Urology short note by S.

Wichien (SNG KKU)

Anatomy kidney -retroperitoneum organ -perirenal fat+Gerota fascia :adrenal gl in gerota -renal a<--aorta :end artery :rt longer than lt -renal v-->drain to IVC :ant to renal a :lt longer than rt :lt adrenal,lt gonodal v--into lt renal Ureter -muscular structure -under gonadal vv Blood supply Proximal ureter -aorta/renal a -medial direction Distal ureter -br from iliac a -lateral direction Relative narrowing -ureteral pelvic junction -across common illiac vv -ureteral vesicle junction Bladder -muscular organ -muscular propia=bladder detrusor -dome of bladder : peritoneum -physio volume 200-400 ml -close to urethra,m.fiber =3 layer :inner long/middel cir/outer long Artery -superior,middle,inferior vesicle a. -internal illiac a. Vein -internal illiac v. Prostate -puboprostatic lig--pubic symphysis -pelvix Fx--prox urethra inj :due to traction this lig -denovillier f--rectum -just beyond apex=ext sphincter Penis 2 corpora cavernosum -erectile body -outer=tunica albuginea -spongy sinusidal tissue -a=cavernosal a<--penile a -n=cavernosal n<--hypogastric plexus (adjacent prostate) 1 corpus spongiosum -underside penis -urethra outer of 3 part -dartos fascia=outer -Buck fascia=inner :dorsal n of penis<--pudendal n :dorsal penile a

Scrotum -testis & epididymis -skindartosext spermatic (Buck) fascia cremasteric fasciaint spermatic fascia tunica vaginalis (parietal&visceral) tunica albugineatestis Ext spermatic fascia = EOM Cremasteric m = IOM/TA Int spermatic fascia = Transversalis fascia Tunica vaginalis = peritoneum Testis -volume 20 ml -Androgen production=leydig cell sperm production=sertoli cell Blood supply -testicular a--aorta -cremasteric a--inf epigastric a -deferential a--sup vesical a Venous -pampiniform plexus=gonodal v -rt=inf vena cava Lt=renal v.

Urology short note by S.Wichien (SNG KKU)

Anatomy (cont) Epididimis -posterolateral of testis -mature sperm to epididyimis -sympathetic stimulate :sperm is conducted along vas def :emission -vas deferen is joined by seminal vesicle to form ejaculatory duct Urinary continence Men int sphincter -smooth m -formed by middle cir layer of bladder -prevent retrograde ejaculation ext sphincter -surround urethra -both smooth,striae muscle Women -no int sphincter/middle layer of BD -continence by coaptation of urethral mucosa and ext striae sphincter Fournier gangrene -NF genitalia/perineum -mortality 30-40% -along dartos,scarpa,colle fascia Risk -urethral stricture -perirectal abscess -poor hygiene -DM,ca Clinical -pain out of proportion to findings -crepitus,necrosis -pain,indurate,fever Tx -prompt DB+broad ATB -if damage ext sphincter=colostomy -testis=separate bl supply :not need to remove Renal cyst Bosniak renal cyst CT classification Category1 -thin wall cyst -no septate -water density -risk ca 0%--no sx Category2 -thin wall cyst -hairline septa -homogeneous hyperdense -<3cm -risk ca 0%--no sx Category2F (follow) -multiple hairline septa -may nodular calcification -hyperdense cyst>3cm -risk ca 5%--f/u progression Category3 -irregular/smooth thick wall or septa -risk ca 50%--sx category4 -3 and enhancing solid component --risk ca 100%--sx Retroperitonium fibrosis -dense fibrotic mass -encase ureter,great vv -ARF -homoge plaque like mass in retro -most idiopathic :may neoplastic process :histiocytosis/lymphoma Med -Ergot -methyldopa -B blocker -steroid Sx -bilat U stent or PCN -uretetolysis

Urology short note by S.Wichien (SNG KKU)

