Table of Contents

Page created on June 8, 2020. Last updated on December 18, 2024 at 16:57

Thanks to Anne Schmidt for her helpful urology notes. I’ve used them quite a bit.

General urological diagnosis and examinations

1. Physical examination of the genitourinary tract

Kidney
- Inspection
  - Oedema -> inflammation
  - Mass if it’s very large
- Palpation
  - Bimanual kidney palpation/ballotation method
  - Mass if it’s very large or thin patient
- Percussion
  - Painful -> pyelonephritis or stones (inflammation or obstruction)
- Auscultation
  - Bruit in area of costovertebral angle -> renal artery stenosis
Urinary bladder
- Palpation
  - Palpable if 150 mL urine
    - Palpable with less urine in children (in them the bladder is intraabdominal)
- Percussion
  - If 150 mL urine
Penis
- Inspection
  - Inspect under foreskin
    - Hygiene
  - Skin lesions
    - STI, syphilis
  - Circumcision
  - Phimosis
  - Location of penal meatus (hypospadias, epispadias)
- Palpation
  - Fibrous plaque -> Peyronie disease
  - Induration of urethra -> periurethritis or stricture
Scrotum and testes
- Inspection
  - Skin lesions
  - Left testicle lower than right
  - Presence/absence of testes
- Palpation – with fingers from both hands
  - Look for masses
  - Check for inguinal hernia (ask patient to cough)
- Transillumination – all scrotal masses should be transilluminated
  - Fluid-filled lesions like hydrocele will radiate reddish light
  - Solid tumours won’t
Epididymis
- Only palpation
- On posterolateral aspect of testicle
- Tenderness and/or induration -> infection
Prostate
- Digital rectal examination
- 5 qualities of the prostate
  - Size
    - Normal -> peanut/walnut size
  - Surface
    - Smooth surface -> normal
    - Rough surface -> carcinoma
  - Tenderness
    - Non-tender -> normal
    - Tender -> prostatitis
  - Consistency
    - Normally, the consistency should be like the thenar region of the palm
    - Hard -> carcinoma or acute prostatitis
    - Glandular -> chronic prostatitis
  - Symmetricity
    - Symmetric -> normal or BPH
    - Asymmetric -> carcinoma
- Procedure
  - Examine sphincter tone
  - Examine the whole ampulla
  - Examine the 5 qualities of the whole prostate
Vulva and vagina
- Inspection
  - Skin lesions
  - Discharge -> STD
  - Congenital malformations
  - Postmenopausal vaginitis
- Palpation
  - Urethra can be palpated through the anterior wall of the vagina
  - Stone, tumour, etc.

2. Symptoms of disorders of the genitourinary tract and differential diagnosis

Urologic symptoms are generally
- Pain, discomfort
- Alterations of urination
- Changes in the gross appearance of the urine
- Abnormal appearance or function of external genitalia
Primary urologic diseases can manifest as GI problems
Systemic manifestations
- Fever
  - Acute pyelonephritis, prostatitis, RCC
  - Chronic pyelonephritis does not cause fever
- Weight loss
  - Advanced stages of cancer
Pain
- Can be felt locally at the area of the diseased organ or elsewhere, as referred pain
Renal pain
- Either dull and aching or sharp and colicky (renal colic)
- Dull and aching renal pain
  - Usually felt at the costovertebral angle
  - Pyelonephritis
- Renal colic
  - Severe, unilateral colicky flank pain
  - Paroxysmal
  - The patient has a severe urge to move around
  - Can radiate to groin, perineum, abdomen, etc.
  - Painful on percussion
  - Nausea, vomiting common
  - Due to ureter or kidney stone
Ureteral pain
- Typically caused by acute obstruction and distension of the ureter
- Ureter pain is felt at the area of the kidney, but may radiate to the groin
Bladder pain
- Acute distension -> overdistension -> discomfort in suprapubic area
- Cystitis -> sharp, burning pain in urethra or penis
  - Pain at the end of urination is typical symptom of cystitis
Prostate pain
- Discomfort in perineal or rectal area -> prostatitis
Testicular/scrotal pain
- Usually due to disease of testis or epididymis, but kidney or ureter stone can cause testicular pain
- Sudden, severe pain
  - Trauma
  - Epididymitis
  - Testicular torsion
  - Kidney or ureter stone
- Less severe pain, insidious onset
  - Hydrocele
  - Tumour
Urethral discharge -> STD
- Gonorrhoea or Chlamydia

