due Lo ureLhral sLrlcLure benlgn prosLaLlc hyperLrophy bladder neck
conLracLure) leads Lo dlfflculLy ln lnlLlaLlon of voldlng a weak sLream and a dlmlnlshed flow raLe wlLh
Lermlnal drlbbllng 8urnlng and frequency are common assoclaLed sympLoms A dlsLended or Lhlckened
bladder wall may be palpable ureLhral lnduraLlon due Lo sLrlcLure benlgn prosLaLlc hyperLrophy or
cancer of Lhe prosLaLe may be noLed on recLal examlnaLlon MeaLal sLenosls and lmpacLed ureLhral
sLones are readlly dlagnosed by physlcal examlnaLlon
Supraveslcal CbsLrucLlon
8enal paln or renal collc and gasLrolnLesLlnal sympLoms are commonly assoclaLed Supraveslcal
obsLrucLlon (eg due Lo ureLeral sLone ureLeropelvlc [uncLlon obsLrucLlon) may be compleLely
asympLomaLlc when lL develops gradually over a perlod of monLhs An enlarged kldney may be palpable
CosLoverLebral angle Lenderness may be presenL
LaboraLory llndlngs
Lvldence of urlnary LracL lnfecLlon hemaLurla or crysLallurla may be seen lmpalred renal funcLlon may
be noLed ln cases of bllaLeral obsLrucLlon osLrenal azoLemla (serum changes reflecLlng lmpalred renal
funcLlon due prlmarlly Lo obsLrucLlon) ls suggesLed by elevaLlon of serum urea nlLrogen and serum
creaLlnlne wlLh a raLlo greaLer Lhan 101
lmaglng SLudles
8adlologlc examlnaLlon ls usually dlagnosLlc ln cases of sLasls Lumors and sLrlcLures ullaLlon and
anaLomlc changes occur above Lhe level of obsLrucLlon whereas dlsLal Lo Lhe obsLrucLlon Lhe
conflguraLlon ls usually normal 1hls helps ln locallzlng Lhe slLe of obsLrucLlon Comblned anLegrade
lmaglng by lnLravenous urograms and reLrograde lmaglng by ureLerograms or ureLhrograms ls
someLlmes needed Lo demonsLraLe Lhe obsLrucLed segmenL ln supraveslcal obsLrucLlon demonsLraLlon
of sLasls and delayed dralnage ls essenLlal Lo esLabllsh and quanLlLaLe Lhe severlLy of obsLrucLlon
ulLrasonography
ulLrasonography reveals Lhe degree of dllaLlon of Lhe renal pelvls and callces and allows for dlagnosls of
hydronephrosls even ln Lhe prenaLal perlod Color uoppler ulLrasound can reveal blood flow and
resLrlcLlve lndlces Lo help deLermlne funcLlonal lmpalrmenL
lsoLope SLudles
A LechneLlum99m u1A scan or MAC3 scan porLray Lhe degree of hydronephrosls as well as renal
funcLlon use of dlureLlcs durlng Lhe scan can provlde speclflc daLa on Lhe slgnlflcance of Lhe obsLrucLlon
and Lhe need for LreaLmenL MulLlple sLudles can reveal ongolng funcLlonal changes
C1 Scan
C1 scan ls of parLlcular value ln reveallng Lhe degree and slLe of obsLrucLlon as well as Lhe cause ln many
cases 1he use of conLrasL (C1 urogram) agenLs allows esLlmaLlon of resldual renal funcLlon
M8 urogram
MagneLlc resonance lmaglng provldes anaLomlc lmages and ldenLlflcaLlon of Lhe slLe of obsLrucLlon
WlLh dynamlc conLrasLenhanced M8 urography funcLlonal lnformaLlon ls also obLalned wlLhouL Lhe use
of lonlzlng radlaLlon
AnLegrade urography
AnLegrade urography vla percuLaneous needle or Lube nephrosLomy ls valuable when Lhe obsLrucLed
kldney falls Lo excreLe Lhe radlopaque maLerlal on excreLory urography 1he WhlLaker LesL requlres
percuLaneous caLheLer access Lo Lhe collecLlng sysLem above Lhe slLe of suspecLed obsLrucLlon 1hls
permlLs fluld lnLroducLlon lnLo Lhe renal pelvls and slmulLaneous measuremenL of urlne flow raLe and
pressures ln Lhe bladder and renal pelvls Lhus provldlng a quanLlLaLlve assessmenL of Lhe degree and
severlLy of obsLrucLlon 1he fluld LransporL can be measured and Lhe degree of obsLrucLlon esLlmaLed by
Lhe use of a pressure monlLor
CompllcaLlons
1he mosL lmporLanL compllcaLlon of urlnary LracL obsLrucLlon ls renal parenchymal aLrophy as a resulL of
backpressure CbsLrucLlon also predlsposes Lo lnfecLlon and sLone formaLlon and lnfecLlon occurrlng
wlLh obsLrucLlon leads Lo rapld kldney desLrucLlon
1reaLmenL
1he flrsL goal of Lherapy ls rellef of Lhe obsLrucLlon (eg caLheLerlzaLlon for rellef of acuLe urlnary
reLenLlon) ueflnlLlve Lherapy ofLen requlres surgery buL mlnlmally lnvaslve Lechnlques are becomlng
uLlllzed more ofLen Slmple ureLhral sLrlcLure may be managed by dllaLlon or lnLernal ureLhroLomy
(lnclslon of Lhe sLrlcLure under dlrecL vlslon Lhrough Lhe resecLoscope) Powever ureLhroplasLy (open
surglcal grafL or flap of skln or buccal mucosa Lo replace ureLhral dlameLer) may be requlred and have
beLLer longLerm success 8enlgn prosLaLlc hyperplasla classlcally requlres exclslon buL laser Lechnlques
are provldlng saLlsfacLory ouLcomes wlLh less morbldlLy lmpacLed ureLeral sLones may elLher be
removed or bypassed by a caLheLer unless lL ls LhoughL LhaL Lhey may pass sponLaneously
ureLeral or ureLeropelvlc [uncLlon obsLrucLlon requlres surglcal repalr however endoscoplc approaches
wlLhln Lhe ureLer or by laparoscopy may be equal Lo open repalr 8enal sLones may be removed
lnsLrumenLally vla reLrograde or anLegrade percuLaneous approach by dlrecL exLracLlon wlLh baskeLs or
by ulLrasonlc or laser llLhoLrlpsy or by lrrlgaLlon Lhrough a Lube placed dlrecLly lnLo Lhe kldney
rellmlnary dralnage above Lhe obsLrucLlon ls someLlmes needed Lo lmprove kldney funcLlon
Cccaslonally lnLesLlnal urlnary dlverslon or permanenL nephrosLomy ls requlred lf damage ls advanced
nephrecLomy may be lndlcaLed
rognosls
1he prognosls depends on Lhe cause slLe duraLlon and degree of kldney damage and renal
decompensaLlon ln general rellef of obsLrucLlon leads Lo lmprovemenL ln kldney funcLlon excepL ln
serlously damaged kldneys especlally Lhose desLroyed by lnflammaLory scarrlng
CraLLanSmlLh !u eL al M8 lmaglng of kldneys funcLlonal evaluaLlon uslng l13 perfuslon lmaglng
edlaLr 8adlol 200333293 Mlu 12693861
admanabhan nlLLl vW rlmary bladder neck obsLrucLlon ln men women and chlldren Curr urol
8ep 20078379 Mlu 17880837

ureLeropelvlc !uncLlon CbsLrucLlon
SLenosls of Lhe renal pelvls ouLleL ls commonly due Lo congenlLal narrowlng of Lhe [uncLlon or
compresslon by anomalous vessels Powever Lhe leslon may be acqulred resenLaLlon ln adulLs ofLen
lncludes Lhe abrupL onseL of flank paln usually followlng lngesLlon of large amounLs of flulds
resenLaLlon ln chlldhood ls now mosL ofLen made followlng Lhe dlagnosls of hydronephrosls by
prenaLal ulLrasonography
1he dlagnosls may be conflrmed wlLh a dlureLlc nuclear renal scan or lnLravenous urography whlch
reveals hydronephrosls wlLh a dllaLed renal pelvls and slow dralnage of elLher radloLracer or conLrasL
medlum Cccaslonally paLlenLs presenL wlLh lnLermlLLenL hydronephrosls and normal urograms excepL
durlng aLLacks of paln when xrays show Lyplcal obsLrucLlon 1hese paLlenLs generally have normal renal
parenchyma 8eLrograde ureLeropyelography ls usually needed ln paLlenLs wlLh chronlc moderaLe Lo
severe obsLrucLlon Lo deLermlne Lhe exLenL of Lhe leslon and Lo provlde assurance LhaL Lhe dlsLal ureLer
ls normal Marked obsLrucLlon may make lL dlfflculL Lo deLermlne wheLher kldney funcLlon ls surglcally
salvageable ln Lhese cases lL may be necessary Lo perform elLher (1) dlfferenLlal radlolsoLope
renography wlLh use of a dlureLlc durlng Lhe sLudy or (2) percuLaneous nephrosLomy and creaLlnlne
clearance by 24hour urlne collecLlon
Severe obsLrucLlon wlLh mlnlmal remalnlng renal funcLlon ls besL LreaLed by unllaLeral nephrecLomy lf
renal funcLlon ls adequaLe ( 10 of LoLal renal funcLlon or 10 mL/mln creaLlnlne clearance) surglcal
repalr of Lhe sLenosls elLher by creaLlon of a renal pelvls flap or by resecLlon of Lhe sLenoLlc area and
reanasLomosls ls warranLed 1he use of ureLeroscopy or percuLaneous nephroscopy wlLh
endopyeloLomy lnclslng Lhe sLrlcLured ureLeropelvlc [uncLlon offers an alLernaLlve meLhod of Lherapy
1hls approach appears less successful ln Lhe presence of a crosslng vessel poor renal funcLlon and
slgnlflcanL hydronephrosls Laparoscoplc repalr has proponenLs as well 1he surglcal resulLs of Lhese
meLhods are excellenL ln Lerms of funcLlonal preservaLlon lmprovemenL of urlne flow and rellef of
sympLoms buL dllaLlon of Lhe callces may perslsL
1an 8! SmlLh Au ureLeropelvlc [uncLlon obsLrucLlon repalr when how whaL? Curr Cpln urol
20041433 Mlu 13073831

ureLeral SLenosls
ureLeral sLenosls can be secondary Lo congenlLal or acqulred leslons CongenlLal causes can lnclude
compresslon by an anomalous vessels such as a lower pole renal arLery ln ureLeropelvlc [uncLlon
obsLrucLlon or a reLroperlLoneal veln or prlmary megaureLer where Lhe dlsLal ureLer ls parLlally
obsLrucLed More commonly Lhe ureLer ls secondarlly obsLrucLed due Lo acqulred condlLlons such as
lnflammaLlon from chronlc ureLeral sLones Lrauma secondary Lo gynecologlc or vascular surgery or
exLernal peneLraLlng Lrauma from a knlfe or gunshoL wound Lnlarged pelvlc lymph nodes or an lllac
arLery aneurysm or reLroperlLoneal flbrosls may obsLrucL Lhe ureLer as can lnLrlnslc ureLeral cancer or
bladder cancer lnfllLraLlng Lhe ureLer aL lLs lnserLlon lnLo Lhe bladder llnally lnfecLlon such as urlnary
Luberculosls can cause dlsLal ureLeral sLrlcLures and bllaLeral ureLeral obsLrucLlon can occur from
bladder neck obsLrucLlon wlLh urlnary reLenLlon secondary Lo benlgn prosLaLlc hyperplasla
Chronlc condlLlons wlLh slow developmenL may noL cause sympLoms whereas acuLe obsLrucLlon such as
LhaL from a sLone wlll cause severe flank paln LhaL may radlaLe Lo Lhe groln or LesLes/labla ulagnosls ls
mosL ofLen made by a C1 urogram wlLh conLrasL LhaL wlll show delayed funcLlon and a dllaLed renal
pelvls and ureLer down Lo Lhe slLe of Lhe obsLrucLlon 1hls ls ofLen an unsuspecLed flndlng on a C1 done
for oLher reasons ln an asympLomaLlc paLlenL
1reaLmenL depends enLlrely on Lhe cause Severe sLenosls may requlre resecLlon of Lhe leslon and
spaLulaLed endLoend anasLomosls of Lhe ureLer Less severe obsLrucLlon may be managed by
cysLoscopy and ureLeral or balloon dllaLlon of Lhe narrowed area under dlrecL vlslon vla a ureLeroscope
lacemenL of an lndwelllng ureLeral sLenL may dllaLe Lhe sLenosls over Llme and be a useful LreaLmenL as
well ln selecLed paLlenLs
8eLroperlLoneal llbrosls
See also ChapLer 22
Cne or boLh ureLers may be compressed by a chronlc lnflammaLory process usually of unknown cause
whlch lnvolves Lhe reLroperlLoneal Llssues of Lhe lumbosacral area aLlenLs LreaLed for mlgralne wlLh
meLhyserglde may develop Lhls flbrosls Scleroslng Podgkln dlsease and flbrosls from meLasLaLlc cancer
have also been lmpllcaLed SympLoms lnclude renal paln low backache and Lhose assoclaLed wlLh
uremla Some paLlenLs presenL wlLh compleLe anurla urlnary lnfecLlon ls unusual lf boLh ureLers are
obsLrucLed Lhe serum creaLlnlne ls elevaLed
LxcreLory urograms show hydronephrosls and a dllaLed ureLer down Lo Lhe polnL of obsLrucLlon 1he
ureLers are dlsplaced medlally ln Lhe lumbar area 8eLrograde ureLerograms show a long segmenL of
ureLeral sLenosls Lhough a caLheLer passes easlly Lhrough Lhe ureLer Sonograms and C1 scans may
demonsLraLe flbrous plaques wlLh proxlmal hydroureLeronephrosls lf Lhe paLlenL ls anurlc lndwelllng
ureLeral caLheLers or percuLaneous nephrosLomy should be done When Lhe paLlenLs condlLlon has
lmproved deflnlLlve Lherapy can be accompllshed lf meLhyserglde ls suspecLed Lo be Lhe causaLlve
agenL flbrosls may subslde when Lhe drug ls dlsconLlnued 1hese paLlenLs may beneflL from
admlnlsLraLlon of corLlcosLerolds Chronlc lndwelllng ureLeral sLenLs have also been used successfully lf
Lhese meLhods fall ureLerolysls musL be performed Lo free Lhe ureLer from Lhe flbrous plaque 1he
lnvolved ureLer should be dlssecLed from Lhe plaque moved Lo a laLeral poslLlon and wrapped wlLh
omenLum Lo prevenL recurrenL enLrapmenL 1hls has been accompllshed qulLe successfully wlLh a
laparoscoplc approach
8enlgn rosLaLlc Pyperplasla
LssenLlals of ulagnosls
- rosLaLlsm nocLurla heslLancy slow sLream Lermlnal drlbbllng frequency
- 8esldual urlne
- AcuLe urlnary reLenLlon
- uremla ln advanced cases
Ceneral ConslderaLlons
1he cause of benlgn prosLaLlc enlargemenL ls noL known buL ls probably relaLed Lo hormonal facLors 1he
mechanlsm for openlng and funnellng Lhe veslcal neck aL Lhe Llme of voldlng ls alLered by hyperplasla of
Lhe prosLaLe whlch causes lncreased ouLflow reslsLance ConsequenLly a hlgher lnLraveslcal pressure ls
requlred Lo accompllsh voldlng causlng hyperLrophy of Lhe veslcal and Lrlgonal muscles 1hls may lead
Lo Lhe developmenL of bladder dlverLlculaouLpockeLlngs of veslcal mucosa beLween Lhe deLrusor
muscle bundles PyperLrophy of Lhe Lrlgone causes excesslve sLress on Lhe lnLraveslcal ureLer produclng
funcLlonal obsLrucLlon and resulLlng ln hydroureLeronephrosls ln laLe cases SLagnaLlon of urlne can lead
Lo lnfecLlon Lhe onseL of cysLlLls exacerbaLes Lhe obsLrucLlve sympLoms 1he perlureLhral and
subLrlgonal prosLaLe enlargemenL produces Lhe mosL slgnlflcanL obsLrucLlon
1he prosLaLe ln young men has an anaLomlc capsule llke an apple peel ln men wlLh prosLaLlc
enlargemenL Lhere ls a Lhlck surglcal capsule slmllar Lo an orange peel composed of perlpherally
compressed Lrue prosLaLlc Llssue (perlpheral zone) 1he hyperplasLlc benlgn perlureLhral glands
correspond Lo Lhe LranslLlon zone and are Lhe cause of Lhe obsLrucLlon (llgure 389)
llgure 389




8enlgn prosLaLlc hyperplasla 1he enlarged perlureLhral glands are enclosed by Lhe surglcal capsule 1he
Lrue prosLaLe has been compressed

Cllnlcal llndlngs
SympLoms and Slgns
1yplcally Lhe paLlenL has lower urlnary LracL sympLoms and noLlces heslLancy and loss of force and
callber of Lhe sLream 1he urgenL need Lo vold when Lhe bladder ls nearly full may be an early slgn Pe
may also be awakened by Lhe urge Lo vold several Llmes aL nlghL (nocLurla) osLvold drlbbllng (Lermlnal
drlbbllng) ls parLlcularly dlsLurblng 1he compllcaLlon of lnfecLlon lncreases Lhe degree of obsLrucLlve
sympLoms and ls ofLen assoclaLed wlLh burnlng on urlnaLlon AcuLe urlnary reLenLlon may supervene
1hls ls assoclaLed wlLh severe urgency suprapublc paln and a dlsLended palpable bladder
1he slze of Lhe prosLaLe recLally ls noL of prlmary dlagnosLlc lmporLance slnce Lhere ls a poor correlaLlon
beLween Lhe slze of Lhe gland and Lhe degree of sympLoms and amounL of resldual urlne 1he Amerlcan
urologlcal AssoclaLlon (AuA) developed a 7lLem selfadmlnlsLered quesLlonnalre (AuA sympLom score)
LhaL can asslsL Lhe paLlenL and physlclan ln evaluaLlng Lhe paLlenLs lower urlnary LracL sympLoms
LaboraLory llndlngs
urlnalysls may reveal evldence of lnfecLlon 8esldual urlne ls commonly lncreased ( 30 cc) and a Llmed
urlnary flow raLe ls decreased ( 1013 cc/s) 1he serum creaLlnlne may be elevaLed ln cases wlLh
prolonged severe obsLrucLlon
lmaglng SLudles
LxcreLory urograms are ofLen normal and noL dlagnosLlc and are Lhus noL requlred ln laLesLage cases
Lhe sLudy may show hydroureLeronephrosls lf severe obsLrucLlon ls presenL 1hls almosL always resolves
afLer prosLaLecLomy 1he enlarged gland may cause an lndenLaLlon ln Lhe lnferlor surface of Lhe bladder
whlch may resulL ln a !hook deformlLy of Lhe dlsLal ureLer 1he posLvoldlng fllm may reveal varylng
amounLs of resldual urlne 8enal ulLrasound examlnaLlon may obvlaLe Lhe need for urograms however
lmaglng ls noL requlred Lo make Lhe dlagnosls or Lo deLermlne Lhe need for or meLhod of LreaLmenL
elvlc ulLrasound ln Lhe offlce seLLlng accuraLely predlcLs Lhe amounL of resldual urlne and Lhus obvlaLes
bladder caLheLerlzaLlon
CysLoscoplc LxamlnaLlon
8ladder cysLoscopy reveals secondary veslcal changes (eg LrabeculaLlon) and enlargemenL of Lhe
perlureLhral prosLaLlc glands however cysLoscopy ls noL requlred Lo make Lhe dlagnosls lL may ldenLlfy
oLher condlLlons such as bladder sLones or Lumors ln selecLed cases
urodynamlc SLudles
SlmulLaneous physlologlc monlLorlng of bladder fllllng and empLylng ureLhral sphlncLer acLlvlLy
abdomlnal pressure and pelvlc floor muscle acLlvlLy (elecLromyography) can be exLremely useful ln
documenLlng wheLher bladder ouLleL obsLrucLlon poor bladder funcLlon or oLher causes are
responslble for lower urlnary LracL sympLoms Whlle urodynamlc sLudles are noL requlred for dlagnosls
ln all cases Lhey are helpful ln cases wlLh large posLvold resldual volumes or underlylng neurologlc
dlsease Lo help deLermlne approprlaLe managemenL
ulfferenLlal ulagnosls
neuropaLhlc bladder may produce a slmllar syndrome A hlsLory suggesLlng a neuropaLhlc dlfflculLy such
as dlabeLes melllLus sLroke or splnal cord ln[ury or compresslon may be obLalned neurologlc deflclL
lnvolvlng S24 ls parLlcularly slgnlflcanL
Cancer of Lhe prosLaLe also causes sympLoms of veslcal neck obsLrucLlon Serum prosLaLespeclflc
anLlgen may be elevaLed ln paLlenLs wlLh benlgn prosLaLlc hyperLrophy and Lhe level lncreases as Lhe
volume of Lhe prosLaLe lncreases 1hus an absoluLe value ls noL dlagnosLlc buL ln general lf lL ls over 10
ng/mL Lhe posslblllLy of cancer should be evaluaLed
AcuLe prosLaLlLls may cause sympLoms of obsLrucLlon buL Lhe paLlenL ls sepLlc and has lnfecLed urlne
1he prosLaLe ls exqulslLely Lender
ureLhral sLrlcLure dlmlnlshes Lhe callber of Lhe urlnary sLream 1here ls usually a hlsLory of gonorrhea or
local Lrauma A reLrograde ureLhrogram shows Lhe sLenoLlc area A sLrlcLure blocks Lhe passage of an
lnsLrumenL or caLheLer
CompllcaLlons
CbsLrucLlon and resldual urlne lead Lo veslcal and prosLaLlc lnfecLlon and occaslonally pyelonephrlLls
Lhese may be dlfflculL Lo eradlcaLe
1he obsLrucLlon may lead Lo Lhe developmenL of bladder dlverLlcula lnfecLed resldual urlne may
conLrlbuLe Lo Lhe formaLlon of calcull
luncLlonal obsLrucLlon of Lhe lnLraveslcal ureLer caused by Lhe hyperLrophlc Lrlgone may lead Lo
hydroureLeronephrosls
1reaLmenL
1he lndlcaLlons for operaLlve managemenL are lmpalrmenL of or LhreaL Lo renal funcLlon and
boLhersome sympLoms 8ecause Lhe degree of obsLrucLlon progresses slowly ln mosL paLlenLs
conservaLlve LreaLmenL may be adequaLe urugs LhaL relax Lhe prosLaLlc capsule and lnLernal sphlncLer (
adrenerglc blocklng agenLs) or decrease Lhe volume of Lhe prosLaLe (3 reducLase lnhlblLors or
anLlandrogens) have been Lrled wlLh conslderable success
ConservaLlve Measures
1reaLmenL of chronlc prosLaLlLls may reduce sympLoms 1he resoluLlon of a compllcaLlng cysLlLls usually
affords some rellef ln order Lo proLecL veslcal Lone Lhe paLlenL should be cauLloned Lo vold as soon as
Lhe urge develops lorclng flulds over a shorL Llme causes rapld veslcal fllllng and decreaslng veslcal
Lone Lhls ls a common cause of sudden acuLe urlnary reLenLlon and Lhus should be avolded aLlenLs
wlLh urlnary obsLrucLlve sympLoms should avold Lhe use of cold remedles lncludlng anLlhlsLamlnes
because Lhey are also a common cause of urlnary reLenLlon 1hese conservaLlve measures are of only
Lemporary helplf anyln paLlenLs wlLh prosLaLlc hyperplasla 1here has been recenL greaL lnLeresL
parLlcularly by paLlenLs ln Lhe use of phyLoLherapy for LreaLmenL of lower urlnary LracL sympLoms
lncludlng saw palmeLLo pumpkln seeds and oLher planL exLracLs uesplLe Lhe clalm of efflcacy however
adequaLe sclenLlflc sLudles have noL been done
ConLroversy surrounds cholces ln Lhe LreaLmenL of benlgn prosLaLlc hyperplasla no LreaLmenL (waLchful
walLlng) may be approprlaLe ln paLlenLs who complaln of mlld Lo moderaLe sympLoms and Lhus have low
AuA sympLom scores and resldual urlne less Lhan 70 cc Lo 100 cc lnLeresL has also focused on
nonoperaLlve medlcal Lherapy for Lhose wlLh more slgnlflcanL sympLoms Adrenerglc blocklng agenLs
relax Lhe lnLernal (bladder neck) sphlncLer and prosLaLlc capsule SelecLlve agenLs LhaL are longacLlng
and preferenLlally work for Lhls purpose lnclude doxazosln and Lamsulosln 3 8educLase lnhlblLors block
converslon of LesLosLerone Lo dlhydroLesLosLerone (Lhe androgen acLlve ln promoLlng prosLaLe growLh)
and are useful for large glands parLlcularly ln comblnaLlon wlLh an alphablocker whlch has been shown
Lo besL prevenL urlnary reLenLlon and oLher common progresslve sympLoms of prosLaLlc obsLrucLlon
CaLheLerlzaLlon ls mandaLory for acuLe urlnary reLenLlon SponLaneous voldlng may reLurn buL a
caLheLer should be lefL lndwelllng for 3 days whlle deLrusor Lone reLurns lf Lhls falls LreaLmenL ls
lndlcaLed
Surglcal Measures
1here are four classlc approaches used ln prosLaLecLomy LransureLhral reLropublc suprapublc and
perlneal 1he LransureLhral rouLe ls preferred ln paLlenLs wlLh glands welghlng under 30 g Lo 70 g
because morbldlLy raLes are lower and Lhe hosplLal sLay ls shorLer Larger glands may requlre open
surgery dependlng on Lhe preference and experlence of Lhe urologlsL 1he deaLh raLe ls low ln each
procedure (12) oLency ls aL greaLesL rlsk when Lhe Lransperlneal exposure ls used buL lmpoLence
occaslonally resulLs followlng LransureLhral resecLlon of Lhe prosLaLe
An alLernaLlve approach Lo Lhe LreaLmenL of benlgn prosLaLlc hyperplasla ls LransureLhral lnclslon of Lhe
prosLaLe 1hls procedure conslsLs of lnclslon of Lhe prosLaLe aL Lhe bladder neck up Lo Lhe
verumonLanum allowlng expanslon of Lhe enLlre prosLaLlc ureLhra lL ls especlally effecLlve when Lhe
prlmary polnL of obsLrucLlon ls caused by a medlan bar or hlgh posLerlor llp of Lhe bladder neck
wlLhouL laLeral lobe obsLrucLlon
AddlLlonal alLernaLlve LreaLmenLs are LransureLhral vaporlzaLlon laser prosLaLecLomy LransureLhral
mlcrowave LhermoLherapy LransureLhral needle ablaLlon and hlghlnLenslLy focused ulLrasound
ablaLlon of Lhe prosLaLe Laser prosLaLecLomy seems Lo have Lhe mosL promlse aL presenL and recenL
daLa suggesL LhaL Polmlum and k1 (poLasslum LlLanyl phosphaLe) laser may have nearly Lhe same
efflcacy as LransureLhral resecLlon of prosLaLe wlLh less morbldlLy Powever longLerm resulLs of
randomlzed Lrlals are pendlng
rognosls
MosL paLlenLs wlLh marked sympLoms recelve conslderable rellef and subsLanLlal lmprovemenL ln urlne
flow followlng surglcal LreaLmenL however Lhose wlLh mllder forms may beneflL from drug Lherapy
Amerlcan urologlcal AssoclaLlon Cllnlcal guldellnes ManagemenL of 8P Avallable aL wwwauaneLorg
Accessed lebruary 23 2009
Lam !S Cooper kL kaplan SA Changlng aspecLs ln Lhe evaluaLlon and LreaLmenL of paLlenLs wlLh benlgn
prosLaLlc hyperplasla Med Clln norLh Am 200488281 Mlu 13049379
1an A eL al MeLaanalysls of holmlum laser enucleaLlon versus LransureLhral resecLlon of Lhe prosLaLe
for sympLomaLlc prosLaLlc obsLrucLlon 8r ! Surg 2007941201 Mlu 17729384

ureLhral SLrlcLure
Acqulred ureLhral sLrlcLures ln men may be due Lo exLernal Lrauma or Lo prlor lnsLrumenLaLlon (mosL
common) SLrlcLures may be lnflammaLory due Lo gonorrhea Luberculous ureLhrlLls or schlsLosomlasls
or may rarely be a compllcaLlon of cancer 1he common presenLlng sympLoms are dysurla weak sLream
splaylng of Lhe urlnary sLream urlnary reLenLlon and urlnary LracL lnfecLlon Lvldence of scarrlng due Lo
Lrauma or lnduraLlon and perlneal flsLula may be seen ureLhroscopy reveals Lhe degree of narrowlng A
reLrograde ureLhrogram dellneaLes Lhe slLe and degree of sLrlcLure
ureLhral sLrlcLure musL be dlfferenLlaLed from bladder ouLleL obsLrucLlon due Lo prosLaLlsm lmpacLed
ureLhral sLones ureLhral forelgn bodles and Lumors
lnlLlal LreaLmenL conslsLs of LransureLhral dlrecLvlslon lnLernal ureLhroLomy (lnclslon of Lhe sLrlcLure)
Successful resulLs are obLalned ln 73 of paLlenLs lor long dense sLrlcLures or Lhose falllng Lo respond
Lo an lnlLlal lnLernal ureLhroLomy open surglcal repalr ls lndlcaLed 1hls ls probably besL achleved by Lhe
Lranspublc or perlneal rouLe lf Lhe leslon lnvolves Lhe membranous ureLhra lf Lhe mld ureLhra ls
lnvolved Lhe perlneal approach ls lndlcaLed lf Lhe dlsLal ureLhra ls lnvolved Lhe venLral penlle approach
ls approprlaLe LndLoend anasLomosls ls saLlsfacLory buL a 1sLage lnlay paLch grafL Lube or pedlcle
flap of prepuLlal skln ls currenLly favored for mosL sLrlcLures
Andrlch uL eL al ureLhral sLrlcLures and Lhelr surglcal LreaLmenL 8r ! urol (lnL) 200086371 Mlu
10971298
kessler 1M eL al LongLerm resulLs of surgery for ureLhral sLrlcLure a sLaLlsLlcal analysls ! urol
2003170840 Mlu 12913712
McAnlnch !W 8econsLrucLlon of exLernal ureLhral sLrlcLures clrcular fasclocuLaneous penlle flap ! urol
1993149488 Mlu 8437232
Wessels P eL al CurrenL conLroversles ln anLerlor ureLhral sLrlcLure repalr freegrafL versus pedlcled
sklnflap reconsLrucLlon World ! urol 199816173

PemaLurla
PemaLurla gross or mlcroscoplc ls a common urologlc consulL because lL can be a presenLlng slgn for
underlylng urologlc mallgnancles 8edcolored urlne may noL necessarlly lnclude blood and mlcroscoplc
examlnaLlon looklng for red blood cells ls prudenL Mlcroscoplc hemaLurla ls deflned as 3 or more red
blood cells per hlghpowered fleld on urlne mlcroscopy ln 2 ouL of 3 properly collecLed speclmens 1he
degree of hemaLurla bears no relaLlon Lo Lhe serlousness of Lhe underlylng cause urlne dlpsLlck LesL ls
Lhe slmplesL meLhod Lo check for blood and has a senslLlvlLy of 91 Lo 100 and a speclflclLy of 63 Lo
99 CauLlon should be Laken because false poslLlves (mensLrual blood myoglobln and hemolysls
among oLhers) and false negaLlves (dlpsLlck exposed Lo molsLure and presence of reduclng agenLs llke
ascorblc acld) can lead Lo confuslng resulLs knowledge of Lhe medlcal hlsLory and medlcaLlons can help
rule ouL oLher causes of colored urlne 8eeLs rlfampln and phenazopyrldlne among oLher subsLances
can cause urlne dlscoloraLlon AnLlcoagulaLlon aL normal LherapeuLlc levels does noL predlspose Lo
hemaLurla and paLlenLs should be evaluaLed for Lhe hemaLurla because 13 Lo 43 of Lhese paLlenLs
may have slgnlflcanL urologlc dlsease
ldeally a cleancaLch mldsLream sample should be collecLed lf LhaL ls noL posslble a caLheLerlzed
speclmen ls lndlcaLed lL ls lmporLanL Lo noLe LhaL hemaLurla can be due Lo urologlc or renal
parenchymal dlsease 1he dlfferenLlal dlagnosls Lhus lncludes benlgn causes llke renal or bladder sLones
paplllary necrosls urlnary LracL lnfecLlons prosLaLlLls or lnsLrumenLaLlon and mallgnanL causes llke
renal renal pelvls bladder prosLaLe or ureLhral cancer 8enal parenchymal causes of hemaLurla lnclude
glomerular and lnLersLlLlal renal dlsease 1hese paLlenLs may have proLelnurla and casLs on Lhe
urlnalysls and Lhe red blood cells are Lyplcally dysmorphlc
aLlenLs wlLh hemaLurla referred Lo urology are classlfled lnLo lowrlsk and hlghrlsk groups Plghrlsk
groups lnclude smokers age older Lhan 40 years hlsLory of exposure Lo pelvlc radlaLlon or
cyclophosphamlde occupaLlonal exposure Lo chemlcals or dyes and hlsLory of urlnary LracL lnfecLlons or
oLher urologlcal dlsorders lL ls recommended LhaL a compleLe workup be performed for all paLlenLs
wlLh sympLomaLlc hemaLurla all paLlenLs wlLh gross hemaLurla and hlghrlsk paLlenLs wlLh mlcroscoplc
hemaLurla 1he workup lncludes hlsLory and physlcal examlnaLlon serum creaLlnlne upper LracL lmaglng
(Lyplcally C1 urogram) cysLoscopy and urlne cyLology AsympLomaLlc paLlenLs younger Lhan 40 years
who have mlcroscoplc hemaLurla and have no rlsk facLors can be evaluaLed wlLh upper LracL lmaglng and
elLher cysLoscopy or volded cyLology as Lhe rlsk of slgnlflcanL paLhology ln Lhls populaLlon ls very low lf
Lhe workup ls negaLlve lL ls recommended LhaL Lhe paLlenL be evaluaLed wlLh urlnalysls volded
cyLology and blood pressure check aL 6 12 24 and 36 monLhs
Culclasure 1l eL al 1he slgnlflcance of hemaLurla ln Lhe anLlcoagulaLed paLlenL Arch lnL Med
1994134649 Mlu 8129498
Crossfeld Cu eL al LvaluaLlon of asympLomaLlc hemaLurla ln adulLs Lhe Amerlcan urologlcal AssoclaLlon
besL pracLlce pollcyparL ll paLlenL evaluaLlon cyLology volded markers lmaglng cysLoscopy
nephrology evaluaLlon and followup urology 200137604 Mlu 11306337
van Savage !C lrled lA AnLlcoagulanL assoclaLed hemaLurla a prospecLlve sLudy ! urol 19931331394