Stone 1.Calcium oxalate -most common stone in USA hypercalciuria -inc resorption of bone -inc absorption in jejunum -urine leak Hyperoxaluria -chronic diarrhea/inflam bowel -fatty stool result in saponification of intes calcium,intes oxalate that unbound to ca excreted by kidney -excess vit-c ingestion -1hyperoxaluria=enz defect in liver 2.Calcium phosphate stone -RTA type1 3.Struvite stone -mg-ammonium-phosphate -form in alkaline urine -proteus,pseudomonas,klebsiella -large stone,fill calyces 4.Uric stone -in acidic urine -pH<5.5 -radiolucent -asso gout,myeloproliferative ds,CMT 5.Cystine stone -primary cystinuria=AR Acute stone 15% = no hematuria Radiographic Non-contrast,helical CT -test of choice -see all stone -exception small indinavir stone IVP Ultrasound Rx -majority = pass spon -10% require admission -relief pain -hydration to promote pass stone -instruct pt to filter urine -obstr.stone+no UTI can safely to 4 wk to spon pass stone (no detect renal damage in 4 wk) -UTI=emer intervention :PCN or ureteral stent :after tx infection=Tx stone electively -4-5mm = 40-50% to pass spon >6mm = <5% to pass spon Med Tx -half=recurrent stone in 5 yr -drink water to urine at least 2L -limit protein/salt intake -not excessive vit-C -studies show that higer calcium diet asso c reduce risk of stone formation -thiazide=dec urinary ca oxalate excre Sx Tx ESWL -extracorporeal shock wave lithotripsy -least invasive for renal stone -ultrasound/fluorosco -<3cm:success rate 50-80% -cystine,calcium phosphate/oxalate (resist to ESWL) Retrograde ureteroscopy -distal uretreal stone -less invasive Percutaneous nephroscopy -large stone filling multiple renal calyx -more powerful instrument

Urology short note by S.Wichien (SNG KKU)

priapism erection>4hr unrelated to sex stimu 2 type 1.low flow -common -ischemic priapism -dec venous outflow,persist inflow :inc intracorporeal pressure -compartment syndrome -normal process erection -med emergency -cavernosal=rigid, glans=flaccid -penile bl gas=hypoxic,acidosis Risk -sickle cell anemia -malignancy,blood dyscrasia -cocain,anti-depress,TPN Tx -pdeudoephredine/baclofen -needle no.18 in corpora for aspirate -inject phenylephrine (200mg/nss 2o) -sickle cell=hydration Sx 1.distal shunt--1st -winter shunt =True-cut needle -Al-Ghorab shunt 2.prox shunt -Grayhack (corporal saphenous v) -Quackel (prox.cavernosum-spongio) 2.hi-flow -rare -penile trauma -cavernous-corporal fistula -no-painful Tx -can resolve -not=embolization Torsion testis -twist of spermatic cord -within tunica vaginalis risk -undescended testis -testicular tumor -bell clamper deformity (poor fixation of testis to scrotum) Newborns=extravaginal torsion Clinical -sudden onset pain -swelling -asymetrical scrotum -tende -hi-riding testis -child=lodt cremasteric reflex Doppler u/s -dec intratesticular flow Sx -midline/bilat transverse incision -detorse testis-->access viable -fix to dartos fascia--medial&lat side -if clearly necrose=orchidectomy -must explore contalat testis -if no have u/s=sx if suspect within 6hr >8o% can salvage testis within 12hr 2o% can salvage

Urology short note by S.Wichien (SNG KKU)

BPH -stromal/epi proliferation of gland -primarily in Transitional zone -rare in < 40 yr -70% in 70 yr -nearly all in 90 yr Natural hx -both obstructive/irritative symptom -lower urinary tract symptom;LUTS -bladder undergoes compensatory hypertrophy to generate enough pressure -sequele of decompensate bladder include urinary retention,dilate,RF DDX in LUTS -UTI -prostatitis -bladder stone -urethral stricture -neurogenic bladder I-PSS -International prostate symptom score -tx is recommended for score >7 Score=0,1,2,3,4,5 1.incomplete emptying 2.frequency 3.intermittency 4.urgency 5.weak stream 6.straining 7.nocturia ; how often A pressure flow study -hi pressure=obstruction -lowpressure=neurogenic bladder BPH treatment 1.Medical therapy absolute indication -urinary retention,bladder stone, -upper tract dilatation,RF relative indication -large postvoid residual,hematuria, -recurrent UTI 1st line therapy Alpha blocker Terazosin,doxazocin -signi lower bl.pressure -s/e-dizziness,orthostatic hypotension -should titrate up over 1-2 wk to their target dose Tamsulosin -newest alpha blocker -low side effect -selective for alpha1a subtype :which predominatein prostate -not need to titrate dose -more retrograde ejaculation Other drugs Finasteride -used for BPH as well as hair loss -5 alpha reductase inhibitor -block conversion testos to dihydrotes 2.Surgical Tx -urinary retention despite med -upper tract dilatation -renal insuff -bladder stone Transurethral resection=TUR -nonhemolytic fluid=1.5%glycine -not nss=electric current -follow TUR=CBI TUR synd -hypervolemic -dilute hyponatremia, -HT,bradycardia -n/v,visaul disturb, -mental status change,seizure Tx=diuretic,correct elyte

Urology short note by S.Wichien (SNG KKU)