3. Urologic laboratory examination. Urinalysis and urine culture

Collection of urine
- In men – Foreskin should be retracted, and meatus cleaned with antiseptic
- In women – Labia should be separated, and meatus cleaned with antiseptic
- Midstream urine is best
- If it’s difficult to acquire a good sample -> urinary catheter
Macroscopic evaluation of urine
- Amount
  - See topic 4
  - 500 – 2500 mL/day = normal
  - 100 – 500 mL/day = oliguria
  - < 100 mL/day = anuria
- Colour
  - Colourless
    - Very dilute urine, overhydration
  - Yellow
    - Normal
  - Cloudy/turbid
    - Pyuria
    - Phosphaturia
    - Chyluria
  - Red
    - Haematuria
    - Haemoglobinuria/myoglobinuria
    - Phenolphthalein (previously used in laxatives)
  - Orange
    - Dehydration
    - Rifampin
  - Brown
    - Urobilinogen
    - Porphyria
  - Drugs like metronidazole, chloroquine, nitrofurantoin, amitriptyline, methyldopa, sulphasalazine, etc. can cause abnormal colour of urine
Biochemical examination of urine
- Can be quickly examined by dipstick
- pH
  - Normal 4 – 8
  - Acidic urine is 4 – 6
    - Acidosis, compensation for respiratory acidosis
    - Increases risk for uric acid stone or cysteine stone
  - Alkaline urine is 7 – 8
    - UTIs caused by urease-producing bacteria (Proteus spp.)
- Proteins
  - Normal is < 0,1 g/L
  - Proteinuria (> 150 mg/day)
    - Benign proteinuria
      - Transient proteinuria
        
        In fever or exercise
      - Orthostatic proteinuria
        
        Idiopathic proteinuria only in upright position
    - Not benign proteinuria
      - Glomerulonephritis
      - Multiple myeloma
      - Diabetic nephropathy
      - Hypertensive nephropathy
    - False positive proteinuria
      - Pyuria, epithelial cells, etc.
- Glucose
  - Urine should be basically glucose-free
  - Glucosuria occurs when the tubular reabsorption capacity of glucose is exceeded
  - Due to uncontrolled diabetes
- Haemoglobin
  - Haemoglobinuria must be differentiated from haematuria by microscopy
  - Haemoglobinuria is due to haemolytic disease
  - Myoglobinuria is due to rhabdomyolysis
  - Dip stick cannot differentiate between haematuria, haemoglobinuria and myoglobinuria
- Ketone bodies
  - Due to ketoacidosis
- Nitrite
  - Elevated in some UTIs
- WBCs
  - Elevated in UTIs
Microscopic examination of urine
- Procedure
  - Centrifugation -> removal of supernatant -> add solution or some drops of supernatant -> add to slide -> 10x, 40x, 400x magnification
- Epithelial cells
  - Squamous cells -> contamination
  - Transitional cells -> urothelial malignancy
- Bacteria
  - Detection of bacteria on microscopy is not reliable -> culture must be performed
- Leukocytes
  - Pyuria if >5 WBCs per field of view at 400x
  - See topic 6
- RBCs
  - Haematuria if >3 RBCs per field of view at 400x
  - See topic 7
- Casts – tubule-shaped structures
  - WBC casts -> pyelonephritis
  - RBC casts -> glomerulonephritis
  - Epithelial casts -> acute tubular necrosis
- Crystals are of low clinical significance
Urine culture
- To determine presence of bacteria, bacterial species, and antibiotic resistance of UTI
PSA
- Classically, the cut-off value was 10 ng/mL
  - There is no universally accepted lower cut-off value
  - The risk for prostate cancer increases as the PSA value increases
- Nowadays derived values are used:
  - Age-specific PSA
  - PSA density – PSA level divided by prostate volume
  - PSA velocity – increase in PSA over time
  - Free PSA to total PSA ratio

4. Symptoms related to the act of urination and quantitative changes of the urine

Symptoms related to the act of urination
- Generally due to cystitis, prostatitis, urethritis, etc.
- Lower urinary tract symptoms (LUTS)
  - Classically seen in BPH, but can be present in other conditions as well
    - See next topic
  - Two types of LUTS
    - Lower urinary tract dysfunctions may manifest as one or both types
    - Voiding or obstructive symptoms
    - Storage or irritative symptoms
- Storage/irritative symptoms – symptoms related to abnormal bladder function
  - Urinary frequency – more than 8x a day
  - Urinary urgency – strong feeling of needing to void
  - Nocturia = the need to wake up multiple times in the night to urinate
    - Heart failure
  - Urinary incontinence
- Voiding/obstructive symptoms – symptoms related to abnormal voiding
  - Hesitancy – delayed initiation of micturition
  - Need for straining to urinate – patient must contract abdominal muscle to urinate
  - Intermittent, not continuous, urine stream
  - Terminal dribbling of urine
  - Sensation of incomplete voiding
- Other symptoms
  - Dysuria = painful urination
    - Typically burning pain
    - UTI
    - Cystitis
  - Enuresis = wetting the bed at night
Quantitative changes of urine
- Normal = 500 – 2500 mL/day
- Polyuria = > 2500 mL/day
  - Diabetes insipidus
  - Diabetes mellitus
  - Diuretics
  - Primary polydipsia (psychogenic)
- Oliguria = 100 – 500 mL/day
  - Due to acute kidney injury
  - Prerenal causes
    - Dehydration
    - Heart failure
    - Renal artery stenosis
  - Intrarenal causes
    - Acute tubular necrosis
    - Acute or chronic glomerulonephritis
    - Acute interstitial nephritis
  - Postrenal causes
    - Obstruction
- Anuria = < 100 mL/day
  - Generally same as for anuria, but more severe