urlnary 1racL lnfecLlons
urlnary LracL lnfecLlon ls Lhe secondmosL common Lype of lnfecLlon ln humans and ls frequenLly
encounLered by prlmary care physlclans as well as urologlsLs
1hese lnfecLlons are caused by a varleLy of pyogenlc bacLerla LhaL Lyplcally produce a nonspeclflc Llssue
response 1he mosL common organlsms are gramnegaLlve bacLerla parLlcularly Lscherlchla coll Less
common are LnLerobacLer aerogenes roLeus vulgarls roLeus mlrabllls seudomonas aeruglnosa and
LnLerococcus faecalls
Cwlng Lo Lhe shorL lengLh of Lhe female ureLhra and bacLerlal colonlzaLlon of Lhe lnLrolLus ascendlng
lnfecLlon ls a common occurrence ln young glrls and ln sexually acLlve women ln men ascendlng
lnfecLlon ls ofLen a consequence of ureLhral lnsLrumenLaLlon
AlLhough relaLlvely uncommon descendlng or hemaLogenous urlnary LracL lnfecLlon ls usually
assoclaLed wlLh local urlnary LracL dlsordersmosL commonly obsLrucLlon and sLasls less commonly
Lrauma forelgn bodles or Lumors
LymphaLlc spread occaslonally occurs from Lhe large bowel or from Lhe cervlx and adnexa ln Lhe female
Lhrough Lhe perlveslcal and perlureLeral lymphaLlcs
ulrecL exLenslon Lo Lhe urlnary bladder of nearby lnflammaLory processes (eg appendlceal abscess
enLeroveslcal flsLula or pelvlc abscess) may occur
redlsposlng lacLors
lnfecLlon ls usually lnlLlaLed or susLalned by predlsposlng facLors redlsposlng sysLemlc facLors lnclude
dlabeLes melllLus lmmunosuppresslon and malnuLrlLlon Lhese dlsorders llkely lnLerfere wlLh normal
bladder and body defense mechanlsms redlsposlng local facLors lnclude lnconLlnence consLlpaLlon
organlc or funcLlonal obsLrucLlon sLasls (resldual urlne) forelgn bodles (especlally caLheLers and sLones)
Lumors or necroLlc Llssue veslcoureLeral reflux faclllLaLes LransporL of bacLerla from Lhe bladder Lo Lhe
kldney whlch subsequenLly predlsposes Lo pyelonephrlLls
ClasslflcaLlon of urlnary 1racL lnfecLlon
urlnary LracL lnfecLlon ls classlfled as (1) upper urlnary LracL lnfecLlon (mosL commonly acuLe or chronlc
pyelonephrlLls or lnfecLlon due Lo renal abscess) (2) lower urlnary LracL lnfecLlon (cysLlLls or ureLhrlLls)
or (3) genlLal lnfecLlon (prosLaLlLls epldldymlLls semlnal veslcullLls or orchlLls)
urologlc lnsLrumenLaLlon or Surgery urlnary 1racL lnfecLlon
ln Lhe absence of urlnary LracL lnfecLlon surgery of Lhe upper urlnary LracL should requlre only shorL
Lerm prophylacLlc anLlbacLerlal Lherapy ln Lhe presence of lnfecLlon one aLLempLs Lo sLerlllze Lhe
sysLem before operaLlon lf sLenLlng or Lube dralnage ls requlred and Lhere are no sympLoms of
lnfecLlon colonlzaLlon does noL call for anLlbacLerlal Lherapy unLll Lhe sLenL or Lube ls Lo be changed or
removed 8roadspecLrum anLlbacLerlal prophylaxls ls sLarLed aL LhaL Llme
WlLh lower urlnary LracL surgery anLlbacLerlal Lherapy ls advlsed before operaLlons lnvolvlng Lhe ureLhra
and Lhe bladder especlally for women ln whom conLamlnaLlon from vaglnal organlsms ls llkely Men
undergolng prosLaLecLomy for obsLrucLlve prosLaLlsm ofLen have urlnary LracL lnfecLlon parLlcularly
when caLheLer dralnage ls used preoperaLlvely ln Lhese cases anLlmlcroblal Lherapy ls necessary before
and afLer surgery Lo prevenL bacLeremla
ln Lhe presence of urlnary LracL lnfecLlon any ureLhral lnsLrumenLaLlon poses a LhreaL of bacLeremla
more apL Lo occur ln men Lhan ln women ApproprlaLe anLlbacLerlal coverage should be lnsLlLuLed
before manlpulaLlon
rlnclples of CaLheLerlzaLlon
AfLer a shorLLerm slngle caLheLerlzaLlon Lhe raLe of lnfecLlon ls 1 Lo 3 Powever ln cerLaln
paLlenLspregnanL women elderly or deblllLaLed paLlenLsand ln Lhe presence of urologlc dlsease Lhe
rlsk ls much hlgher An lndwelllng caLheLer ofLen leads Lo colonlzaLlon especlally ln women 1he
lncldence ls proporLlonaLe Lo Lhe duraLlon of caLheLerlzaLlon and reaches approxlmaLely 93 afLer 3
days
SLrlcL asepLlc Lechnlque ls of crlLlcal lmporLance ln caLheLerlzaLlon roper cleanslng of Lhe genlLalla ls
essenLlal lodophor preparaLlons may be used for cleanlng Lhe vaglnal lnLrolLus or Lhe glans penls Many
common urlnary LracL paLhogens are presenL ln normal colonlc flora and Lhese organlsms ofLen galn
access Lo Lhe urlnary LracL of caLheLerlzed paLlenLs CrossconLamlnaLlon of urlnary caLheLers (passlve
Lransmlsslon of bacLerla from paLlenL Lo paLlenL on Lhe hands of hosplLal personnel) ls a frequenL mode
of Lransfer of reslsLanL organlsms Measures dlrecLed Lo Lhe prevenLlon of caLheLer crossconLamlnaLlon
are essenLlal Closed caLheLer dralnage ls probably Lhe besL way Lo reduce crossconLamlnaLlon
WlLh sLerlle Lechnlque durlng caLheLerlzaLlon and a closed dralnage sysLem mosL caLheLers can be kepL
sLerlle for 4872 hours ln a closed dralnage sysLem an added alrlock or oneway valve prevenLlng reflux
of urlne from Lhe collecLlng bag Lo Lhe dralnlng Lubes also helps prevenL lnfecLlon 1he general prlnclples
are as follows (1) lndwelllng caLheLers should be used only when absoluLely necessary (2) CaLheLers
should be lnserLed wlLh sLrlcL asepLlc Lechnlque (3) A closed dralnage sysLem preferably wlLh a oneway
valve ls advlsable (4) nonobsLrucLed dependenL dralnage ls essenLlal (3) unnecessary lrrlgaLlon of Lhe
sysLem should be avolded (6) lf Lhe caLheLer ls needed for a prolonged perlod lL should be changed
every 23 weeks Lo mlnlmlze encrusLaLlon and sLone formaLlon (7) CaLheLerlzed paLlenLs wlLh
asympLomaLlc caLheLer colonlzaLlon should be glven anLlbloLlcs [usL before Lhe caLheLer ls changed or
removednoL durlng Lhe perlod of caLheLerlzaLlon unless sympLomaLlc lnfecLlon occurs
LvaluaLlon
lmaglng of Lhe urlnary LracL ls recommended ln every febrlle lnfanL or young chlld followlng Lhe flrsL
urlnary LracL lnfecLlon lmaglng lncludes a renal and bladder ulLrasound and a voldlng cysLoureLhrogram
1he renal ulLrasound may deLecL hydronephrosls dupllcaLlon anomalles sLones or abnormallLles of Lhe
bladder wall and should be obLalned aL Lhe earllesL convenlenL Llme A cysLogram may be obLalned by
lnsLlllaLlon of conLrasL medlum wlLh fluoroscopy or by lnsLlllaLlon of a radlonucllde 8adlonucllde
cysLography has Lhe advanLage of decreased radlaLlon whlle Lhe conLrasLvoldlng cysLoureLhrogram has
Lhe advanLage of provldlng beLLer anaLomlc deLall whlch may help deLecL bladder or ureLhral
abnormallLles LlLher meLhod should lnclude a voldlng phase because reflux ls Lhe mosL llkely
abnormallLy Lo be deLecLed and may only occur wlLh voldlng 1he cysLogram should be obLalned once
Lhe chlld ls free of lnfecLlon lmaglng recommendaLlons ln adulLs wlLh a urlnary LracL lnfecLlon vary
dependlng on Lhe paLlenLs pasL hlsLory and presenL sympLoms
AnLlbacLerlal 1herapy
1he cholce of anLlbloLlcs depends on Lhe Lype of organlsm and lLs senslLlvlLy as deLermlned by urlne
culLures lor uncompllcaLed lnfecLlon adequaLe urlne concenLraLlons of Lhe anLlbloLlc deLermlne
efflcacy buL ln cases of bacLeremla and sepLlc shock serum concenLraLlons are cruclal Commonly used
oral medlcaLlons are sulfonamldes nlLrofuranLoln amplclllln LrlmeLhoprlmsulfameLhoxazole
fluoroqulnolones and oxyLeLracycllne lor parenLeral Lherapy amlnoglycosldes and cephalosporlns are
effecLlve agalnsL Lhe mosL common organlsms (le mlrabllls L aerogenes and aeruglnosa)
AcuLe yelonephrlLls
LssenLlals of ulagnosls
- Chllls fever and flank paln
- lrequency and urgency of urlnaLlon dysurla
- yurla and bacLerlurla
- 8acLerlal growLh on urlne culLures
Ceneral ConslderaLlons
LxcepL ln Lhe presence of sLasls forelgn bodles Lrauma or lnsLrumenLaLlon pyelonephrlLls ls an
ascendlng Lype of lnfecLlon aLhogenlc organlsms usually reach Lhe kldney from Lhe bladder ofLen vla
an lncompeLenL ureLeroveslcal [uncLlon
Cllnlcal llndlngs
SympLoms and Slgns
ln acuLe aLLacks paln ls presenL ln one or boLh flanks ulagnosls ln lnfanLs requlres a hlgh lndex of
susplclon slnce Lhey may presenL wlLh nonspeclflc sympLoms such as fever and fallure Lo Lhrlve ?oung
chlldren commonly presenL wlLh poorly locallzed abdomlnal paln lrrlLaLlve lower urlnary LracL
sympLoms may be presenL Chllls and fever are common Severe lnfecLlon may produce hypoLenslon
perlpheral vasoconsLrlcLlon and acuLe renal fallure Cross hemaLurla ls noL common
LaboraLory llndlngs
yurla and bacLerlurla are conslsLenL flndlngs LeukocyLosls wlLh a shlfL Lo Lhe lefL ls common urlne
culLure ldenLlfles Lhe organlsm
lmaglng SLudles
ln acuLe aLLacks only mlnlmal changes such as delayed vlsuallzaLlon and poor concenLraLlng ablllLy are
noLed on lnLravenous urography C1 scans may demonsLraLe zones of decreased enhancemenL ln Lhe
renal parenchyma as well as perlnephrlc faL sLrandlng 8enal or ureLeral calcull may be seen on plaln
abdomlnal xrays or nonenhanced C1 scans ChesL xray may show a small lpsllaLeral pleural effuslon
ulfferenLlal ulagnosls
neumonla acuLe cholecysLlLls or splenlc lnfarcLlon can be confused wlLh pyelonephrlLls AcuLe
appendlclLls someLlmes causes pyurla and mlcrohemaLurla Any acuLe abdomlnal lllness such as
pancreaLlLls dlverLlcullLls or lnLesLlnal anglna can slmulaLe pyelonephrlLls ApproprlaLe chesL xrays and
urlnalysls usually makes Lhe dlsLlncLlon
CompllcaLlons
lf Lhe dlagnosls ls mlssed ln Lhe acuLe sLage Lhe lnfecLlon may become chronlc 8oLh acuLe and chronlc
pyelonephrlLls lead Lo progresslve renal damage
1reaLmenL
Speclflc anLlbloLlc Lherapy should be glven for aL leasL 7 days Lo eradlcaLe Lhe lnfecLlng organlsm afLer
proper ldenLlflcaLlon and senslLlvlLy deLermlnaLlon SympLomaLlc LreaLmenL ls lndlcaLed for paln and
lrrlLaLlve voldlng sympLoms AdequaLe fluld lnLake Lo assure opLlmum urlnary ouLpuL ls requlred lallure
Lo slmulLaneously ldenLlfy and LreaL predlsposlng facLors (eg obsLrucLlon) ls Lhe prlnclpal cause of
fallure Lo respond Lo Lherapy leadlng Lo chronlc pyelonephrlLls
rognosls
1he prognosls ls good wlLh adequaLe LreaLmenL of boLh Lhe lnfecLlon and lLs predlsposlng cause
dependlng on Lhe degree of preexlsLlng renal parenchymal damage
LmphysemaLous yelonephrlLls
LmphysemaLous pyelonephrlLls ls a form of acuLe necroLlzlng pyelonephrlLls secondary Lo a gas
produclng bacLerla (L coll ln 66 of cases and klebslella ln 26) lL ls commonly seen ln paLlenLs wlLh
poorly conLrolled dlabeLes (over 90 of cases) or ln paLlenLs wlLh upper urlnary LracL obsLrucLlon 1he
dlagnosls ls made by Lhe usual slgns of acuLe pyelonephrlLls and by Lhe presence of gas ln Lhe renal
collecLlng sysLem and parenchyma seen on plaln fllms ulLrasound or C1 1he condlLlon ls llfe
LhreaLenlng wlLh a morLallLy raLe of 40 Lo 80 wlLh lnLravenous anLlbloLlcs alone CbsLrucLlon
requlres dralnage elLher percuLaneously or by sLenL placemenL CperaLlve LreaLmenL lncludlng
nephrecLomy and dralnage along wlLh anLlbloLlcs decreases Lhe morLallLy raLe Lo less Lhan 20
Chronlc yelonephrlLls
Chronlc pyelonephrlLls ls Lhe resulL of lnadequaLely LreaLed or recurrenL acuLe pyelonephrlLls 1he
dlagnosls ls prlmarlly made by xray slnce paLlenLs rarely have slgns or sympLoms unLll laLe ln Lhe
course when Lhey develop chronlc flank paln hyperLenslon anemla or renal fallure yurla ls noL a
conslsLenL flndlng 8ecause chronlc pyelonephrlLls may be a progresslve locallzed lmmune response
lnlLlaLed by bacLerla long slnce eradlcaLed urlne culLures are usually sLerlle Larly cases may have no
flndlngs on lnLravenous urography whereas ln laLe cases lL may reveal small kldneys wlLh Lyplcal callceal
deformlLles (clubblng) wlLh evldence of perlpheral scarrlng and a Lhln corLex voldlng
cysLoureLhrography may documenL veslcoureLeral reflux as Lhe cause CompllcaLlons lnclude
hyperLenslon sLone formaLlon and chronlc renal fallure
AnLlbloLlc LreaLmenL ls noL helpful ln Lhese paLlenLs unless ongolng lnfecLlon can be documenLed 1he
prognosls depends on Lhe sLaLus of renal funcLlon buL ls generally noL good parLlcularly when Lhe
dlsease ls conLracLed ln chlldhood rogresslve deLerloraLlon of renal funcLlon usually occurs
xanLhogranulomaLous pyelonephrlLls ls a form of chronlc pyelonephrlLls seen mosL frequenLly ln mlddle
aged dlabeLlc women and rarely ln chlldren 1he dlsease ls usually unllaLeral and ls assoclaLed wlLh
prolonged obsLrucLlng nephrollLhlasls aLlenLs ofLen have nonspeclflc sympLoms slmllar Lo Lhose of
acuLe pyelonephrlLls buL have an enlarged kldney wlLh calcull and a mass ofLen lndlsLlngulshable from
Lumor roLeus specles are common causaLlve agenLs nephrecLomy ls usually Lhe LreaLmenL of cholce
Lhough a parLlal nephrecLomy may be performed for focal dlsease PlsLologlc examlnaLlon conflrms Lhe
dlagnosls followlng nephrecLomy by Lhe demonsLraLlon of foamy llpldladen macrophages
aplllary necrosls
1hls dlsorder conslsLs of lschemlc necrosls of Lhe renal paplllae or of Lhe enLlre pyramld Lxcesslve
lngesLlon of analgeslcs slckle cell LralL dlabeLes obsLrucLlon wlLh lnfecLlon and sysLemlc condlLlons
decreaslng renal blood flow are common predlsposlng facLors
1he sympLoms are usually Lhose of chronlc cysLlLls wlLh recurrlng exacerbaLlons of pyelonephrlLls 8enal
paln or renal collc may be presenL AzoLemlc manlfesLaLlons may be Lhe presenLlng sympLoms ln acuLe
aLLacks locallzed flank Lenderness and generallzed Loxemla may occur LaboraLory flndlngs conslsL of
pyurla hemaLurla occaslonally glycosurla and acldosls lmpalred kldney funcLlon ls shown by elevaLed
serum creaLlnlne and urea nlLrogen lnLravenous urography usually shows lmpalred funcLlon and poor
vlsuallzaLlon ln advanced cases Lvldence of ulceraLlon cavlLaLlon or llnear breaks ln Lhe base of Lhe
paplllae and radlolucenL defecLs due Lo sloughed paplllae may be seen Lhe laLLer may become calclfled
8eLrograde urograms may be needed for proper lmaglng lf kldney funcLlon ls markedly lmpalred
revenLlve measures conslsL of proper managemenL of dlabeLlc paLlenLs wlLh recurrenL lnfecLlons and
avoldance of chronlc use of analgeslc compounds conLalnlng phenaceLln and asplrln
lnLenslve anLlbacLerlal Lherapy may be needed Lhough lL ls commonly unsuccessful ln eradlcaLlng
lnfecLlon LlLLle can be done surglcally excepL Lo remove obsLrucLlng paplllae and correcL predlsposlng
facLors (eg reflux obsLrucLlon) lf ldenLlfled
ln severe cases Lhe prognosls ls poor 8enal LransplanLaLlon may be requlred
8enal Abscess
Whlle renal abscess ls occaslonally due Lo hemaLogenous spread of a dlsLanL sLaphylococcal lnfecLlon
mosL abscesses are secondary Lo chronlc nonspeclflc lnfecLlon of Lhe kldney ofLen compllcaLed by sLone
formaLlon 1he onseL may be acuLe wlLh hlgh fever buL occaslonally lowgrade fever and general
malalse are Lhe presenLlng sympLoms Locallzed cosLoverLebral angle Lenderness and a palpable flank
mass may be presenL A mass may be evldenL on lnLravenous urograms u1A scans sonograms C1
scans or renal anglograms lf Lhe abscess ls due Lo hemaLogenous spread Lhe urlne does noL conLaln
bacLerla unless Lhe abscess has broken lnLo Lhe pelvlcallceal sysLem More frequenLly gramnegaLlve
organlsms are found as would be expecLed ln llghL of Lhe preponderance of ascendlng lnfecLlon
lf organlsm senslLlvlLy can be esLabllshed by approprlaLe LesLs (blood and urlne culLures and senslLlvlLy
LesLs) LreaLmenL wlLh Lhe proper anLlbloLlc ls lndlcaLed Many lnfecLlons have responded Lo
percuLaneous dralnage and lrrlgaLlon wlLh anLlbloLlc soluLlons especlally ln cases of unllocular abscess
cavlLy seen on elLher ulLrasound or C1 examlnaLlon ln mulLllocular abscess or perslsLenL bacLeremla
desplLe percuLaneous dralnage surglcal dralnage or even hemlnephrecLomy may be necessary
When Lhe abscess ls found Lo be secondary Lo chronlc renal lnfecLlon nephrecLomy ls usually lndlcaLed
because of advanced desLrucLlon of Lhe kldney
erlnephrlc Abscess
Abscess beLween Lhe renal capsule and Lhe perlrenal fascla mosL ofLen resulLs from rupLure of an
lnLrarenal abscess lnLo Lhe perlnephrlc space L coll ls Lhe mosL common causaLlve organlsm 1he
paLhogenesls usually beglns wlLh severe pyonephrosls secondary Lo obsLrucLlon as wlLh renal or
ureLeral calcull Cllnlcal flndlngs are slmllar Lo Lhose of renal abscess A pleural effuslon on Lhe affecLed
slde and slgns of psoas muscle lrrlLaLlon are common Abdomlnal plaln fllms may show obllLeraLlon of
Lhe psoas muscle shadow and an lnLravenous urogram may show poor concenLraLlon of conLrasL
medlum and hydronephrosls C1 scan ls Lhe currenL sLudy of cholce for dlagnosls
1reaLmenL lnvolves prompL dralnage of Lhe abscess and use of approprlaLe sysLemlc anLlbloLlcs
lncludlng coverage of anaerobes ercuLaneous dralnage ls ofLen successful however open surglcal
dralnage ls necessary lf percuLaneous dralnage ls lncompleLe MorLallLy ranges beLween 20 and 30
wlLh anLlbloLlcs and dralnage whereas LreaLmenL wlLh anLlbloLlcs alone lncreases Lhls raLe Lo 73 Lo
100
CysLlLls
CysLlLls ls more common ln females and ls usually an ascendlng lnfecLlon ln males lL usually occurs ln
assoclaLlon wlLh ureLhral or prosLaLlc obsLrucLlon prosLaLlLls forelgn bodles or Lumors 1he urlnary
bladder ls normally capable of clearlng bacLerlal lnoculaLlon unless an underlylng paLhologlc process
lnLerferes wlLh lLs defenslve mechanlsms
ln Lhe acuLe phase Lhe prlnclpal sympLoms of cysLlLls are dysurla frequency urgency and hemaLurla
lowgrade fever and suprapublc perlneal and low back paln may be presenL ln chronlc cysLlLls lrrlLaLlve
sympLoms are usually mllder
Lvldence of prosLaLlLls ureLhrlLls or vaglnlLls may be presenL LaboraLory flndlngs ln addlLlon Lo
hemaLurla conslsL of bacLerlurla and pyurla LeukocyLosls ls noL common urlne culLure ldenLlfles Lhe
organlsm CysLoscopy ls noL advlsable ln Lhe acuLe phase ln chronlc cysLlLls evldence of mucosal
lrrlLaLlon may be presenL
ln any documenLed recurrenL lower urlnary LracL lnfecLlon (parLlcularly ln males) a compleLe urologlc
workup ls lndlcaLed lnsLrumenLaLlon ls conLralndlcaLed ln Lhe acuLe phase buL cysLoscopy ls essenLlal Lo
ldenLlfy Lhe predlsposlng facLor ln chronlc or recurrenL bacLerlal cysLlLls
Speclflc anLlbacLerlal Lherapy ls glven accordlng Lo senslLlvlLy LesLlng of recovered organlsms (L coll ln
80 of cases) SLerlllzaLlon of urlne should usually be followed by a varlable perlod of conLlnuous
anLlbloLlc Lherapy (dependlng on Lhe predlsposlng facLor or Lhe chronlclLy and recurrence of Lhe
dlsease) rolonged suppresslve medlcaLlon ls usually lndlcaLed ln cases assoclaLed wlLh voldlng
dysfuncLlon
ln females wlLh recurrenL posLcolLal cysLlLls premedlcaLlon (eg sulfonamldes nlLrofuranLoln) on Lhe
nlghL of lnLercourse and Lhe followlng day ln addlLlon Lo lmmedlaLe posLcolLal voldlng decreases
recurrences
rosLaLlLls
AcuLe 8acLerlal rosLaLlLls
AcuLe bacLerlal prosLaLlLls ls a severe acuLe febrlle lllness caused by ascendlng collform bacLerla whlch
frequenLly colonlze Lhe male ureLhra SympLoms lnclude hlgh fever chllls low back and perlneal paln
and urlnary frequency and urgency wlLh dlmlnlshed sLream or reLenLlon Cn examlnaLlon Lhe prosLaLe ls
exLremely Lender swollen and warm Lo Lhe Louch A flucLuanL abscess may be palpable 1he prosLaLe
musL be examlned cauLlously because vlgorous palpaLlon may cause acuLe sepLlcemla LaboraLory
flndlngs lnclude pyurla bacLerlurla and leukocyLosls
1ransureLhral manlpulaLlon by caLheLer or cysLoscopy should be avolded urlnary reLenLlon should be
LreaLed by lnLroduclng a percuLaneous suprapublc Lube 1reaLmenL wlLh sysLemlc anLlbloLlcs
(fluoroqulnolones or amlnoglycosldes and amplcllllncephalosporln) should be sLarLed lmmedlaLely and
should be ad[usLed laLer when resulLs of urlne culLure or blood culLure (or boLh) and senslLlvlLy LesLs are
known L coll ls found ln 80 of cases 1reaLmenL wlLh oral anLlbloLlcs for several weeks afLer Lhe lnlLlal
phase has subslded ls necessary Lo eradlcaLe Lhe bacLerla compleLely A prosLaLlc abscess usually
requlres open perlneal dralnage or LransureLhral unrooflng 1he prognosls ls good lf LreaLmenL ls
Lhorough and prompL
Chronlc rosLaLlLls
Chronlc prosLaLlLls ls a common and complex problem WlLh dlfferenLlal dlagnosls lncludlng ureLhrlLls
bacLerlal and nonbacLerlal prosLaLlLls prosLaLodynla (chronlc pelvlc paln syndrome CS) and semlnal
veslcullLls asslgnlng Lhe correcL dlagnosls may challenge even Lhe experL 1he sympLoms are varled and
lnclude suprapublc paln low back paln orchlalgla dysurla aL Lhe Llp of Lhe penls and urlnary frequency
and urgency 1he urlnalysls may be normal 1here may be a clear whlLe ureLhral dlscharge rosLaLe
examlnaLlon may reveal a sofL boggy prosLaLe
Lxpressed prosLaLlc secreLlons may conLaln numerous leukocyLes ( 10 per hlghpower fleld) ln clumps
as well as macrophages CulLures of urlne are usually sLerlle buL culLures of expressed prosLaLlc
secreLlons and urlne obLalned afLer prosLaLlc massage are usually poslLlve ln bacLerlal prosLaLlLls
Chlamydla or ureaplasma may be an offendlng organlsm parLlcularly ln men under age 33
ueLermlnaLlon of Lhe slLe of lnfecLlon may requlre dlfferenLlal culLures 1he flrsL parL of Lhe volded urlne
sLream ls collecLed as v81 and Lhe mldsLream speclmen as v82 1he prosLaLe ls Lhen massaged Lo obLaln
expressed prosLaLlc secreLlons and Lhe posLmassage urlne ls collecLed as v83 1he dlfferenLlal leukocyLe
and bacLerlal counLs from each of Lhese speclmens can help locallze Lhe slLe of lnfecLlon lf v81 has hlgh
levels of leukocyLes and bacLerla relaLlve Lo Lhe oLher speclmens ureLhrlLls ls llkely lf v82 has hlgh
levels a slLe above Lhe bladder neck ls llkely and lf Lhe expressed prosLaLlc secreLlons v83 or boLh
have hlgh counLs prosLaLlLls ls llkely
1reaLmenL depends on culLure resulLs buL lf Lhere ls no bacLerlal growLh on culLure LeLracycllne 230
mg Lo 300 mg four Llmes a day for 14 days may be curaLlve lor chronlc bacLerlal prosLaLlLls aL leasL a 6
week course of a fluoroqulnolone or LrlmeLhoprlmsulfameLhoxazole ls ofLen glven Surglcal LreaLmenL
for prosLaLlLls ls rarely lndlcaLed or helpful Some paLlenLs lmprove followlng dlsconLlnuaLlon of caffelne
and alcohol and a few respond Lo repeaLed prosLaLlc massage aLlenLs wlLh no evldence of bacLerlal
lnfecLlon or obsLrucLlve flndlngs and Lhose who have recurrenL pelvlc paln ln assoclaLlon wlLh voldlng
dysfuncLlon (eg lnLermlLLenL or weak urlnary sLream) may be LreaLed wlLh adrenerglc blocklng agenLs
or blofeedback Lo decrease Lhe lnLernal and exLernal sphlncLer Lone 3 8educLase lnhlblLors may be
helpful and phyLoLherapy has proponenLs buL needs furLher sLudy
nlckel !C 8ecommendaLlons for Lhe evaluaLlon of paLlenLs wlLh prosLaLlLls World ! urol 20032173
Mlu 12684833
Schaeffer A! LLlology and managemenL of chronlc pelvlc paln syndrome ln men urology 200463(suppl
3A)73

AcuLe LpldldymlLls
AcuLe epldldymlLls ls mosL commonly a dlsease of young males caused by bacLerlal lnfecLlon ascendlng
from Lhe ureLhra or prosLaLe 1he dlsease ls less common ln older males buL when lL does occur lL ls
mosL ofLen due Lo lnfecLlon secondary Lo urlnary LracL obsLrucLlon or lnsLrumenLaLlon
1he sympLoms are sudden paln ln Lhe scroLum rapld unllaLeral scroLal enlargemenL and marked
Lenderness LhaL exLends Lo Lhe spermaLlc cord ln Lhe groln and may be relleved by scroLal elevaLlon
(rehns slgn) lever ls presenL An acuLe hydrocele may resulL and secondary orchlLls wlLh a swollen
palnful LesLlcle may occur LaboraLory sLudles reveal pyurla bacLerlurla and marked leukocyLosls
LpldldymlLls musL be dlfferenLlaLed from Lorslon of Lhe LesLls LesLlcular Lumor and Luberculous
epldldymlLls A LechneLlum99m perLechneLaLe scan reveals lncreased upLake wlLh epldldymlLls buL
decreased upLake wlLh Lorslon ScroLal ulLrasound dlsLlngulshes beLween Lhe solld mass of a LesLlcular
Lumor and an enlarged lnflamed epldldymls and can also ldenLlfy epldldymal or LesLlcular abscess
whlch requlres operaLlve LreaLmenL lncreased blood flow on uoppler ulLrasound also helps dlsLlngulsh
epldldymlLls from Lorslon Lhough lL ls noL compleLely rellable
CulLured asplraLes from lnflamed epldldymldes of males under age 33 Lend Lo show gonococcl and
chlamydlae ln men older Lhan 33 L coll ls mosL common Lpldldymal asplraLlon for culLure ls noL
requlred rouLlnely however yurla wlLh a negaLlve urlne culLure suggesLs Lhe presence of chlamydlal
lnfecLlon ln boLh prosLaLe and epldldymls (See also secLlon on 1uberculosls)
1reaLmenL conslsLs of anLlbloLlcs usually cefLrlaxone and doxycycllne ln males under age 33 and
fluoroqulnolones ln Lhose over age 33 ln some paLlenLs paln ls relleved by scroLal hypoLhermla and
conslderaLlon should be glven Lo lnfllLraLlon of Lhe spermaLlc cord by 1 buplvacalne nonsLeroldal anLl
lnflammaLory drugs are recommended Lo ald ln paln rellef ln mosL lnsLances prompL LreaLmenL resulLs
ln rapld resoluLlon of paln fever and swelllng aLlenLs musL refraln from exerLlon for 1 Lo 3 weeks
LxacerbaLlons can be conLrolled by LreaLlng Lhe predlsposlng facLor Chronlc epldldymlLls rarely resolves
compleLely lL has no consequences excepL occaslonally ln bllaLeral cases sLerlllLy due Lo scarrlng and
obsLrucLlon of Lhe dellcaLe epldldymal Lubules 8arely epldldymecLomy ls necessary
1uberculosls
1uberculosls ls a commonly mlssed genlLourlnary lnfecLlon LhaL should be consldered ln any case of
pyurla wlLhouL bacLerlurla or ln any case of urlnary LracL lnfecLlon LhaL does noL respond Lo LreaLmenL
CenlLourlnary Luberculosls ls always secondary Lo pulmonary lnfecLlon Lhough ln many cases Lhe
prlmary focus has healed or ls qulescenL lnfecLlon occurs vla Lhe hemaLogenous rouLe 1he kldneys and
(less commonly) Lhe prosLaLe are Lhe prlnclpal slLes of urlnary LracL lnvolvemenL Lhough any parL of Lhe
genlLourlnary sysLem can be affecLed
aLhology
8enal Luberculosls usually sLarLs as a Luberculoma LhaL gradually enlarges caseaLes and flnally
ulceraLes breaklng lnLo Lhe pelvlcallceal sysLem CaseaLlon and scarrlng are Lhe prlnclpal paLhologlc
feaLures of renal Luberculosls ln Lhe ureLer Luberculosls usually leads Lo dlsLal sLrlcLures perlureLerlLls
and mural flbrosls
ln Lhe bladder Lhe lnfecLlon ls characLerlzed by areas of hyperemla and a coalescenL group of Lubercles
followed by ulceraLlons 8ladder wall flbrosls and conLracLlon are Lhe end resulLs
ureLhral lnvolvemenL ln Lhe male ls uncommon buL when presenL leads Lo ureLhral sLrlcLure usually ln
Lhe bulbous porLlon erlureLhral abscess and flsLula are posslble compllcaLlons
CenlLal Luberculosls may lnvolve Lhe prosLaLe semlnal veslcles and epldldymldes elLher separaLely or ln
assoclaLlon wlLh renal lnvolvemenL 1ubercle formaLlon wlLh laLer caseaLlon and flbrosls ls Lhe baslc
paLhologlc feaLure 1he prosLaLe becomes enlarged wlLh palpable nodules and an lrregular conslsLency
1he affecLed semlnal veslcle ls flbroLlc and dlsLended lnduraLlon and Lhlckenlng of Lhe epldldymls and
beadlng of Lhe vas deferens are characLerlsLlc flndlngs 1he LesLlcles are rarely lnvolved
Cllnlcal llndlngs
SympLoms and Slgns
1he paLlenL commonly presenLs wlLh lower urlnary LracL lrrlLaLlon usually wlLh pyurla Less common
manlfesLaLlons are hemaLurla renal paln and renal collc
LaboraLory llndlngs
SLerlle pyurla ls Lhe rule buL 13 of cases have secondary bacLerlal lnfecLlon (eg L coll) MycobacLerla
can be ldenLlfled on an acldfasL sLaln of Lhe cenLrlfuged sedlmenL of Lhe flrsL mornlng urlne collecLed on
3 successlve days (poslLlve ln 90 of cases) CulLure of Lhe sedlmenL should yleld Lhe mycobacLerla
whlch may Lhen be speclaLed by nlacln and nlLraLe LesLs boLh of whlch musL be poslLlve for a dlagnosls
of MycobacLerlum Luberculosls
lmaglng SLudles
8adlologlc flndlngs LhaL suggesL genlLourlnary Luberculosls lnclude moLheaLen caseous renal cavlLles or
blzarre lrregular callces SLrlcLures ln sLralghL rlgld moderaLely dllaLed ureLers and a conLracLed bladder
wlLh veslcoureLeral reflux are all suggesLlve evldence
1reaLmenL
Medlcal 1reaLmenL
1uberculosls musL be LreaLed as a sysLemlc dlsease Cnce Lhe dlagnosls ls esLabllshed medlcal
LreaLmenL ls lndlcaLed regardless of Lhe need for surgery Whenever posslble medlcal LreaLmenL should
be conLlnued for aL leasL 3 monLhs before surgery ls consldered
AcLlve medlcaLlons agalnsL Luberculosls lnclude rlfampln lsonlazld pyrazlnamlde eLhambuLol and
sLrepLomycln SLandard lnlLlal LreaLmenL ls wlLh rlfampln lsonlazld and pyrazlnamlde for 8 weeks
yrldoxlne 100 mg/d ls glven ln dlvlded doses Lo counLeracL Lhe vlLamln 86 depleLlon effecL of
lsonlazld ln paLlenLs wlLh more severe lnfecLlons eLhambuLol or sLrepLomycln may be added Lo Lhe
lnlLlal LreaLmenL lollowlng Lhe lnlLlal 8 weeks of Lherapy rlfampln and lsonlazld are conLlnued ln
comblnaLlon Lhree Llmes per week for anoLher 8 weeks Llver funcLlon LesLs musL be followed ln vlew of
Lhe hepaLoLoxlclLy of rlfampln lsonlazld and pyrazlnamlde
Surglcal Measures
lf medlcal Lherapy falls Lo cure a unllaLeral leslon nephrecLomy may be necessary Powever Lhls ls rare
ln bllaLeral dlsease LhaL has serlously damaged one kldney and ls ln an early sLage ln Lhe oLher unllaLeral
nephrecLomy may be consldered ln locallzed polar leslons parLlal nephrecLomy may be done
ln unllaLeral epldldymal lnvolvemenL epldldymecLomy plus conLralaLeral vasecLomy ls lndlcaLed Lo
prevenL descenL of Lhe lnfecLlon Lo Lhe prosLaLe bllaLeral epldldymecLomy should be done lf boLh sldes
are lnvolved
lor a severely conLracLed bladder augmenLaLlon enLerocysLoplasLy lncreases veslcal capaclLy followlng
eradlcaLlon of Lhe lnfecLlon
rognosls
ln a hlgh percenLage of cases cure ls obLalned by medlcal means unllaLeral renal leslons have Lhe besL
prognosls
Cooper CS eL al 1he ouLcome of sLopplng prophylacLlc anLlbloLlcs ln older chlldren wlLh veslcoureLeral
reflux ! urol 2000163269 Mlu 10604374
Podson LM Wlllls nS Cralg !C AnLlbloLlcs for acuLe pyelonephrlLls ln chlldren Cochrane uaLabase SysL
8ev 2007 4Cu003772
Smalll l vazquez !C AnLlbloLlcs for asympLomaLlc bacLerlurla ln pregnancy Cochrane uaLabase SysL 8ev
20072Cu000490
Wlse C! Marella vk CenlLourlnary manlfesLaLlons of Luberculosls urol Clln norLh Am 200330111
Mlu 12380363

8enal SLone
LssenLlals of ulagnosls
- llank paln hemaLurla (gross or mlcroscoplc) pyelonephrlLls prevlous sLone passage
- CosLoverLebral angle Lenderness
- SLone vlsuallzed on urography ulLrasonography or nonconLrasL splral C1 scan
Ceneral ConslderaLlons
SLone dlsease ls common wlLh Lhe llfeLlme rlsk of sLone formaLlon ln Lhe unlLed SLaLes exceedlng 12 ln
males and 6 ln females revalence of sLone dlsease varles by raclal background and geographlc
locaLlon wlLhln Lhe unlLed SLaLes wlLh older whlLe males and souLheasLern sLaLes havlng Lhe hlghesL
prevalence SevenLyflve percenL of mosL sLones are composed of calclum salLs (oxalaLe phosphaLe)
whlle urlc acld and sLruvlLe sLones (magneslumammonlum phosphaLe sLones LhaL form secondary Lo
ureaspllLLlng organlsms) consLlLuLe 10 each lormaLlon of calclum sLones can be due Lo one or
mulLlple facLors LhaL lnclude hypercalclurla hypoclLraLurla hyperoxalurla and hyperurlcosurla ln
paLlenLs wlLh hyperparaLhyroldlsm or Lhose who lngesL large amounLs of calclum or vlLamln u or ln
paLlenLs who are dehydraLed or lmmoblllzed hypercalclurla promoLes sLone formaLlon
urlc acld sLones form ln acldlc urlne CysLlne sLones whlch make up 1 of all sLones usually form
secondary Lo lmpalred renal reabsorpLlon of cysLlne Cwlng Lo Lhe radlodenslLy of sulfur cysLlne sLones
are radlopaque (albelL less so Lhan calclum sLones) whereas urlc acld sLones are radlolucenL SLones LhaL
obsLrucL Lhe ureLeropelvlc [uncLlon or ureLer lead Lo hydronephrosls and posslbly lnfecLlon
Cllnlcal llndlngs
SympLoms and Slgns
lf Lhe sLone acuLely obsLrucLs Lhe ureLeropelvlc [uncLlon or a callx moderaLe Lo severe renal paln ls
noLed ofLen accompanled by nausea vomlLlng and lleus 1he paln sLarLs ln Lhe upper laLeral back and
may radlaLe anLerlorly and lnferlorly Loward Lhe groln Cross or mlcroscoplc hemaLurla ls common
SympLoms of lnfecLlon lf presenL are exacerbaLed nonobsLrucLlng calcull are usually palnless 1hls
lncludes sLaghorn calcull whlch may form a casL of all callces and Lhe pelvls ln Lhe sympLomaLlc paLlenL
Lhere may be cosLoverLebral angle Lenderness and a quleL abdomen lnfecLlon secondary Lo obsLrucLlon
may lead Lo hlgh fever and a rlgld abdomen
LaboraLory llndlngs
WlLh acuLe lnfecLlon leukocyLosls ls Lo be expecLed urlnalysls may reveal red and whlLe blood cells and
bacLerla A pP of 76 or hlgher lmplles Lhe presence of ureaspllLLlng organlsms A pP conslsLenLly below
33 ls compaLlble wlLh Lhe formaLlon of urlc acld or cysLlne sLones lf Lhe pP ls flxed beLween 60 and 70
renal Lubular acldosls should be consldered as a cause of nephrocalclnosls CrysLals of urlc acld
(rhombold) or cysLlne (hexagonal) ln Lhe urlne are suggesLlve A 24hour urlne collecLlon can help
ldenLlfy Lhe meLabollc effecL LhaL predlsposes Lo sLone formaLlon (hypercalclurla hypoclLraLurla
hyperoxalurla) Pypercalclurla can be resorpLlve (due Lo hyperparaLhyroldlsm) absorpLlve (lncreased
gasLrolnLesLlnal absorpLlon) or renal (lncreased urlne loss of calclum) ClLraLe ls a sLone lnhlblLor and
hypoclLraLurla predlsposes Lo sLone formaLlon
lncreases ln urlne calclum and phosphaLe plus hypercalcemla (and hypophosphaLemla) suggesL Lhe
presence of hyperparaLhyroldlsm and measuremenL of serum paraLhyrold hormone ls helpful Lxcesslve
urlnary urlc acld ls compaLlble wlLh urlc acld sLone formaLlon
A quallLaLlve LesL for urlnary cysLlne should be parL of Lhe rouLlne evaluaLlon lf levels are elevaLed a 24
hour quanLlLaLlve measuremenL should be made Pyperchloremlc acldosls suggesLs dlsLal renal Lubular
acldosls wlLh secondary renal calclflcaLlons 1oLal renal funcLlon ls lmpalred only lf Lhe sLones are
bllaLeral and parLlcularly lf chronlc lnfecLlon compllcaLes Lhe cllnlcal presenLaLlon
lmaglng SLudles
AbouL 90 of calcull are radlopaque Lhe ma[orlLy are calclum sLones and can be seen on plaln xray
LxcreLory urography ls necessary Lo verlfy Lhelr locaLlon wlLhln Lhe urlnary LracL and also affords a
quallLaLlve measure of renal funcLlon An acuLely obsLrucLed kldney may show only lncreaslng denslLy of
Lhe renal shadow wlLhouL slgnlflcanL radlopaque maLerlal ln Lhe callces A nonopaque sLone (urlc acld) ls
ldenLlfled as a radlolucenL defecL ln Lhe opaque conLrasL medla Calcull larger Lhan 1 cm casL a speclflc
acousLlc shadow on ulLrasonography Splral (hellcal) C1 has become Lhe flrsL sLudy of cholce because
Lhe enLlre urlnary LracL can be scanned rapldly and wlLhouL conLrasL ln[ecLlon (llgure 3810) Calcull can
be readlly ldenLlfled and dlsLlngulshed from cloL or Lumor laln xray of Lhe skeleLal sysLem may ldenLlfy
ageLs dlsease sarcoldosls or osLeoporosls due Lo prolonged lmmoblllzaLlon responslble for
hypercalclurla
llgure 3810




C1 scan wlLhouL lnLravenous conLrasL demonsLraLlng a lefL renal calculus (arrow)