Kidney inj blunt 90% Gr description 1 normal Ix,hematuria subcap,no paren lacerate 2 <1cm dept 3 >1cm dept 4 through collecting system main renal a/v 5 shattered kidney avulsion hilum Tx -blunt=NoM -penetrate=usually require explor Urine extravasate -not require explore -need re imaging -if persist=stent/nephrostomy All gr5 -consider immediate explor I/C for sx Absolutely -life threatening hmg from RA -renal pedicle avulsion (gr5) -expanding,pulsatile retro.hematoma Relative -large lacerate renal pelvis or UPJ -co-exist bowel/pancreatic inj -persist uri.leak/abscess fail drain -devitalized paren+urine leak -comp RA thrombosis both KN -abnor intra-op one shot IV urogram -fail angiogram -renovascu.HT Ureter inj -RP=most sensi test Sx Lower ureter (below illiac a) -best=ureter reimplant Mid ureter -ureter-ureterostomy -tension free Repair Long defect -tubularized flap BD (Boari flap) -mobilize BD to psoas m (psoas hitch) Partial inj -1repaie+stent Bladder inj Intraperitoneum rupture--full BD inj--explore Extraperitoneum rupture--cath 7-10 d Ix--CT cystogram Urethra inj Should suspect -pelvic trauma -bloody meatus -hematuria,inability to void -peineal hematoma Dx -retrograde urethrography Ant inj -penile&bulbar -blunt straddle inj -penetrating trauma Tx -all case should cath drainage :complete disrupt=SPC -not immediate sx -1-2 cm defect=can end to end -large defect=graft/flap Post inj -mb&prostatic -pelvic crush inj Tx -SPC+delayed repair Testis inj -blunt inj -testis compress against pubic bone -rupture tunica albugenia -Ix=u/s Sx -hematocele=drainage (ischemic atrophy) -rupture tunica albu=1repair -major devascular=orchidectomy Penile inj Penile Fx -rupture tunica albugenia in SI :force against partner PS/perineum -audible pop sound -rapid penile detumescence -immediate swelling/ecchymosis -if Buck fascia disrupt=butterfly lesion -penis=eggplant appearance Dx -retrograde urethrogram (r/o urethral inj) Sx (avod ED/deformity) -exploration=circumcising incision -repair defect

Urology short note by S.Wichien (SNG KKU)

RCC -malignancy of renal epi -most=sporadic -risk contralat 2-3% Hereditary synd VHL -vhl gene -clear cell RCC Birt Hogg Dube synd -oncocytoma -chromophobe tumor Hereditary papillary RCC Type -clear cell type -papillary type 1,2 -chromoprobe -collecting duct -unclassify Presentation -palpable mass -frank pain -hematuria paraneoplastic manifestation -anemia,polycythemia, -hepatic dysfunction(Stauffer synd) -cachexia -hypercalcemia Metastasis (20-30% of pt present metas) -retroperitoneal LN--most com -lung -luver,bone,brain Tx 1.localized dz -partial/nephron sparing nephrectomy -radical nephrectomy 2.invade RV/IVC -cross clamp above/below thrombus -cavotomy to remove thrombus -aware thrombus emboli Sx Radical nephrectomy -kidney,ipsil adrenal gland, all fat within gerota fascia -open or laparoscopic approach Partial nephrectomy -<4cm in size -equally effective for ca control -prefer in risk for renal insuff -most needs by open approach Laparoscopic cryoablation -small lesion -<3cm -argon gas,liquid nitrogen Adjuvant Tx -metastatic ca is resistant to RTx,CMT -cytoreductive nephrectomy :IL-2 or INF based immunotherapy -nephrectomy+immunoTx :current std of metas pt Prognosis factor -tumor stage/grade/size F/u -abdo/chest imaging 6-12 m 5-10 yr

Urology short note by S.Wichien (SNG KKU)

Ca bladder 1.transitional cell ca -most common -smoking,industrial solvent, mobile exhaust 2.squamous cell ca -chronic irritation -catheter,vesicle stone,schistosoma 3.adenoca -urachal remnant -bladder exstrophy 1.invasive type 2.non-invasive type Dx by 1.bimanual exam--fixation 2.TUR BT--tumor+muscular bladder 3.Ix--HDN (locally advance) Presentation -painless hematuria -irritative voiding symptom Grading TNM staging Cis:ca in situ Ta:mucosa T1:lamina p. T2a:superficial BD muscle T2b:deep BD muscle T3a:perivesicle fat (micro) T3b:perivesicle fat (gross) T4:adjacent structure *Cis,Ta,T1 : superficial BD ca *T2,3,4 : muscle invasive bladder Tx 1.non invasive -TUR alone -hi-risk recur (hi-grade) :intravesicle BCG, MMC 2.invasive (T2) -cystectomy c LN dissection Reconstruction 1.continent urinary diversion orthotopic neobladder -no urethra involved -detubularized distal ileum -anastomosis prox urethra 2.non-continent urinary diversion ileal conduit -urostomy -in CKD,unresect bladder -in bleeding/voiding pain Cystectomy -low midline incision -men=+prostate -women=+uterus,ovary,ant vagina Metastatic bladder ca -TCC=chemosensitive ca -std tx=MVAC Methotrexate Vinblastine Adriamycin Cisplatin -replaced MVAC by gemza+cisplatin (fewer toxic)