SLone Analysls
lf a sLone has prevlously been passed or lf one ls recovered lLs chemlcal composlLlon should be
analyzed Such lnformaLlon may be useful when plannlng a prevenLlve program
ulfferenLlal ulagnosls
AcuLe pyelonephrlLls may begln wlLh acuLe renal paln mlmlcklng LhaL of renal sLone urlnalysls reveals
pyurla and urograms or C1 falls Lo reveal a calculus
8enal adenocarclnoma may bleed lnLo Lhe Lumor causlng acuLe paln mlmlcklng LhaL of an obsLrucLlng
sLone lmaglng can make Lhe dlfferenLlaLlon
1ranslLlonal cell Lumors of Lhe renal pelvls or callces mlmlc urlc acld sLone boLh are radlolucenL C1 scan
wlLhouL conLrasL or ulLrasound reveal Lhe sLone by vlrLue of lncreased denslLy compared wlLh ad[acenL
sofL Llssues
8enal Luberculosls ls compllcaLed by sLone formaLlon ln 10 of cases yurla wlLhouL bacLerlurla ls
suggesLlve urography reveals Lhe moLheaLen callces Lyplcal of Luberculosls
aplllary necrosls may cause renal collc lf a sloughed papllla obsLrucLs Lhe ureLeropelvlc [uncLlon
lmaglng (parLlcularly C1) seLLles Lhe lssue
8enal lnfarcLlon may cause renal paln and hemaLurla Lvldence of a cardlac leslon nonfuncLlon of Lhe
kldney on urography and excluslon of a calculus help ln dlfferenLlaLlon lnfarcLlon ls conflrmed by
anglography radlolsoLoplc renography or color uoppler ulLrasound
CLher condlLlons Lo be consldered ln Lhe dlfferenLlal dlagnosls lnclude ureLeropelvlc [uncLlon
obsLrucLlon obsLrucLlon due Lo blood cloLs ureLeral sLrlcLures or fungal bezoars and renal abscess
CompllcaLlons
AcLlng as a forelgn body a sLone lncreases Lhe probablllLy of lnfecLlon Powever prlmary lnfecLlon may
lnclLe sLone formaLlon A sLone lodged ln Lhe ureLeropelvlc [uncLlon leads Lo progresslve
hydronephrosls A sLaghorn calculus as lL grows may desLroy renal Llssue by pressure and Lhe lnfecLlon
LhaL ls usually presenL also conLrlbuLes Lo renal damage 1he presence of an obsLrucLed renal unlL should
be consldered and ls a urologlc emergency uralnage of Lhe kldney should be performed prompLly wlLh
lnserLlon of a ureLeral sLenL or percuLaneous nephrosLomy Lube
revenLlon
An effecLlve prevenLlve reglmen depends on sLone analysls and chemlcal sLudles of Lhe serum and urlne
Ceneral Measures
Lnsure a hlgh fluld lnLake (34 L/d) Lo keep soluLes well dlluLed 1hls measure alone may decrease
sLoneformlng poLenLlal by 30 1reaL lnfecLlon relleve sLasls or obsLrucLlon and advlse Lhe paLlenL Lo
avold prolonged lmmoblllzaLlon
Speclflc Measures
Calclum SLones
8emove Lhe paraLhyrold Lumor lf presenL Plgh dleLary sodlum promoLes renal calclum absorpLlon and
resLrlcLlon Lo 100 meq/d may be helpful LlmlLaLlon of proLelns and carbohydraLes may also reduce
hypercalclurla 8ecenL randomlzed Lrlals have shown LhaL ln men wlLh recurrenL calclum oxalaLe sLones
and hypercalclurla resLrlcLed lnLake of anlmal proLeln and salL comblned wlLh a normal calclum lnLake
provldes greaLer proLecLlon Lhan Lhe LradlLlonal lowcalclum dleL oLasslum clLraLe can decrease sLone
formaLlon by lncreaslng urlne levels of clLraLe whlch ls a sLone lnhlblLor
Cral orLhophosphaLes are effecLlve ln reduclng Lhe sLoneformlng poLenLlal of urlne by decreaslng urlne
calclum and lncreaslng lnhlblLor acLlvlLy 1hlazlde dlureLlcs such as hydrochloroLhlazlde 30 mg Lwlce
dally decrease Lhe calclum conLenL ln urlne by 30 lf hyperurlcosurla ls colncldenL wlLh calclum
urollLhlasls Lhen allopurlnol and urlnary alkallnlzaLlon can reduce Lhe formaLlon of uraLe crysLals whlch
may acL as a nldus for calclum crysLalllzaLlon
lor a paLlenL wlLh prlmary absorpLlve hypercalclurla cellulose sodlum phosphaLe can be glven 1hls
subsLance comblnes wlLh calclum ln Lhe guL Lo prevenL absorpLlon
CxalaLe SLones (Calclum CxalaLe)
rescrlbe phosphaLe or a Lhlazlde dlureLlc (see above) LllmlnaLlon of excesslve oxalaLe ln coffee Lea
colas leafy green vegeLables and chocolaLe may also be helpful Lxcess vlLamln C can be meLabollzed Lo
oxalaLe and Lhus should be avolded
MagneslumAmmonlumhosphaLe SLones
1hese sLones are usually secondary Lo urlnary LracL lnfecLlon due Lo bacLerla LhaL produce urease
(prlmarlly proLeus specles) LradlcaLlon of Lhe lnfecLlon prevenLs furLher sLone formaLlon buL ls
lmposslble when sLones are presenL AceLohydroxamlc acld a urease lnhlblLor can be used for oral
chemolysls and can poLenLlaLe anLlbloLlc acLlon AfLer all calcull have been removed prevenLlon of sLone
growLh ls besL accompllshed by urlnary acldlflcaLlon and longLerm use of anLlbloLlcs
MeLabollc SLones (urlc Acld CysLlne)
1hese subsLances are mosL soluble aL a pP of 70 or hlgher Clve poLasslum clLraLe 10 meq Lo 20 meq by
mouLh Lhree Llmes a day and monlLor Lhe urlne pP wlLh a llLmus paper lndlcaLor lor urlc acld sLone
formers llmlL purlnes ln Lhe dleL and glve allopurlnol lf Lhey have hyperurlcemla aLlenLs wlLh mlld
cysLlnurla may need only urlnary alkallnlzaLlon as descrlbed prevlously lor severe cysLlnurla
penlclllamlne 30 mg/kg/d orally reduces urlnary cysLlne Lo safe levels enlclllamlne should be
supplemenLed wlLh pyrldoxlne 30 mg/d orally 1lopronln whlch has fewer slde effecLs Lhan u
penlclllamlne and capLoprll can be used as well
1reaLmenL
ConservaLlve Measures
lnLervenLlon ls noL requlred for small nonobsLrucLlve asympLomaLlc callceal sLones PydraLlon and
dleLary managemenL may be sufflclenL Lo prevenL growLh of exlsLlng or new calclum sLones ln paLlenLs
wlLhouL meLabollc abnormallLles 1hose wlLh ldenLlflable meLabollc dlsorders may beneflL from Lhe
speclflc measures descrlbed prevlously aLlenLs wlLh known urlc acld sLones can be LreaLed wlLh
hydraLlon and urlnary alkallnlzaLlon whlch can help dlssolve Lhe sLone aLlenLs wlLh acLlve lnfecLlon
obsLrucLlon or lnLracLable nausea or paln may need deflnlLlve LreaLmenL ln Lhe acuLe seLLlng a ureLeral
sLenL can be lnserLed endoscoplcally under lnLravenous sedaLlon
ureLeroscoplc lnLervenLlon
aLlenLs wlLh small sLones can be managed wlLh ureLeronephroscopy and laser llLhoLrlpsy or baskeLlng
of Lhe sLones 1he presence of a ureLeral sLenL several days prlor helps passlvely dllaLe Lhe ureLer and
makes Lhe ureLeroscopy easler 1hls ls done under general anesLheLlc and as an ouLpaLlenL procedure
ercuLaneous lnLervenLlon (Lndourology)
ln selecLed paLlenLs wlLh sympLomaLlc or large pelvlc sLones percuLaneous sLone removal may be
successful A percuLaneous LracL enLers Lhe renal collecLlng sysLem Lhrough an approprlaLe callx
(percuLaneous nephrosLomy) 1he LracL ls subsequenLly dllaLed and endoscoplc exLracLlon of Lhe sLones
(percuLaneous nephroscopy and percuLaneous nephrollLhoLomy) ls done ulverlzaLlon of Lhe
fragmenLs by means of ulLrasonlc elecLrohydraullc or laser probes passed Lhrough Lhe nephrosLomy
LracL can be done 8esldual sLones afLer lnfecLlon may be dlssolved by percuLaneous lrrlgaLlon wlLh
hemlacldrln lor cysLlne and urlc acld sLones alkallne or oLher lrrlganLs LhaL lncrease Lhe speclflc crysLal
solublllLy may be used (eg n aceLylLlyslne or proplonyl glyclne for cysLlne sLones) Speclflc anLlbloLlc
LreaLmenL for lnfecLlon musL be glven before lrrlgaLlon Lo prevenL sepsls
Success wlLh Lhese endourologlc meLhods approaches 100 1he advanLages over surglcal procedures
lnclude no lnclslon and rapld recovery and reLurn Lo full acLlvlLy ulsadvanLages lnclude Lhe occaslonal
need for mulLlple LreaLmenLs Lo compleLely remove Lhe calcull and Lhe uncommon occurrence of
slgnlflcanL hemorrhage
LxLracorporeal Shock Wave LlLhoLrlpsy (LSWL)
WlLh Lhls Lechnlque paLlenLs are poslLloned ln Lhe paLh of shock waves focused on Lhe renal calcull wlLh
Lhe ald of fluoroscopy or ulLrasound Ceneral or reglonal anesLhesla ls requlred ln selecLed paLlenLs buL
sedaLlon ls sufflclenL ln mosL cases 1he shock waves (more Lhan 1300 are usually glven) pulverlze Lhe
sLones and Lhe small parLlcles pass sponLaneously over 2 Lo 3 days 8esulLs are excellenL Calclum
sLones and magneslumammonlumphosphaLe sLones have been LreaLed successfully 8ecause of Lhe
physlcal properLles of Lhe crysLal laLLlce LSWL ls noL as effecLlve ln fragmenLlng cysLlne sLones
8adlolucenL urlc acld sLones whlch can be vlsuallzed uslng conLrasL medlum vla lnLravenous
pyelography or reLrograde ureLeropyelography are amenable Lo LSWL LreaLmenL aLlenLs wlLh low
volume sLaghorn calcull can be managed wlLh LSWL Lhough percuLaneous nephrollLhoLomy remalns Lhe
LreaLmenL of cholce for mosL sLaghorn calcull
A varleLy of devlces now effecLlvely pulverlze sLones uslng less energy and Lhus can be used wlLh only
lnLravenous sedaLlon an lncreased number of pulses are requlred Lo obLaln Lhe same resulLs as wlLh
prevlous hlgherenergy devlces Some lnsLrumenLs use ulLrasound lnsLead of xray for sLone locallzaLlon
Cpen Surglcal 8emoval of SLones
Lndourologlc lnLervenLlon and LSWL have markedly decreased Lhe lndlcaLlons for open surgery 8arely
boLh percuLaneous nephrollLhoLomy and LSWL are conLralndlcaLed and open nephrollLhoLomy ls
necessary 1he goal of any approach ls Lo remove all sLone fragmenLs and Lhe approach chosen musL
allow for lnLraoperaLlve locallzaLlon by radlography or ulLrasonography lnclslons lnLo Lhe renal pelvls
(pyelollLhoLomy) or Lhe renal parenchyma (radlal nephroLomy or anaLrophlc nephrollLhoLomy) may be
requlred for compleLe sLone removal lnsLlllaLlon of a mlxLure of Lhrombln and calclum lnLo Lhe kldney
causes Lhe fragmenLs Lo become Lrapped ln a dense cloL whlch ls removed Lhrough a pyeloLomy lnclslon
(coagulum pyelollLhoLomy) CperaLlve nephroscopy allows a full vlew of all Lhe callces and removal of all
fragmenLs 8ench surgery wlLh auLoLransplanLaLlon of Lhe kldney may be requlred ln very few
lnsLances 8arely poorly funcLlonlng kldneys conLalnlng sympLomaLlc sLones requlre nephrecLomy
rognosls
1he recurrence raLe of renal sLone can be as hlgh as 40 and can be decreased wlLh sufflclenL aLLenLlon
Lo measures for prevenLlon of sLone formaLlon 1he danger of recurrenL sLone ls progresslve renal
damage due Lo obsLrucLlon and lnfecLlon
ureLeral SLone
LssenLlals of ulagnosls
- Severe ureLerorenal collc
- PemaLurla
- nausea vomlLlng and lleus
- SLone vlslble on excreLory urography or splral C1
Ceneral ConslderaLlons
ureLeral sLones orlglnaLe ln Lhe kldney When sympLoms occur ureLeral obsLrucLlon ls lmpllclL and renal
funcLlon endangered CompllcaLlng lnfecLlon may occur MosL ureLeral sLones pass sponLaneously
especlally lf Lhey are less Lhan 03 cm ln greaLesL dlmenslon
Cllnlcal llndlngs
SympLoms and Slgns
1he onseL of paln ls usually abrupL aln ls felL ln Lhe cosLoverLebral angle and radlaLes Lo Lhe lpsllaLeral
lower abdomlnal quadranL nausea vomlLlng abdomlnal dlsLenLlon and gross hemaLurla are common
When Lhe sLone approaches Lhe bladder sympLoms mlmlc cysLlLls wlLh frequency and urgency lf Lhe
kldney ls lnfecLed acuLe ureLeral obsLrucLlon exacerbaLes Lhe lnfecLlon
1he paLlenL ls usually ln such agony LhaL only parenLeral oplolds wlll glve rellef CosLoverLebral angle
Lenderness and guardlng may be evldenL Absence of bowel sounds and abdomlnal dlsLenLlon slgnlfy
lleus lever may occur as a resulL of compllcaLlng renal lnfecLlon
LaboraLory llndlngs
LaboraLory flndlngs are Lhe same as for renal sLone
lmaglng SLudles
LxcreLory urograms or splral C1 ls essenLlal laln fllms may reveal an opaclLy ln Lhe reglon of Lhe ureLer
ConflrmaLlon of ureLeral locaLlon requlres demonsLraLlon of confluence of sLone and ureLeral conLrasL
Splral C1 ls dlagnosLlc and ls currenLly used as Lhe flrsLllne lmaglng modallLy (llgure 3811) 1hls
procedure deplcLs Lhe degree of obsLrucLlon and Lhe slze and poslLlon of Lhe sLone lnformaLlon LhaL
permlLs selecLlon of approprlaLe LreaLmenL A radlolucenL sLone appears as a fllllng defecL wlLhln a
proxlmally dllaLed ureLerlndlsLlngulshable from a ureLeral Lumor or blood cloL by lnLravenous
urography C1 scan dlscrlmlnaLes beLween sLone and Lumor or cloL denslLy CysLoscopy ureLeral
caLheLerlzaLlon reLrograde urography and ureLeroscopy may also be helpful
llgure 3811




C1 scan wlLhouL lnLravenous conLrasL demonsLraLlng a lefL ureLeral calculus (arrow)

ulfferenLlal ulagnosls
A Lumor of Lhe kldney or renal pelvls may bleed and passage of a blood cloL may cause ureLeral collc
urograms may reveal a radlolucenL area ln Lhe ureLer surrounded by Lhe radlopaque urlne A C1 scan
wlLh and wlLhouL conLrasL agenLs reveals no radlopaclLy ln Lhe ureLer and helps deflne Lhe renal
parenchymal or renal pelvls Lumor
A prlmary Lumor of Lhe ureLer may cause obsLrucLlng paln and hemaLurla 1he urogram reveals Lhe
ureLeral fllllng defecL ofLen wlLh secondary obsLrucLlon A C1 scan can dlfferenLlaLe a sLone from Lumor
urlnary cyLologlc sLudy may reveal mallgnanL uroLhellal cells
AcuLe pyelonephrlLls may cause paln as severe as LhaL seen wlLh sLone yurla and bacLerlurla are found
buL do noL rule ouL sLone SLone ls absenL on nonconLrasL C1 or urography
A sloughed papllla (consequenL Lo condlLlons such as dlabeLes melllLus) Lraverslng Lhe ureLer may cause
collc and produces a urogram compaLlble wlLh urlc acld sLone aplllary sloughs should be evldenL
however
CompllcaLlons
lf obsLrucLlon from Lhe ureLeral sLone ls prolonged progresslve renal damage may ensue 8llaLeral
sLones may cause anurla requlrlng lmmedlaLe dralnage of Lhe proxlmal collecLlng sysLem wlLh
lndwelllng ureLeral caLheLers or percuLaneous nephrosLomy
lnfecLlon may supervene buL many renal lnfecLlons are laLrogenlc (le lnLroduced aL Lhe Llme of sLone
manlpulaLlon)
revenLlon
See 8enal SLone
1reaLmenL
Ceneral Measures
MosL ureLeral sLones pass sponLaneouslyparLlcularly Lhose less Lhan 03 cm ln dlameLer Cnce Lhe
dlagnosls has been esLabllshed analgeslcs should be glven and Lhe paLlenL hydraLed 8ecenL reporLs
have found alphablocker Lherapy useful ln expulslon of dlsLal ureLeral sLones by relaxlng smooLh
muscle erlodlc plaln fllms should be Laken Lo follow Lhe progress of Lhe sLone and lnLerval renal
ulLrasound sLudles obLalned Lo assess Lhe degree of hydronephrosls 1he urlne should be sLralned unLll
Lhe sLone passes ln order Lo recover Lhe calculus for analysls WlLh larger sLones acuLe obsLrucLlon can
be Lemporarlly relleved by lnserLlng an lndwelllng ureLeral sLenL
Speclflc Measures
lf Lhe sLone causes lnLracLable paln progresslve hydronephrosls or acuLe lnfecLlon lL should be
removed CbsLrucLlng sLones ln Lhe upper Lwo Lhlrds of Lhe ureLer can ofLen be successfully LreaLed by
ureLeroscopy or LSWL wlLh or wlLhouL ureLeral sLenL lnserLlon Lo help faclllLaLe sLone passage
ureLeroscopy permlLs ulLrasonlc or laser fragmenLaLlon or sLone baskeL reLrleval under dlrecL vlslon
8eLrograde baskeL exLracLlon under fluoroscoplc conLrol may be used Lo remove small dlsLal ureLeral
sLones Cpen surglcal removal (ureLerollLhoLomy) ls only very rarely requlred for ureLeral sLones LSWL
has been applled Lo ureLeral sLones ln Lhe proxlmal ureLer buL ls more problemaLlc ln Lhe dlsLal ureLer
owlng Lo bone lnLerference by surroundlng pelvls whlch lnLerferes wlLh lmaglng and aLLenuaLes shock
wave force
rognosls
AbouL 80 of ureLeral sLones pass sponLaneously erlodlc plaln fllms of Lhe abdomen or excreLory
urograms porLrays progress of Lhe sLone and warn of ensulng renal damage LhaL would prompL
operaLlve lnLervenLlon
veslcal SLone
rlmary veslcal calcull are rare ln Lhe unlLed SLaLes buL are common ln SouLheasL Asla and Lhe Mlddle
LasL 1he cause ls probably dleLary Secondary sLones usually compllcaLe veslcal ouLleL obsLrucLlon wlLh
resldual urlne and lnfecLlon 90 of Lhose affecLed are men CLher causes of bladder sLasls such as
neurogenlc bladder and bladder dlverLlcula also promoLe veslcal sLone formaLlon 1hey are common ln
veslcal schlsLosomlasls or ln assoclaLlon wlLh radlaLlon cysLlLls lorelgn bodles ln Lhe bladder may acL as
a nldus for Lhe preclplLaLlon of urlnary salLs MosL sLones conLaln urlc acld or sLruvlLe (ln lnfecLed urlne)
Cllnlcal llndlngs
SympLoms and Slgns
SympLoms of bladder neck obsLrucLlon are ellclLed 1here may be sudden lnLerrupLlon of Lhe sLream and
ureLhral paln lf a sLone occludes Lhe bladder neck durlng voldlng PemaLurla ls common veslcal
dlsLenLlon may be noLed evldence of ureLhral sLrlcLure or an enlarged prosLaLe ls usually found
LaboraLory llndlngs
yurla and hemaLurla are almosL always presenL
lmaglng SLudles
veslcal calcull may be mlssed on plaln xrays due Lo Lhe hlgh componenL of radlolucenL urlc acld
LxcreLory urograms reveal a fllllng defecL ln Lhe bladder resldual urlne ls usually deplcLed on Lhe
posLvoldlng fllm C1 scan or ulLrasound dlfferenLlaLes beLween sLones and veslcal Lumors or blood cloLs
buL dlrecL vlslon endoscoplcally ls preferred
lnsLrumenLal LxamlnaLlon
lnablllLy Lo pass a caLheLer lnLo Lhe bladder slgnlfles ureLhral sLrlcLure CaLheLerlzaLlon may demonsLraLe
resldual urlne CysLoscopy vlsuallzes Lhe sLones and may reveal an obsLrucLlng prosLaLe
ulfferenLlal ulagnosls
A pedunculaLed veslcal Lumor may suddenly occlude Lhe veslcal neck durlng voldlng LxcreLory
urograms pelvlc ulLrasound C1 scan or cysLoscopy leads Lo deflnlLlve dlagnosls
LxLraveslcal opaclflcaLlons may slmulaLe sLones on a plaln fllm
CompllcaLlons
AcLlng as forelgn bodles bladder sLones exacerbaLe urlne lnfecLlon and foll anLlbloLlc Lherapy glven for
Lhe purpose of sLerlllzlng Lhe urlne SLones obsLrucLlng Lhe ureLhra musL be removed
revenLlon
revenLlon requlres rellef of Lhe prlmary obsLrucLlon removal of Lhe sLones and sLerlllzaLlon of Lhe
urlne
1reaLmenL
Ceneral Measures
Analgeslcs should be glven for paln and anLlmlcroblals for conLrol of lnfecLlon unLll Lhe sLones can be
removed
Speclflc Measure
Small sLones can be removed or crushed LransureLhrally (cysLollLhalopaxy) Larger sLones are ofLen
dlslnLegraLed by LransureLhral elecLrohydraullc llLhoLrlpsy (shock wavegeneraLlng probe) or laser
desLrucLlon or Lhey may requlre suprapublc Lransveslcal removal (veslcollLhoLomy) Suprapublc
prosLaLecLomy helps address Lhe cause of obsLrucLlon and provldes access for open sLone removal
rognosls
8ecurrenL veslcal sLone ls uncommon lf Lhe obsLrucLlon and lnfecLlon are LreaLed
nephrocalclnosls
nephrocalclnosls ls a preclplLaLlon of calclum ln Lhe Lubules parenchyma and occaslonally Lhe
glomerull lL always causes renal funcLlonal lmpalrmenL ofLen severe SLones may be found ln Lhe
callces and pelvls 1he common causes are prlmary or secondary hyperparaLhyroldlsm excesslve mllk
alkall or vlLamln u lnLake or Lhey may be found wlLh severe renal damage assoclaLed wlLh renal Lubular
acldosls or sarcoldosls CalclflcaLlons may also be seen ln Lhe skln lungs sLomach spleen and corneas
or around Lhe [olnLs
Cllnlcal llndlngs
SympLoms and Slgns
1here are no speclflc sympLoms ln chlldhood Lhe paLlenL may merely fall Lo Lhrlve SLones or sand may
be passed 1he complalnLs are usually Lhose of Lhe prlmary dlsease hyslcal examlnaLlon may reveal an
enlarged paraLhyrold gland corneal calclflcaLlons and pseudorlckeLs
LaboraLory llndlngs
1he urlne may be lnfecLed ln renal Lubular acldosls Lhe pP ls flxed beLween 60 and 70 urlnary calclum
ls hlgh ln hyperparaLhyroldlsm boLh prlmary and secondary 1esLs of renal funcLlon are depressed
uremla ls common Pypercalcemla and hypophosphaLemla are seen wlLh prlmary hyperparaLhyroldlsm
secondary hyperparaLhyroldlsm may be assoclaLed wlLh a low serum calclum and an elevaLed serum
phosphaLe Pyperchloremlc acldosls and hypokalemla accompany renal Lubular acldosls
lmaglng SLudles
A plaln xray reveals puncLaLe calclflcaLlons ln Lhe paplllae of Lhe kldneys Callceal or pelvlc sLones may
also be noLed 1he paLLern of calclflcaLlon may have Lo be dlfferenLlaLed from renal Luberculosls and
medullary sponge kldney
CompllcaLlons
CompllcaLlons lnclude renal damage caused by Lhe calclflcaLlons and renal and ureLeral calcull Chronlc
renal lnfecLlon may compllcaLe Lhe prlmary dlsease
1reaLmenL rognosls
1he prlmary cause should be LreaLed lf posslble (eg paraLhyroldecLomy) PydraLlon wlLh lsoLonlc sallne
along wlLh furosemlde can help enhance calclum excreLlon ulsconLlnue vlLamln u and mllkalkall
producers lf Lhe prlmary cause was due Lo excesslve lnLake WlLh hyperchloremlc acldosls alkallnlze Lhe
urlne wlLh poLasslum clLraLe CsLeomalacla requlres admlnlsLraLlon of vlLamln u and calclum even
Lhough nephrocalclnosls ls presenL
lf nephrocalclnosls ls secondary Lo prlmary renal dlsease Lhe ouLlook ls poor lf Lhe cause ls correcLable
and renal funcLlon ls falrly good Lhe prognosls ls more favorable
8orghl L eL al Comparlson of Lwo dleLs for Lhe prevenLlon of recurrenL sLones ln ldlopaLhlc
hypercalclurla n Lngl ! Med 200234677 Mlu 11784873
8orghl L eL al Medlcal LreaLmenL of nephrollLhlasls Lndocrlnol MeLab Clln norLh Am 2002311031
Mlu 12474643
Curhan CC Lpldemlology of sLone dlsease urol Clln norLh Am 200734287 Mlu 17678980
ark S earle MS aLhophyslology and managemenL of calclum sLones urol Clln norLh Am
200734323 Mlu 17678983
arsons !k eL al Lfflcacy of alphablockers for Lhe LreaLmenL of ureLeral sLones ! urol 2007177983
Mlu 17296392
Shlne S urlnary calculus lvu vs C1 renal sLone? A crlLlcally appralsed Loplc Abdom lmaglng 20073341
Wen CC nakada S? 1reaLmenL selecLlon and ouLcomes renal calcull urol Clln norLh Am 200734409
Mlu 17678990
Wolf !S 1reaLmenL selecLlon and ouLcomes ureLeral calcull urol Clln norLh Am 200734421 Mlu
17678991

ln[urles Lo Lhe kldney
LssenLlals of ulagnosls
- PlsLory or evldence of Lrauma usually locallzed
- PemaLurla
- llank mass
- lallure Lo opaclfy Lhe kldney or exLravasaLlon of urlne on excreLory urography
Ceneral ConslderaLlons
8enal ln[ury ls uncommon buL poLenLlally serlous and ofLen accompanled by mulLlsysLem Lrauma 1he
mosL common causes are aLhleLlc lndusLrlal or auLomoblle accldenLs 1he degree of ln[ury may range
from conLuslon Lo laceraLlon of Lhe parenchyma or dlsrupLlon of Lhe renal pedlcle
Cllnlcal llndlngs
SympLoms and Slgns
Cross hemaLurla followlng Lrauma means ln[ury Lo Lhe urlnary LracL aln and Lenderness over Lhe renal
area may be slgnlflcanL buL could be due Lo musculoskeleLal ln[ury Pemorrhaglc shock may resulL from
renal laceraLlon and lead Lo ollgurla nausea vomlLlng and abdomlnal dlsLenLlon (lleus) are Lhe rule
hyslcal examlnaLlon may reveal ecchymosls or peneLraLlng ln[ury ln Lhe cosLoverLebral angle or flank
LxLravasaLlon of blood or urlne may produce a palpable flank mass CLher ln[urles should be soughL

LaboraLory llndlngs
Serlal hemaLocrlL deLermlnaLlons wlll glve clues Lo perslsLenL bleedlng PemaLurla ls Lo be expecLed buL
Lhe absence of hemaLurla does noL exclude renal ln[ury (as ln renal vascular ln[ury)
lmaglng SLudles
A plaln fllm may reveal obllLeraLlon of Lhe psoas shadow Lhls suggesLs Lhe presence of a reLroperlLoneal
hemaLoma or urlnary exLravasaLlon 8owel gas may be dlsplaced from Lhe area Lvldence of Lransverse
verLebral process or rlb fracLures may be noLed ln Lhe pasL Lhe excreLory urogram was used for
evaluaLlng renal Lrauma LxcreLory urograms may show a normal kldney lf lL ls mlldly conLused or may
show exLravasaLlon of conLrasL medlum lf Lhe kldney ls laceraLed nonfuncLlon suggesLs ln[ury Lo Lhe
vascular pedlcle 1he excreLory urogram should demonsLraLe LhaL Lhe conLralaLeral kldney ls normal C1
scan wlLh lnLravenous conLrasL medlum ls now Lhe meLhod of cholce for sLaglng a paLlenL wlLh
hemodynamlcally sLable renal Lrauma C1 scans may mlss urlnary exLravasaLlon lf performed Loo rapldly
followlng lnLravenous conLrasL admlnlsLraLlonbefore Lhe conLrasL ls excreLed lnLo Lhe collecLlng
sysLem and ureLer lf renal vascular damage ls suspecLed and Lhe paLlenLs condlLlon ls sLable
preoperaLlve renal anglography may faclllLaLe plannlng of renovascular reconsLrucLlon or permlL arLerlal
sLenLlng ln speclal clrcumsLances selecLlve renal arLery embollzaLlon may conLrol segmenLal arLerlal
bleedlng 8enal lmaglng ls lndlcaLed ln any adulL wlLh gross hemaLurla or mlcroscoplc hemaLurla wlLh
shock lmaglng ls also requlred wlLh deceleraLlon ln[urles and ls lndlcaLed ln chlldren wlLh any hemaLurla
of less Lhan 30 red blood cells per hlghpower fleld
ulfferenLlal ulagnosls
8ony fracLures or conLuslon of sofL Llssues ln Lhe reglon of Lhe kldney may cause confuslon PemaLurla
mlghL be secondary Lo veslcal ln[ury 1he absence of a perlrenal mass (le hemaLoma or urlnoma) or
conLrasL exLravasaLlon on urograms or C1 scan would rule ouL slgnlflcanL Lrauma
CompllcaLlons
Larly
1he mosL serlous compllcaLlon ls conLlnued perlrenal hemorrhage whlch may be faLal Serlal
hemaLocrlL blood pressure and pulse deLermlnaLlons are essenLlal Serlal C1 scans may also be useful
Lvldence of an enlarglng flank mass lmplles perslsLenL bleedlng ln mosL cases bleedlng sLops
sponLaneously probably as a resulL of Lamponade by Lhe perlrenal fascla uelayed bleedlng 1 or 2 weeks
laLer ls rare lnfecLlon of Lhe perlrenal hemaLoma may occur
LaLe
ulLrasound should be obLalned 1 Lo 3 monLhs afLer managemenL of renal Lrauma Lo look for progresslve
hydronephrosls from ureLeral obsLrucLlon 1he blood pressure should be checked aL regular lnLervals
because hyperLenslon may be a laLe sequela
1reaLmenL
1reaL shock and hemorrhage wlLh flulds and Lransfuslon MosL paLlenLs wlLh blunL renal Lrauma sLop
bleedlng and heal sponLaneously 8ed resL ls lndlcaLed unLll hemaLurla resolves lf bleedlng perslsLs
laparoLomy ls lndlcaLed
eneLraLlng renal Lrauma requlres exploraLlon LaceraLlons may be suLured Lhe collecLlng sysLem
closed and urlnary exLravasaLlon dralned nephrecLomy or parLlal nephrecLomy may be necessary Lo
remove devlLallzed Llssue and secure Lhe collecLlng sysLem
LaLe compllcaLlons may occur erlnephrlc abscess should be dralned PyperLenslon due Lo renal
lschemla requlres vascular reconsLrucLlon or nephrecLomy
rognosls
MosL ln[ured kldneys heal sponLaneously Lhough Lhe paLlenL musL be examlned aL lnLervals for Lhe
onseL of hyperLenslon due Lo renal lschemla or progresslve hydronephrosls due Lo secondary ureLeral
sLrlcLure Many paLlenLs wlLh genlLourlnary Lrauma have assoclaLed ln[urles ln mosL cases deaLh ls due
Lo assoclaLed ln[ury raLher Lhan renal ln[ury
ln[urles Lo Lhe ureLer
LssenLlals of ulagnosls
- Anurla or ollgurla prolonged lleus or flank paln followlng pelvlc operaLlon
- CnseL of urlnary dralnage Lhrough wound or vaglna
- uemonsLraLlon of urlnary exLravasaLlon or ureLeral obsLrucLlon by urography
Ceneral ConslderaLlons
MosL ureLeral ln[urles are laLrogenlc ln Lhe course of pelvlc surgery ureLeral ln[ury may occur durlng
LransureLhral bladder or prosLaLe resecLlon or ureLeral manlpulaLlon for sLone or Lumor ureLeral ln[ury
ls rarely a consequence of peneLraLlng Lrauma unlnLenLlonal ureLeral llgaLlon durlng operaLlon on
ad[acenL organs may be asympLomaLlc Lhough hydronephrosls and loss of renal funcLlon resulLs
ureLeral dlvlslon leads Lo exLravasaLlon and ureLerocuLaneous flsLula
Cllnlcal llndlngs
SympLoms
lf Lhe ureLeral ln[ury ls noL recognlzed aL surgery Lhe paLlenL may complaln of flank and lower
abdomlnal paln on Lhe ln[ured slde lleus and pyelonephrlLls may develop LaLer urlne may draln
Lhrough Lhe wound (or Lhrough Lhe vaglna followlng Lransvaglnal surgery) Wound dralnage may be
evaluaLed by comparlng creaLlnlne levels found ln Lhe dralnage fluld wlLh serum levels urlne exhlblLs
very hlgh creaLlnlne levels when compared wlLh serum lnLravenous admlnlsLraLlon of 3 mL of lndlgo
carmlne causes Lhe urlne Lo appear bluegreen Lherefore dralnage from a ureLerocuLaneous flsLula
becomes blue compared Lo serous dralnage Anurla followlng pelvlc surgery noL respondlng Lo
lnLravenous flulds means bllaLeral ureLeral llgaLlon unLll proved oLherwlse erlLoneal slgns may occur lf
urlne leaks lnLo Lhe perlLoneal cavlLy
LaboraLory llndlngs
Mlcroscoplc hemaLurla ls usually found buL may be absenL 1esLs of renal funcLlon may be normal unless
boLh ureLers are occluded
lmaglng SLudles
LxcreLory urograms may show evldence of ureLeral occluslon LxLravasaLlon of radlopaque fluld may be
seen ln Lhe reglon of Lhe ureLer 8eLrograde ureLerography deplcLs Lhe slLe and naLure (occluslon or
dlvlslon) of Lhe ln[ury
ulLrasonography may reveal hydroureLer and hydronephrosls or a fluld mass represenLlng urlnary
exLravasaLlon 8adlonucllde scannlng shows delayed excreLlon wlLh an accumulaLlon of counLs ln Lhe
pelvls and renal parenchyma resulLlng from ureLeral obsLrucLlon alLhough urlnary exLravasaLlon ls
deLecLed anaLomlc speclflclLy for slLe of ln[ury ls noL clearly deflned
ulfferenLlal ulagnosls
ureLeral ln[ury may mlmlc perlLonlLls lf urlne leaks lnLo Lhe perlLoneal cavlLy LxcreLory urography
reveals Lhe ureLeral lnvolvemenL
Cllgurla may be due Lo dehydraLlon Lransfuslon reacLlon or bllaLeral lncompleLe ureLeral ln[ury A
survey of fluld and elecLrolyLe lnLake and ouLpuL lncludlng serlal body welghLs should prove deflnlLlve
1oLal anurla lmplles bllaLeral ureLeral ln[ury and lndlcaLes Lhe need for lmmedlaLe urologlc lnvesLlgaLlon
veslcovaglnal and ureLerovaglnal flsLulas may be confused MeLhylene blue soluLlon lnsLllled lnLo Lhe
bladder sLalns Lhe dralnage of a veslcovaglnal flsLula CysLoscopy may show Lhe veslcal defecL
8eLrograde ureLerography should reveal a ureLeral flsLula 1he presence of boLh ln[urles occurrlng
slmulLaneously should also be consldered and evaluaLed
CompllcaLlons
1hese lnclude urlnary flsLula ureLeral obsLrucLlon or sLenosls wlLh hydronephrosls renal lnfecLlon
perlLonlLls and uremla (wlLh bllaLeral ln[ury)
revenLlon
8efore operaLlon for large pelvlc masses whlch may cause dlsplacemenL of Lhe ureLers caLheLers should
be placed ln Lhe ureLers Lo faclllLaLe Lhelr ldenLlflcaLlon aL surgery AlLhough Lhe caLheLers may noL
prevenL ln[ury Lhey faclllLaLe recognlLlon of a ureLeral ln[ury
1reaLmenL
ln[ury 8ecognlzed aL Surgery
ureLeral ulvlslon
8epalr of a ureLer lnadverLenLly cuL durlng surgery conslsLs of anasLomosls of Lhe ends over an
lndwelllng sLenL (ureLeroureLerosLomy) relmplanLlng Lhe ureLer lnLo Lhe bladder lf Lhe ln[ury ls
[uxLaveslcal (neoureLerocysLosLomy) or anasLomoslng Lhe proxlmal segmenL of dlvlded ureLer Lo Lhe
slde of Lhe conLralaLeral ureLer (LransureLeroureLerosLomy) 1he anasLomosls musL be Lenslon free and
Lhe area of repalr musL be dralned
ureLeral 8esecLlon
8epalr of a ureLer from whlch a subsLanLlal segmenL has been removed requlres lnLerposlLlon of a
ureLeral subsLlLuLe or moblllzaLlon of Lhe proxlmal and dlsLal ureLer Lo provlde a Lenslonfree
anasLomosls WlLh loss of Lhe dlsLal ureLer Lhe bladder may be hlLched cephalad Lo Lhe psoas muscle or
a bladder flap may be creaLed Lo faclllLaLe a ureLeral lmplanL ln exLreme cases auLoLransplanL of Lhe
kldney Lo Lhe pelvls may be necessary
ln[ury ulscovered afLer Surgery
Larly reoperaLlon ls recommended uependlng on Lhe flndlngs any of Lhe procedures noLed above may
be uLlllzed lf a long segmenL of ureLer ls noL vlable an lnLesLlnal ureLer may be consLrucLed lf
hydronephrosls ls advanced or lf sepsls develops percuLaneous nephrosLomy should precede repalr
When Lhe paLlenLs condlLlon ls sLable deflnlLlve repalr can be accompllshed nephrecLomy may be
lndlcaLed lf Lhe conLralaLeral kldney ls normal and Lhere ls a conLralndlcaLlon Lo
LransureLeroureLerosLomy (such as calcull or upper LracL LranslLlonal cell carclnoma)
rognosls
ln cases of laLrogenlc ln[ury Lhe resulLs are besL lf Lhe ln[ury ls recognlzed aL Lhe Llme of surgery LaLe
repalr lf severe perlureLeral flbrosls has developed ls less llkely Lo afford a good ouLcome
ln[urles Lo Lhe 8ladder
LssenLlals of ulagnosls
- PlsLory of Lrauma (lncludlng surglcal or endoscoplc)
- lracLure of Lhe pelvls
- Suprapublc paln and abdomlnal muscle rlgldlLy
- PemaLurla
- LxLravasaLlon shown on cysLogram
Ceneral ConslderaLlons
1he mosL common cause of veslcal ln[ury ls an exLernal blow over a full bladder 8upLure of Lhe organ ls
seen ln 13 of paLlenLs wlLh pelvlc fracLure 1he bladder may be lnadverLenLly opened durlng pelvlc
surgery or ln[ured by cysLoscoplc maneuvers (eg LransureLhral resecLlon of bladder Lumor) lf Lhe ln[ury
ls lnLraperlLoneal (40 of all bladder rupLures) blood and urlne wlll exLravasaLe lnLo Lhe perlLoneal
cavlLy produclng slgns of perlLonlLls lf lL ls exLraperlLoneal (34 of all bladder rupLures) a mass
develops ln Lhe pelvls AbouL 6 of all bladder rupLures have a comblnaLlon of boLh lnLraperlLoneal and
exLraperlLoneal exLravasaLlon
Cllnlcal llndlngs
SympLoms and Slgns
1here ls usually a hlsLory of hypogasLrlc or pelvlc Lrauma PemaLurla and suprapublc paln and an
lnablllLy Lo vold are expecLed AssoclaLed ln[ury may cause hemorrhaglc shock 1here ls suprapublc
Lenderness and guardlng lnLraperlLoneal exLravasaLlon causes perlLoneal slgns whlle exLraperlLoneal
exLravasaLlon resulLs ln formaLlon of a pelvlc urlnoma
LaboraLory llndlngs
A falllng hemaLocrlL reflecLs conLlnued bleedlng PemaLurla ls expecLed ln paLlenLs who are able Lo vold
A paLlenL who cannoL vold should be caLheLerlzed unless pelvlc fracLure (and ureLhral ln[ury) ls
suspecLed or blood ls noLed aL Lhe ureLhral meaLus
lmaglng SLudles
A plaln fllm may reveal fracLure of Lhe pelvls An exLraperlLoneal collecLlon of blood and urlne may
dlsplace Lhe bowel gas laLerally or ouL of Lhe pelvls lf bladder Lrauma ls suspecLed cysLography should
precede excreLory urography LxLravasaLlon ls mosL rellably demonsLraLed by a posLdralnage cysLogram
fllm lf one suspecLs ureLhral Lrauma a reLrograde ureLhrogram should precede caLheLer lnserLlon 1he
excreLory urogram may suggesL Lhe dlagnosls of bladder perforaLlon buL by lLself ls lnsufflclenL Lo
exclude bladder ln[ury A C1 cysLogram can be used buL lmages of Lhe bladder obLalned by passlve
bladder fllllng afLer caLheLer clamplng are noL sufflclenL Lo exclude a bladder ln[ury 1he bladder should
be fllled Lo capaclLy by gravlLy wlLh dlluLed conLrasL (330400 mL) a pelvlc xray Laken and Lhen Lhe
bladder should be empLled and anoLher pelvlc xray Laken 1hls meLhod should ldenLlfy even subLle
leaks
ulfferenLlal ulagnosls
8enal ln[ury ls also assoclaLed wlLh bladder Lrauma and usually presenLs wlLh hemaLurla LxcreLory
urograms show changes compaLlble wlLh renal Lrauma Lhe cysLogram ls negaLlve
ln[ury Lo Lhe membranous ureLhra can mlmlc exLraperlLoneal rupLure of Lhe bladder A ureLhrogram
reveals Lhe slLe of ln[ury ureLhral dlsrupLlon ls a conLralndlcaLlon Lo ureLhral caLheLerlzaLlon
CompllcaLlons
LxLraperlLoneal exLravasaLlon may lead Lo pelvlc abscess lnLraperlLoneal exLravasaLlon causes delayed
perlLonlLls ollgurla and azoLemla
1reaLmenL
1reaL shock hemorrhage and oLher llfeLhreaLenlng ln[urles Marked exLraperlLoneal exLravasaLlon
should be dralned Lhe bladder decompressed by elLher a suprapublc or ureLhral caLheLer and
approprlaLe anLlbloLlcs admlnlsLered Small exLraperlLoneal exLravasaLlons are LreaLed nonoperaLlvely
by ureLhral caLheLer
lnLraperlLoneal exLravasaLlon of bladder urlne requlres exploraLory laparoLomy mldllne cysLoLomy
bladder closure and bladder caLheLer dralnage eneLraLlng ln[urles (le gunshoL sLabblng) requlre
exploraLlon and closure of Lhe bladder 1he ureLers should also be evaluaLed ln all cases of bladder
ln[ury by preoperaLlve lmaglng or lnLraoperaLlve assessmenL whlch may be done by ln[ecLlng lndlgo
carmlne and looklng for ureLeral exLravasaLlon or by reLrograde passage of 3l feedlng Lubes Lhrough Lhe
ureLeral orlflce
rognosls
Larly dlagnosls mlnlmlzes morbldlLy and morLallLy raLes 1he prognosls depends chlefly on Lhe severlLy
of assoclaLed ln[urles
ln[urles Lo Lhe ureLhra
Membranous ureLhra
ln[ury Lo Lhe membranous ureLhra ls usually a consequence of pelvlc fracLure and Lhus ls assoclaLed wlLh
hemorrhage and mulLlorgan ln[ury 1he mechanlsm of ln[ury ls blunL Lrauma and deceleraLlon resulLlng
ln shearlng forces applled Lo Lhe prosLaLe and urogenlLal dlaphragm eneLraLlng ln[urles resulL from
exLernal mlsslles or laceraLlon by bone fragmenLs acLlng as secondary pro[ecLlles
lf Lhe ureLhral dlsrupLlon ls lncompleLe Lhe paLlenL may be able Lo vold and hemaLurla would be
lnevlLable ureLhral ln[ury ls suspecLed lf blood ls expressed from Lhe ureLhral meaLus ln cases of
compleLe avulslon exLravasaLlon causes a suprapublc mass 8ecLal examlnaLlon may reveal a
nonpalpable or upwardly dlsplaced prosLaLe
xray reveals a fracLured pelvls ureLhrography dellneaLes any exLravasaLlon and cysLography ldenLlfles
an assoclaLed bladder ln[ury An lmmedlaLe excreLory urogram or C1 scan should be obLalned ln all cases
Lo assess kldney and ureLeral funcLlon
1reaLmenL musL be coordlnaLed wlLh care of assoclaLed ln[ury Cnce a membranous ureLhral ln[ury wlLh
urlnary exLravasaLlon has been ldenLlfled suprapublc cysLosLomy should be performed elLher aL Lhe
Llme of laparoLomy or percuLaneously before placemenL of exLernal pelvlc flxaLlon ueflnlLlve ureLhral
repalr may be delayed unLll Lhe paLlenL has recovered from Lhe acuLe ln[ury and pelvlc fracLures have
healed Cccaslonally when ureLhral dlsrupLlon ls lncompleLe laLe repalr ls unnecessary rlmary repalr
may be lndlcaLed ln cases of severe prosLaLomembranous dlslocaLlon ma[or bladder neck laceraLlon or
concomlLanL pelvlc vascular or recLal ln[ury
LaLe sequelae are ureLhral sLrlcLure lmpoLence and lnconLlnence ureLhral sLrlcLure musL be ldenLlfled
by reLrograde ureLhrography and may be LreaLed by LransureLhral lnclslon of Lhe sLrlcLure or
ureLhroplasLy lmpoLence due Lo ln[ury of nerves Lo Lhe corpora cavernosa LhaL course ad[acenL Lo Lhe
membranous ureLhra may resolve wlLhouL LreaLmenL durlng Lhe year followlng ln[ury vascular ln[ury of
Lhe hypogasLrlc or pudendal arLerles may cause lmpoLence followlng Lrauma CavernosomeLry and
arLerlography conflrms Lhe dlagnosls approprlaLe LreaLmenL may lnclude vascular reconsLrucLlon
lnconLlnence depends on Lhe neurologlc sLaLus of Lhe paLlenL Medlcal or surglcal Lherapy ls uLlllzed Lo
lncrease bladder capaclLy and bladder ouLleL reslsLance
8ulbous ureLhra
1he bulbous ureLhra may be ln[ured as a resulL of lnsLrumenLaLlon or more commonly falllng asLrlde an
ob[ecL (sLraddle ln[ury) ureLhral conLuslon may cause a perlneal hemaLoma wlLhouL ln[ury Lo Lhe
ureLhral wall LaceraLlon leads Lo urlnary exLravasaLlon
erlneal paln and some ureLhral bleedlng are Lo be expecLed Sudden swelllng ln Lhe perlneum may
develop followlng aLLempLed urlnaLlon LxamlnaLlon reveals a perlneal mass swelllng due Lo
exLravasaLlon of blood and urlne lnvolves Lhe penls and scroLum and may spread onLo Lhe abdomlnal
wall
lf Lhe paLlenL can vold well and Lhe perlneal hemaLoma ls small no LreaLmenL ls necessary lf
ureLhrography reveals slgnlflcanL exLravasaLlon suprapublc cysLosLomy should be performed Mlnor
ln[ury wlLhouL exLravasaLlon (conLuslon compresslon by hemaLoma) may be managed by careful
lnserLlon of a ureLhral caLheLer
1he only serlous compllcaLlon ls sLrlcLure whlch requlres subsequenL lnLernal ureLhroLomy or surglcal
repalr
endulous ureLhra
LxLernal ln[ury Lo Lhls porLlon of Lhe ureLhra ls noL common slnce Lhe penls ls so moblle 1he erecL
organ however ls vulnerable MosL Lrauma Lo Lhls area ls secondary Lo lnsLrumenLaLlon or sex play As a
rule Lhese ln[urles are mlld alLhough a few may be compllcaLed by sLrlcLure
ureLhral bleedlng and penlle swelllng are Lo be expecLed A ureLhrogram reveals Lhe slLe and severlLy of
ln[ury
lf voldlng ls normal no LreaLmenL ls requlred A large hemaLoma may requlre dralnage lf slgnlflcanL
ln[ury ls presenL a suprapublc Lube should be lnserLed and delayed surglcal repalr performed afLer
swelllng and lnflammaLlon have resolved
ln[urles Lo Lhe enls
Mechanlsms of penlle ln[ury lnclude peneLraLlon blunL Lrauma Lo Lhe erecL penls durlng sexual acLlvlLy
(eg fracLure of corpora cavernosa) avulslon of skln and ampuLaLlon
1ournlqueL ln[ury ls also uncommon Lhe clrcumferenLlal compresslon may be due Lo a rubber band a
sLeel rlng sLrlng or a halr and may be exacerbaLed by subsequenL erecLlon 1he LournlqueL may have
been applled unlnLenLlonally buL chlld abuse cases have been reporLed ln whlch Lhe penls has been
llgaLed as punlshmenL for enuresls
1reaLmenL lncludes assessmenL and care of ureLhral ln[urles lf presenL 8emoval of LournlqueL spllL
Lhlckness skln grafLlng of avulslon ln[urles and prlmary closure of corporal laceraLlons are prlnclples of
Lherapy 1he penls may be acuLely relmplanLed up Lo 16 hours followlng ampuLaLlon uslng mlcrosurglcal
Lechnlques
ln[urles Lo Lhe ScroLum 1esLls
Avulslon of Lhe scroLal skln may requlre a meshed spllLLhlckness skln grafL lf Lhe avulslon ls severe
lnvolvlng Lhe skln and darLos muscle Lhen Lhe LesLes may be lmplanLed ln Lhe subcuLaneous Llssue of
Lhe Lhlgh and dressed ouLslde Lhe wound wlLh 023 aceLlc acldsoaked gauze ScroLal reconsLrucLlon ls
performed aL a laLer Llme frequenLly by uslng skln grafLs
eneLraLlng Lrauma rarely ln[ures Lhe moblle LesLes LaceraLlons should be explored debrlded and
closed prlmarlly lf hemorrhage lnLo Lhe Lunlca vaglnalls ls noLed dralnage ls lndlcaLed
8lunL Lrauma Lo Lhe LesLes may cause conLuslon or rupLure 8upLure of Lhe Lunlca albuglnea may be
demonsLraLed by ulLrasonography as abnormal echoLexLure of Lhe parenchyma ln cases of rupLure
scroLal exploraLlon allows debrldemenL and closure of Lhe Lunlca albuglnea 1he LesLes may ulLlmaLely
undergo aLrophy desplLe Lhese efforLs
Comez 8C eL al Consensus sLaLemenL on bladder ln[urles 8r ! urol 20049427 Mlu 13217426
Morey Al eL al 8econsLrucLlon of posLerlor ureLhral dlsrupLlon ln[urles ouLcome analysls ln 82 paLlenLs
! urol 1997137306 Mlu 8996343
SanLuccl 8A eL al LvaluaLlon and managemenL of renal ln[urles sLaLemenL of Lhe 8enal 1rauma
SubcommlLLee 8r ! urol (lnL) 200493937 Mlu 13142141
Wessels P eL al CrlLerla for nonoperaLlve LreaLmenL of slgnlflcanL peneLraLlng renal laceraLlons ! urol
199713724

1umors of Lhe CenlLourlnary 1racL
1umors of Lhe genlLourlnary LracL are among Lhe mosL common neoplasLlc dlseases found ln adulLs
rosLaLe cancer for example ls Lhe mosL common cancer ln men (33) and renal and bladder cancer
accounL for nearly 10 of all mallgnanL Lumors ln men buL only abouL 3 ln women Lven Lhough
excellenL dlagnosLlc meLhods are avallable one Lhlrd of all genlLourlnary Lumors are noL found unLll
reglonal or dlsLanL spread has occurred Advances ln dlagnosls and LreaLmenL of genlLourlnary LracL
Lumors have occurred ln recenL years and Lhe prognosls has lmproved ln condlLlons such as Wllms
Lumor LesLlcular cancer and bladder cancer 1he malnsLay of dlagnosls conLlnues Lo be physlcal
examlnaLlon compleLe urlnalysls lnLravenous urography or C1 and cysLoscopy whenever lndlcaLed
CuraLlve LreaLmenL of Lhese Lumors conLlnues Lo be surglcal ln mosL lnsLances
8enal Adenocarclnoma (8enal Cell Carclnoma)
LssenLlals of ulagnosls
- alnless gross or mlcroscoplc LoLal hemaLurla
- Solld renal parenchymal mass on lnLravenous urography wlLh nephroLomograms renal
ulLrasound or abdomlnal C1 scan
- araneoplasLlc syndromes common
Ceneral ConslderaLlons
MallgnanL Lumors of Lhe kldney accounL for approxlmaLely 3 of all Lumors ln adulLs CfLen Lhe
dlagnosls ls suspecLed because of mlcroscoplc hemaLurla or manlfesLaLlons of meLasLases such as
paLhologlc fracLures or superflclal skln nodules 1he cause ls unknown Lhough rlsk facLors lnclude
clgareLLe smoklng obeslLy and hyperLenslon 1he dlsease occurs ln men Lhree Llmes more commonly
Lhan ln women A suppressor gene on chromosome 3p has been shown Lo be presenL ln von Plppel
Llndau renal cancers as well as ln mosL sporadlc renal adenocarclnomas 1he mosL common cell Lype ls
clear cell (also called convenLlonal) carclnoma accounLlng for 70 Lo 80 of renal carclnomas 1he cell
of orlgln ls ln Lhe proxlmal convoluLed Lubule CLher cell Lypes lnclude paplllary (1013) chromophobe
(33) and collecLlng ducL renal carclnoma (1) 1he Lumor meLasLaslzes commonly Lo Lhe lungs (30
60) ad[acenL renal hllar lymph nodes (23) lpsllaLeral adrenal (12) opposlLe kldney (2) and lyLlc
leslons ln malnly long bones (3040)
numerous condlLlons predlspose Lo renal cell cancer lncludlng von PlppelLlndau syndrome (cerebellar
hemangloblasLomas reLlnal anglomaLosls and bllaLeral renal cell carclnoma) Luberous sclerosls and
acqulred renal cysLlc dlsease developlng ln paLlenLs wlLh endsLage renal dlsease araneoplasLlc
syndromes are common ln renal cell carclnoma and are ofLen whaL suggesLs Lhe dlagnosls yeL Lhey
rarely have prognosLlc slgnlflcance 1hese syndromes lnclude hypercalcemla eryLhrocyLosls
hyperLenslon fever of unknown orlgln anemla and hepaLopaLhy (SLauffers syndrome) 8enal cell
carclnoma has a predllecLlon for produclng occluslve Lumor Lhrombl ln Lhe renal veln and Lhe lnferlor
vena cava (parLlcularly from Lhe rlghL) manlfesLed by slgns of lower exLremlLy edema and acuLe scroLal
varlcocele when occludlng Lhe lefL renal veln 1hls phenomenon of lnferlor vena cava Lhrombus occurs ln
approxlmaLely 3 Lo 10 of paLlenLs Cccaslonally Lhe Lumor Lhrombus reaches up Lhrough Lhe lnferlor
vena cava Lo Lhe rlghL aLrlum
Cllnlcal llndlngs
SympLoms and Slgns
alnless gross or mlcroscoplc hemaLurla LhroughouL Lhe urlnary sLream (LoLal hemaLurla) occurs ln
60 of paLlenLs 1he degree of hemaLurla ls noL necessarlly relaLed Lo Lhe slze or sLage of Lhe Lumor
AlLhough a Lrlad of hemaLurla flank paln and a palpable flank mass suggesLs renal cell carclnoma fewer
Lhan 10 of paLlenLs wlll so presenL 8oLh paln and a palpable mass are laLe evenLs occurrlng only wlLh
Lumors LhaL are very large or lnvade surroundlng sLrucLures or when hemorrhage lnLo Lhe Lumor has
occurred SympLoms due Lo meLasLases may be Lhe lnlLlal complalnL (eg bone paln resplraLory dlsLress)
LaboraLory llndlngs
Mlcroscoplc urlnalysls reveals hemaLurla ln mosL paLlenLs 1he eryLhrocyLe sedlmenLaLlon raLe may be
elevaLed buL ls nonspeclflc LlevaLlon of Lhe hemaLocrlL and levels of serum calclum alkallne
phosphaLase and amlnoLransferases occur ln less Lhan 10 of paLlenLs 1hese flndlngs nearly always
resolve wlLh curaLlve nephrecLomy and Lhus are noL usually slgns of meLasLases Anemla unrelaLed Lo
blood loss occurs ln 20 Lo 40 of paLlenLs parLlcularly Lhose wlLh advanced dlsease
lmaglng SLudles
1he dlagnosls of renal cell carclnoma ls ofLen made by C1 (and less frequenLly by lnLravenous
urography) performed as an lnlLlal sLep ln Lhe workup of hemaLurla an enlgmaLlc meLasLaLlc leslon or
susplclous laboraLory flndlngs (llgure 3812) ulLrasonography and C1 scan ofLen reveal lncldenLal renal
masses whlch now accounL for 30 of Lhe lnlLlal dlagnoses of renal cancer ln paLlenLs wlLhouL
manlfesLaLlons of renal dlsease laln abdomlnal xrays may reveal a calclfled renal mass buL only 20
of renal masses conLaln demonsLrable calclflcaLlon (1wenLy percenL of masses wlLh perlpheral
calclflcaLlon are mallgnanL over 80 wlLh cenLral calclflcaLlon are mallgnanL) 1he lnlLlal Lechnlque for
workup of hemaLurla ls currenLly C1 urography lnLravenous urography alone deflnes only 73 of renal
mass leslons ulfferenLlaLlon of Lhe mosL common renal mass (le a slmple benlgn cysL) can be made by
Lhe flndlng of a radlolucenL cenLer wlLh a Lhln wall and a sharp lnLerface beLween Lhe mass and Lhe renal
corLex (Lhe Lyplcal beak slgn of a corLlcal cysL)
llgure 3812






A Adenocarclnoma of Lhe lefL kldney C1 scan of Lhe abdomen shows an exophyLlc leslon from Lhe
mldpolar kldney (arrow) 8 C1 scan showlng a large lefL renal mass (arrow) lncldenLally found on
lmaglng done Lo evaluaLe nonspeclflc abdomlnal paln llnal paLhology revealed clear cell renal
carclnoma

ulLrasonography
lurLher deflnlLlon of all renal masses seen on lnLravenous urography ls requlred Cccaslonally some
masses deLecLed on C1 requlre furLher characLerlzaLlon by ulLrasound Abdomlnal ulLrasonography can
deflne Lhe mass as a benlgn slmple cysL or a solld mass ln 90 Lo 93 of cases Abdomlnal ulLrasound
can also ldenLlfy a vena caval Lumor Lhrombus and lLs cephalad exLenL ln Lhe cava
lsoLope Scannlng
Cccaslonally a renal mass ls suspecLed on lnLravenous urography buL ls equlvocal or noL seen on
ulLrasound ln Lhese cases a renal corLlcal lsoLope scannlng agenL such as LechneLlum99m uMSA ls
helpful lsoLope scans of a renal Lumor or cysL show an area of decreased upLake whereas an area of
lncreased upLake lndlcaLes a renal pseudoLumor or a hyperLrophled column of 8erLln
C1 Scan
C1 scan ls Lhe dlagnosLlc procedure of cholce when a solld renal mass ls noLed on ulLrasound C1 scan
accuraLely dellneaLes renal cell carclnoma ln over 93 of cases Cver 80 of Lumors are enhanced by
lodlnaLed conLrasL medlum reflecLlng Lhelr hlgh vascularlLy
C1 scan ls also helpful ln local sLaglng and can reveal Lumor peneLraLlon of perlnephrlc faL enlargemenL
of local hllar lymph nodes lndlcaLlng meLasLases or Lumor Lhrombl ln Lhe renal veln or lnferlor vena
cava C1 anglography can dellneaLe Lhe renal vasculaLure whlch ls helpful ln surglcal plannlng for parLlal
nephrecLomles
M8l
M8l ls noL more accuraLe Lhan C1 and ls much more expenslve lL ls however Lhe mosL accuraLe
nonlnvaslve means of deLecLlng renal veln or vena caval Lhrombl WlLh Lhe furLher reflnemenL of pulse
sequenclng and Lhe use of paramagneLlc conLrasL agenLs M8l has become one of Lhe prlmary
Lechnlques for sLaglng solld renal masses MagneLlc resonance anglography (M8A) has become
parLlcularly useful for mapplng Lhe blood supply and Lhe relaLlonshlp Lo ad[acenL sLrucLures ln
candldaLes for parLlal nephrecLomy
CLher ulagnosLlc or SLaglng 1echnlques
lsoLoplc bone scannlng ls useful ln paLlenLs wlLh bone paln elevaLed alkallne phosphaLase or known
meLasLases ChesL xray ls sufflclenL lf negaLlve buL lf equlvocal Lhen C1 scan of Lhe chesL can be used Lo
deLecL meLasLases 1here are currenLly no Lumor markers speclflc for renal cell carclnoma Cccaslonally
asplraLlon cyLology of Lhe mass can be useful ln an enlgmaLlc case revlously such procedures were
dlscouraged because of fear of dlssemlnaLlng Lhe Lumor along Lhe needle LracL buL Lhls has proved Lo be
rare and Lhe Lechnlque ls safe 1he dlagnosls ls mosL ofLen made by nonlnvaslve means and needle
asplraLlon ls requlred only ln lndeLermlnaLe cases ( 10)
ulfferenLlal ulagnosls
A varleLy of leslons ln Lhe reLroperlLoneum and kldney oLher Lhan renal cysLs may slmulaLe renal cancer
1hese lnclude leslons due Lo hydronephrosls adulL polycysLlc kldney dlsease Luberculosls
xanLhogranulomaLous pyelonephrlLls meLasLaLlc cancer from anoLher prlmary cancer anglomyollpoma
or oLher benlgn renal Lumors or adrenal cancer and reLroperlLoneal llpomas sarcomas or abscesses ln
general Lhe radlographlc M8l or ulLrasonographlc Lechnlques descrlbed prevlously should make Lhe
dlfferenLlaLlon PemaLurla may be caused by renal ureLeral or bladder calcull renal pelvls ureLeral or
bladder Lumors or many oLher benlgn condlLlons usually dellneaLed by Lhe sLudles descrlbed
CysLoscopy ls obllgaLory ln hemaLurlc paLlenLs wlLh a normal C1 scan or lnLravenous urogram Lo rule ouL
dlsease of Lhe bladder and Lo deLermlne Lhe source of Lhe hemaLurla
CompllcaLlons
Cccaslonally paLlenLs may presenL wlLh acuLe flank paln secondary Lo hemorrhage wlLhln a Lumor or
collc secondary Lo obsLrucLlng ureLeral cloLs 1umor ln Lhe renal veln or vena cava may cause an acuLe
lefL varlcocele or lower exLremlLy edema assoclaLed wlLh proLelnurla aLhologlc fracLures due Lo
osLeolyLlc meLasLases ln long bones are common as are sympLomaLlc braln meLasLases
1reaLmenL
SLaglng ls Lhe key Lo deslgnlng Lhe LreaLmenL plan (1able 381) aLlenLs wlLh dlsease conflned wlLhln
Lhe renal fascla (CeroLas fascla) or llmlLed Lo nonadherenL renal veln or vena caval Lumor Lhrombl
(sLages 11 12 and 13a) are besL LreaLed by radlcal nephrecLomy 1hls lnvolves en bloc removal of Lhe
kldney and surroundlng CeroLa fascla (lncludlng Lhe lpsllaLeral adrenal) Lhe renal hllar lymph nodes and
Lhe proxlmal half of Lhe ureLer araaorLlc node dlssecLlon has noL been proven beneflclal and ls noL
rouLlnely performed ln paLlenLs wlLh very large Lumors and a normal conLralaLeral kldney radlcal
nephrecLomy ls recommended 8ecenL reporLs have advocaLed lncludlng Lhe lpsllaLeral adrenal gland ln
Lhe resecLlon only ln cases where Lhe mass ls large or lnvolvlng Lhe upper pole of Lhe kldney aLlenLs
wlLh Lumors ln sollLary kldneys Lhose wlLh dlabeLes melllLus or renal lnsufflclency and Lhose wlLh
Lumors under 4 cm (even wlLh a normal opposlLe kldney) should be consldered for parLlal nephrecLomy
because Lhe prognosls ln such cases (lf negaLlve surglcal marglns are obLalned) ls Lhe same as LhaL of
radlcal nephrecLomy Laparoscoplc radlcal or parLlal nephrecLomy has been advocaLed as a meLhod
equal Lo Lhe open approach wlLh Lhe advanLages of less blood loss shorLer hosplLallzaLlon and earller
reLurn Lo normal funcLlon lL ls Lhe gold sLandard ln lnsLlLuLlons wlLh approprlaLe experLlse Laparoscoplc
or percuLaneous cryoablaLlon of renal cancer has also shown conslderable promlse AlLernaLlvely
radlofrequency ablaLlon has been uLlllzed for small renal Lumors buL Lhls procedure requlres more
deflnlLlve sLudy and longer followup ln LreaLed paLlenLs
1able 381 1nM SLaglng ClasslflcaLlon and rognosls of 8enal Cell Cancer


8obson SLage 1 n M 3?ear Survlval ()
l 1umor conflned by renal capsule 11 ( 70 cm Lumor) n0 (nodes negaLlve) M0 (no dlsLanL
meLasLases) 80100
12 ( 70 cm Lumor)
ll 1umor exLenslon Lo perlrenal faL or lpsllaLeral adrenal buL conflned by CeroLas fascla 13a n0
M0 3060
llla 8enal veln or lnferlor vena cava lnvolvemenL 13b (renal veln lnvolvemenL) n0 M0
3060 (renal veln)
13c (renal veln and caval lnvolvemenL below Lhe dlaphragm)
2333 (vena cava)
14b (caval lnvolvemenL above Lhe dlaphragm)
lllb LymphaLlc lnvolvemenL 113 n1 (slngle reglonal node lnvolved) M0 1333
n2 (mulLlple reglonal conLralaLeral or bllaLeral nodes lnvolved)
lllc ComblnaLlon of llla and lllb 134 n12 M0 1333
lva Spread Lo conLlguous organs excepL lpsllaLeral adrenal 14 n12 M0 03
lvb ulsLanL meLasLases 114 n02 M1 03


nephrecLomy has noL been assoclaLed wlLh lmproved survlval raLes ln paLlenLs wlLh mulLlple dlsLanL
meLasLases (sLage lv) and Lhe procedure ls noL recommended unless paLlenLs are sympLomaLlc or a
promlslng LherapeuLlc proLocol ls belng sLudled llanlgan and oLhers have shown however LhaL up Lo a
6monLh lmprovemenL ln survlval can be achleved wlLh nephrecLomyeven wlLh sofL Llssue
meLasLaslsln selecLed paLlenLs who also recelve lnLerferon alfa aLlenLs wlLh sollLary pulmonary
meLasLases have beneflLed from [olnL surglcal removal of boLh Lhe prlmary leslon and Lhe meLasLaLlc
leslon (30 survlval aL 3 years) reoperaLlve arLerlal embollzaLlon ln paLlenLs wlLh or wlLhouL
meLasLases does noL lmprove survlval raLes Lhough lL may be helpful as a slngle LreaLmenL measure ln
paLlenLs wlLh sympLomaLlc buL nonresecLable prlmary leslons 8adlaLlon Lherapy ls of llLLle beneflL
excepL as LreaLmenL for sympLomaLlc bone meLasLases MedroxyprogesLerone for meLasLaLlc renal cell
carclnoma has glven an equlvocal 3 Lo 10 response raLe of shorL duraLlon vlnblasLlne has also had a
response raLe of approxlmaLely 20 agaln of mlnlmal duraLlon 1here are no oLher cyLoLoxlc
chemoLherapeuLlc agenLs of beneflL
lmmunoLherapy wlLh lnLerferon alfa has had a 13 Lo 20 response raLe CLher lnLerferons alone
(lnLerferon beLa lnLerferon gamma) or ln comblnaLlon wlLh chemoLherapeuLlc agenLs have been less
effecLlve Lhan lnLerferon alfa AdopLlve lmmunoLherapyuslng lymphocyLes (lymphoklneacLlvaLed
klller cells) from exposure of Lhe paLlenLs own perlpheral blood lymphocyLes Lo lnLerleukln2 (lL2) ln
vlLro followed by relnfuslon lnLo Lhe paLlenL along wlLh sysLemlc lL2 lnfuslonhas shown up Lo 33
ob[ecLlve response raLes Plghdose lnLravenous lL2 causes a profound caplllary leak syndrome and
subsLanLlal LoxlclLy SubsequenL sLudles have shown only a 16 response raLe
8ecenL advances ln research on Lhe von PlppelLlndau Lumor suppressor gene has led Lo ldenLlflcaLlon of
growLh facLors lncludlng vascular endoLhellal growLh facLor (vLCl) and plaLeleLderlved growLh facLor as
molecular LargeLs ln LreaLlng advanced renal cancer lnlLlal sLudles uslng bevaclzumab an anLlvascular
endoLhellal growLh facLor anLlbody have shown promlslng resulLs Sorafenlb a Lyroslne klnase lnhlblLor
LhaL blocks Lhe paLhway leadlng Lo Lhe producLlon of several growLh facLors has been sLudled ln
paLlenLs wlLh meLasLaLlc renal cancer and shown longer medlan progresslonfree survlval Lhan placebo
(24 weeks vs 6 weeks) SunlLlnlb anoLher Lyroslne klnase lnhlblLor has shown longer progresslonfree
survlval and hlgher response raLes Lhan lnLerferon alfa ln paLlenLs wlLh meLasLaLlc renal cancer 1hese
oral agenLs are currenLly used as flrsLllne Lherapy ln Lhls group of paLlenLs
1emslrollmus ls anoLher LargeLed agenL LhaL ls a speclflc lnhlblLor of Lhe mammallan LargeL of rapamycln
klnase (m1C8 lnhlblLor) and has shown promlslng resulLs lL ls now used as flrsLllne Lherapy ln poor
prognosls paLlenLs Many oLher agenLs are currenLly belng sLudled
rognosls
aLlenLs wlLh locallzed renal cancer (sLages 11 12 and 13a) LreaLed surglcally have 3year survlval raLes
of approxlmaLely 70 Lo 80 whereas raLes for Lhose wlLh local nodal exLenslon or dlsLanL meLasLases
are 13 Lo 23 and less Lhan 10 respecLlvely MosL paLlenLs who presenL wlLh mulLlple dlsLanL
meLasLases succumb Lo dlsease wlLhln 13 monLhs (1able 381) 1he advenL of new agenLs for renal
cancer may lmprove Lhe ouLcome ln Lhese paLlenLs
8enal Sarcoma
8enal sarcomas lnclude rhabdomyosarcoma llposarcoma flbrosarcoma and lelomyosarcoma Lhe laLLer
ls Lhe mosL common Lhough all are very uncommon Sarcomas are hlghly mallgnanL and are usually
deLecLed aL a laLe sLage and Lhus have a poor prognosls 1he dlagnosLlc approach ls slmllar Lo LhaL of
renal cell carclnoma 1he hlsLology of Lhe leslon ls rarely suspecLed preoperaLlvely 1hese Lumors have a
Lendency Lo surround Lhe renal vasculaLure and do noL exhlblL neovascularlLy on M8A
1reaLmenL ls surglcal wlLh wlde local exclslon however local recurrence and subsequenL dlsLanL
meLasLases are Lhe rule 1here ls no Lherapy of proved beneflL for meLasLaLlc dlsease
Secondary MallgnanL 8enal 1umors
MeLasLaLlc Lumors Lo Lhe kldney are more common Lhan prlmary renal Lumors and ofLen develop from
prlmary Lumors of dlsLanL slLes mosL commonly Lhe lung sLomach and breasL lL ls rare for Lhe
dlagnosls Lo be made before auLopsy Lhls suggesLs LhaL renal meLasLasls ls a laLe evenL 1here are
usually no sympLoms Lhough mlcroscoplc hemaLurla occurs ln 10 Lo 20 of cases lnLravenous
urograms may be normal slnce Lhe Lumors are locaLed perlpherally ln Lhe parenchyma ConLlguous
spread of a Lumor ad[acenL Lo Lhe kldney ls noL lnfrequenL (eg Lumors of Lhe adrenal colon and
pancreas and reLroperlLoneal sarcomas) 1umors such as lymphoma leukemla and mulLlple myeloma
may also lnfllLraLe Lhe kldney 8ouLlne radlologlc hemaLologlc and chemlcal examlnaLlons should
demonsLraLe Lhe prlmary Lumor ln mosL cases
8enlgn 8enal 1umors
8enal Adenoma
8enal adenoma ls Lhe mosL common benlgn solld parenchymal leslon 1umors less Lhan 3 cm ln
dlameLer have been consldered benlgn and Lhose larger Lhan 3 cm mallgnanL however small leslons are
noL hlsLologlcally dlsLlngulshable from renal adenocarclnomas and Lhe blology cannoL be predlcLed
preoperaLlvely 1hese Lumors should be consldered poLenLlally mallgnanL and should be LreaLed
aggresslvely
8enal CncocyLoma
8enal oncocyLomas are benlgn renal neoplasms 1he Lumors are generally asympLomaLlc and noL
assoclaLed wlLh Lhe paraneoplasLlc syndromes 1he flndlng of a cenLral sLellaLe scar on C1 or a spoke
wheel paLLern of feedlng arLerles on anglography may suggesL Lhe dlagnosls alLhough Lhese flndlngs
have been found Lo be unrellable CncocyLomas can coexlsL wlLh renal carclnoma ln Lhe same leslon or
ln oLher leslons ln Lhe same kldney (730) 1hls flndlng along wlLh dlfflculLy dlfferenLlaLlng
oncocyLoma from clear cell or chromophobe renal cancers on flneneedle asplraLes make lL dlfflculL Lo
make a deflnlLlve dlagnosls preoperaLlvely ConsequenLly deflnlLlve LreaLmenL of Lhese leslons wlLh
radlcal or parLlal nephrecLomy or wlLh Lhermal or cryoablaLlon have been recommended
MesoblasLlc nephroma
MesoblasLlc nephroma ls a benlgn congenlLal renal Lumor seen ln early chlldhood whlch musL be
dlsLlngulshed from Lhe hlghly mallgnanL nephroblasLoma or Wllms Lumor unllke Wllms Lumor
mesoblasLlc nephroma ls commonly dlagnosed wlLhln Lhe flrsL few monLhs of llfe PlsLologlcally lL ls
dlsLlngulshed from Wllms Lumor by cells resembllng flbroblasLs or smooLh muscle cells and by Lhe lack of
eplLhellal elemenLs 1he prognosls ls excellenL compleLe surglcal resecLlon ls curaLlve and nelLher
chemoLherapy nor radloLherapy ls requlred
Anglomyollpoma
Anglomyollpoma ls a benlgn hamarLoma seen mosL ofLen bllaLerally ln adulLs wlLh Luberous sclerosls
(whlch also lncludes adenoma sebaceum epllepsy and menLal reLardaLlon) 1he Lumor ls also common
ln mlddleaged women buL only unllaLerally 1hese Lumors can be deLecLed followlng sponLaneous
reLroperlLoneal hemorrhage Lhough 30 of Lhese leslons are currenLly dlagnosed lncldenLally C1 scan
can be dlagnosLlc wlLh negaLlve Pounsfleld unlLs deLecLed ln Lhe faLconLalnlng area of Lhe Lumor
Cccaslonally an anglomyollpoma eludes dlagnosls preoperaLlvely and requlres nephrecLomy (especlally
Lhe llpldpoor anglomyollpoma) AsympLomaLlc paLlenLs wlLh small ( 4 cm) Lumors and Lyplcal flndlngs
on C1 scan of faL wlLhln Lhe Lumor do noL requlre surgery as Lhe prognosls ls excellenL wlLhouL
LreaLmenL 1hese paLlenLs can be followed wlLh serlal lmaglng 1hose presenLlng wlLh a reLroperlLoneal
hemorrhage or a slze greaLer Lhan 4 cm should have Lhe Lumor removed surglcally or wlLh parLlal
nephrecLomy or vla anglolnfarcLlon whlch has been shown Lo be effecLlve
CLher 8enlgn 8enal 1umors
CLher benlgn renal Lumors lnclude (1) flbroma a renal parenchymal capsular or perlnephrlc flbrous
mass (2) llpoma an adlpose deposlL wlLhln or around Lhe kldney ofLen perlhllar or wlLhln Lhe renal
slnus (3) lelomyoma a common reLroperlLoneal Lumor LhaL may arlse from Lhe renal capsule or renal
vascular walls and (4) hemangloma whlch ls occaslonally found Lo be Lhe eluslve cause of hemaLurla
Pemanglomas are generally qulLe small and Lhe dlagnosls can be conflrmed by dlrecL vlslon of Lhe
leslon ln Lhe renal collecLlng sysLem on ureLeroscopy
Pudes C eL al 1emslrollmus lnLerferon alfa or boLh for advanced renalcell carclnoma new Lng ! Med
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MoLzer 8! eL al SunlLlnlb versus lnLerferon alfa ln meLasLaLlc renalcell carclnoma new Lng ! Med
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anLuck A! eL al lncldenLal renal Lumors urology 200036190 Mlu 10923076
arLon M eL al 8ole of cyLoklne Lherapy ln 2006 and beyond for meLasLaLlc renal cell cancer ! Clln Cncol
2006243384 Mlu 17138344
orLls A! Clayman 8v Should laparoscopy be Lhe sLandard approach used for radlcal nephrecLomy?
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wlLh meLasLaLlc renal cell carclnoma ! Clln Cncol 2006242303 Mlu 16636341
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urol 200313431
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1umors of Lhe 8enal elvls Callces
LssenLlals of ulagnosls
- Cross or mlcroscoplc hemaLurla
- 8adlolucenL fllllng defecL ln Lhe renal pelvls or Lhe callces on lnLravenous urography or C1
- MallgnanL cells on urlne cyLologlc sLudy
Ceneral ConslderaLlons
ln over 90 of cases Lumors lnvolvlng Lhe collecLlng sysLem of Lhe kldney are uroLhellal ( or LranslLlonal
cell) carclnomas Less Lhan 3 of Lumors ln Lhls locaLlon are squamous carclnomas (ofLen ln assoclaLlon
wlLh chronlc lnflammaLlon and sLone formaLlon) or adenocarclnomas 1he cause of uroLhellal carclnoma
of Lhe upper urlnary LracL ls slmllar Lo LhaL of eplLhellal Lumors ln Lhe ureLer or bladder Lhere ls a sLrong
assoclaLlon wlLh clgareLLe smoklng and exposure Lo lndusLrlal chemlcals Lxcesslve use of phenaceLln
conLalnlng analgeslcs and Lhe presence of 8alkan nephrlLls are also predlsposlng facLors
Cllnlcal llndlngs
SympLoms and Slgns
Cross or mlcroscoplc palnless hemaLurla occurs ln over 70 of paLlenLs 1he leslons are usually
asympLomaLlc unless bleedlng causes acuLe flank paln secondary Lo obsLrucLlng cloLs resenLlng
sympLoms can ofLen be due Lo meLasLases Lo bone Lhe llver or Lhe lungs hyslcal examlnaLlon ls
usually negaLlve for any poslLlve flndlngs
LaboraLory llndlngs
Mlcroscoplc hemaLurla on urlnalysls ls Lhe rule yurla ls noL seen CyLologlc examlnaLlon of volded urlne
speclmens may be dlagnosLlc ln hlghgrade Lumors urlne obLalned from Lhe ureLer by reLrograde
caLheLerlzaLlon or by brushlng wlLh speclallzed ureLeral lnsLrumenLs can lmprove Lhe dlagnosLlc accuracy
of cyLologlc examlnaLlons ulrecL blopsy durlng ureLeroscopy ls Lhe mosL accuraLe 1here are no
commonly assoclaLed paraneoplasLlc syndromes or dlagnosLlc serum Lumor markers ln uroLhellal
carclnoma A large number of urlne markers are currenLly belng sLudled buL only ln slLu hybrldlzaLlon
sLudles ldenLlfylng abnormallLles ln chromosomes 3 7 17 and 9p21 can be recommended aL presenL
lmaglng SLudles
1he dlagnosls ls commonly made on C1 urography or lnLravenous urography and conflrmed by
reLrograde pyelography whlch reveals a radlolucenL fllllng defecL ln Lhe renal pelvls or callces 8enal
ulLrasound or C1 scan can be used Lo rule ouL calculus C1 scan ls also useful ln local sLaglng of Lhe
Lumor 1he Lumors meLasLaslze Lo Lhe lungs llver and bone so chesL xray C1 scan of Lhe lungs and
llver and a bone scan are useful Lo deLermlne Lhe presence of meLasLases uroLhellal carclnoma Lends
Lo be mulLlfocal ln Lhe urlnary LracL lnvolvlng Lhe opposlLe kldney (12) lpsllaLeral ureLer or bladder
(3830) Survelllance of Lhese poLenLlal slLes ls lmporLanL
Lndoscoplc llndlngs
CysLoscopy ls necessary when gross hemaLurla ls presenL Lo deLermlne Lhe locaLlon of Lhe bleedlng
8eLrograde pyelography and ureLeral cyLologlc sLudles or brushlng as descrlbed prevlously can be
useful Lhough mlldly abnormal cyLologlc flndlngs may occur ln paLlenLs wlLh upper LracL lnflammaLlon or
calcull 8lgld or flexlble ureLeroscopes can be used Lo vlew Lhe upper ureLer and renal pelvls dlrecLly
8lopsy of upper LracL leslons ls posslble Lhrough Lhese lnsLrumenLs AlLhough percuLaneous approaches
Lo Lhe renal collecLlng sysLem have been perfecLed Lhelr use for dlagnosls or LreaLmenL of suspecLed
uroLhellal carclnoma ln rouLlne cases ls noL recommended because of Lhe posslblllLy of spreadlng Lumor
cells ouLslde Lhe kldney
ulfferenLlal ulagnosls
A varleLy of condlLlons may mlmlc LranslLlonal cell carclnoma of Lhe renal pelvls lncludlng calcull
sloughed renal paplllae Luberculosls and renal cell carclnoma wlLh pelvlc exLenslon of Lhe Lumor 1hese
can usually be ruled ouL by Lhe dlagnosLlc sLudles descrlbed prevlously
CompllcaLlons
Cccaslonally bleedlng may be severe enough Lo requlre lmmedlaLe nephrecLomy lnfecLlon may
develop parLlcularly when Lhere ls obsLrucLlon and hydronephrosls requlrlng prompL use of sysLemlc
anLlbloLlcs
1reaLmenL
8enal uroLhellal carclnoma ls LreaLed by nephroureLerecLomy (perlfasclal nephrecLomy and removal of
Lhe enLlre ureLer down Lo and lncludlng Lhe ureLeral orlflce wlLhln Lhe bladder) 1ransureLeral or
percuLaneous endoscoplc Lechnlques for resecLlon of selecLed lowgrade leslons have been successful
upper LracL lnsLlllaLlon of bacllle CalmeLLeCuerln (8CC) or mlLomycln C have been reporLed wlLh
modesL resulLs Plgh recurrence raLes and Lhe poLenLlal for local Lumor spread would argue agalnsL Lhls
approach ln hlghgrade or exLenslve leslons Laparoscoplc nephroureLerecLomy has become common
pracLlce buL managemenL of Lhe dlsLal ureLer and bladder cuff by Lhls Lechnlque has been Lhe sub[ecL of
conLroversy 8eglonal lymph node dlssecLlons have noL been LradlLlonally performed alLhough recenL
reporLs have shown some beneflL for paLlenLs wlLh aggresslve dlsease 8ecause 30 of Lhese paLlenLs
wlll develop uroLhellal carclnoma of Lhe bladder cysLoureLhroscopy musL be performed posLoperaLlvely
lL ls usually done quarLerly durlng Lhe flrsL year Lwlce Lhe second year and Lhen annually
rognosls
8ecause mosL of Lhese Lumors are low grade and nonlnvaslve Lhe 3year Lumorfree survlval raLe ls
hlgher Lhan 90 for leslons LreaLed wlLh compleLe removal of Lhe lpsllaLeral upper urlnary LracL Survlval
raLes are much lower for leslons LhaL lnvade Lhe renal parenchyma or are of hlgh hlsLologlc grade A
poor prognosls ls assoclaLed wlLh Lumors havlng hlsLologlc feaLures of squamous carclnoma or
adenocarclnoma 1hese Lumors are mlldly radlosenslLlve buL preoperaLlve or posLoperaLlve
radloLherapy has noL been parLlcularly helpful MeLasLaLlc leslons are parLlcularly problemaLlc and
survlvors are rare ChemoLherapy comblnaLlons whlch have shown beneflL ln uroLhellal carclnoma of
Lhe bladder (meLhoLrexaLe vlnblasLlne Adrlamycln and clsplaLln MvAC or gemclLablne and clsplaLln)
are also efflcaclous ln uroLhellal carclnoma of Lhe upper urlnary LracL
1umors of Lhe ureLer
LssenLlals of ulagnosls
- Cross or mlcroscoplc hemaLurla
- 8adlolucenL fllllng defecL ln Lhe ureLer on C1 urography lnLravenous urography or reLrograde
pyelography
- MallgnanL cells on urlne cyLologlc sLudy
Ceneral ConslderaLlons
ureLeral Lumors are rarely benlgn buL benlgn flbroeplLhellal polyps do occaslonally occur wlLhln Lhe
ureLer More Lhan 90 of ureLeral Lumors are uroLhellal carclnomas 1he cause ls unknown buL Lobacco
smoklng and exposure Lo lndusLrlal chemlcals are known Lo be assoclaLed ureLeral uroLhellal carclnoma
ls ofLen found ln assoclaLlon wlLh renal pelvls uroLhellal carclnoma and sllghLly less ofLen wlLh bladder
uroLhellal carclnoma 1he leslons develop ln persons aged 60 Lo 70 years and are Lwlce as common ln
men as ln women More Lhan 60 of Lhese Lumors occur ln Lhe lower ureLer
Cllnlcal llndlngs
SympLoms and Slgns
Cross or mlcroscoplc hemaLurla ls Lhe rule (80 of cases) 8ecause ureLeral Lumors grow slowly Lhey
may noL cause sympLoms even Lhough Lhey compleLely obsLrucL Lhe kldney Cccaslonally gross
hemaLurla may cause acuLe obsLrucLlon because of cloLs 1he lnlLlal presenLaLlon may be due Lo
sympLomaLlc meLasLases Lo bone lungs or llver
LaboraLory llndlngs
urlnalysls commonly reveals hemaLurla 1here are no blochemlcal markers speclflc Lo Lhe dlagnosls
Lhough paLlenLs wlLh meLasLases may have abnormal llver funcLlon LesLs or anemla Serum creaLlnlne
levels may be elevaLed wlLh compleLe unllaLeral obsLrucLlon ln elderly paLlenLs CyLologlc sLudles of
volded urlne or ureLeral urlne or brush blopsy sLudles may be dlagnosLlc
lmaglng SLudles
1he dlagnosls may be made on C1 or lnLravenous urography Lhough Lhe Lumor ofLen obsLrucLs Lhe
ureLer compleLely so LhaL cysLoscopy and reLrograde pyelography are requlred for deflnlLlon of Lhe
leslon 1hese sLudles ofLen reveal a fllllng defecL ln Lhe ureLer (classlcally descrlbed as a gobleL slgn) 1he
ureLer ls dllaLed proxlmal Lo Lhe leslon C1 scan ls useful ln rullng ouL nonopaque calcull and ln
abdomlnal Lumor sLaglng ChesL xray C1 scans and bone scans are helpful ln deLermlnlng Lhe presence
of meLasLases
Lndoscoplc llndlngs
CysLoscopy ls necessary when gross hemaLurla ls presenL Lo deLermlne Lhe slLe of bleedlng 8eLrograde
pyelography may Lhen be necessary ureLeroscopy may provlde a dlrecL vlew of Lhe Lumor and access
for blopsy
ulfferenLlal ulagnosls
nonopaque calcull sloughed renal paplllae blood cloLs or exLrlnslc compresslon by reLroperlLoneal
masses or nodes may all produce slgns sympLoms and xray flndlngs slmllar Lo Lhose wlLh ureLeral
Lumors 1he radlographlc cyLologlc and endourologlc sLudles llsLed above should make Lhe dlsLlncLlon
buL surglcal exploraLlon ls requlred occaslonally
1reaLmenL
MosL ureLeral LranslLlonal cell carclnomas are noL assoclaLed wlLh meLasLases and can be deflnlLlvely
LreaLed wlLh nephroureLerecLomy SelecLed paLlenLs wlLh nonlnvaslve lowgrade leslons may be LreaLed
by segmenLal ureLeral resecLlon wlLh endLoend anasLomosls (ureLeroureLerosLomy) ln some paLlenLs
carefully selecLed wlLh lowgrade nonlnvaslve Lumors resecLlon or laser ablaLlon can be consldered
8eglonal lymph node dlssecLlons have noL been LradlLlonally performed alLhough recenL reporLs have
shown some beneflL reoperaLlve or posLoperaLlve radlaLlon Lherapy appears Lo be of no beneflL As
wlLh renal pelvls and bladder uroLhellal carclnoma cysLoscopy should be performed perlodlcally
posLoperaLlvely aLlenLs wlLh meLasLases are rarely helped by removal of Lhe prlmary Lumor 1hese
Lumors are responslve Lo chemoLherapy 1radlLlonal agenLs LhaL have been used lnclude clsplaLln wlLh
gemclLablne or MvAC 1hese have shown reasonable response raLes buL poor longLerm ouLcomes
rognosls
1he 3year survlval raLe for paLlenLs wlLh lowgrade nonlnvaslve leslons LreaLed surglcally approaches
100 1hose wlLh hlghgrade or lnvaslve leslons have a poorer prognosls and Lhose wlLh meLasLases
have a 3year survlval raLe of less Lhan 10
1umors of Lhe 8ladder
LssenLlals of ulagnosls
- Cross or mlcroscoplc hemaLurla
- MallgnanL cells on urlne cyLologlc sLudy
- CysLoscoplc vlsuallzaLlon of Lhe Lumor
- PlsLologlc conflrmaLlon of Lhe leslons
Ceneral ConslderaLlons
veslcal neoplasms accounL for nearly 6 of all cancers ln men and are Lhe secondmosL common cancer
of Lhe genlLourlnary LracL ln men ln women Lhese Lumors accounL for 2 of all cancers and are Lhe
mosL common cancer of Lhe genlLourlnary LracL Men are affecLed Lwlce as ofLen as women More Lhan
90 of Lumors are uroLhellal carclnomas whlle a few are squamous cell carclnomas (assoclaLed wlLh
chronlc lnflammaLlon as ln bllharzlasls) or adenocarclnomas (ofLen seen aL Lhe dome of Lhe bladder ln
paLlenLs wlLh a urachal remnanL)
MosL uroLhellal carclnomas (7080) are superflclal (noL lnvaslve lnLo Lhe bladder wall) when
recognlzed Cnly 10 Lo 13 of recurrenL Lumors become lnvaslve
1he cause of uroLhellal carclnoma ls unknown Lhere ls a sLrong assoclaLlon wlLh chronlc clgareLLe
smoklng and exposure Lo chemlcals prevalenL ln dye rubber leaLher palnL and oLher chemlcal
lndusLrles Common use of arLlflclal sweeLeners such as cyclamaLes and saccharln was LhoughL Lo be
relaLed Lo bladder Lumor developmenL buL evldence Lo subsLanLlaLe Lhls clalm has noL been
forLhcomlng
1he LreaLmenL and prognosls depend enLlrely on Lhe degree of anaplasla (grade) and Lhe depLh of
peneLraLlon of Lhe bladder wall or beyond (1able 382) MosL of Lhese Lumors develop on Lhe Lrlgone
and Lhe ad[acenL posLerolaLeral wall Lhus ureLeral lnvolvemenL wlLh obsLrucLlon ls common 1umors
Lend Lo be mulLlfocal wlLhln Lhe bladder ApproxlmaLely 3 of paLlenLs develop upper urlnary LracL
uroLhellal carclnoma as well
1able 382 1reaLmenL and rognosls of 8ladder 1umors 8elaLed Lo SLage of ulsease