Urology short note by S.Wichien (SNG KKU)

Ca prostate -most com non-skin ca in men -recom PR+PSA at 50 yr :fam hx should at 45 yr -metastasis--pelvic LN/bone Gleason score -grade 1-5 -1score=most com histo p 2score=second most com histo p Gleason+PSA+PR -used to estimate localize ca -gleason 8-10,PSA>20=micrometas Tx 1.Localize dz -rad.prostatectomy -brachyTx -EBRT Low risk dz -radical prostatectomy+ uni/bilat cavernosal n sparing Hi-risk dz -non n.sparing sx or EBRT+ andro Tx Expectant Tx in -useful in survival <10 yr -lw gleason <=6 -early stage cT1 1.watch closely w PR 2.repeat Bx in 1yr 2.spreading dz -no longer curable -hormone Tx Sx approach RRP -lower midline -PS to 5 cm below umbilicus -remove LN btw ext illiac/obturator vv -n.alongnpodterolat to prostate Peritoneal Prostatectomy -transverse incision btw scrotum-anus -dec bl loss -difficult remove LN/n.sparing Ca testis -15-35 yr -solid ca -risk=cryptochidism -most metas=retroperitoneal LN Germ cell -seminoma -non-seminoma Non-germ cell -leydid/sertoli cell -rare Tumor markers (non seminoma ) -B-hCG -AFP Ix -chest/abdo imaging -percu.bx of testis :no role-->seed,change lymp drain -r/o metas to testis :open bx through inguinal canal Tx no enlarge LN -often micrometas -offer adjuvant cmt RPLND -limited LN involve=stage 1,2a,2b pure seminoma -EBRT to retro.node Disseminated dzor large LN -cmt Sx Orchidectomy -inguinal incision -not violate scrotal skin -c/p=scrotal hematoma RPLND -midline incision -xiphoid to pubic symphysis -c/p=gut obs,chylous ascites, bleeding (lumbar v) anejaculate (bilat postgan sym inj) (should limit one side)

Urology short note by S.Wichien (SNG KKU)

Ped urology 1.UPJ obstruction -most com of HDN in neonate -abnormal development of smooth m. -abnormal lower pole RA=2cause Clinical -most neonate = asymptomatic -older child = flank/abdo pain Initial evaluate -u/s -VCUG -nuclear scan=dx of choice Tx -mild to mod hydroneprosis can observe and will resolved by 2 yr Sx repair in -severe hydroneprosis -dec renal function -infection while on ATB Sx -open pyeloplasty=gold std -endo approach=endopyelotomy :older child/adult 2.Vesicoureteral reflux -2nd most common of HDN -female > male -2/3 present c UTI -often inherited anomaly -45% of sibling of child c reflux -when BD grow,BD wall thicken :most low grade reflux resolved Primary reflux -congen anomaly -def of longi BD m. intramural ureter Secondary reflux -BOO -inc in intravesical pressure VCUG 1=reflux to ureter 2=reflux to pelvis,calyx 3=diate ureter,pelvis 4=tortious ureter 5 =very tortious Rx Conservative Tx -ATB prophylaxis Sx 1.Open sx reimplant of ureter to BD -gold std 2.Cystoscope+inject a bulking agent -collagen,synthetic material -inc resistance at ureter orrifice 3.Ureterocele -cystic dilation of distal ureter -persistence membrane btw ureter bud & urogeni sinus -80% asso upper pole duplicate ureter ureterocele c orifice in -Trigone=orthotopic -Distal to BD neck=ectopic Orthotopic ureterocele -usually produce ipsilat hydroneprosis -large lesion can bilat hydroneprosis Ectopic ureterocele -can obstruct urethra -result in BOO -bilat hydroneprosis Rx depend on clinical presentation Urosepsis(rare) -emer by endoscopic incising and ureteral drainage Uninfect -elective c endoscopic incision 25% will develop reflux and require 2nd procedure,such as reimplantation 4.PUV -tissue fold in prostatic urethra -BOO -VCUG--dilate post urethra -pulmo.hypoplasia :most serious outcome :intrauterine oligohydramnios Tx -foley cath-recover renal fxn -cystoscopic ablation/resection