ConvenLlonal SLage 1nM SLage 1umor lnvolvemenL 1reaLmenL 3?ear Survlval ()
C 1a Mucosa only 1ransureLhral resecLlon 8390
A 11 Submucosal lnvaslon (lamlna proprla) 1ransureLhral resecLlon and lnLraveslcal
chemolmmunoLherapy 6080
81 12a Superflclal muscle lnvaslon 1oLal cysLecLomy and pelvlc lymphadenecLomy 3033
82 12b ueep muscle lnvaslon 1oLal cysLecLomy and pelvlc lymphadenecLomy 3030
C 13 erlveslcal faL lnvaslon 1oLal cysLecLomy and pelvlc lymphadenecLomy 3040
u1 134n+ 8eglonal lymph node lnvaslon SysLemlc chemoLherapy 633
u2 134M1 ulsLanL meLasLases SysLemlc chemoLherapy 010


Cllnlcal llndlngs
SympLoms and Slgns
Cross hemaLurla ls a common flndlng Lhough mlcroscoplc hemaLurla ofLen leads Lo Lhe dlagnosls
aLlenLs wlLh dlffuse superflclal Lumors parLlcularly carclnoma ln slLu may have urlnary frequency and
urgency Cccaslonally large necroLlc Lumors become secondarlly lnfecLed and paLlenLs exhlblL
sympLoms of cysLlLls aln secondary Lo cloL reLenLlon Lumor exLenslon lnLo Lhe bony pelvls or ureLeral
obsLrucLlon may occur buL are noL frequenL presenLlng complalnLs When boLh ureLers are obsLrucLed
azoLemla wlLh aLLendanL secondary sympLoms may be Lhe flndlng LhaL requlres dlagnosLlc sLudles
LxLernal physlcal examlnaLlon ls noL generally reveallng Lhough occaslonally a suprapublc mass may be
palpable 8ecLal examlnaLlon may reveal large Lumors parLlcularly when Lhey have lnvaded Lhe pelvlc
slde walls 1hus blmanual examlnaLlon ls a necessary parL of sLaglng evaluaLlon
LaboraLory llndlngs
Mlcroscoplc hemaLurla ls Lhe only conslsLenL dlagnosLlc flndlng aLlenLs wlLh bllaLeral ureLeral
obsLrucLlon may have azoLemla and anemla Llver meLasLases may cause elevaLlon of serum
Lransamlnases and alkallne phosphaLase 1here are no paraneoplasLlc syndromes or Lumor markers
conslsLenLly presenL ln paLlenLs wlLh uroLhellal carclnoma urlnary markers currenLly belng sLudled are
varlous LumorassoclaLed anLlgens growLh facLors and nuclear maLrlx proLelns buL none are proved Lo
be accuraLe enough Lo obvlaLe cysLoscopy for dlagnosls
lmaglng SLudles
Small bladder Lumors are noL seen on lnLravenous urography buL may be seen on C1 Larger Lumors
usually produce fllllng defecLs ln Lhe bladder on boLh urography or C1 (llgure 3813) ureLeral
obsLrucLlon wlLh hydroureLeronephrosls may occur as well lnvaslon of Lhe bladder wall may be
predlcLed ln paLlenLs wlLh asymmeLry or marked lrregularlLy of Lhe bladder wall nonlnvaslve leslons
seen on C1 or lnLravenous urography Lend Lo be exophyLlc wlLhln Lhe bladder wlLhouL evldence of
bladder wall dlsLorLlon
llgure 3813




nonconLrasL C1 scan showlng spaceoccupylng leslon (LranslLlonal cell carclnoma) on Lhe posLerolnferlor
of Lhe bladder (arrow)

ulLrasonography by exLernal LransrecLal or LransureLhral rouLes can accuraLely deflne moderaLeslzed
bladder Lumors and can ofLen deplcL deep lnvaslon
C1 scan can be useful for sLaglng buL Lhe depLh of bladder wall peneLraLlon and dellneaLlon of Lumor
deposlLs ln ad[acenL nonenlarged lymph nodes are noL accuraLely deflned ln paLlenLs wlLh nodal
meLasLases suspecLed on C1 scans flneneedle asplraLlon and cyLologlc sLudles may conflrm Lhe
dlagnosls and ellmlnaLe Lhe need for surglcal exploraLlon M8l ls helpful ln Lhe pelvls where moLlon
arLlfacLs are mlnor and Lhe scanL pelvlc faL ls [usL enough Lo provlde organ dlfferenLlaLlon Powever Lhe
lnformaLlon ls noL superlor Lo LhaL obLalned wlLh C1
urlnary CyLologlc SLudles
uroLhellal Lumors shed neoplasLlc cells lnLo Lhe urlne ln large numbers Lowgrade Lumor cells may noL
appear abnormal on cyLologlc examlnaLlon buL hlghergrade Lumor cells can be deLecLed by cyLologlc
sLudy 1hese sLudles are mosL useful ln checklng for recurrence of uroLhellal carclnoma llow cyLomeLry
(dlfferenLlal sLalnlng of unA and 8nA wlLhln urlne cells Lo measure Lhe amounL of nuclear proLeln and
Lhus Lhe relaLlve number of aneuplold abnormal cells) has been used Lo screen paLlenLs wlLh some
success 1hls Lechnlque may be useful for early dlagnosls of recurrence 1he urlnary fluorescence ln slLu
hybrldlzaLlon (llSP) assay ls more senslLlve and comparably speclflc for bladder cancer cells as compared
Lo cyLology
Lndoscoplc llndlngs
CysLoscopy ls mandaLory ln any adulL paLlenL wlLh unexplalned hemaLurla and a normal C1 or
lnLravenous urogram Many uroLhellal carclnomas are noL ldenLlfled on C1 or lnLravenous urography
CysLoscoplc examlnaLlon should deLecL nearly all Lumors ln Lhe bladder (llgure 3814) Cnly a few
paLlenLs wlll have carclnoma ln slLu (hlghgrade nonlnvaslve Lumor) LhaL ls noL vlslble Any Lumor seen
should be blopsled Superflclalappearlng Lumors can be dlagnosed and removed LransureLhrally aL Lhe
same Llme 1he enLlre bladder lncludlng Lhe bladder neck should be rouLlnely scruLlnlzed ln all paLlenLs
wlLh mlcroscoplc hemaLurla ln paLlenLs wlLhouL vlslble Lumor and no oLher causes of hemaLurla
random blopsles may be dlagnosLlc of carclnoma ln slLu A blmanual examlnaLlon should be done durlng
cysLoscopy ln all paLlenLs wlLh uroLhellal carclnoma Lo be cerLaln LhaL Lhe bladder ls noL flxed slgnlfylng
exLenslve exLraveslcal exLenslon
llgure 3814




1ranslLlonal cell (paplllary) carclnoma of Lhe bladder wlLh mlnlmal lnvaslon of Lhe bladder wall

SLaglng
1herapy depends on Lhe sLage of Lhe Lumor as seen on hlsLologlc secLlons and examlnaLlons for
meLasLases 1able 382 seLs forLh Lhe sLage LreaLmenL and prognosls of paLlenLs wlLh uroLhellal
carclnoma of Lhe bladder 1he hlsLologlc grade of Lhe Lumor ls also lmporLanL ln deLermlnlng LreaLmenL
and prognosls buL ln general low and hlghgrade hlsLologlc characLerlsLlcs Lend Lo occur ln low and
hlghsLage Lumors respecLlvely
As prevlously dlscussed C1 scan M8l or boLh may be helpful ln predlcLlng Lhe sLage of Lhe Lumor
lsoLope bone scannlng chesL xray and chesL C1 scan evaluaLe Lhe posslblllLy of bone or pulmonary
meLasLases and should be done before deLermlnlng Lherapy ln paLlenLs wlLh lnvaslve leslons
1reaLmenL
1ransureLhral 8esecLlon lulguraLlon and Laser 1herapy
Lndoscoplc LransureLhral resecLlon of superflclal and submucosally lnvaslve lowgrade Lumors can be
curaLlve neverLheless because Lhe Lumor recurs ln more Lhan 30 of paLlenLs cysLoscopy should be
performed perlodlcally CuarLerly examlnaLlons are recommended durlng Lhe flrsL year followlng Lumor
resecLlon every 6 monLhs durlng Lhe second year and annually LhereafLer erlodlc urlnary cyLologlc
examlnaLlons can be helpful as well C1 or lnLravenous urography ls recommended yearly for Lhe flrsL 3
Lo 3 years buL ls noL mandaLory 8ecurrenL small Lumors wlLhouL obvlous lnvaslon may be LreaLed by
fulguraLlon only Lhough blopsy ls recommended Lo documenL Lhe sLage and grade
neodymlum?AC lasers have been used for deslccaLlon of lowgrade lowsLage Lumors 1here ls as yeL
no proven advanLage Lo Lhls approach excepL LhaL paLlenLs can be LreaLed under local anesLhesla as
ouLpaLlenLs and perhaps LhaL Lumor cells are rendered nonvlable and Lhus lncapable of relmplanLaLlon
elsewhere ln Lhe bladder or ureLhra 8lopsles for dlagnosls and sLaglng are sLlll requlred
lnLraveslcal ChemoLherapy
A varleLy of chemoLherapeuLlc agenLs have been used ln paLlenLs wlLh recurrenL lowgrade lowsLage
Lumors MlLomycln C ls lnsLllled lnLo Lhe bladder by caLheLer (40 mg ln 40 mL of waLer) and lefL
lndwelllng for 2 hours aLlenLs are LreaLed once a week for 1 monLh and Lhen monLhly for up Lo 2 years
1reaLmenL resulLs ln decreased frequency of recurrence or no recurrence ln nearly 30 of paLlenLs
CLher agenLs lnclude LhloLepa and doxorublcln lmmunoLherapeuLlc drugs whlch lnclude 8CC are
effecLlve ln prophylaxls (60) of recurrenL paplllary Lumors and curaLlve (70) ln carclnoma ln slLu a
hlghly mallgnanL leslon less responslve Lo Lhe cyLoLoxlc agenLs descrlbed earller Slde effecLs of 8CC
lnclude veslcal lrrlLablllLy (90) and sysLemlc 8CCosls (1) AlLhough Lhe mechanlsm of acLlon of 8CC ls
noL enLlrely known lL ls suspecLed Lo lnduce 1cell recrulLmenL and subsequenL cyLoklne release locally
aL Lhe Lumor slLe lL ls Lhe mosL effecLlve agenL currenLly used lnLerferon alfa has also been sLudled and
ls effecLlve (nearly 30 of cases) for carclnoma ln slLu wlLh less LoxlclLy Lhan 8CC however lLs
durablllLy as a slngle agenL ls poor 1he comblnaLlon of 8CC and lnLerferon alfa has shown nearly 30
response raLes and ls occaslonally used ln paLlenLs who have falled 8CC lmmedlaLe posLLransureLhral
resecLlon lnLraveslcal chemoLherapy wlLh mlLomycln C has shown a subsLanLlal decrease ln recurrence
raLes and ls now sLandard of care
8adlaLlon 1herapy
ueflnlLlve radlaLlon Lherapy should be reserved for paLlenLs who have lnoperable musclelnvaslve
bladder cancer locallzed Lo Lhe pelvls or who refuse surglcal LreaLmenL as Lhe 3year survlval raLe ls only
30 ln some paLlenLs wlLh recurrence afLer radlaLlon Lherapy salvage cysLecLomy can be curaLlve (ln aL
leasL 30 of cases) Lhough surglcal morbldlLy raLes are hlgh
Much conLroversy surrounds Lhe use of radlaLlon Lherapy preoperaLlvely Some auLhors have clalmed a
downsLaglng effecL wlLh 2000 cCy glven over 1 week or 4000 cCy glven over 3 Lo 4 weeks 1he sLudles
were poorly conLrolled however and subsequenL reporLs have noL conflrmed Lhese flndlngs CurrenLly
urologlc oncologlsLs rarely use preoperaLlve radlaLlon Lherapy
Surglcal 1herapy
Cccaslonal paLlenLs are seen wlLh musclelnvaslve leslons (12) locallzed Lo an area ln Lhe bladder well
away from Lhe bladder base or orlflces and wlLhouL Lumor ln oLher slLes of Lhe bladder (proved by
mulLlple blopsles) or beyond arLlal cysLecLomy (removal of Lhe Lumor and a 3cm surroundlng margln
of normal bladder) ls approprlaLe ln Lhese paLlenLs Such Lumors are rare and paLlenLs musL be selecLed
carefully for parLlal cysLecLomy All oLher paLlenLs wlLh hlghgrade or lnvaslve (12 and 13) leslons
wlLhouL dlsLanL spread or a flxed pelvls on blmanual examlnaLlon are besL LreaLed by cysLecLomy and
pelvlc lymph node dlssecLlon 1hls lncludes removal of Lhe bladder and Lhe prosLaLe ln men 8emoval of
Lhe enLlre ureLhra may be necessary ln selecLed paLlenLs wlLh Lumors aL Lhe bladder neck or ln Lhe
prosLaLe or ln Lhose wlLh dlffuse carclnoma ln slLu ln Lhe bladder ln women Lhe uLerus Lhe ureLhra and
Lhe anLerlor vaglnal wall are usually removed urlnary dlverslon ls requlred and ls commonly
accompllshed by creaLlon of an lleal dlverslon ConLlnenL cuLaneous urlnary dlverslons requlrlng
lnLermlLLenL cuLaneous caLheLerlzaLlon raLher Lhan cuLaneous bag dralnage became popular ln Lhe laLe
1980s 1he baslc prlnclples are largevolume reservolrs wlLh deLubularlzaLlon of bowel Lo malnLaln low
lnLrapouch pressures and consLrucLlon of an lnLussuscepLed or pllcaLed lleal segmenL Lo provlde
cuLaneous conLlnence CrLhoLoplc reservolrs also have been devlsed uslng bowel conflguraLlons slmllar
Lo Lhose descrlbed above Lo connecL dlrecLly Lo Lhe membranous ureLhra ln men and ln Lhe dlsLal Lwo
Lhlrds of Lhe female ureLhra permlLLlng Lhe paLlenL Lo vold normally 1hese procedures are approprlaLe
ln boLh men and women and have been shown Lo be safe wlLh mlnlmal lncrease ln morbldlLy over
cuLaneous dlverslons 8ecenLly laparoscoplc and roboLlc cysLecLomy and urlnary dlverslon has been
done ln a few cenLers ln Lhe unlLed SLaLes and Lurope
SysLemlc ChemoLherapy
ChemoLherapy ln Lhe form of CMv (clsplaLln meLhoLrexaLe vlnblasLlne) or MvAC (CMv plus doxorublcln
Adrlamycln) has been used precysLecLomy (neoad[uvanL) or posLcysLecLomy (ad[uvanL) for muscle
lnvaslve Lumors or as LreaLmenL of meLasLaLlc uroLhellal cancer More recenLly gemclLablne and
clsplaLln have become sLandard of care afLer a randomlzed Lrlal showed slmllar efflcacy Lo MvAC wlLh
fewer slde effecLs A recenL randomlzed Lrlal showed lmproved survlval ln paLlenLs wlLh locally advanced
bladder cancer who recelved neoad[uvanL chemoLherapy and cysLecLomy compared Lo Lhose who
underwenL cysLecLomy alone Ad[uvanL chemoLherapy has been shown ln randomlzed Lrlals Lo help
paLlenLs wlLh locoreglonal dlsease buL noL paLlenLs wlLh locallzed dlsease (sLage 1112) Several reporLs
of efflcacy wlLh elLher CMv or MvAC for LreaLmenL of meLasLaLlc dlsease have shown a 60 overall
ob[ecLlve response raLe wlLh a 30 compleLe response raLe A few longLerm survlvors wlLh apparenL
cure have been reporLed (1013) and elLher of Lhese reglmens Lhus appears Lo be a deflnlLe advance
ln Lhe LreaLmenL of uroLhellal cancer CLher chemoLherapeuLlc agenLs used ln uroLhellal cancer lnclude
pacllLaxel and carboplaLln ln varlous reglmens LhaL appear Lo have slmllar efflcacy wlLh less LoxlclLy
1hese resulLs have caused a few lnvesLlgaLors Lo sLudy chemoLherapy alone or ln comblnaLlon wlLh
radlaLlon Lo aLLempL bladder salvage ln paLlenLs wlLh lnvaslve bladder cancer and Lhls has become a
vlable alLernaLlve Lo cysLecLomy ln selecLed paLlenLs
rognosls
ApproxlmaLely half of Lhe lowgrade superflclal Lumors are conLrolled by LransureLhral surgery or
lnLracavlLary use of chemoLherapeuLlc agenLs (1able 382) lollowlng radlcal cysLecLomy Lhe 3year
survlval raLe varles wlLh Lhe exLenL sLage and grade of Lhe Lumor buL wlLh 12n0M0 Lumors averages
abouL 30 Lo 70 1he compllcaLlons of urlnary dlverslon (ureLeral obsLrucLlon wlLh hydronephrosls
pyelonephrlLls and nephrollLhlasls) also lnfluence Lhe ouLcome
Carclnoma of Lhe rosLaLe
LssenLlals of ulagnosls
- alpable rockhard nodule ln Lhe prosLaLe on recLal examlnaLlon
- Serum prosLaLespeclflc anLlgen elevaLlon
- PlsLologlc conflrmaLlon on needle blopsy
- CsLeoblasLlc bone meLasLases ln advanced cases
Ceneral ConslderaLlons
ln adulL men prosLaLe cancer ls Lhe mosL common neoplasm (afLer skln cancer) and Lhe secondmosL
common cause of deaLh due Lo cancer 1he Lumor ls more prevalenL ln black men Lhan ln any oLher
group ln Lhe unlLed SLaLes 1he Lumor rarely occurs before age 40 and Lhe lncldence lncreases wlLh age
such LhaL more Lhan 73 of men older Lhan age 83 have prosLaLe cancer on auLopsy ln mosL of Lhese
older men however Lhe dlsease ls noL cllnlcally apparenL only 10 of men over age 63 develop cllnlcal
evldence of Lhe dlsease nlneLyflve percenL of Lumors are adenocarclnomas 1he Lumor arlses prlmarlly
ln Lhe perlpheral zone (83) an area LhaL dlffers ln embryologlc derlvaLlon from Lhe perlureLhral
(LranslLlon) zone whlch ls Lhe slLe of formaLlon of benlgn prosLaLlc hyperplasla 1he cause of prosLaLe
cancer ls unknown buL many facLors appear Lo be lnvolved lncludlng geneLlc hormonal dleLary
(parLlcular hlghfaL dleLs) and perhaps envlronmenLal carclnogenlc lnfluences
Screenlng
AlLhough screenlng wlLh annual prosLaLespeclflc anLlgen (SA) monlLorlng and dlglLal recLal
examlnaLlon has been conLroverslal due Lo lack of evldence LhaL lL affecLs morLallLy lL ls recommended
by Lhe Amerlcan Cancer SocleLy and Lhe Amerlcan urologlcal AssoclaLlon and ls wldely lmplemenLed lL
has been shown LhaL Lhe comblnaLlon of dlglLal recLal examlnaLlon and serum SA monlLorlng ls beLLer
Lhan elLher alone as a screenlng meLhod 1here are Lwo ongolng randomlzed Lrlals LhaL wlll address
wheLher screenlng affecLs morLallLy from prosLaLe cancer (Lhe rosLaLe Lung Colon and Cvarlan Cancer
Screenlng 1rlal naLlonal Cancer lnsLlLuLe and Lhe Luropean 8andomlzed SLudy of Screenlng for
rosLaLe Cancer) Screenlng ls recommended for mosL men age 30 or older for black men 43 or older
and for Lhose wlLh flrsLdegree relaLlves dlagnosed wlLh prosLaLe cancer Lach paLlenL should recelve
deLalled lnformaLlon prlor Lo screenlng so Lhey undersLand Lhe posslble beneflLs and rlsks of screenlng
(shared declslon maklng)
Cllnlcal llndlngs
SympLoms and Slgns
lncldenLal or sLage A (11) carclnoma of Lhe prosLaLe presenLs no physlcal slgns (lL ls nonpalpable) and ls
only dlagnosed by Lhe paLhologlsL when prosLaLe Llssue ls removed as LreaLmenL for sympLomaLlc
bladder ouLleL obsLrucLlon presumed Lo be caused by benlgn prosLaLlc hyperplasla or ls found by an
elevaLed SA (11c) aLlenLs wlLh sLage 8 (12) or hlgher dlsease have a hard nodule on Lhe prosLaLe LhaL
can be felL durlng recLal examlnaLlon (1able 383) revlously 30 of paLlenLs presenLed wlLh evldence
of meLasLases lncludlng welghL loss anemla bone paln (commonly ln Lhe lumbosacral area) or acuLe
neurologlc deflclL ln Lhe lower llmbs 1oday however fewer Lhan 20 of paLlenLs presenL ln Lhls way
because of earller dlagnosls due Lo wlde use of SA screenlng (sLage mlgraLlon)
1able 383 1reaLmenL and rognosls of rosLaLe Cancer 8elaLed Lo 1umor SLage


ConvenLlonal SLage 1nM SLage 1997 Cllnlcal llndlngs 1reaLmenL 13?ear
8ecurrencelree Survlval ()
A1 11a nonpalpable Lumor lncldenLal flndlng aL LransureLhral prosLaLecLomy (lowgrade cancer
seen ln 3 of prosLaLe) CbservaLlon 100
A2 11b Same as above excepL Lumor ls hlghgrade or 3 of prosLaLe ls lnvolved or boLh
8adlcal prosLaLecLomy wlLh pelvlc lymphadenecLomy C8 7080
81 12a 1umor lnvolves 1 lobe or less LxLernal beam radlaLlon C8 83
82 12b 1umor lnvolves more Lhan 1 lobe 8rachyLherapy 6070
C 13a unllaLeral exLraprosLaLlc exLenslon 2060
C2 13b 8llaLeral exLraprosLaLlc exLenslon Pormonal Lherapy (orchlecLomy or
LP8P/anLlandrogen) plus exLernal beam radlaLlon 010
13c Semlnal veslcle lnvaslon
14a lnvades bladder neck or recLum
14b lnvades levaLor muscle and/or flxed Lo pelvlc sldewall
u n+ or M+ elvlc lymph node lnvolvemenL or dlsLanL meLasLases Pormonal Lherapy
(orchlecLomy or LP8P/anLlandrogen) when sympLomaLlc lrradlaLlon for lsolaLed bone paln 010


LP8P luLelnlzlng hormonereleaslng hormone
LaboraLory llndlngs
aLlenLs wlLh exLenslve meLasLases may have anemla due Lo bone marrow replacemenL by Lumor 1hose
wlLh bllaLeral ureLeral obsLrucLlon secondary Lo Lrlgonal compresslon by Lumor may exhlblL azoLemla
and uremla Serum alkallne phosphaLase ls ofLen elevaLed ln paLlenLs wlLh bone meLasLases buL noL ln
Lhose wlLh locallzed dlsease
SA ls elevaLed ln Lhe serum of approxlmaLely 60 of men wlLh prosLaLe cancer Levels above 4 ng/mL
are consldered abnormal buL rlse normally wlLh age and volume of benlgn prosLaLlc hyperLrophy and
can be falsely elevaLed due Lo cysLoscopy prosLaLe blopsy or ureLhral caLheLerlzaLlon buL noL by normal
dlglLal recLal examlnaLlon
MeLhods for enhanclng SA speclflclLy lnclude Lhe followlng (1) agespeclflc SA (younger men age
30 years normal 23 ng/mL older men age 70 years normal 63 ng/mL) (2) SA denslLy (SA
dlvlded by prosLaLe volume) where less Lhan 013 ng/mL suggesLs cancer (3) percenLfree SA (LoLal
SA mlnus complexed SA) where when less Lhan 10 Lhe rlsk of prosLaLe cancer ls 60 (only useful
wlLh LoLal SA 210 ng/mL) Whlle LoLal SA ls useful for sLaglng lL ls noL absoluLe SA appears Lo be
mosL helpful ln followlng up on paLlenLs afLer LreaLmenL as levels fall Lo almosL nll wlLh compleLe
response 1here are several new prosLaLe cancer markers currenLly belng lnvesLlgaLed buL none are
LhoughL Lo be more senslLlve and speclflc Lhan SA aL presenL
lmaglng SLudles
1ransrecLal ulLrasound has become very useful for evaluaLlng prosLaLe volume and guldlng blopsy
needles lnLo Lhe perlpheral zone and oLher speclflc areas such as Lhe base Lhe apex and Lhe LranslLlon
zone of Lhe prosLaLe 1he sLudy can also reveal Lyplcal hypoecholc perlpheral zone leslons ln 70 of
paLlenLs wlLh palpable leslons 8ecause many prosLaLe cancers are noL hypoecholc and noL all
hypoecholc leslons are cancer LransrecLal ulLrasound alone for screenlng for prosLaLe cancer ls noL
recommended An lnLravenous urogram or C1 may reveal urlnary reLenLlon or dlsLal ureLeral
obsLrucLlon LxLenslve leslons may exhlblL a raggededged fllllng defecL ln Lhe bladder base A chesL xray
may help ln ldenLlfylng Lhe uncommon lung meLasLases buL more ofLen shows Lyplcal osLeoblasLlc
meLasLases ln Lhe Lhoraclc splne or rlbs An abdomlnal xray may reveal meLasLases ln Lhe lumbosacral
splne or lllum A C1 scan of Lhe pelvls may show an enlarged prosLaLe and large pelvlc or paraaorLlc
lymph nodes however Lhe sLudy ls rarely accuraLe for sLaglng and ls noL rouLlnely recommended unless
Lhe SA ls hlgher Lhan 20 ng/mL or Lhe Cleason sum of Lhe Lumor ls 7 or more or Lhe Lumor ls palpable
ouLslde of Lhe prosLaLe (sLage C/13) llneneedle asplraLlon and cyLologlc sLudles or laparoscoplc
dlssecLlon of abnormal nodes may provlde lmporLanL sLaglng daLa LndorecLal and pelvlc M8l appear Lo
be more helpful Lhan C1 scan ln pelvlc sLaglng of prosLaLe cancer A monoclonal anLlbody CyL336
(whlch ldenLlfles Lhe lnLracellular eplLope of prosLaLespeclflc membrane anLlgen) has been coupled
wlLh a radlolsoLope for dlagnosls of sofL Llssue meLasLases 8esulLs show LhaL Lhe rosLasclnL scan ls 60
accuraLe buL LhaL lL has a relaLlvely hlgh falseposlLlve raLe whlch llmlLs lLs usefulness
8lopsy
1he dlagnosls ls esLabllshed by LransrecLal ulLrasoundgulded blopsles ln mosL lnsLances 8ecause Lhe
greaL ma[orlLy of paLlenLs have blopsles due Lo an elevaLed serum SA (sLage 11c) and no abnormal
flndlngs on LransrecLal ulLrasound blopsles of Lhe base mlddle and apex of Lhe prosLaLe
concenLraLlng on Lhe perlpheral zone wlLh 6 blopsles per slde of Lhe prosLaLeare requlred for accuraLe
dlagnosls
ulfferenLlaLlon of Lhe Lumor ls graded by Lhe paLhologlsL uslng Lhe Cleason scale whlch asslgns a grade
of 1 Lo 3 (low Lo hlgh grade) for boLh Lhe prlmary and secondary forms of Lhe Lumor 1he Lwo numbers
are added and Lhe cancer can Lhus be Cleason sum 2 Lo Cleason sum 10 wlLh 10 belng Lhe mosL poorly
dlfferenLlaLed cancer 1he llkellhood of meLasLasls can be lnferred from Lhe Cleason sum 7 (4 + 3) or
more ls an aggresslve cancer
SLaglng
8ecLal examlnaLlon can provlde lnlLlal sLaglng ln paLlenLs wlLh palpable Lumors (1able 383) needle
blopsy ls conflrmaLory and hlsLologlc gradlng can falrly accuraLely predlcL Lhe meLasLaLlc poLenLlal of Lhe
Lumor A normal lsoLoplc (LechneLlum 99m) bone scan rules ouL bone meLasLases buL ls noL necessary lf
Cleason score ls less Lhan 7 and/or SA ls less Lhan 20 ng/mL A pelvlc C1 scan may be useful Lo deflne
pelvlc lymphadenopaLhy ln paLlenLs wlLh hlghgrade leslons SA over 20 ng/mL or boLh 1he
laparoscoplc approach Lo pelvlc lymph node dlssecLlon has provlded Lhe same prognosLlc lnformaLlon as
an open surglcal procedure wlLh less morbldlLy and a markedly reduced hosplLal sLay 1hls approach ls
useful ln paLlenLs wlLh hlghgrade or hlghsLage leslons and Lhose consldered for radlcal perlneal
prosLaLecLomy CysLoscopy ls noL requlred excepL ln large leslons suspecLed Lo lnvolve Lhe bladder neck
and Lrlgone
ulfferenLlal ulagnosls
nodules caused by benlgn prosLaLlc hyperplasla may be dlfflculL Lo dlsLlngulsh from cancer benlgn
nodules are usually rubbery whereas cancerous nodules have a much harder conslsLency llbrosls
followlng a prlor prosLaLecLomy for benlgn dlsease or secondary Lo chronlc prosLaLlLls or prlor blopsles
may be assoclaLed wlLh leslons lndlsLlngulshable from cancerous nodules and requlre blopsy for
deflnlLlon Cccaslonally phlebollLhs or prosLaLlc calcull on Lhe surface of Lhe prosLaLe may be confuslng
however LransrecLal ulLrasound can be helpful ln Lhe dlfferenLlaLlon and for blopsy guldance
1reaLmenL
CuraLlve 1herapy
CuraLlve LreaLmenL for locallzed prosLaLe cancer lncludes radlcal prosLaLecLomy exLernal beam
radlaLlon Lherapy and Lransperlneal radloacLlve seed placemenL (brachyLherapy wlLh 123l 103d or
192lr) CompleLe sLaglng ls lmporLanL so LhaL approprlaLe candldaLes wlll be selecLed aLlenLs wlLh
locallzed prosLaLe cancer are sLraLlfled lnLo Lhree rlsk groups (1able 384) Lowrlsk paLlenLs have slmllar
3year recurrence survlval raLes lrrespecLlve of Lhe curaLlve LreaLmenL modallLy lnLermedlaLerlsk and
hlghrlsk paLlenLs have beLLer recurrencefree raLes wlLh prosLaLecLomy or exLernal beam radlaLlon
compared Lo brachyLherapy none of Lhese modallLles have been compared ln randomlzed Lrlals 1he
only reporLed randomlzed Lrlal compared waLchful walLlng Lo radlcal prosLaLecLomy and LhaL showed
lmproved dlseasefree as well as overall survlval ln Lhe prosLaLecLomy group SLudles have shown LhaL
neoad[uvanL androgen deprlvaLlon and exLernal beam radlaLlon lmprove survlval ln paLlenLs wlLh
locallzed prosLaLe cancer especlally paLlenLs ln Lhe lnLermedlaLe and hlghrlsk groups aLlenLs wlLh
grossly poslLlve pelvlc lymph nodes are noL candldaLes for curaLlve Lherapy 8ecenL advances ln surglcal
Lechnlque have led Lo a low lncldence of lnconLlnence (14) and preservaLlon of poLency ln up Lo 70
of paLlenLs AlLernaLlve procedures lnclude exLernal beam pelvlc lrradlaLlon plus lnLersLlLlal radlaLlon
8ecenLly laparoscoplc and roboLlcasslsLed laparoscoplc radlcal prosLaLecLomy has been shown Lo have
decreased blood loss and lengLh of hosplLal sLay and more rapld reLurn Lo normal acLlvlLy Lhan open
surgery lL ls as yeL uncerLaln lf longLerm compllcaLlons and efflcacy wlll be lmproved as well
1able 384 Locallzed rosLaLe Cancer 8lsk Croups


Low rlsk SA 10 ng/ml

Cllnlcal sLage 11c12a

Cleason score 26

lnLermedlaLe rlsk SA 1020 ng/ml

Cllnlcal sLage 12b

Cleason score 7

Plgh rlsk SA 20 ng/ml

Cllnlcal sLage 12c

Cleason score 810



SA prosLaLespeclflc anLlgen
alllaLlve 1herapy
aLlenLs wlLh meLasLaLlc dlsease cannoL be cured buL slgnlflcanL palllaLlon can be offered Androgen
deprlvaLlon Lherapy ln Lhe form of luLelnlzlng hormonereleaslng hormone (LP8P agonlsL or bllaLeral
orchlecLomy) ls effecLlve ln 7080 of sympLomaLlc paLlenLs LsLrogenbased LreaLmenLs are less
commonly used due Lo Lhe numerous slde effecLs (ln abouL 23 of paLlenLs) lncludlng congesLlve hearL
fallure LhrombophleblLls and myocardlal lnfarcLlon and Lhus should noL be used excepL ln selecLed
paLlenLs 1hese hormonal LreaLmenLs are noL addlLlve and use of boLh LreaLmenLs slmulLaneously has
no advanLages over use of elLher alone LP8P agonlsLs have shown efflcacy comparable Lo LhaL of
esLrogen or orchlecLomy wlLh reduced slde effecLs and are preferred by paLlenLs who flnd bllaLeral
orchlecLomy unaccepLable 1he drug musL be glven by ln[ecLlon every 3 Lo 4 monLhs and ls expenslve
SLudles have also shown LhaL lf an LP8P agonlsL ls used concomlLanL admlnlsLraLlon of an anLlandrogen
(fluLamlde or blcaluLamlde) sllghLly lmproves survlval SLudles Lo deLermlne lf orchlecLomy plus an
anLlandrogen ls more effecLlve Lhan orchlecLomy alone have noL shown an advanLage Lo Lhe
comblnaLlon CsLeoporosls ls a longLerm slde effecL of elLher orchlecLomy or LP8P agonlsL
ConLroversy conLlnues concernlng wheLher Lo LreaL asympLomaLlc paLlenLs aL Lhe Llme of dlagnosls or Lo
walL unLll sympLoms develop 8ecause elLher approach ls palllaLlve only and Lhere are no deflnlLlve
sLudles showlng survlval advanLages wlLh early LreaLmenL lL ls recommended LhaL LreaLmenL be
wlLhheld unLll SA ls relaLlvely hlgh ( 20 ng/ml) or sympLoms occur excepL ln paLlenLs who cannoL
accepL a noLreaLmenL phllosophy 8ecenL sLudles do show LhaL paLlenLs who have had a radlcal
prosLaLecLomy and have nodeposlLlve dlsease do have a sllghL survlval advanLage wlLh early hormonal
LreaLmenL
aLlenLs whose prosLaLe cancer becomes hormone refracLory (medlan of 18 monLhs afLer sLarLlng
LreaLmenL) can be LreaLed by keLoconazole (whlch lnhlblLs adrenal androgen producLlon) wlLh oral
corLlcosLerolds for shorLLerm response 8adlaLlon Lherapy for sympLomaLlc bone leslons can be helpful
as can local lrradlaLlon for an obsLrucLlng or bleedlng prosLaLe Lumor Cn occaslon LransureLhral
prosLaLecLomy ls requlred Lo relleve bladder ouLleL obsLrucLlon ChemoLherapy wlLh doceLaxel and
prednlsone has recenLly shown a sllghL survlval advanLage ln phase lll Lrlals
rosLaLe Cancer revenLlon
8ecause Lhe eLlology of prosLaLe cancer ls noL known prevenLlon ls dlfflculL Lo deLermlne Powever
Lhere ls evldence LhaL a lowfaL dleL and lycopene (found ln processed LomaLoes) decrease Lhe growLh of
prosLaLe cancer cells ln vlLro and ln vlvo ln anlmals lurLher largescale epldemlologlc sLudles suggesL a
decrease ln prosLaLe cancer ln humans who consumed vlLamln L and selenlum Powever Lhese sLudles
were noL planned speclflcally for Lhls purpose and Lhus Lhe resulLs were quesLlonable A currenL
randomlzed Lrlal comparlng selenlum and vlLamln L (SLLLC1) was recenLly halLed due Lo Lhe lack of
evldence of prosLaLe cancer prevenLlon 1he largesL chemoprevenLlon Lrlal (rosLaLe Cancer revenLlon
1rlal C1) wlLh over 18000 men compared flnasLerlde (3 reducLase) Lo placebo and found a 23
reducLlon ln prosLaLe cancer wlLh flnasLerlde buL also showed an lncreased rlsk of hlghgrade cancer ln
Lhe flnasLerldeLreaLed paLlenLs Whlle Lhls ls LhoughL Lo be an arLlfacL of Lhe sLudy Lhese resulLs have
llmlLed enLhuslasm for recommendlng prevenLlon Lherapy wlLh flnasLerlde rouLlnely
rognosls
8adlcal prosLaLecLomy cures 70 Lo 80 of Lhe paLlenLs sulLable for LhaL operaLlon buL lLs use should
be llmlLed Lo Lhose wlLh a reasonable llfe expecLancy (1able 383) CurrenLly abouL 60 Lo 70 of
paLlenLs wlLh prosLaLlc cancer are amenable Lo curaLlve Lherapy when Lhelr dlsease ls dlscovered
Sarcoma of Lhe rosLaLe
Sarcoma of Lhe prosLaLe ls rare Palf of all cases occur ln boys under age 3 1he Lumor ls hlghly mallgnanL
and meLasLaslzes Lo Lhe pelvlc and lumbar lymph nodes lungs llver and bone SympLoms of urlnary
LracL obsLrucLlon are presenL 1he prosLaLe ls enlarged CysLography or excreLory urography may show
superlor dlsplacemenL of Lhe bladder or encroachmenL of Lhe Lumor lnLo Lhe bladder Lndoscopy reveals
Lhe mass and allow blopsy
1oLal prosLaLocysLecLomy posLoperaLlve radloLherapy and chemoLherapy have cured a few cases ln
adulLs ln chlldren comblnaLlon chemoLherapy wlLh surgery for resldual Lumor has shown lncreaslng
success 1he Lumor ls relaLlvely radloreslsLanL
8lllAxelson A eL al 8adlcal prosLaLecLomy versus waLchful walLlng ln early prosLaLe cancer new Lng !
Med 20033321977 Mlu 13888698
8olla M eL al LongLerm resulLs wlLh lmmedlaLe androgen suppresslon and exLernal lrradlaLlon ln
paLlenLs wlLh locally advanced prosLaLe cancer (an LC81C sLudy) a phase lll randomlsed Lrlal LanceL
2002360103 Mlu 12126818
Chu kC eL al 1rends ln prosLaLe cancer morLallLy among black men and whlLe men ln Lhe unlLed SLaLes
Cancer 2003971307 Mlu 12627316
uAmlco Av eL al 8lochemlcal ouLcome afLer radlcal prosLaLecLomy exLernal beam radlaLlon Lherapy or
lnLersLlLlal radlaLlon Lherapy for cllnlcally locallzed prosLaLe cancer !AMA 1998280969 Mlu
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Crnberg P rosLaLe cancer epldemlology LanceL 2003361839 Mlu 19333337
Leman LS eL al LCA2 a hlghly speclflc serum marker for prosLaLe cancer urology 200769714 Mlu
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Moul !W opulaLlon screenlng for prosLaLe cancer and emerglng concepLs for young men Clln rosLaLe
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1annock ll eL al uoceLaxel plus prednlsone or mlLoxanLrone plus prednlsone for advanced prosLaLe
cancer new Lng ! Med 20043311302 Mlu 13470213
1hompson lM ChemoprevenLlon of prosLaLe cancer agenLs and sLudy deslgns ! urol 2007178S9

1umors of Lhe ureLhra
MallgnanL Lumors of Lhe ureLhra are rare 1he dlsease ls more common ln women Lhan ln men (41)
Squamous cell Lypes are seen mosL ofLen ln boLh sexes
ln women ureLhral bleedlng ls Lhe mosL common sympLom ulsLal ureLhral leslons of low grade and
wlLhouL exLenslon can be LreaLed by radloLherapy or wlde local exclslon Advanced dlsease ls besL
LreaLed by comblnaLlon radloLherapy chemoLherapy and surgery Lo achleve good local and dlsLanL
dlsease conLrol Surgery lncludes anLerlor exenLeraLlon (removal of Lhe bladder uLerus adnexa and
ureLhra wlLh Lhe anLerlor vaglnal wall) lncludlng pelvlc lymphadenecLomy and urlnary dlverslon 1he
prognosls ls excellenL for dlsLal leslons wlLhouL exLenslon buL 3year survlval raLes are less Lhan 30 for
Lhose wlLh proxlmal leslons
ln men Lhe leslon ls mosL commonly ln Lhe bulbomembranous ureLhra and ls assoclaLed wlLh a hlsLory
of chronlc ureLhral sLrlcLures ofLen secondary Lo gonorrheal lnfecLlon aLlenLs presenL wlLh ureLhral
bleedlng a weak urlnary sLream and a perlneal mass 1he dlagnosls ls made by ureLhroscopy and
blopsy ulsLal penlle ureLhral leslons can be LreaLed by parLlal or LoLal penecLomy Leslons ln Lhe bulbous
ureLhra or more proxlmal leslons requlre exLenslve surglcal resecLlon lncludlng en bloc removal of Lhe
penls ureLhra prosLaLe bladder wlLh overlylng publs pelvlc lymph nodes and urlnary dlverslon ln boLh
men and women wlLh dlsLal leslons groln lymphaLlcs may be lnvolved buL node dlssecLlon ls requlred
only when gross dlsease ls palpable rophylacLlc node dlssecLlon ls conLroverslal llveyear survlval
raLes are 60 for dlsLal ureLhral Lumors buL less Lhan 40 for Lhe more common proxlmal leslons
rlmary lrradlaLlonoLher Lhan Lo dlsLal leslons ln Lhe femalels rarely helpful aLlenLs wlLh meLasLaLlc
dlsease may respond Lo meLhoLrexaLe or clsplaLln alone or ln comblnaLlon buL ob[ecLlve remlsslons are
usually of shorL duraLlon
1umors of Lhe 1esLls
LssenLlals of ulagnosls
- alnless flrm mass wlLhln Lhe LesLlcle ln a man aged 18 Lo 40
- LlevaLed serum levels of Lhe beLa subunlL of human chorlonlc gonadoLropln ( hCC)
feLoproLeln lacLlc dehydrogenase or all Lhree
- Lnlarged reLroperlLoneal nodes on abdomlnal C1 scan
- alpable abdomlnal mass ln advanced cases
Ceneral ConslderaLlons
MosL LesLlcular Lumors are mallgnanL germ cell Lumors nongerm cell Lumors such as SerLoll cell
Lumors and Leydlg cell Lumors are rare and usually benlgn Cerm cell Lumors are caLegorlzed as elLher
semlnomaLous (33) or nonsemlnomaLous (embryonal 20 LeraLocarclnoma 38 LeraLoma 3
chorlocarclnoma 2) CrypLorchldlsm predlsposes Lo LesLlcular cancer wlLh Lhe lncldence lncreaslng
lnversely wlLh Lhe level of LesLlcular descenL (le LesLlcles remalnlng ln Lhe abdomen have a much hlgher
lncldence of cancer) MeLasLases flrsL develop ln Lhe reLroperlLoneal nodes rlghLslded Lumors
meLasLaslze prlmarlly Lo Lhe lnLeraorLocaval reglon [usL below Lhe renal vessels and lefLslded Lumors
prlmarlly Lo Lhe lefL paraaorLlc area aL Lhe same level ulsLanL spread ls Lo supraclavlcular areas (lefL
prlmarlly) and Lhe lungs !usL under 30 of paLlenLs have meLasLases when flrsL seen
Cllnlcal llndlngs
SympLoms and Slgns
1esLlcular Lumors presenL as a palnless flrm mass wlLhln Lhe LesLlcular subsLance 1hey ofLen have been
presenL for several monLhs before Lhe paLlenL seeks consulLaLlon Cccaslonally (10) a hydrocele ls
presenL obscurlng palpaLlon of Lhe mass A few paLlenLs have sponLaneous bleedlng lnLo Lhe mass
causlng paln aLlenLs wlLh hlgh serum levels of hCC may have gynecomasLla aLlenLs wlLh exLenslve
abdomlnal meLasLases may presenL wlLh abdomlnal paln anorexla and welghL loss LxamlnaLlon may
reveal palpable reLroperlLoneal nodes when spread ls exLenslve or palpable supraclavlcular nodes
parLlcularly on Lhe lefL slde
LaboraLory llndlngs
ln general LesLlcular Lumors do noL alLer Lhe usual laboraLory parameLers buL serum Lumor markers are
dlagnosLlcally helpful aLlenLs wlLh exLenslve reLroperlLoneal meLasLases may have bllaLeral ureLeral
obsLrucLlon LhaL causes azoLemla and anemla
Serum lacLlc dehydrogenase parLlcularly lsoenzyme l ls elevaLed ln approxlmaLely 60 of paLlenLs
PCC a parLlcularly senslLlve marker ls a glycoproLeln produced by 63 of nonsemlnomaLous LesLlcular
Lumors buL only 10 of semlnomas 1he alpha subunlL of Lhe molecule ls ldenLlcal Lo LP buL Lhe beLa
subunlL ls unlque Lo LesLlcular Lumors ln adulL men 1here ls crossreacLlvlLy ln some assays beLween Lhe
alpha and beLa subunlLs LreaLed paLlenLs who develop modesL elevaLlons should have slmulLaneous
assay of LP Lo be cerLaln Lhe marker deLecLed ls hCC
leLoproLeln ls elevaLed ln 70 of paLlenLs wlLh nonsemlnomaLous LesLlcular cancer buL ls noL elevaLed
ln paLlenLs wlLh semlnoma aLlenLs ln whom hlsLologlc sLudy has shown semlnoma buL ln whom serum
Al ls elevaLed should be suspecLed of havlng nonsemlnomaLous elemenLs ln Lhe prlmary speclmen or
meLasLaLlc leslons
ApproxlmaLely 83 of paLlenLs demonsLraLe elevaLlon of one of Lhese markers aL presenLaLlon Serum
levels decrease when Lhe Lumor ls compleLely removed or regresses Markers are used malnly Lo follow
Lumor regresslon or predlcL recrudescence as even mlnuLe amounLs of Lumor may cause serum
elevaLlons however Lumor may be presenL wlLhouL elevaLlon of serum markers
lmaglng SLudles
Abdomlnal C1 scan deflnes enlarged lymph nodes ln approxlmaLely 90 of cases when Lhey are presenL
ChesL xray and C1 scan wlll deLecL mosL pulmonary meLasLases
ScroLal ulLrasound ls useful for ldenLlfylng Lhe Lyplcal hypoecholc leslon ln Lhe LesLlcle 8egardless of Lhe
flndlngs on ulLrasound however a young man wlLh an lnLraLesLlcular mass on palpaLlon requlres
surglcal deflnlLlon of Lhe mass
ulfferenLlal ulagnosls
1esLlcular masses ln men aged 18 Lo 40 are frequenLly mallgnanL and should be LreaLed accordlngly
Confuslon can occur wlLh scroLal hydroceles cord hydroceles epldldymal masses or cysLs or
epldldymlLls MosL of Lhese can be dlfferenLlaLed from masses wlLhln Lhe LesLlcle by palpaLlon buL lf noL
scroLal ulLrasound ls usually helpful
1reaLmenL
See also 1able 383
1able 383 1reaLmenL and rognosls of 1esLlcular Cancer 8elaLed Lo 1umor SLage


ConvenLlonal SLage 1nM SLage Cllnlcal llndlngs 1reaLmenL 3?ear Survlval ()
l 11 Conflned Lo LesLlcle nonsemlnoma 8Lnu vs survelllance semlnoma lrradlaLlon
93
llA n1 8eglonal nodes 2 cm Ad[uvanL chemoLherapy 90
nonsemlnoma 8Lnu or chemoLherapy semlnoma x81 or chemoLherapy
ll8 n2 nodes 23 cm Ad[uvanL chemoLherapy 83
nonsemlnoma 8Lnu or ad[uvanL chemoLherapy semlnoma x81 or
chemoLherapy
llC n3 nodes 3 cm ChemoLherapy followed by resecLlon of resldual dlsease 70
lll M+ ulsLanL meLasLases ChemoLherapy followed by resecLlon of resldual dlsease 70


noLe All paLlenLs undergo lngulnal orchlecLomy
8Lnu reLroperlLoneal lymph node dlssecLlon
lngulnal orchlecLomy wlLh hlgh llgaLlon of Lhe cord aL Lhe lnLernal rlng ls proper lnlLlal LreaLmenL for all
subLypes of LesLlcular cancer 8arely ls lnclslonal blopsy of Lhe LesLlcle advlsable 8ecommendaLlons for
furLher Lherapy (reLroperlLoneal node dlssecLlon chemoLherapy radlaLlon Lherapy) are Lhen based on
Lhe paLhologlc flndlngs A sLaglng workup lncludlng posLoperaLlve measuremenL of serum markers
chesL xray and chesL and abdomlnal C1 scan ls conducLed Lo deLermlne Lhe exLenL of dlsease
nonsemlnomaLous 1umors
lollowlng orchlecLomy reLroperlLoneal lymph node dlssecLlon ls recommended for all paLlenLs wlLh
nonsemlnomaLous LesLlcular cancer excepL ln Lhe presence of bulky abdomlnal or dlsLanL meLasLases
aLlenLs wlLh pure chorlocarclnoma are an excepLlon and do noL usually requlre reLroperlLoneal surgery
because Lhe dlsease ln such cases ls lnvarlably sysLemlc and requlres mulLlagenL chemoLherapy 1he
exLenL of lymphadenecLomy depends on Lhe LesLlcle lnvolved buL ln general lncludes paraaorLlc and
paracaval nodes from Lhe renal vessels down Lo Lhe aorLlc blfurcaLlon and along Lhe exLernal lllac arLery
Lo Lhe lnLernal lngulnal rlng on Lhe lnvolved slde Semlnal emlsslon can be preserved loss of Lhls
funcLlon was prevlously a compllcaLlon of reLroperlLoneal lymph node dlssecLlon because of lnLerrupLlon
of auLonomlc nerves crosslng Lhe aorLa and near Lhe aorLlc blfurcaLlon
8ecause of Lhe assoclaLed morbldlLy some have proposed LhaL reLroperlLoneal lymph node dlssecLlon
be wlLhheld afLer orchlecLomy ln paLlenLs wlLh normal serum markers and no evldence of
reLroperlLoneal nodal dlsease on abdomlnal C1 scan and who have no flndlngs of dlsLanL meLasLases on
chesL xray and C1 scan 1he raLlonale was LhaL only 20 of Lhese paLlenLs wlll develop recurrenL
dlsease whlch could Lhen be LreaLed when lL appeared 1hls approach should be dlscussed aL lengLh
wlLh Lhe paLlenL Lo ensure hls rellable compllance wlLh a program for frequenL followup
aLlenLs wlLh any nonsemlnomaLous cell Lype who have exLenslve reLroperlLoneal or chesL meLasLases
are besL LreaLed afLer orchlecLomy by mulLlagenL chemoLherapy followed by exclslon of perslsLenL
masses ComblnaLlon chemoLherapy wlLh bleomycln eLoposlde and clsplaLln achleves over a 90 cure
raLe ln sLage ll paLlenLs and a 70 cure raLe ln sLage lll paLlenLs aLlenLs who do noL respond may be
LreaLed wlLh lfosfamlde doxorublcln or boLh wlLh some expecLaLlon of success
Semlnoma
ln Lhe absence of exLenslve dlsLanL spread paLlenLs wlLh pure semlnoma should be LreaLed wlLh
exLernal beam radlaLlon Lherapy (2300 cCy) Lo Lhe abdomen followlng orchlecLomy A recenL sLudy
showed LhaL one cycle of carboplaLln ls equlvalenL Lo radlaLlon Lherapy for sLage l semlnoma ln Lhe
presence of bulky abdomlnal dlsease or more dlsLanL meLasLases survlval raLes are beLLer wlLh
mulLlagenL chemoLherapy (descrlbed earller) glven lnlLlally ln lleu of radlaLlon Lherapy aLlenLs wlLh
subsLanLlal resldual reLroperlLoneal Lumor ( 3 cm) afLer chemoLherapy may beneflL from surglcal
removal of Lhe remalnlng Lumor
rognosls
Lven ln Lhe presence of meLasLases many of Lhese paLlenLs can be cured 1he only excepLlon ls paLlenLs
wlLh chorlocarclnoma who sLlll have a poor survlval raLe (33 aL 3 years) desplLe exLenslve
chemoLherapy
1umors of Lhe enls
Cancer of Lhe penls ls a rare dlsease occurrlng ln Lhe flfLh Lo slxLh decades 1he cause ls uncerLaln 1he
dlsease ls rarely seen ln clrcumclsed men 1he leslon commonly ls on Lhe glans penls or foreskln Larly
cases may exhlblL a palnless red velveLy leslon buL mosL ofLen Lhe leslon ls an exophyLlc nodular or
warLllke growLh wlLh secondary lnfecLlon 1he lnlLlal dlagnosls ls made by a generous lnclslonal blopsy of
Lhe leslon whlch reveals squamous cell carclnoma ln over 93 of cases 1he Lumors Lend Lo meLasLaslze
Lo superflclal or deep lngulnal nodes Lhough Lhe aLLendanL lnfecLlon may cause enlarged Lender nodes
whlch may be dlfflculL Lo dlfferenLlaLe from meLasLaLlc cancer
1he dlfferenLlal dlagnosls lncludes syphlllLlc chancre sofL chancre due Lo Paemophllus ducreyl lnfecLlon
and slmple or glanL condyloma 8lopsy usually dlfferenLlaLes among Lhese condlLlons
Small nonlnfllLraLlng leslons can be LreaLed wlLh fluorouracll cream exLernal beam radlaLlon or laser
Lherapy Powever close followup ls mandaLory ln paLlenLs so LreaLed Larger leslons noL lnvolvlng deep
sLrucLures are LreaLed by parLlal penlle ampuLaLlon aL leasL 2 cm proxlmal Lo Lhe leslon leavlng enough
of Lhe penls for adequaLe dlrecLlon of Lhe urlnary sLream ueeply lnfllLraLlng leslons requlre LoLal
penecLomy wlLh formaLlon of a perlneal ureLhrosLomy
aLlenLs wlLh hlghrlsk feaLures (hlgh 1 sLage hlgh grade or presence of lymphovascular lnvaslon) are aL
rlsk of lngulnal nodal meLasLases rophylacLlc node dlssecLlon has been assoclaLed wlLh lmproved
survlval
alpable lngulnal nodes should be LreaLed by anLlbloLlcs for 6 weeks followlng LreaLmenL of Lhe prlmary
leslon Lo ellmlnaLe lnfecLlon erslsLenLly palpable nodes requlre bllaLeral lllolngulnal lymphadenecLomy
An alLernaLlve would be flneneedle asplraLlon of Lhe palpable nodes and node dlssecLlon lf poslLlve for
meLasLases Lven Lhose who undergo delayed node dlssecLlon when Lhe nodes become palpable can be
cured Lhough Lhls ls a lower percenLage 8adlaLlon Lherapy for palpable nodes or as prophylaxls for
nonpalpable nodes has been occaslonally effecLlve
aLlenLs wlLh dlsLanL meLasLases (Lo Lhe lungs or bone) have a poor prognosls Lhough clsplaLln and
meLhoLrexaLe have shown ob[ecLlve buL noL durable responses llveyear survlval raLes for paLlenLs wlLh
nonlnvaslve leslons locallzed Lo Lhe penls are 80 for Lhose wlLh lngulnal node lnvolvemenL 30 and
for Lhose wlLh dlsLanL meLasLases nll
llanlgan 8C eL al CyLoreducLlve nephrecLomy ln paLlenLs wlLh meLasLaLlc renal cancer a comblned
analysls ! urol 20041711071 Mlu 14767273
Clas AS eL al 1umor markers ln Lhe dlagnosls of prlmary bladder cancer A sysLemaLlc revlew ! urol
20031691973 Mlu 12771702
Crossman P8 eL al neoad[uvanL chemoLherapy plus cysLecLomy compared wlLh cysLecLomy alone for
locally advanced bladder cancer n Lngl ! Med 2003349839 LrraLum ln n Lngl ! Med 20033491880
Cschwend !L eL al 8adlcal cysLecLomy for lnvaslve bladder cancer conLemporary resulLs and remalnlng
conLroversles Lur urol 200038121 Mlu 10893001
Pan M eL al rosLaLespeclflc anLlgen and screenlng for prosLaLe cancer Med Clln norLh Am
200488243 Mlu 13049377
Pernandez ! 1hompson lM ulagnosls and LreaLmenL of prosLaLe cancer Med Clln norLh Am
200488267 Mlu 13049378
!eweLL MA Croll 8! nervesparlng reLroperlLoneal lymphadenecLomy urol Clln norLh Am 200734149
Mlu 17484920
!eweLL MAS eL al ManagemenL of recurrence and followup sLraLegles for paLlenLs wlLh nonsemlnoma
LesLls cancer urol Clln norLh Am 200330819 Mlu 14680317
!oudl ln Crane Cn Cuonnell MA Mlnlmally lnvaslve managemenL of upper LracL uroLhellal carclnoma
Curr urol 8ep 2006723 8evlew
!oudl ln SmlLh 8! Cuonnell MA naLlonal 8CClnLerferon hase 2 lnvesLlgaLor Croup llnal resulLs from
a naLlonal mulLlcenLer phase ll Lrlal of comblnaLlon baclllus CalmeLLeCuLrln plus lnLerferon alpha28 for
reduclng recurrence of superflclal bladder cancer urol Cncol 200624344
klrkall Z 1uzel L 1ranslLlonal cell carclnoma of Lhe ureLer and renal pelvls CrlL 8ev Cncol PemaLol
200347133 Mlu 12900009
kondagunLa Cv MoLzer 8! Ad[uvanL chemoLherapy for sLage ll nonsemlnomaLous germ cell Lumors
urol Clln norLh Am 200734179 Mlu 17484923
LoLan ? 8oehrborn CC SenslLlvlLy and speclflclLy of commonly avallable bladder Lumor markers versus
cyLology resulLs of a comprehenslve llLeraLure revlew and meLaanalyses urology 200361109 Mlu
12339279
MaLlaga 88 eL al 8adlofrequency ablaLlon of renal Lumors Curr urol 8ep 2004339 Mlu 14733836
MeullleL L eL al ChemoprevenLlon of prosLaLe cancer wlLh selenlum an updaLe on currenL cllnlcal Lrlals
and precllnlcal flndlngs ! Cell 8lochem 200491443 Mlu 14733676
Mlchaelson Mu eL al SelecLlve bladder preservaLlon for musclelnvaslve LranslLlonal cell carclnoma of
Lhe urlnary bladder 8r ! Cancer 200490378 Mlu 14760367
Molnzadeh A Clll lS Laparoscoplc radlcal cysLecLomy wlLh urlnary dlverslon Curr Cpln urol 20041483
Mlu 13073833
nanus uM eL al Cllnlcal use of monoclonal anLlbody Pu!391 Lherapy LargeLlng prosLaLe speclflc
membrane anLlgen ! urol 2003170S84
nelll M eL al ManagemenL of lowsLage LesLlcular semlnoma urol Clln norLh Am 200734127 Mlu
17484918
Cuonnell MA Comblned baclllus CalmeLLeCuerln and lnLerferon use ln superflclal bladder cancer
LxperL 8ev AnLlcancer 1her 20033809 Mlu 14686703
Cuonnell MA racLlcal appllcaLlons of lnLraveslcal chemoLherapy and lmmunoLherapy ln hlghrlsk
paLlenLs wlLh superflclal bladder cancer urol Clln norLh Am 200332121 8evlew
Cllver 81 eL al 8adloLherapy versus slngledose carboplaLln ln ad[uvanL LreaLmenL of sLage l semlnoma
a randomlsed Lrlal LanceL 2003366293 Mlu 16039331
enLyala Sn eL al rosLaLe cancer a comprehenslve revlew Med Cncol 20001783 Mlu 10871814
8aghavan u 1esLlcular cancer malnLalnlng Lhe hlgh cure raLe Cncology 200317218 Mlu 12632864
8oberLs !1 eL al LongLerm survlval resulLs of a randomlzed Lrlal comparlng gemclLablne/clsplaLln and
meLhoLrexaLe/vlnblasLlne/doxorublcln/clsplaLln ln paLlenLs wlLh locally advanced and meLasLaLlc bladder
cancer Ann Cncol 200617(suppl 3)v118
8osenberg !L Carroll 8 Small L! updaLe on chemoLherapy for advanced bladder cancer ! urol
200317414 8evlew
Salsorn l eL al llne needle asplraLlon cyLology predlcLs lngulnal lymph node meLasLasls wlLhouL
anLlbloLlc preLreaLmenL ln penlle carclnoma 8r ! urol (lnL) 2006971223 Mlu 16686716
Sarosdy Ml eL al use of a mulLlLargeL fluorescence ln slLu hybrldlzaLlon assay Lo dlagnose bladder
cancer ln paLlenLs wlLh hemaLurla ! urol 200617644 Mlu 16733364
Secln l eL al LvaluaLlon of reglonal lymph node dlssecLlon ln paLlenLs wlLh upper urlnary LracL
uroLhellal cancer lnL ! urol 20071426 Mlu 17199836
Sonpavde C SLernberg Cn 1reaLmenL of meLasLaLlc uroLhellal cancer opporLunlLles for drug dlscovery
and developmenL 8r ! urol (lnL) 20081021334 8evlew
SLenzl A PlLl L CrLhoLoplc bladder reconsLrucLlon ln womenwhaL we have learned over Lhe lasL
decade CrlL 8ev Cncol PemaLol 200347147 Mlu 12900008
SLuder uL eL al CrLhoLoplc lleal neobladder 8r ! urol (lnL) 200493183 Mlu 14678400
SylvesLer 8! CosLerllnck W van der Mel[den A A slngle lmmedlaLe posLoperaLlve lnsLlllaLlon of
chemoLherapy decreases Lhe rlsk of recurrence ln paLlenLs wlLh sLage 1a 11 bladder cancer a meLa
analysls of publlshed resulLs of randomlzed cllnlcal Lrlals ! urol 20041712186 qulz 2433
vaughn u! ChemoLherapy for goodrlsk germ cell Lumors currenL concepLs and conLroversles urol Clln
norLh Am 200734171 Mlu 17484922

neuropaLhlc (neurogenlc) 8ladder
A neuropaLhlc bladder has abnormal acLlvlLy secondary Lo a neurologlc condlLlon 1o undersLand Lhe
varleLy of neuropaLhlc bladder condlLlons a baslc undersLandlng of Lhe normal lnnervaLlon and
myoneurophyslology ls requlred
Myoneural AnaLomy
1he urlnary bladder and lLs lnvolunLary sphlncLer develop and dlfferenLlaLe from Lhe Lubular urogenlLal
slnus 1he dlfferenLlaLlon of Lhe encaslng mesenchymal cells forms Lhe musculaLure of Lhe deLrusor and
ureLhral sphlncLer
lnnervaLlon
1he lnnervaLlon of Lhe bladder and lLs lnvolunLary sphlncLer ls vla Lhe auLonomlc nervous sysLem 1he
parasympaLheLlc supply Lo Lhe bladder and Lhe sphlncLer ls vla Lhe pelvlc nerves whlch arlse from S24
1hese flbers also carry Lhe sLreLch sensory recepLors Lo Lhe same splnal cord cenLer (S24)
1he sensory supply for paln Louch and LemperaLure ls carrled vla Lhe sympaLheLlc flbers arlslng from
Lhe Lhoracolumbar segmenLs (111L2)
MoLor and sensory supply of Lhe Lrlgone ls vla Lhe Lhoracolumbar sympaLheLlc flbers
1he sLrlaLed exLernal sphlncLer as well as Lhe enLlre urogenlLal dlaphragm recelves lLs moLor and
sensory lnnervaLlon from Lhe somaLlc flbers arlslng from S24 (vla Lhe pudendal nerve)
lL ls clear LhaL Lhe S24 segmenL ls Lhe orlgln of Lhe moLor supply Lo Lhe bladder musculaLure Lo Lhe
lnvolunLary sphlncLer and Lo Lhe sLrlaLed exLernal sphlncLer 1he Lrlgone ls Lhe only sLrucLure LhaL ls
parLly lndependenL ln lLs lnnervaLlon 1hls ls why segmenL S24 ls called Lhe splnal cord cenLer for
mlcLurlLlon lL ls locaLed aL Lhe level of Lhe 112 and L1 verLebral bodles 1here are connecLlons beLween
Lhe splnal reflex cenLer and Lhe mldbraln and cerebral corLex 1hrough Lhese connecLlons lnhlblLlon and
conLrol of Lhe splnal cord reflexes can be malnLalned 1he mlcLurlLlon reflex ls coordlnaLed ln Lhe
ponLlne mlcLurlLlon cenLer
Myoneurophyslology
1he prlmary funcLlons of Lhe urlnary bladder are Lo sLore and empLy urlne aL a safe pressure and ln a
conLlnenL fashlon lnLacL myoneural elemenLs are essenLlal for Lhese funcLlons 1he prlmary reservolr
funcLlon ls posslble because of Lhe speclallzed deLrusor muscle arrangemenL and because of Lhe bladder
compllance phenomenon 1he normal adulL bladder can accommodaLe volumes up Lo 400 mL wlLhouL
lncreaslng lnLraveslcal pressure 8ladder fullness ls percelved Lhrough lncreases ln sLreLchlng of bladder
mechanorecepLors
ulsLenLlon and sLreLch lnlLlaLe deLrusor acLlvlLy LhaL can be conLrolled and lnhlblLed by Lhe hlgh corLlcal
cenLers or can be allowed Lo progress Lo acLlve deLrusor conLracLlon and voldlng normally durlng
voldlng deLrusor conLracLlon conLlnues unLll Lhe bladder ls compleLely empLy unless voldlng ls
volunLarlly lnLerrupLed or lnhlblLed
8efore voldlng beglns Lhe pelvlc floor and Lhe sLrlaLed exLernal sphlncLer relax Lhe bladder base
descends and Lhe bladder ouLleL assumes a funnel shape As a resulL ureLhral reslsLance decreases 1hls
ls followed by deLrusor muscle conLracLlon and a rlse ln lnLraveslcal pressure Lo 20 Lo 40 cm of waLer
whlch resulLs ln a urlne flow of abouL 13 Lo 30 mL/s When Lhe bladder ls compleLely empLy Lhe pelvlc
floor and sLrlaLed exLernal sphlncLer conLracL elevaLlng Lhe bladder base lncreaslng ureLhral pressure
and endlng voldlng lnLacL nerve paLhways are essenLlal for Lhese synchronlzed acLlvlLles Lo occur
CysLomeLry
CysLomeLry ls a slmple meLhod for LesLlng Lhe bladders sLorage funcLlon and glves Lhe followlng
lnformaLlon bladder capaclLy exLenL of accommodaLlon or compllance Lhe ablllLy Lo sense bladder
fllllng and LemperaLure and Lhe presence of an approprlaLe deLrusor muscle conLracLlon ln addlLlon
posLvold resldual urlne can be measured aL Lhe same Llme A normal cysLomeLrogram ls shown ln llgure
3813A
llgure 3813




CysLomeLrograms A normal cysLomeLrogram 8 CysLomeLrogram ln a paLlenL wlLh hyperreflexlc
bladder caused by LransecLlon of Lhe splnal cord above S2 C CysLomeLrogram ln a paLlenL wlLh an
areflexlc flaccld neuropaLhlc bladder caused by a myelomenlngocele

uroflowmeLry
uroflowmeLry ls Lhe measuremenL of urlne flow raLe lf deLrusor conLracLlon ls properly coordlnaLed
wlLh sphlncLer relaxaLlon Lhen Lhe ouLleL reslsLance falls as Lhe bladder pressure lncreases and Lhe flow
raLe ls adequaLe normally Lhe flow raLe changes wlLh age buL ls more Lhan 20 mL/s ln men under 60
and more Lhan 23 mL/s ln women under 30 years of age Any flow raLe below 13 mL/s suggesLs
obsLrucLlon or deLrusor dysfuncLlon A flow raLe under 10 mL/s sLrongly suggesLs underlylng paLhology
urodynamlcs
urodynamlc sLudles requlre measuremenL of bladder pressure durlng mlcLurlLlon 1he pressure
measured wlLhln Lhe bladder (lnLraveslcal pressure) ls a comblnaLlon of Lhe lnLraabdomlnal pressure
and Lhe pressure generaLed by Lhe deLrusor 1o deLermlne Lhe deLrusor pressure Lhe lnLraabdomlnal
pressure ls measured wlLh a recLal caLheLer and Lhls pressure ls subLracLed from Lhe LoLal lnLraveslcal
pressure (measured by Lhe bladder caLheLer) 1he urlne flow raLes may Lhen be assessed ln llghL of Lhe
deLrusor pressure no consensus exlsLs on a crlLlcal value for pressure and flow LhaL ls dlagnosLlc of
obsLrucLlon nomograms have been developed for evaluaLlng Lhe pressureflow relaLlonshlp and Lhus Lo
caLegorlze Lhese values as obsLrucLed equlvocal or unobsLrucLed
LlecLromyographlc 8ecordlng
needle or paLch elecLrodes may be employed Lo record Lhe acLlvlLy of Lhe exLernal sphlncLer 1hls
lnformaLlon ls useful when obLalned durlng mlcLurlLlon lncreased acLlvlLy ln Lhe sphlncLer afLer voldlng
beglns suggesLs deLrusorsphlncLer dyssynergla
ClasslflcaLlon Cllnlcal llndlngs
Several classlflcaLlon sysLems exlsL LhaL descrlbe Lhe varleLy of paLhologlc bladder condlLlons LhaL
develop secondary Lo neuropaLhles Many bladder condlLlons are predlcLable on Lhe basls of Lhe
neurologlc leslon A leslon above Lhe braln sLem (le sLroke) affecLlng mlcLurlLlon frequenLly resulLs ln
lnvolunLary bladder conLracLlons (deLrusor hyperreflexla) wlLh coordlnaLed (synerglsLlc) sphlncLer
relaxaLlon 1hese paLlenLs have urge lnconLlnence
A compleLe leslon of Lhe splnal cord (le Lrauma) above Lhe 112 verLebral body may leave Lhe splnal
reflex cenLer lnLacL 1hls ofLen leads Lo whaL has been caLegorlzed as an upper moLor neuron leslon
1hese paLlenLs have deLrusor hyperreflexla and uncoordlnaLed sphlncLer acLlvlLy (deLrusorsphlncLer
dyssynergla) AlLhough deLrusor conLracLlons can generaLe abnormally hlgh lnLraveslcal pressure Lhey
are noL effecLlve ln produclng adequaLe urlne flow because of Lhe spasLlc exLernal sphlncLer 1hus Lhere
ls resldual urlne 8ladder capaclLy ls reduced ueLrusor conLracLlon and mass reflexes can be lnlLlaLed
from cerLaln Lrlgger areas
llgure 38138 ls a Lyplcal cysLomeLrogram of a hyperreflexlc bladder
An ln[ury Lo Lhe splnal reflex cenLer or below ofLen leads Lo whaL has been caLegorlzed as a lower moLor
neuron leslon 1hese paLlenLs ofLen develop deLrusor areflexla 1rauma ls Lhe mosL common cause buL
Lumors rupLured lnLerverLebral dlsks and menlngomyelocele may also cause Lhls Lype of neuropaLhlc
bladder 8oLh moLor and sensory flbers are usually affecLed and Lhere ls loss of sense of fullness (llgure
3813C) 1hese conLracLlons are usually weak and unsusLalned and bladder empLylng ls lncompleLe
resulLlng ln large amounLs of resldual urlne
1he bladder dynamlcs ln a person wlLh a neuropaLhlc bladder ofLen change over Llme 1hls may occur
secondary Lo changes ln lnnervaLlon (le LeLherlng of splnal cord mulLlple sclerosls recovery from splnal
shock) or changes ln Lhe bladder lor example a paLlenL wlLh a hyperreflexlc bladder and dyssynerglc
sphlncLer ofLen develops a LrabeculaLed noncompllanL bladder over Llme 1hese changes requlre
perlodlc reevaluaLlon of all paLlenLs wlLh neuropaLhlc bladders regardless of Lhe lnlLlal classlflcaLlon
ulfferenLlal ulagnosls
CysLlLls lnLersLlLlal cysLlLls and organlc obsLrucLlon are occaslonally confused wlLh neuropaLhlc bladder
buL assoclaLed neurologlc leslons usually make Lhe dlagnosls of neuropaLhlc bladder easy
sychosomaLlc dlsLurbances can cause spasm of Lhe exLernal sphlncLer lncompleLe voldlng reLenLlon
or lnconLlnence
CompllcaLlons
Common compllcaLlons lnclude urlnary LracL lnfecLlon sLone formaLlon and lnconLlnence 1he mosL
serlous consequences of Lhese leslons are Lhe hydrodynamlc backpressure on Lhe kldneys
hydronephrosls lnfecLlon decompensaLlon of Lhe ureLeroveslcal [uncLlon and loss of renal funcLlon
1reaLmenL
lmmedlaLely followlng splnal cord ln[ury Lhere ls a shock phase LhaL may lasL a few weeks Lo 2 Lo 3
years 1he average Llme ls 2 Lo 3 monLhs 1he bladder ls compleLely dlssoclaLed from nervous conLrol
and Lhus has no sensaLlon and ls areflexlc
1reaLmenL ls almed aL avoldlng Lhe aforemenLloned compllcaLlons ln Lhe hope of parLlal or compleLe
recovery uurlng Lhe shock phase conLlnuous closed dralnage or preferably clean lnLermlLLenL (every
46 hours) caLheLerlzaLlon should be lnsLlLuLed unLll bladder acLlvlLy ls resLored
Pyperreflexlc 8ladder
ln Lhe hyperreflexlc bladder aLLalnlng a funcLlonal bladder depends on moblllzlng resldual urlne and
lncreaslng Lhe bladder capaclLy 8esldual urlne volume can be decreased by reduclng ureLhral reslsLance
by several meLhods LransureLhral prosLaLecLomy dlvlslon of Lhe exLernal sphlncLer pudendal nerve
manlpulaLlon (ablaLlon or elecLrlcal sLlmulaLlon) or alphablocker pharmacologlc Lherapy Clean
lnLermlLLenL caLheLerlzaLlon may also be requlred Lo evacuaLe Lhe resldual urlne
luncLlonal capaclLy can be lncreased by decreaslng deLrusor lnsLablllLy wlLh anLlchollnerglc
parasympaLholyLlc drugs (le oxybuLynln or LolLerodlne) or by operaLlve augmenLaLlon 1hls ls ofLen
performed wlLh small or large lnLesLlne (enLerocysLoplasLy)
Converslon Lo a flaccld areflexlc bladder can be achleved by cord rhlzoLomy 1he sLorage funcLlon of Lhe
bladder ls preserved and Lhe paLlenL can be managed by clean lnLermlLLenL caLheLerlzaLlon
Supraveslcal urlnary dlverslon may be called for ln paLlenLs wlLh upper LracL deLerloraLlon due Lo
elevaLed sLorage pressures or female lnconLlnence Male lnconLlnence may be conLrolled by a condom
caLheLer
Areflexlc 8ladder
luncLlon of Lhe flaccld bladder can be lmproved by measures LhaL faclllLaLe compleLe empLylng Lhese
lnclude voldlng by Lhe Crede maneuver (suprapublc pressure) LransureLhral resecLlon of Lhe bladder
neck Lo reduce ouLleL reslsLance and Llmed voldlng or Llmed clean lnLermlLLenL caLheLerlzaLlon An
lndwelllng ureLhral caLheLer or suprapublc cysLosLomy ls requlred ln a few cases buL chronlc lnLubaLlon
should be avolded lf posslble
Suprapublc urlnary dlverslon (lleal or colon condulL eLc) can clrcumvenL deLerloraLlon of upper LracLs
lmplanLable prosLheLlc sphlncLers perlureLhral bulklng agenL ln[ecLlons or ureLhral sllngs may also
lmprove urlnary conLrol
A new Lechnlque of mlcroanasLomosls of a lumbar venLral nerve rooL Lo Lhe S3 venLral rooL has
generaLed promlslng resulLs ln chlldren wlLh splna blflda 1hls Lechnlque ls reporLed Lo resulL ln
lmproved bladder funcLlon ln chlldren wlLh an areflexlc bladder as well as Lhose wlLh a hyperreflexlc
bladder
rognosls
8enal ln[ury from elevaLed bladder pressure and lnfecLlon are Lhe mosL serlous consequences of
neuropaLhlc bladder When dlverslon or bladder augmenLaLlon ls requlred proper Llmlng of Lhe
operaLlon ls essenLlal for preservaLlon of kldney funcLlon aLlenLs wlLh a neuropaLhlc bladder requlre
close followup of Lhelr kldneys wlLh renal ulLrasound and serum creaLlnlne deLermlnaLlons
Cooper CS eL al edlaLrlc reconsLrucLlve surgery Curr Cpln urol 200010193 Mlu 10838896
van Arendonk k! eL al lmproved efflcacy of exLended release oxybuLynln ln chlldren wlLh dayLlme
urlnary lnconLlnence converLed from regular oxybuLynln urology 200668862

Slmple 8enal CysL
A slmple renal cysL ls usually unllaLeral and sollLary buL may be mulLlple and bllaLeral 1he cause of Lhls
dlsorder ls unclear 1he cysL can compress and desLroy ad[acenL parenchyma CysLs conLaln fluld LhaL
resembles (buL ls noL) urlne MosL are dlagnosed ln paLlenLs afLer Lhe fourLh decade Cccaslonally whaL
appears Lo be a slmple cysL may ln facL be a paplllary cysLadenocarclnomaan uncommon form of renal
cancer wlLh boLh solld and cysLlc componenLs ln Lhose cases however ulLrasound usually
demonsLraLes a complex mass wlLh boLh cysLlc and solld componenLs
llank paln may be a presenLlng sympLom Lhough mosL renal cysLs are found lncldenLally on urography
done for oLher purposes A mass may be felL ln Lhe flank or upper quadranL and musL be dlsLlngulshed
from Lumor urlnalysls and LesLs of renal funcLlon are normal LxcreLory urograms reveal a mass LhaL
dlsLorLs ad[acenL callces nephroLomography shows a radlolucenL mass (ln conLradlsLlncLlon Lo Lumor) lf
Lhe C1 scan or ulLrasound reveals an equlvocal cysLlc mass cysL asplraLlon may be performed Lhe fluld
submlLLed for cyLologlc examlnaLlon and Lhe cysL fllled wlLh conLrasL maLerlal Lo dellneaLe lLs wall A
slmple cysL musL be dlsLlngulshed from adenocarclnoma of Lhe kldney ulLrasonography or C1 scan
usually makes LhaL dlsLlncLlon
CompllcaLlons are rare buL bleedlng lnLo or lnfecLlon of a cysL may occur
lf Lhe dlagnosls of cysL ls esLabllshed surgery ls noL necessary unless Lhe leslon causes paln or endangers
renal funcLlon Slmple percuLaneous asplraLlon wlLh lnsLlllaLlon of 93 eLhanol may sufflce lf sclerosls
falls laparoscoplc or open exclslon may be performed
8enal ArLery Aneurysm
Aneurysm of Lhe renal arLery ls relaLlvely rare lL resulLs from weakenlng of Lhe arLery wall by
arLerlosclerosls posLsLenoLlc dllaLlon lnLlmal or perlmedlal flbroplasla or Lrauma lf Lhe aneurysm
causes sLenosls of Lhe arLery hyperLenslon may ensue secondary Lo lschemla and acLlvaLlon of Lhe
renlnangloLensln sysLem A plaln abdomlnal xray may reveal a rlngllke calclflcaLlon ln Lhe wall
Anglography or C1 scan ls dlagnosLlc
Surgery ls lndlcaLed ln Lhe followlng slLuaLlons (1) secondary renal lschemla and hyperLenslon (2)
dlssecLlng aneurysm (3) aneurysm assoclaLed wlLh paln or hemaLurla (4) anLlclpaLlon of pregnancy (3)
aneurysm colncldenL wlLh slgnlflcanL sLenosls (6) radlographlc evldence of lncompleLe calclflcaLlon or
lncrease ln slze on serlal fllms and (7) aneurysm conLalnlng Lhrombus wlLh evldence of dlsLal
embollzaLlon lf Lhe aneurysm rupLures emergency nephrecLomy may be necessary
8enal lnfarcLlon
1he common causes of renal arLery occluslon lnclude emboll due Lo subacuLe lnfecLlve endocardlLls
aLrlal or venLrlcular Lhrombl arLerlosclerosls polyarLerlLls nodosa Lrauma and ln Lhe neonaLe
umblllcal arLery caLheLerlzaLlon MulLlple emboll are common and lead Lo paLchy renal lschemla
Cccluslon of a maln renal arLery causes renal LoLal lnfarcLlon
1he paLlenL may suffer from severe flank paln or Lhe leslon may be sllenL PemaLurla ls common
LxcreLory urograms may reveal no excreLlon of radlopaque maLerlal or may only opaclfy a porLlon of Lhe
kldney WlLh compleLe acuLe occluslon of Lhe maln renal arLery a ureLeral caLheLer dralns no urlne yeL
Lhe reLrograde urogram reveals normal anaLomy 8enal anglography color uoppler ulLrasound or
magneLlc resonance anglography makes Lhe dlagnosls by reveallng occluslon of Lhe arLery or arLerloles
a renal scan shows slmllar flndlngs C1 scan afLer Lhe lnLravenous ln[ecLlon of radlopaque medlum shows
no concenLraLlon ln Lhe lschemlc area ureLeral sLone may mlmlc renal lnfarcLlon buL urograms C1
scan or anglograms dlsLlngulsh one from Lhe oLher lollowlng renal lnfarcLlon hyperLenslon may
develop secondary Lo renal lschemla lL may laLer resolve sponLaneously
lf Lhe dlagnosls ls made prompLly (wlLhln 38 hours) LhrombecLomy or endarLerecLomy should be
consldered CLherwlse anLlcoagulaLlon Lherapy should be lnsLlLuLed (eg heparln) 1hrombolyLlc Lherapy
(eg sLrepLoklnase) may be used Lo lyse Lhe cloL lf permanenL hyperLenslon develops deflnlLlve
LreaLmenL of Lhe arLerlal occluslon or nephrecLomy (preferably laparoscoplc) should be performed
8enal veln 1hrombosls
1hrombosls of Lhe renal veln affecLs boLh lnfanLs and adulLs and can be elLher acuLe or chronlc ln
chlldren Lhrombosls may be caused by severe dehydraLlon (eg due Lo lleocollLls and dlarrhea or Lhe
nephroLlc syndrome) ln adulLs lL may be secondary Lo renal lnfecLlon ascendlng Lhrombosls of Lhe
vena cava or caval occluslon due Lo Lumor Lhrombus 1here ls usually flank paln and a palpable
dlsLended kldney lf renal veln Lhrombosls ls secondary Lo lnfecLlon Lhe paLlenL ls sepLlc and urlnalysls
reveals pus cells and bacLerla ln nonlnfecLlous cases Lhe urlne may reveal mlcrohemaLurla and mlld
proLelnurla 1he paLlenL wlLh bllaLeral lnvolvemenL ls azoLemlc nephroLlc syndrome may develop
LxcreLory urograms show delayed opaclflcaLlon ln an enlarged kldney 1he callces are elongaLed LaLer
Lhe kldney may become aLrophlc 8enal anglography reveals sLreLchlng and bowlng of arLerloles
SelecLlve renal venography demonsLraLes Lhe Lhrombus as does renal ulLrasound
1reaLmenL should aLLempL Lo ellmlnaLe Lhe underlylng cause whenever posslble lf Lhe dlagnosls of
unllaLeral lnfecLed renal veln Lhrombosls can be esLabllshed nephrecLomy should be performed ln
bllaLeral dlsease anLlcoagulanL or LhrombolyLlc Lherapy (or boLh) ls requlred
veslcal llsLulas
veslcal flsLulas may be congenlLal or acqulred CongenlLal flsLulas usually lnvolve Lhe urachus Acqulred
flsLulas may be laLrogenlc or due Lo Lrauma Lumor or lnflammaLlon
1he mosL common Lypes of veslcal flsLulas are veslcovaglnal veslcolnLesLlnal and veslcocuLaneous
veslcovaglnal flsLulas are commonly secondary Lo gynecologlc or blrLh Lrauma rarely Lhey occur as a
compllcaLlon of lnfllLraLlng cervlcal carclnoma veslcolnLesLlnal flsLulas are mosL ofLen due Lo
lnflammaLory bowel dlsease Crohn dlsease dlverLlcullLls and appendlclLls CysLosLomy ln Lhe presence
of bladder ouLleL obsLrucLlon bladder cancer or forelgn body may resulL ln veslcocuLaneous flsLula
ulagnosLlc maneuvers lnclude cysLoscopy convenLlonal cysLography barlum enema or barlum swallow
and C1 scan wlLh conLrasL lnfuslon Cral charcoal may be useful for deLecLlng a urlnary lnLesLlnal flsLula
as Lhe granules can be seen ln spun urlne under Lhe mlcroscope
1herapy for veslcovaglnal flsLula requlres surglcal closure wlLh placemenL of an omenLal flap beLween
Lhe bladder and Lhe vaglna lor veslcolnLesLlnal flsLula Lhe prlmary lnLesLlnal leslon musL be resecLed
and Lhe bladder closed An lndwelllng ureLhral caLheLer ls necessary durlng Lhe heallng perlod
lnLersLlLlal CysLlLls
1hls leslon ls mosL commonly found ln mlddleaged women urlnary frequency boLh day and nlghL ls
mosL ofLen accompanled by suprapublc paln wlLh bladder dlsLenLlon 1he cause ls uncerLaln Lhough
some suggesL an auLolmmune collagen dlsease whlle oLhers have documenLed Lhe presence of masL
cells and masL cell medlaLors (hlsLamlne and prosLaglandln) ln bladder blopsy speclmens of affecLed
paLlenLs
1he dlagnosls ls based on Lhe hlsLory and Lhe resulLs of cysLoscopy under general anesLhesla CysLoscopy
reveals a smallcapaclLy bladder and puncLaLe hemorrhage followlng forceful dlsLenLlon (SLudles
suggesL Lhls ls a nonspeclflc flndlng) 8lopsy may reveal lymphocyLlc lnfllLraLlon masL cell lnfllLraLlon
and submucosal flbrosls ln paLlenLs suspecLed of havlng lnLersLlLlal cysLlLls one musL rule ouL carclnoma
ln slLu urlne cyLologlc sLudy aL Lhe Llme of cysLoscopy and random bladder blopsy
1reaLmenL of esLabllshed cases of lnLersLlLlal cysLlLls ofLen falls 8esponse has been obLalned wlLh
hydraullc bladder overdlsLenLlon lnLraveslcal LreaLmenL wlLh 30 dlmeLhylsulfoxlde 04
oxychlorosene sodlum or sodlum penLosanpolysulfaLe SysLemlc corLlcosLerolds have Lhelr proponenLs
as well and 8CC has been Lrled wlLh some success Some paLlenLs requlre operaLlve augmenLaLlon of
bladder capaclLy by enLerocysLoplasLy or rarely cysLoureLhrecLomy and permanenL urlnary dlverslon
urlnary SLress lnconLlnence
lnvolunLary loss of urlne durlng sLress (coughlng sneezlng or physlcal sLraln) ls a common complalnL of
posLmenopausal women 1he cause ls relaLed Lo pelvlc relaxaLlon wlLh age resulLlng ln descenL of Lhe
Lrlgone and proxlmal ureLhra 1here ls obllLeraLlon of Lhe ureLhroveslcal angle whlch normally provldes
reslsLance aL Lhe bladder ouLleL 1he dlagnosls ls made by Lhe hlsLory and physlcal examlnaLlon and
urodynamlc evaluaLlon When Lhe bladder ls full Lhe paLlenL should be asked Lo cough whlle ln boLh Lhe
suplne and uprlghL poslLlons produclng lnconLlnence ulglLal pressure applled Lo Lhe paraureLhral
Llssues ln an anLerlor dlrecLlon Lhrough Lhe vaglna reesLabllshes Lhe ureLhroveslcal angle and prevenLs
sLress lnconLlnence (Marshall LesL)
1reaLmenL ln paLlenLs wlLh normal bladder funcLlon and low resldual urlne ls lnlLlaLed wlLh behavloral
Lherapy and perlneal exerclses lf unsuccessful pharmacologlc meLhods lnclude oxybuLynln and
ephedrlne ueflnlLlve managemenL ls surglcal CurrenLly Lhe mosL effecLlve surglcal approach ls a sllng
procedure wlLh a plece of auLologous or synLheLlc fascla aLLached Lo Lhe recLus muscle or os publs and
surroundlng Lhe ureLhra aL Lhe bladder neck newer approaches lnclude Lhe use of collagen ln[ecLlon
lnLo Lhe perlureLhral Llssues resulLlng ln lncreased ureLhral ouLflow reslsLance
lemale ureLhrlLls erlureLhrlLls
ureLhrlLls ln Lhe female may be acuLe or chronlc AcuLe ureLhrlLls can be gonorrheal ln orlgln Chemlcal
ureLhrlLls ls occaslonally acqulred from exposure Lo soap or baLh olls Chronlc ureLhrlLls ls a common
problem ln women slnce Lhe female ureLhra ls exposed Lo paLhogenlc bacLerla because of lLs anaLomlc
locaLlon ureLhral Lrauma lnsLrumenLaLlon and lncrease ln Lhe number of paLhogenlc organlsms lead Lo
lnfecLlon and overL ureLhrlLls ureLhrlLls usually precedes cysLlLls
Pormonal changes assoclaLed wlLh menopause cause vaglnal and ureLhral mucosal changes leadlng Lo
lrrlLaLlve sympLoms and lncreased suscepLlblllLy Lo lnflammaLlon
ureLhrlLls usually causes lrrlLaLlve voldlng sympLoms slmllar Lo Lhose of cysLlLls and occaslonally
funcLlonal obsLrucLlve sympLoms LxamlnaLlon may reveal ureLhral dlscharge marked Lenderness or
congesLed everLed mucosa aL Lhe exLernal meaLus lnduraLlon of Lhe ureLhra may be assoclaLed wlLh
vaglnlLls and cervlclLls Lndoscopy may reveal obsLrucLlon mucosal congesLlon and lnflammaLory
polyps ureLhral callbraLlon rarely reveals obsLrucLlon Spasm of Lhe exLernal sphlncLer may be noLed
1reaLmenL ls dlrecLed Lo Lhe underlylng cause LsLrogen cream ls lndlcaLed for senlle vaglnlLls Surglcal
LreaLmenL conslsLs of ureLhral dllaLlon and openlng and dralnlng lnfecLed perlureLhral ducLs Alpha
blockers glven orally may also help decrease ureLhral reslsLance CorrecLlon of vaglnlLls cervlclLls and
cervlcal eroslons helps ln amelloraLlng sympLoms
lemale ureLhral Caruncle
ureLhral caruncle commonly seen afLer menopause represenLs granulomaLous overgrowLh of Lhe
posLerlor llp of Lhe exLernal meaLus 1he caruncle ls Lender and causes paln wlLh lnLercourse and
urlnaLlon 1he prlmary concern ls excluslon of ureLhral cancer 1reaLmenL ls compleLe exclslon
lemale ureLhral ulverLlculum
ureLhral dlverLlculum ln Lhe female commonly presenLs as recurrenL lower urlnary LracL lnfecLlon lL
should be suspecLed whenever urlnary lnfecLlon falls Lo resolve wlLh LreaLmenL SympLoms are urlnary
drlbbllng and cysLlc swelllng ln Lhe anLerlor vaglnal wall durlng voldlng lf dlverLlculum ls suspecLed lL
can usually be ldenLlfled durlng panendoscopy and opaclfled by conLrasL medlum on a voldlng
cysLoureLhrogram whlle occludlng Lhe exLernal meaLus 1hese leslons occaslonally conLaln sLones or
Lumors 1reaLmenL conslsLs of Lransvaglnal dlverLlculecLomy
8rubaker L Surglcal LreaLmenL of urlnary lnconLlnence ln women CasLroenLerology 2004126S71
Chancellor M8 ?oshlmura n 1reaLmenL of lnLersLlLlal cysLlLls urology 200463(suppl 3A)83
ulokno AC Medlcal managemenL of urlnary lnconLlnence CasLroenLerology 2004126S77
nlckel !C lnLersLlLlal cysLlLls A chronlc pelvlc paln syndrome Med Clln norLh Am 200488467 Mlu
13049388

SpermaLocele
SpermaLocele ls a reLenLlon cysL of a Lubule of Lhe reLe LesLls or Lhe head of Lhe epldldymls 1he cysL ls
dlsLended wlLh a mllky fluld LhaL conLalns sperm LocaLed aL Lhe superlor pole of Lhe LesLls and capuL
epldldymldls Lhe spermaLocele ls sofL and flucLuanL and can be LranslllumlnaLed no LreaLmenL ls
needed unless Lhe spermaLocele ls palnful ln whlch case surglcal exclslon may be performed
varlcocele
varlcocele ls due Lo lncompeLenL valves ln Lhe LesLlcular veln permlLLlng Lransmlsslon of hydrosLaLlc
venous pressure dlsLenLlon and LorLuoslLy of Lhe pamplnlform plexus resulLs varlcocele ls found ln 13
of male adolescenLs wlLh lefLslded predomlnance (90) presumably because of venous dralnage of Lhe
lefL LesLes Lo Lhe lefL renal veln causlng lncreased reLrograde venous pressure 8llaLeral varlcoceles are
palpable ln less Lhan 2 of male adulLs
Mlld varlcoceles are commonly asympLomaLlc buL a dragglng scroLal sensaLlon may be noLed
varlcocele may lead Lo lnferLlllLy ln some men
AsympLomaLlc varlcocele ls besL unLreaLed unless lL ls a suspecLed facLor ln male lnferLlllLy 1reaLmenL
Lhen conslsLs of operaLlve llgaLlon of Lhe spermaLlc veln aL or above Lhe lnLernal lngulnal rlng ln
recurrenL varlcocele Lransfemoral caLheLerlzaLlon and occluslon or ablaLlon of Lhe spermaLlc veln may
be performed wlLh a deLachable balloon or scleroslng agenLs 1he Lechnlcal success raLe ls hlgh
1orslon of Lhe SpermaLlc Cord
1orslon of Lhe spermaLlc cord (lnLravaglnal Lorslon or Lorslon wlLhln Lhe space of Lhe Lunlca vaglnalls) ls
mosL common ln adolescenL boys A LwlsL ln Lhe spermaLlc cord lnLerferes wlLh LesLlcular blood supply lf
Lorslon ls compleLe LesLlcular lnfarcLlon may occur wlLhln 4 Lo 6 hours 1he cause ls unknown buL an
underlylng anaLomlc abnormallLy (spaclous Lunlca vaglnalls loose epldldymoLesLlcular connecLlon
undescended LesLls) ls usually presenL
Cllnlcal flndlngs conslsL of preclplLous onseL of lower abdomlnal and scroLal paln and scroLal swelllng
1here may be a hlsLory of prevlous Lrauma ln young adolescenLs 1he LesLls ls swollen Lender and
reLracLed 1he paln ls noL relleved by LesLlcular supporL 1he cord above Lhe swelllng ls normal 1he
cremasLerlc reflex ls usually absenL on Lhe affecLed slde
1orslon musL be dlfferenLlaLed from orchlLls epldldymlLls and paln due Lo LesLlcular Lrauma
1echneLlum 99m perLechneLaLe scan may dlfferenLlaLe orchlLlsepldldymlLls from LesLlcular Lorslon lf
performed early ln Lhe course of sympLoms 1he former demonsLraLes lncreased blood flow ln conLrasL
Lo Lhe lschemlc paLLern of Lorslon Color uoppler ulLrasound ls more deflnlLlve and less Llme consumlng
and can dellneaLe Lhe lack of LesLlcular blood flow no radlologlc sLudy ls compleLely accuraLe and
lmaglng should be used Lo conflrm Lhe cllnlcal declslon LhaL Lhe cause of Lhe acuLe scroLum ls noL
Lorslon lf Lhe dlagnosls cannoL be esLabllshed by examlnaLlon hlsLory and lmaglng exploraLlon ls
requlred
1orslon of Lhe spermaLlc cord ls a surglcal emergency! ConLralaLeral orchlopexy ls always necessary
because of frequenL bllaLeral lnvolvemenL (le Lhe bell clapper deformlLy lack of flxaLlon of Lhe cord
sLrucLures by Lhe LesLlcular medlasLlnum) and Lhe hlgh lncldence of recurrenL Lorslon and lnferLlllLy ln
bllaLeral cases
1orslon of 1esLlcular Appendages
1he epldldymls and Lhe LesLlcle ofLen have a vesLlglal remnanL of embryologlc ducLs known as an
appendlx LesLls or appendlx epldldymls 1hese sLrucLures can undergo sponLaneous lnfarcLlon usually ln
young boys causlng acuLe LesLlcular paln and swelllng LhaL may be dlfflculL Lo dlfferenLlaLe from
LesLlcular Lorslon WlLh Lorslon of Lhe appendlx LesLls or epldldymls physlcal examlnaLlon ofLen
demonsLraLes polnL Lenderness aL Lhe slLe of Lhe Lorsed appendage Cccaslonally Lhe lnfarcLed
appendage can be seen Lhrough Lhe scroLal wall as a blue doL slgn on Lhe scroLum 1hls slgn ls only
vlslble early ln Lhe course prlor Lo hydrocele formaLlon and onseL of scroLal edema ScroLal ulLrasound
occaslonally dellneaLes Lhe enlarged appendage and a normal LesLlcle esLabllshlng Lhe dlagnosls ln
mosL casesand cerLalnly ln equlvocal oneslmmedlaLe scroLal exploraLlon and removal of Lhe
lnfarcLed appendage ls requlred Lo rule ouL LesLlcular Lorslon AlLhough Lhe appendages ofLen occur
bllaLerally appendlceal Lorslon does noL Lhus removal of Lhe opposlLe appendage ls noL lndlcaLed
Male lnferLlllLy
Male lnferLlllLy accounLs for 30 Lo 30 of lnferLlle couples (1013 of marrlages) 8oLh parLners should
be evaluaLed for causes of lnferLlllLy
1he causes of male lnferLlllLy lnclude Lhe followlng congenlLal anomalles (geneLlc such as kllnefelLers
syndrome or developmenLal such as absenL vas deferens) Lrauma (boLh LesLlcular resulLlng ln aLrophy
and neurologlc resulLlng ln erecLlle or e[aculaLory dysfuncLlon) lnfecLlons (elLher sysLemlc or
reproducLlve organ speclflc) endocrlne dlsorders (plLulLary lnsufflclency androgen deflclency) acqulred
anaLomlc abnormallLles (varlcocele vasecLomy) or drug slde effecLs (nlLrofuranLoln esLrogens
anLlneoplasLlc agenLs)
ulagnosls
1he mosL lmporLanL aspecL of lnferLlllLy evaluaLlon ls Lhe hlsLory whlch uncovers Lhe cause ln many
paLlenLs 1he physlcal examlnaLlon ls no less lmporLanL and may reveal small LesLlcles a varlcocele or
absence of Lhe vas deferens
Semen Analysls
Semen analysls ls essenLlal ln evaluaLlon of male facLor lnferLlllLy AL leasL Lwo samples should be
analyzed slnce values may vary over Llme and wlLh Lhe meLhod of collecLlon 1he speclmen ls produced
by masLurbaLlon afLer 3 days of e[aculaLory absLlnence and collecLed ln a clean wldemouLh conLalner
and examlned wlLhln 2 hours ueLermlnaLlon of Lhe volume pP llquefacLlon sperm counL vlablllLy
abnormal forms and moLlllLy consLlLuLes a compleLe analysls normal values lnclude volume of more
Lhan 20 mL concenLraLlon greaLer Lhan 20 mllllon sperm per mL more Lhan 30 moLlle sperm and
73 or more vlable sperm (World PealLh CrganlzaLlon crlLerla)
Pormone SLudles
aLlenLs wlLh no sperm ln Lhe e[aculaLe (azoospermla) or very low counLs (ollgospermla 10 mllllon
sperm/ml) should have serum lSP LP and LesLosLerone levels measured aLlenLs wlLh low
LesLosLerone should have prolacLln levels checked and lf elevaLed should be lnvesLlgaLed for plLulLary
Lumor A slgnlflcanL elevaLlon of lSP represenLs a problem wlLh spermaLogenesls
1esLlcular 8lopsy
1esLlcular blopsles are lndlcaLed ln azoospermlc paLlenLs Lo dlsLlngulsh obsLrucLlve versus parenchymal
dlsease 1esLlcular blopsy should be performed ln paLlenLs wlLh unexplalned ollgospermla Lo esLabllsh a
hlsLologlc dlagnosls Lo assess prognosls and Lo dlrecL LreaLmenL lf Lhe serum lSP ls more Lhan Lwo
Llmes normal one may presume Lhe presence of severe and lrreverslble LesLlcular damage wlLhouL
conflrmaLory LesLls blopsy
vasography requlres ln[ecLlon of conLrasL maLerlal lnLo Lhe vas 1he purpose of Lhls sLudy ls Lo dellneaLe
obsLrucLlon of Lhe vas epldldymls semlnal veslcle or e[aculaLory ducL vasography ls used ln paLlenLs
who are azoospermlc and have no evldence of reLrograde e[aculaLlon whlle demonsLraLlng normal
spermaLogenesls on LesLlcular blopsy Semlnal frucLose levels should be obLalned before operaLlve
exposure of Lhe vas Absence of frucLose would lndlcaLe obsLrucLlon of Lhe e[aculaLory ducL and lf Lhls
dlagnosls ls conflrmed by vasography Lhe obsLrucLlng Llssue may be resecLed by LransureLhral meLhods
CLher ulagnosLlc SLudles
1he sperm peneLraLlon assay performed by lncubaLlon of sperm wlLh hamsLer eggs whose zona
pelluclda has been enzymaLlcally removed offers an ob[ecLlve meLhod of deLermlnlng Lhe ablllLy of
sperm Lo peneLraLe Lhe ovum 1he cervlcal mucus peneLraLlon LesL compares sperm moLlllLy ln cervlcal
mucus wlLh a known sLandard AlLhough Lhese Lwo lmporLanL parameLers of sperm funcLlon can be
evaluaLed nelLher LesL alone can esLabllsh Lhe cause of male facLor lnferLlllLy
AnLlsperm anLlbodles can be measured ln Lhe serum of elLher Lhe male or female parLner or ln Lhe
semlnal fluld 1hls assessmenL ls lndlcaLed when sponLaneous sperm aggluLlnaLlon or decreased sperm
moLlllLy ls noLed on semen analysls lf anLlsperm anLlbodles are found lmmunosuppresslve Lherapy ln
Lhe form of sLerolds may be effecLlve ln reduclng aggluLlnaLlon (clumplng) and lncreaslng moLlllLy
AnoLher meLhod of LreaLlng anLlsperm anLlbodles ls ln vlLro sperm washlng wlLh lmmunobeads coaLed
by anLlhuman anLlbody 1he sperm noL bound by anLlbody remaln ln Lhe supernaLanL and can be used
for lnLrauLerlne lnsemlnaLlon
SLudles Lo deLecL a nonpalpable varlcocele are noL recommended excepL ln cases ln whlch Lhe physlcal
examlnaLlon ls lnadequaLe hyslcal examlnaLlon ls Lhe mosL effecLlve meLhod of deLecLlng cllnlcally
slgnlflcanL varlces venography ls reserved for paLlenLs wlLh recurrenL varlces slnce ldenLlflcaLlon of
collaLeral venous channels would dlrecL cholce of Lherapy
1ransrecLal ulLrasound ls used Lo supporL Lhe dlagnosls of e[aculaLory ducL obsLrucLlon ln Lhe
azoospermlc paLlenL Absence of Lhe semlnal veslcles or dlsLenLlon due Lo dlsLal obsLrucLlon can be
ldenLlfled 1hls sLudy should be preceded by measuremenL of frucLose ln Lhe e[aculaLe (lack of frucLose
suggesLs obsLrucLlon of Lhe e[aculaLory ducL) and examlnaLlon of posLe[aculaLe urlne (Lo deLermlne Lhe
presence of sperm suggesLlng reLrograde e[aculaLlon)
1reaLmenL
nonoperaLlve 1reaLmenL
rlmary male lnferLlllLy may be caused by hypogonadoLroplc hypogonadlsm dlagnosed by
demonsLraLlng low serum levels of lSP LP and LesLosLerone SpermaLogenesls may be sLlmulaLed by
admlnlsLraLlon of hCC followed by lSP lsolaLed absence of elLher lSP or LP ls rare Lhe LP deflclency ls
overcome by admlnlsLraLlon of LesLosLerone and lack of lSP ls LreaLed by admlnlsLraLlon of
menoLroplns PyperprolacLlnemla may conLrlbuLe Lo male lnferLlllLy and would be LreaLed wlLh
bromocrlpLlne
lnfecLlon of Lhe reproducLlve organs should be LreaLed when found durlng evaluaLlon of male lnferLlllLy
lnfecLlon may cause lnferLlllLy lmmedlaLely by several mechanlsms decreased spermaLogenesls due Lo
hyperLhermla lmmune lnLeracLlon wlLh sperm causlng aggluLlnaLlon and decreased moLlllLy as well as
laLer sequelae such as obsLrucLlon of Lhe e[aculaLory LracL yospermla suggesLs Lhe dlagnosls and
LreaLmenL should be deslgned Lo ellmlnaLe Lhe common paLhogens nelsserla gonorrhoeae Chlamydla
LrachomaLls and ureaplasma urealyLlcum (all are senslLlve Lo LeLracycllne)
lf anLlsperm anLlbodles are found ln elLher parLner sLerolds may be used Lo suppress Lhe lmmune
sysLem Cne musL use sLerolds wlLh cauLlon and afLer Lhorough dlscusslon of posslble slde effecLs wlLh
Lhe paLlenL acne hyperLenslon gasLrolnLesLlnal bleedlng and avascular necrosls of Lhe hlp have been
reporLed wlLh sLerold admlnlsLraLlon 8esponse Lo LreaLmenL ls assessed by repeaL semen analysls and
measuremenL of anLlsperm anLlbodles ln Lhe paLlenLs serum Sperm washlng ln an aLLempL Lo remove
cyLoLoxlc anLlbodles may lmprove moLlllLy and decrease clumplng washed semen may Lhen be lnsLllled
lnLo Lhe uLerus (arLlflclal lnsemlnaLlon of Lhe husbands semen) or used ln con[uncLlon wlLh ln vlLro
ferLlllzaLlon Lechnlques
8eLrograde e[aculaLlon or lack of semlnal emlsslonusually due Lo splnal cord ln[ury or sympaLheLlc
nerve ln[ury durlng reLroperlLoneal surgery leadlng Lo bladder neck (le lnLernal sphlncLer)
lncompeLencecan be LreaLed wlLh adrenerglc drugs or anLlhlsLamlnes Lo reesLabllsh lnLernal
sphlncLer funcLlon and anLegrade e[aculaLlon AlLernaLlvely alkallnlzed posLe[aculaLe urlne can be
collecLed and cenLrlfuged and Lhe concenLraLed sperm lnsLllled lnLo Lhe female parLners uLerus
Clomlphene and Lamoxlfen are anLlesLrogens LhaL are currenLly used ln paLlenLs wlLh ldlopaLhlc
ollgospermla Lhough Lhe efflcacy of Lhese medlcaLlons has been doubLed
CperaLlve 1herapy
LlgaLlon of varlcocele ylelds pregnancy ln 30 Lo 30 of paLlenLs Several approaches are avallable
lncludlng lngulnal and reLroperlLoneal 1ransvenous occluslon of Lhe spermaLlc veln by balloon ls useful
especlally ln cases of recurrenL varlcocele
CbsLrucLlon of Lhe epldldymlsvas sysLem may be amenable Lo vasovasosLomy or vasoepldldymosLomy
CurrenLly Lhese procedures are performed wlLh Lhe ald of Lhe operaLlng mlcroscope and paLency ls
esLabllshed ln 30 Lo 90 of cases
CbsLrucLlon of Lhe e[aculaLory ducLs ls rare When Lhls dlagnosls ls made LransureLhral resecLlon of Lhe
ducLs may esLabllsh paLency
AsslsLed 8eproducLlve 1echnlques
1hese lnclude Lhe followlng arLlflclal lnsemlnaLlon wlLh husbands sperm (AlP) gameLe lnLrafalloplan
Lransfer (Cll1) and ln vlLro ferLlllzaLlon (lvl) uslng lnLracyLoplasmlc sperm ln[ecLlon (lCSl) afLer
reLrlevlng eggs by Lransvaglnal ulLrasound guldance and sperm by LesLlcular asplraLlon ln selecLed
parLners ln cases of male facLor lnferLlllLy noL amenable Lo LreaLmenL arLlflclal lnsemlnaLlon by donor
sperm ls also avallable
8ong CW koo P 1he adolescenL varlcocele Lo LreaL or noL Lo LreaL urol Clln norLh Am 200431309
Mlu 13313060
8rugh vM lll LlpshulLz Ll Male facLor lnferLlllLy LvaluaLlon and managemenL Med Clln norLh Am
200488367 Mlu 13049383
Carlsen L eL al LffecLs of e[aculaLory frequency and season on varlaLlons ln semen quallLy lerLll SLerll
200482338 Mlu 13302284
Popps Cv eL al 1he dlagnosls and LreaLmenL of Lhe azoospermlc paLlenL ln Lhe age of lnLracyLoplasmlc
sperm ln[ecLlon urol Clln norLh Am 200229893 Mlu 12316760
!arow ! Lndocrlne causes of male lnferLlllLy urol Clln norLh Am 20033083 Mlu 12380360
Slddlq lM Slgman M A new look aL Lhe medlcal managemenL of lnferLlllLy urol Clln norLh Am
200229949 Mlu 12316764
Wald M eL al 1herapeuLlc LesLls blopsy for sperm reLrleval Curr Cpln urol 200717431 Mlu
17921779

rlaplsm
rlaplsm ls a rare dlsorder ln whlch prolonged palnful erecLlon occurs usually noL assoclaLed wlLh
sexual sLlmulaLlon 1he blood ln Lhe corpora cavernosa becomes hypervlscous buL noL cloLLed AbouL
23 of cases are assoclaLed wlLh leukemla meLasLaLlc carclnoma slckle cell anemla or Lrauma ln mosL
cases Lhe cause ls uncerLaln
lf Lhe erecLlon does noL subslde needle asplraLlon of Lhe sludged blood of Lhe corpora followed by
lavage wlLh alphaadrenerglc agenLs such as phenylephrlne should be performed uelayed or
unsuccessful LreaLmenL may resulL ln lmpoLence unsuccessful LreaLmenL calls for Lhe WlnLer procedure
ln whlch a blopsy needle ls passed Lhrough Lhe glans lnLo one of Lhe corpora creaLlng a flsLula beLween
corpora cavernosa and corpus sponglosum lf Lhls procedure ls successful Lhen poLency ls usually
malnLalned CLher procedures lnclude exclslng Lhe Lunlca albuglnea aL Lhe Llp of Lhe corpora
cavernosum proxlmal cavernosalsponglosum shunL and saphenous velncavernous shunL lf prlaplsm
perslsLs lmpoLence resulLs
ln slckle cell anemla hydraLlon and hyperLransfuslon ofLen glve rellef and should consLlLuLe lnlLlal
Lherapy
eyronles ulsease (lasLlc lnduraLlon of Lhe enls)
llbrosls of Lhe dorsal coverlng sheaLhs of Lhe corpora cavernosa occaslonally occurs wlLhouL known
cause ln men over age 43 1rauma Lo Lhe penls durlng lnLercourse has been lmpllcaLed ln Lhe eLlology of
eyronles dlsease 1he flbrosls does noL permlL Lhe lnvolved surface Lo lengLhen wlLh erecLlon Lhus
leadlng Lo dorsal chordee 1he dlsorder may be due Lo vascullLls ln Lhe connecLlve Llssues alpaLlon of
Lhe penlle shafL reveals a ralsed flrm plaque dorsally 1here ls an assoclaLlon wlLh uupuyLren
conLracLure
ConLroversy exlsLs regardlng LreaLmenL LxpecLanL Lherapy or medlcal LreaLmenL lncludlng vlLamln L
paraamlnobenzolc acld colchlclne and lnLraleslonal verapamll may llmlL progresslon of dlsease
CperaLlve Lherapy ls necessary for paLlenLs who do noL respond or for lmpoLenL paLlenLs ln Lhe poLenL
paLlenL elLher pllcaLlon of Lhe Lunlca albuglnea on Lhe opposlLe slde of Lhe plaque or a nesblL
procedureexclslon of an elllpse of Lhe Lunlca albuglnea from Lhe venLral convex aspecL of Lhe shafL
and suLure closureor plaque exclslon and dermal grafLlng have been used successfully lf Lhe paLlenL ls
lmpoLenL lnserLlon of a penlle prosLhesls ls Lhe procedure of cholce
1aylor lL Levlne LA eyronles dlsease urol Clln norLh Am 200734317 Mlu 17983892

hlmosls araphlmosls
hlmoslslnablllLy Lo reLracL Lhe foreskln Lo expose Lhe glansmay be congenlLal buL ls more ofLen
acqulred AL blrLh Lhe foreskln cannoL be easlly reLracLed buL by age 3 Lhe prepuce becomes pllanL and
Lhe glans can be exposed and cleansed lf Lhe foreskln ls Lhen reLracLable clrcumclslon ls noL necessary
Acqulred phlmosls ls usually a resulL of chronlc and recurrenL bacLerlal balanlLls (lnfecLlon of Lhe
prepuce) common ln paLlenLs wlLh dlabeLes or balanlLls xeroLlca obllLerans 1hese paLlenLs are besL
LreaLed by clrcumclslon
araphlmosls ls Lhe lnablllLy Lo reduce a prevlously reLracLed foreskln 1he prepuce becomes flxed ln Lhe
reLracLed poslLlon proxlmal Lo Lhe corona WlLh prolonged reLracLlon lymphedema of Lhe prepuce
exacerbaLes Lhe condlLlon and lncreases Lhe clrcumferenLlal pressure of Lhe shafL proxlmal Lo Lhe glans
Manual reducLlon can usually be accompllshed uslng Lhe lndex flngers Lo pull Lhe prepuce dlsLally whlle
pushlng Lhe glans lnLo Lhe prepuce lf Lhls measure falls Lhe prepuLlal clcaLrlx may be lnclsed (dorsal sllL)
and Lhe foreskln reduced wlLh relaLlve ease Clrcumclslon may be performed as an elecLlve procedure
once Lhe edema has subslded
CondylomaLa AcumlnaLa
CondylomaLa acumlnaLa are warLllke leslons LhaL occur on Lhe penls scroLum ureLhra and perlneum ln
men and Lhe vaglna cervlx and perlneum ln women 1hey are caused by human paplllomavlrus and are
usually LransmlLLed by sexual conLacL aln and bleedlng are common presenLlng complalnLs WarLs
ouLslde Lhe ureLhra can be LreaLed wlLh exclslon appllcaLlon of podophyllum resln llquld nlLrogen or
CC2 laser ureLhroscopy ls needed Lo deLermlne Lhe proxlmal exLenL of leslons ln Lhe ureLhra
lnLraureLhral fulguraLlon CC2 laser LreaLmenL ln[ecLlon of fluorouracll soluLlon or lnLerferon can be
LherapeuLlc

lmpoLence
lmpoLence ls Lhe lnablllLy Lo obLaln and susLaln an erecLlon saLlsfacLory for sexual lnLercourse
Causes of lmpoLence
Causes can be grouped lnLo Lhe followlng caLegorles neurologlc vascular endocrlne sysLemlc
pharmacologlc and psychologlc 1reaLmenL ls dlrecLed accordlngly
neurologlc
8eflex erecLlons are medlaLed by Lhe afferenL flbers of Lhe pudendal nerve and efferenL flbers of Lhe
parasympaLheLlc ouLflow (S24) sychogenlc erecLlons are lnlLlaLed vla cerebral cenLers Speclflc
neurologlc dlseases LhaL may cause lmpoLence may be congenlLal (splna blflda) acqulred
(cerebrovascular accldenL Alzhelmer dlsease mulLlple sclerosls) laLrogenlc (elecLroshock Lherapy)
neoplasLlc (plLulLary or hypoLhalamlc Lumors) LraumaLlc (cord compresslon) lnfecLlous (Labes dorsalls)
and nuLrlLlonal (vlLamln deflclency)
vascular
vascular causes of lmpoLence may be cardlac (anglnal syndromes congesLlve fallure) aorLolllac dlsease
(Lerlche syndrome aLherosclerosls oLher embollc phenomena) mlcroanglopaLhy (dlabeLes radlaLlon
ln[ury) and abnormal venous dralnage
Lndocrlne
1he accepLed endocrlne causes of lmpoLence are hypogonadlsm hyperprolacLlnemla plLulLary Lumors
hypoLhyroldlsm Addlson dlsease Cushlng syndrome acromegaly and LesLlcular femlnlzlng syndrome
harmacologlc
lmpoLence ls a common and ofLen unsuspecLed compllcaLlon of many LherapeuLlc and llllclL drugs
Ma[or groups LhaL may cause sexual dysfuncLlon are Lhe followlng Lranqulllzers anLldepressanLs
anLlanxleLy agenLs anLlchollnerglc drugs anLlhyperLenslves and many drugs wlLh abuse poLenLlal Cne
should recognlze LhaL vlrLually all anLlhyperLenslves (lncludlng dlureLlcs) can be assoclaLed wlLh
lmpoLence or e[aculaLory dysfuncLlon urugs wlLh abuse poLenLlal lnclude alcohol (boLh as a dlrecL affecL
and secondary Lo clrrhosls) and cocalne
sychogenlc
up Lo 30 of cases of lmpoLence are relaLed Lo psychogenlc facLors LsLabllshlng an organlc cause of
lmpoLence ls lmporLanL ln chooslng approprlaLe Lherapy lacLors LhaL lndlcaLe a psychogenlc cause are
Lhe followlng selecLlve erecLlle dysfuncLlon (eplsodlc normal nocLurnal erecLlons normal erecLlons wlLh
masLurbaLlon) sudden onseL assoclaLed anxleLy or exLernal sLress affecL dlsLurbances (anger anxleLy
gullL fear) and paLlenL convlnced of an organlc cause
ulagnosls
1he hlsLory and physlcal examlnaLlon suggesL Lhe cause ln mosL cases ConflrmaLory LesLs are necessary
Lo ensure an approprlaLe cholce of Lherapy
ln lnvesLlgaLlng a posslble neurologlc cause of lmpoLence Lhe neurologlc examlnaLlon should lnclude
revlew of sysLems wlLh respecL Lo bladder and bowel funcLlon More lnvaslve sLudles lnclude a
cysLomeLrogram wlLh beLhanechol supersenslLlvlLy LesLlng elecLromyography of Lhe exLernal ureLhral
sphlncLer and bulbosphlncLerlc reflex laLency
vascular lmpoLence ls suggesLed by slgns of perlpheral vascular dlsease as well as a hlsLory of
aLheroscleroLlc hearL dlsease nonlnvaslve dlagnosLlc LesLlng ls performed by uoppler penllebrachlal
lndex A penlle blood pressure Lo brachlal blood pressure raLlo less Lhan 06 suggesLs a vascular cause
venous leak requlres cavernosography and cavernosomeLry ArLerlography ls rarely requlred buL may be
lndlcaLed ln paLlenLs wlLh a hlsLory of pelvlc Lrauma
Lndocrlne evaluaLlon mandaLes measuremenL of serum LesLosLerone and prolacLln many lnvesLlgaLors
lnclude assessmenL of lSP and LP 8ouLlne auLomaLed chemlcal screenlng may suggesL oLher hormonal
abnormallLles LhaL requlre addlLlonal LesLlng 1hese sLudles should also deLecL sysLemlc dlsease capable
of causlng lmpoLence clrrhosls renal fallure scleroderma and dlabeLes
sychogenlc lmpoLence may be esLabllshed by nocLurnal penlle Lumescence monlLorlng or ouLpaLlenL
snapgauge cuffs AddlLlonal LesLlng lncludes one of Lhe followlng MlnnesoLa MulLlphaslc ersonallLy
lnvenLory ue8ogaLls Sexual luncLlon lnvenLory and Walker Sex lorm
1reaLmenL
nonoperaLlve 1reaLmenL
llrsLllne LreaLmenL lncludes oral phosphodlesLerase lnhlblLors (slldenafll vardenafll Ladalafll) 1hese
medlcaLlons are conLralndlcaLed ln men wlLh hearL dlsease who are Laklng nlLroglycerln 1hese
medlcaLlons work ln paLlenLs who have normal blood flow and neurologlc lnnervaLlon ln paLlenLs
wlLhouL arLerlalvascular causes of lmpoLence lnLracorporal ln[ecLlons of papaverlne phenLolamlne or
prosLaglandln L1 (or all Lhree) offer a nonoperaLlve means of resLorlng sexual funcLlon lnLracLable
psychogenlc lmpoLence may also respond Lo Lhls LreaLmenL lnLraureLhral pelleLs of alprosLadll
(prosLaglandln L1) can also be used however Lhey ofLen cause paln and are noL favored by mosL
paLlenLs llnally a vacuum erecLlon devlce can be used Lo susLaln erecLlon
Lndocrlne dlsLurbances responslble for lmpoLence lnclude hypoLesLosLeronemla and
hyperprolacLlnemla 1esLosLerone deflclency ls LreaLed by replacemenL Lherapy uslng a oncedally
Loplcal LesLosLerone gel or depoL LesLosLerone lnLramuscular ln[ecLlon every 2 Lo 3 weeks
PyperprolacLlnemla ls LreaLed by bromocrlpLlne Lherapy Lhe paLlenL should be evaluaLed Lo assess Lhe
presence of a plLulLary Lumor
harmacologlc causes of lmpoLence requlre alLerlng medlcal LreaLmenL Lo amelloraLe or ellmlnaLe
secondary lmpoLence 1he ablllLy Lo change medlcaLlons depends on Lhe severlLy of Lhe underlylng
dlsease
sychogenlc lmpoLence ls LreaLed by a Lralned sex LheraplsL and response may be anLlclpaLed ln mosL
cases 1he lmporLance of ellmlnaLlng organlc causes of lmpoLence before embarklng on psychologlcal
Lherapy ls obvlous 1he besL psychologlcal meLhods applled Lo organlc lmpoLence do noL resolve Lhe
dysfuncLlon buL serve Lo frusLraLe boLh Lhe LheraplsL and paLlenL
CperaLlve 1reaLmenL
enlle prosLhesls lnserLlon ls currenLly Lhe mosL common operaLlve meLhod for LreaLmenL of lmpoLence
1wo caLegorles of prosLhesls are ln use semlrlgld and lnflaLable 1he semlrlgld prosLheses are composed
of a rlgld shafL and a flexlble hlnge aL Lhe penllepublc [uncLlon or a malleable sofL meLal case wlLhln Lhe
prosLhesls Lhe erecLlon ls consLanL and ls saLlsfacLory Lo effecL vaglnal peneLraLlon buL Lhe penlle
clrcumference ls noL equal Lo LhaL of a naLural erecLlon
lnflaLable prosLheses offer erecLlons more slmllar ln slze Lo Lhose experlenced by Lhe paLlenL prlor Lo Lhe
onseL of lmpoLence when compared Lo Lhose achleved by semlrlgld prosLheses 1wo Lypes of lnflaLable
prosLheses are avallable 1he sLandard lnflaLable prosLhesls conslsLs of Lwo corporal lnflaLable rods a
reservolr slLuaLed ln Lhe reLropublc space and a pump placed ln Lhe scroLum Lhe new lnflaLable rods
comblne Lhe slmpllclLy of Lwo corporal rods wlLh Lhe sophlsLlcaLlon of a selfconLalned pump and
reservolr sysLem (llexlllaLe and Pydroflex) permlLLlng Lhe convenlence of lnflaLlon and deflaLlon
wlLhouL Lublng and mulLlple componenLs
SaLlsfacLory resulLs are achleved ln 83 of paLlenLs CompllcaLlons common Lo boLh Lypes of prosLheses
are lnfecLlon and eroslon of skln or ureLhra 1he lnflaLable prosLheses are also aL rlsk for mechanlcal
fallure of Lhe pump Lublng or reservolr leak and aneurysm or rupLure of Lhe corporal cyllnders
ArLerlal revascularlzaLlon of Lhe penlle arLerles has meL wlLh llmlLed success AorLolllac reconsLrucLlon
lmproves erecLlle funcLlon ln only 30 of cases Mlcrosurglcal revascularlzaLlon of Lhe penlle arLerles
(dorsal arLery of Lhe penls or deep corporal arLerles) ls successful ln 60 of paLlenLs Whlle Lhese
meLhods avold Lhe rlsks of prosLheLlc lnfecLlon and offer Lhe advanLage of reesLabllshlng Lhe naLural
physlologlc mechanlsms or erecLlon Lhe medlocre success raLe (when compared wlLh Lhe resulLs of
prosLheLlc lnserLlon) would suggesL LhaL mlcrosurglcal penlle revascularlzaLlon be reserved for carefully
selecLed cases
SefLel Au eL al Cfflce evaluaLlon of male sexual dysfuncLlon urol Clln norLh Am 200734463 Mlu
17983888





ln[urles Lo Lhe kldney
LssenLlals of ulagnosls
- PlsLory or evldence of Lrauma usually locallzed
- PemaLurla
- llank mass
- lallure Lo opaclfy Lhe kldney or exLravasaLlon of urlne on excreLory urography
Ceneral ConslderaLlons
8enal ln[ury ls uncommon buL poLenLlally serlous and ofLen accompanled by mulLlsysLem Lrauma 1he
mosL common causes are aLhleLlc lndusLrlal or auLomoblle accldenLs 1he degree of ln[ury may range
from conLuslon Lo laceraLlon of Lhe parenchyma or dlsrupLlon of Lhe renal pedlcle
Cllnlcal llndlngs
SympLoms and Slgns
Cross hemaLurla followlng Lrauma means ln[ury Lo Lhe urlnary LracL aln and Lenderness over Lhe renal
area may be slgnlflcanL buL could be due Lo musculoskeleLal ln[ury Pemorrhaglc shock may resulL from
renal laceraLlon and lead Lo ollgurla nausea vomlLlng and abdomlnal dlsLenLlon (lleus) are Lhe rule
hyslcal examlnaLlon may reveal ecchymosls or peneLraLlng ln[ury ln Lhe cosLoverLebral angle or flank
LxLravasaLlon of blood or urlne may produce a palpable flank mass CLher ln[urles should be soughL

LaboraLory llndlngs
Serlal hemaLocrlL deLermlnaLlons wlll glve clues Lo perslsLenL bleedlng PemaLurla ls Lo be expecLed buL
Lhe absence of hemaLurla does noL exclude renal ln[ury (as ln renal vascular ln[ury)
lmaglng SLudles
A plaln fllm may reveal obllLeraLlon of Lhe psoas shadow Lhls suggesLs Lhe presence of a reLroperlLoneal
hemaLoma or urlnary exLravasaLlon 8owel gas may be dlsplaced from Lhe area Lvldence of Lransverse
verLebral process or rlb fracLures may be noLed ln Lhe pasL Lhe excreLory urogram was used for
evaluaLlng renal Lrauma LxcreLory urograms may show a normal kldney lf lL ls mlldly conLused or may
show exLravasaLlon of conLrasL medlum lf Lhe kldney ls laceraLed nonfuncLlon suggesLs ln[ury Lo Lhe
vascular pedlcle 1he excreLory urogram should demonsLraLe LhaL Lhe conLralaLeral kldney ls normal C1
scan wlLh lnLravenous conLrasL medlum ls now Lhe meLhod of cholce for sLaglng a paLlenL wlLh
hemodynamlcally sLable renal Lrauma C1 scans may mlss urlnary exLravasaLlon lf performed Loo rapldly
followlng lnLravenous conLrasL admlnlsLraLlonbefore Lhe conLrasL ls excreLed lnLo Lhe collecLlng
sysLem and ureLer lf renal vascular damage ls suspecLed and Lhe paLlenLs condlLlon ls sLable
preoperaLlve renal anglography may faclllLaLe plannlng of renovascular reconsLrucLlon or permlL arLerlal
sLenLlng ln speclal clrcumsLances selecLlve renal arLery embollzaLlon may conLrol segmenLal arLerlal
bleedlng 8enal lmaglng ls lndlcaLed ln any adulL wlLh gross hemaLurla or mlcroscoplc hemaLurla wlLh
shock lmaglng ls also requlred wlLh deceleraLlon ln[urles and ls lndlcaLed ln chlldren wlLh any hemaLurla
of less Lhan 30 red blood cells per hlghpower fleld
ulfferenLlal ulagnosls
8ony fracLures or conLuslon of sofL Llssues ln Lhe reglon of Lhe kldney may cause confuslon PemaLurla
mlghL be secondary Lo veslcal ln[ury 1he absence of a perlrenal mass (le hemaLoma or urlnoma) or
conLrasL exLravasaLlon on urograms or C1 scan would rule ouL slgnlflcanL Lrauma
CompllcaLlons
Larly
1he mosL serlous compllcaLlon ls conLlnued perlrenal hemorrhage whlch may be faLal Serlal
hemaLocrlL blood pressure and pulse deLermlnaLlons are essenLlal Serlal C1 scans may also be useful
Lvldence of an enlarglng flank mass lmplles perslsLenL bleedlng ln mosL cases bleedlng sLops
sponLaneously probably as a resulL of Lamponade by Lhe perlrenal fascla uelayed bleedlng 1 or 2 weeks
laLer ls rare lnfecLlon of Lhe perlrenal hemaLoma may occur
LaLe
ulLrasound should be obLalned 1 Lo 3 monLhs afLer managemenL of renal Lrauma Lo look for progresslve
hydronephrosls from ureLeral obsLrucLlon 1he blood pressure should be checked aL regular lnLervals
because hyperLenslon may be a laLe sequela
1reaLmenL
1reaL shock and hemorrhage wlLh flulds and Lransfuslon MosL paLlenLs wlLh blunL renal Lrauma sLop
bleedlng and heal sponLaneously 8ed resL ls lndlcaLed unLll hemaLurla resolves lf bleedlng perslsLs
laparoLomy ls lndlcaLed
eneLraLlng renal Lrauma requlres exploraLlon LaceraLlons may be suLured Lhe collecLlng sysLem
closed and urlnary exLravasaLlon dralned nephrecLomy or parLlal nephrecLomy may be necessary Lo
remove devlLallzed Llssue and secure Lhe collecLlng sysLem
LaLe compllcaLlons may occur erlnephrlc abscess should be dralned PyperLenslon due Lo renal
lschemla requlres vascular reconsLrucLlon or nephrecLomy
rognosls
MosL ln[ured kldneys heal sponLaneously Lhough Lhe paLlenL musL be examlned aL lnLervals for Lhe
onseL of hyperLenslon due Lo renal lschemla or progresslve hydronephrosls due Lo secondary ureLeral
sLrlcLure Many paLlenLs wlLh genlLourlnary Lrauma have assoclaLed ln[urles ln mosL cases deaLh ls due
Lo assoclaLed ln[ury raLher Lhan renal ln[ury
ln[urles Lo Lhe ureLer
LssenLlals of ulagnosls
- Anurla or ollgurla prolonged lleus or flank paln followlng pelvlc operaLlon
- CnseL of urlnary dralnage Lhrough wound or vaglna
- uemonsLraLlon of urlnary exLravasaLlon or ureLeral obsLrucLlon by urography
Ceneral ConslderaLlons
MosL ureLeral ln[urles are laLrogenlc ln Lhe course of pelvlc surgery ureLeral ln[ury may occur durlng
LransureLhral bladder or prosLaLe resecLlon or ureLeral manlpulaLlon for sLone or Lumor ureLeral ln[ury
ls rarely a consequence of peneLraLlng Lrauma unlnLenLlonal ureLeral llgaLlon durlng operaLlon on
ad[acenL organs may be asympLomaLlc Lhough hydronephrosls and loss of renal funcLlon resulLs
ureLeral dlvlslon leads Lo exLravasaLlon and ureLerocuLaneous flsLula
Cllnlcal llndlngs
SympLoms
lf Lhe ureLeral ln[ury ls noL recognlzed aL surgery Lhe paLlenL may complaln of flank and lower
abdomlnal paln on Lhe ln[ured slde lleus and pyelonephrlLls may develop LaLer urlne may draln
Lhrough Lhe wound (or Lhrough Lhe vaglna followlng Lransvaglnal surgery) Wound dralnage may be
evaluaLed by comparlng creaLlnlne levels found ln Lhe dralnage fluld wlLh serum levels urlne exhlblLs
very hlgh creaLlnlne levels when compared wlLh serum lnLravenous admlnlsLraLlon of 3 mL of lndlgo
carmlne causes Lhe urlne Lo appear bluegreen Lherefore dralnage from a ureLerocuLaneous flsLula
becomes blue compared Lo serous dralnage Anurla followlng pelvlc surgery noL respondlng Lo
lnLravenous flulds means bllaLeral ureLeral llgaLlon unLll proved oLherwlse erlLoneal slgns may occur lf
urlne leaks lnLo Lhe perlLoneal cavlLy
LaboraLory llndlngs
Mlcroscoplc hemaLurla ls usually found buL may be absenL 1esLs of renal funcLlon may be normal unless
boLh ureLers are occluded
lmaglng SLudles
LxcreLory urograms may show evldence of ureLeral occluslon LxLravasaLlon of radlopaque fluld may be
seen ln Lhe reglon of Lhe ureLer 8eLrograde ureLerography deplcLs Lhe slLe and naLure (occluslon or
dlvlslon) of Lhe ln[ury
ulLrasonography may reveal hydroureLer and hydronephrosls or a fluld mass represenLlng urlnary
exLravasaLlon 8adlonucllde scannlng shows delayed excreLlon wlLh an accumulaLlon of counLs ln Lhe
pelvls and renal parenchyma resulLlng from ureLeral obsLrucLlon alLhough urlnary exLravasaLlon ls
deLecLed anaLomlc speclflclLy for slLe of ln[ury ls noL clearly deflned
ulfferenLlal ulagnosls
ureLeral ln[ury may mlmlc perlLonlLls lf urlne leaks lnLo Lhe perlLoneal cavlLy LxcreLory urography
reveals Lhe ureLeral lnvolvemenL
Cllgurla may be due Lo dehydraLlon Lransfuslon reacLlon or bllaLeral lncompleLe ureLeral ln[ury A
survey of fluld and elecLrolyLe lnLake and ouLpuL lncludlng serlal body welghLs should prove deflnlLlve
1oLal anurla lmplles bllaLeral ureLeral ln[ury and lndlcaLes Lhe need for lmmedlaLe urologlc lnvesLlgaLlon
veslcovaglnal and ureLerovaglnal flsLulas may be confused MeLhylene blue soluLlon lnsLllled lnLo Lhe
bladder sLalns Lhe dralnage of a veslcovaglnal flsLula CysLoscopy may show Lhe veslcal defecL
8eLrograde ureLerography should reveal a ureLeral flsLula 1he presence of boLh ln[urles occurrlng
slmulLaneously should also be consldered and evaluaLed
CompllcaLlons
1hese lnclude urlnary flsLula ureLeral obsLrucLlon or sLenosls wlLh hydronephrosls renal lnfecLlon
perlLonlLls and uremla (wlLh bllaLeral ln[ury)
revenLlon
8efore operaLlon for large pelvlc masses whlch may cause dlsplacemenL of Lhe ureLers caLheLers should
be placed ln Lhe ureLers Lo faclllLaLe Lhelr ldenLlflcaLlon aL surgery AlLhough Lhe caLheLers may noL
prevenL ln[ury Lhey faclllLaLe recognlLlon of a ureLeral ln[ury
1reaLmenL
ln[ury 8ecognlzed aL Surgery
ureLeral ulvlslon
8epalr of a ureLer lnadverLenLly cuL durlng surgery conslsLs of anasLomosls of Lhe ends over an
lndwelllng sLenL (ureLeroureLerosLomy) relmplanLlng Lhe ureLer lnLo Lhe bladder lf Lhe ln[ury ls
[uxLaveslcal (neoureLerocysLosLomy) or anasLomoslng Lhe proxlmal segmenL of dlvlded ureLer Lo Lhe
slde of Lhe conLralaLeral ureLer (LransureLeroureLerosLomy) 1he anasLomosls musL be Lenslon free and
Lhe area of repalr musL be dralned
ureLeral 8esecLlon
8epalr of a ureLer from whlch a subsLanLlal segmenL has been removed requlres lnLerposlLlon of a
ureLeral subsLlLuLe or moblllzaLlon of Lhe proxlmal and dlsLal ureLer Lo provlde a Lenslonfree
anasLomosls WlLh loss of Lhe dlsLal ureLer Lhe bladder may be hlLched cephalad Lo Lhe psoas muscle or
a bladder flap may be creaLed Lo faclllLaLe a ureLeral lmplanL ln exLreme cases auLoLransplanL of Lhe
kldney Lo Lhe pelvls may be necessary
ln[ury ulscovered afLer Surgery
Larly reoperaLlon ls recommended uependlng on Lhe flndlngs any of Lhe procedures noLed above may
be uLlllzed lf a long segmenL of ureLer ls noL vlable an lnLesLlnal ureLer may be consLrucLed lf
hydronephrosls ls advanced or lf sepsls develops percuLaneous nephrosLomy should precede repalr
When Lhe paLlenLs condlLlon ls sLable deflnlLlve repalr can be accompllshed nephrecLomy may be
lndlcaLed lf Lhe conLralaLeral kldney ls normal and Lhere ls a conLralndlcaLlon Lo
LransureLeroureLerosLomy (such as calcull or upper LracL LranslLlonal cell carclnoma)
rognosls
ln cases of laLrogenlc ln[ury Lhe resulLs are besL lf Lhe ln[ury ls recognlzed aL Lhe Llme of surgery LaLe
repalr lf severe perlureLeral flbrosls has developed ls less llkely Lo afford a good ouLcome
ln[urles Lo Lhe 8ladder
LssenLlals of ulagnosls
- PlsLory of Lrauma (lncludlng surglcal or endoscoplc)
- lracLure of Lhe pelvls
- Suprapublc paln and abdomlnal muscle rlgldlLy
- PemaLurla
- LxLravasaLlon shown on cysLogram
Ceneral ConslderaLlons
1he mosL common cause of veslcal ln[ury ls an exLernal blow over a full bladder 8upLure of Lhe organ ls
seen ln 13 of paLlenLs wlLh pelvlc fracLure 1he bladder may be lnadverLenLly opened durlng pelvlc
surgery or ln[ured by cysLoscoplc maneuvers (eg LransureLhral resecLlon of bladder Lumor) lf Lhe ln[ury
ls lnLraperlLoneal (40 of all bladder rupLures) blood and urlne wlll exLravasaLe lnLo Lhe perlLoneal
cavlLy produclng slgns of perlLonlLls lf lL ls exLraperlLoneal (34 of all bladder rupLures) a mass
develops ln Lhe pelvls AbouL 6 of all bladder rupLures have a comblnaLlon of boLh lnLraperlLoneal and
exLraperlLoneal exLravasaLlon
Cllnlcal llndlngs
SympLoms and Slgns
1here ls usually a hlsLory of hypogasLrlc or pelvlc Lrauma PemaLurla and suprapublc paln and an
lnablllLy Lo vold are expecLed AssoclaLed ln[ury may cause hemorrhaglc shock 1here ls suprapublc
Lenderness and guardlng lnLraperlLoneal exLravasaLlon causes perlLoneal slgns whlle exLraperlLoneal
exLravasaLlon resulLs ln formaLlon of a pelvlc urlnoma
LaboraLory llndlngs
A falllng hemaLocrlL reflecLs conLlnued bleedlng PemaLurla ls expecLed ln paLlenLs who are able Lo vold
A paLlenL who cannoL vold should be caLheLerlzed unless pelvlc fracLure (and ureLhral ln[ury) ls
suspecLed or blood ls noLed aL Lhe ureLhral meaLus
lmaglng SLudles
A plaln fllm may reveal fracLure of Lhe pelvls An exLraperlLoneal collecLlon of blood and urlne may
dlsplace Lhe bowel gas laLerally or ouL of Lhe pelvls lf bladder Lrauma ls suspecLed cysLography should
precede excreLory urography LxLravasaLlon ls mosL rellably demonsLraLed by a posLdralnage cysLogram
fllm lf one suspecLs ureLhral Lrauma a reLrograde ureLhrogram should precede caLheLer lnserLlon 1he
excreLory urogram may suggesL Lhe dlagnosls of bladder perforaLlon buL by lLself ls lnsufflclenL Lo
exclude bladder ln[ury A C1 cysLogram can be used buL lmages of Lhe bladder obLalned by passlve
bladder fllllng afLer caLheLer clamplng are noL sufflclenL Lo exclude a bladder ln[ury 1he bladder should
be fllled Lo capaclLy by gravlLy wlLh dlluLed conLrasL (330400 mL) a pelvlc xray Laken and Lhen Lhe
bladder should be empLled and anoLher pelvlc xray Laken 1hls meLhod should ldenLlfy even subLle
leaks
ulfferenLlal ulagnosls
8enal ln[ury ls also assoclaLed wlLh bladder Lrauma and usually presenLs wlLh hemaLurla LxcreLory
urograms show changes compaLlble wlLh renal Lrauma Lhe cysLogram ls negaLlve
ln[ury Lo Lhe membranous ureLhra can mlmlc exLraperlLoneal rupLure of Lhe bladder A ureLhrogram
reveals Lhe slLe of ln[ury ureLhral dlsrupLlon ls a conLralndlcaLlon Lo ureLhral caLheLerlzaLlon
CompllcaLlons
LxLraperlLoneal exLravasaLlon may lead Lo pelvlc abscess lnLraperlLoneal exLravasaLlon causes delayed
perlLonlLls ollgurla and azoLemla
1reaLmenL
1reaL shock hemorrhage and oLher llfeLhreaLenlng ln[urles Marked exLraperlLoneal exLravasaLlon
should be dralned Lhe bladder decompressed by elLher a suprapublc or ureLhral caLheLer and
approprlaLe anLlbloLlcs admlnlsLered Small exLraperlLoneal exLravasaLlons are LreaLed nonoperaLlvely
by ureLhral caLheLer
lnLraperlLoneal exLravasaLlon of bladder urlne requlres exploraLory laparoLomy mldllne cysLoLomy
bladder closure and bladder caLheLer dralnage eneLraLlng ln[urles (le gunshoL sLabblng) requlre
exploraLlon and closure of Lhe bladder 1he ureLers should also be evaluaLed ln all cases of bladder
ln[ury by preoperaLlve lmaglng or lnLraoperaLlve assessmenL whlch may be done by ln[ecLlng lndlgo
carmlne and looklng for ureLeral exLravasaLlon or by reLrograde passage of 3l feedlng Lubes Lhrough Lhe
ureLeral orlflce
rognosls
Larly dlagnosls mlnlmlzes morbldlLy and morLallLy raLes 1he prognosls depends chlefly on Lhe severlLy
of assoclaLed ln[urles
ln[urles Lo Lhe ureLhra
Membranous ureLhra
ln[ury Lo Lhe membranous ureLhra ls usually a consequence of pelvlc fracLure and Lhus ls assoclaLed wlLh
hemorrhage and mulLlorgan ln[ury 1he mechanlsm of ln[ury ls blunL Lrauma and deceleraLlon resulLlng
ln shearlng forces applled Lo Lhe prosLaLe and urogenlLal dlaphragm eneLraLlng ln[urles resulL from
exLernal mlsslles or laceraLlon by bone fragmenLs acLlng as secondary pro[ecLlles
lf Lhe ureLhral dlsrupLlon ls lncompleLe Lhe paLlenL may be able Lo vold and hemaLurla would be
lnevlLable ureLhral ln[ury ls suspecLed lf blood ls expressed from Lhe ureLhral meaLus ln cases of
compleLe avulslon exLravasaLlon causes a suprapublc mass 8ecLal examlnaLlon may reveal a
nonpalpable or upwardly dlsplaced prosLaLe
xray reveals a fracLured pelvls ureLhrography dellneaLes any exLravasaLlon and cysLography ldenLlfles
an assoclaLed bladder ln[ury An lmmedlaLe excreLory urogram or C1 scan should be obLalned ln all cases
Lo assess kldney and ureLeral funcLlon
1reaLmenL musL be coordlnaLed wlLh care of assoclaLed ln[ury Cnce a membranous ureLhral ln[ury wlLh
urlnary exLravasaLlon has been ldenLlfled suprapublc cysLosLomy should be performed elLher aL Lhe
Llme of laparoLomy or percuLaneously before placemenL of exLernal pelvlc flxaLlon ueflnlLlve ureLhral
repalr may be delayed unLll Lhe paLlenL has recovered from Lhe acuLe ln[ury and pelvlc fracLures have
healed Cccaslonally when ureLhral dlsrupLlon ls lncompleLe laLe repalr ls unnecessary rlmary repalr
may be lndlcaLed ln cases of severe prosLaLomembranous dlslocaLlon ma[or bladder neck laceraLlon or
concomlLanL pelvlc vascular or recLal ln[ury
LaLe sequelae are ureLhral sLrlcLure lmpoLence and lnconLlnence ureLhral sLrlcLure musL be ldenLlfled
by reLrograde ureLhrography and may be LreaLed by LransureLhral lnclslon of Lhe sLrlcLure or
ureLhroplasLy lmpoLence due Lo ln[ury of nerves Lo Lhe corpora cavernosa LhaL course ad[acenL Lo Lhe
membranous ureLhra may resolve wlLhouL LreaLmenL durlng Lhe year followlng ln[ury vascular ln[ury of
Lhe hypogasLrlc or pudendal arLerles may cause lmpoLence followlng Lrauma CavernosomeLry and
arLerlography conflrms Lhe dlagnosls approprlaLe LreaLmenL may lnclude vascular reconsLrucLlon
lnconLlnence depends on Lhe neurologlc sLaLus of Lhe paLlenL Medlcal or surglcal Lherapy ls uLlllzed Lo
lncrease bladder capaclLy and bladder ouLleL reslsLance
8ulbous ureLhra
1he bulbous ureLhra may be ln[ured as a resulL of lnsLrumenLaLlon or more commonly falllng asLrlde an
ob[ecL (sLraddle ln[ury) ureLhral conLuslon may cause a perlneal hemaLoma wlLhouL ln[ury Lo Lhe
ureLhral wall LaceraLlon leads Lo urlnary exLravasaLlon
erlneal paln and some ureLhral bleedlng are Lo be expecLed Sudden swelllng ln Lhe perlneum may
develop followlng aLLempLed urlnaLlon LxamlnaLlon reveals a perlneal mass swelllng due Lo
exLravasaLlon of blood and urlne lnvolves Lhe penls and scroLum and may spread onLo Lhe abdomlnal
wall
lf Lhe paLlenL can vold well and Lhe perlneal hemaLoma ls small no LreaLmenL ls necessary lf
ureLhrography reveals slgnlflcanL exLravasaLlon suprapublc cysLosLomy should be performed Mlnor
ln[ury wlLhouL exLravasaLlon (conLuslon compresslon by hemaLoma) may be managed by careful
lnserLlon of a ureLhral caLheLer
1he only serlous compllcaLlon ls sLrlcLure whlch requlres subsequenL lnLernal ureLhroLomy or surglcal
repalr
endulous ureLhra
LxLernal ln[ury Lo Lhls porLlon of Lhe ureLhra ls noL common slnce Lhe penls ls so moblle 1he erecL
organ however ls vulnerable MosL Lrauma Lo Lhls area ls secondary Lo lnsLrumenLaLlon or sex play As a
rule Lhese ln[urles are mlld alLhough a few may be compllcaLed by sLrlcLure
ureLhral bleedlng and penlle swelllng are Lo be expecLed A ureLhrogram reveals Lhe slLe and severlLy of
ln[ury
lf voldlng ls normal no LreaLmenL ls requlred A large hemaLoma may requlre dralnage lf slgnlflcanL
ln[ury ls presenL a suprapublc Lube should be lnserLed and delayed surglcal repalr performed afLer
swelllng and lnflammaLlon have resolved
ln[urles Lo Lhe enls
Mechanlsms of penlle ln[ury lnclude peneLraLlon blunL Lrauma Lo Lhe erecL penls durlng sexual acLlvlLy
(eg fracLure of corpora cavernosa) avulslon of skln and ampuLaLlon
1ournlqueL ln[ury ls also uncommon Lhe clrcumferenLlal compresslon may be due Lo a rubber band a
sLeel rlng sLrlng or a halr and may be exacerbaLed by subsequenL erecLlon 1he LournlqueL may have
been applled unlnLenLlonally buL chlld abuse cases have been reporLed ln whlch Lhe penls has been
llgaLed as punlshmenL for enuresls
1reaLmenL lncludes assessmenL and care of ureLhral ln[urles lf presenL 8emoval of LournlqueL spllL
Lhlckness skln grafLlng of avulslon ln[urles and prlmary closure of corporal laceraLlons are prlnclples of
Lherapy 1he penls may be acuLely relmplanLed up Lo 16 hours followlng ampuLaLlon uslng mlcrosurglcal
Lechnlques
ln[urles Lo Lhe ScroLum 1esLls
Avulslon of Lhe scroLal skln may requlre a meshed spllLLhlckness skln grafL lf Lhe avulslon ls severe
lnvolvlng Lhe skln and darLos muscle Lhen Lhe LesLes may be lmplanLed ln Lhe subcuLaneous Llssue of
Lhe Lhlgh and dressed ouLslde Lhe wound wlLh 023 aceLlc acldsoaked gauze ScroLal reconsLrucLlon ls
performed aL a laLer Llme frequenLly by uslng skln grafLs
eneLraLlng Lrauma rarely ln[ures Lhe moblle LesLes LaceraLlons should be explored debrlded and
closed prlmarlly lf hemorrhage lnLo Lhe Lunlca vaglnalls ls noLed dralnage ls lndlcaLed
8lunL Lrauma Lo Lhe LesLes may cause conLuslon or rupLure 8upLure of Lhe Lunlca albuglnea may be
demonsLraLed by ulLrasonography as abnormal echoLexLure of Lhe parenchyma ln cases of rupLure
scroLal exploraLlon allows debrldemenL and closure of Lhe Lunlca albuglnea 1he LesLes may ulLlmaLely
undergo aLrophy desplLe Lhese efforLs
Comez 8C eL al Consensus sLaLemenL on bladder ln[urles 8r ! urol 20049427 Mlu 13217426
Morey Al eL al 8econsLrucLlon of posLerlor ureLhral dlsrupLlon ln[urles ouLcome analysls ln 82 paLlenLs
! urol 1997137306 Mlu 8996343
SanLuccl 8A eL al LvaluaLlon and managemenL of renal ln[urles sLaLemenL of Lhe 8enal 1rauma
SubcommlLLee 8r ! urol (lnL) 200493937 Mlu 13142141
Wessels P eL al CrlLerla for nonoperaLlve LreaLmenL of slgnlflcanL peneLraLlng renal laceraLlons ! urol
199713724