5. Urinary storage and voiding dysfunction

The lower urinary tract
- Involves bladder, urethra, and external urethral sphincter
- Has two functions
  - Symptom-free storage of urine which is constantly draining from the kidneys
  - Periodical, voluntary, unobstructed, and complete voiding of stored urine
- Central or peripheral neurological problems can interfere with the carefully coordination of the lower urinary tract
  - Demyelination (MS)
  - Spinal cord lesions
Urinary storage dysfunction
- Caused by
  - Detrusor overactivity (overactive bladder)
    - Neurogenic or secondary to chronic bladder outlet obstruction
  - Low bladder compliance
    - Fibrosis
    - Cystitis with oedema
  - Detrusor and sphincter dyssynergia (DSD) syndrome
    - The detrusor contracts while the external urethral sphincter is contracted -> intravesical pressure increases
  - Weak pelvic floor muscles
    - After vaginal delivery
  - Prostatitis
- Causes storage symptoms
  - Urgency
  - Frequency
  - Nocturia
  - Incontinence
Urinary voiding dysfunction
- Caused by
  - Bladder outlet obstruction
    - BPH
    - Urethral stricture
    - DSD syndrome
  - Underactive detrusor
- Causes voiding symptoms
  - Hesitancy
  - Straining
  - Intermittent urine stream
  - Terminal dribbling of urine
  - Sensation of incomplete voiding

6. Pyuria and its examination

Pyuria refers to >5 WBCs per field of view at 400x
Urine may be grossly cloudy
Dipsticks
- Can test for the presence of leukocyte esterase, an enzyme produced by WBCs
- Can test for nitrite -> positive indicates bacteriuria
  - However, it can be false negative (bacteria which don’t produce nitrite)
Bacterial culture should be performed to check for bacteriuria
- If culture is negative, it should be repeated
Meares and Stamey’s 4-glass urine collection
- Used to determine the location of the bacterial infection within the urinary tract
- Only performed in men
- Four glasses are taken
  - 1^st glass – the first 10 mL of urine
  - The patient then voids another approx. 100 mL of urine
  - 2^nd glass – another 10 mL of urine
  - 3^rd glass – the patient’s prostate is massaged, and the fluid ejected from the urethra is collected
  - 4^th glass – another 10 mL of urine after the prostate massage
- The first glass represents the urethral specimen
- The second glass represents the bladder specimen
- The third and fourth glasses represent the prostate specimen
- Each glass is cultured for bacteria and examined for WBCs -> which glass has bacteria will give information on the location of the infection
Causes of bacteriuria + pyuria
- Urinary tract infection
Causes of sterile pyuria (no bacteriuria)
- Infection which is treated with Abs
- Stone
- Mycobacterial or chlamydial infection
- Presence or recent use of catheter or endoscopic procedure
Causes of sterile pyuria with haematuria
- Bladder cancer
- Glomerulonephritis
- Pyelonephritis
- Interstitial nephritis
Causes of bacteriuria without pyuria
- Bacterial colonization of urine sample

7. Haematuria and its evaluation

Haematuria refers to > 3 RBCs per field of view at 400x
Microhaematuria or microscopic haematuria – haematuria which is not grossly visible
Macrohaematuria or gross haematuria – haematuria which is grossly visible
Painless haematuria is due to a urinary tract cancer until proven otherwise!
Important questions
- Is urination painful?
- Which part or parts of the urine stream is bloody?
- Have you had a sore throat recently?
  - Post-streptococcal glomerulonephritis
- Family history of Alport syndrome, polycystic kidney, sickle cell anaemia
- Do you take any drugs?
- Have you had chemotherapy recently?
- Pure blood, or with clots?
Origin of bleeding according to which part of the urine stream which is bloody
- Initial part (initial haematuria)
  - Anterior urethral bleeding
- Terminal part (terminal haematuria)
  - Posterior urethral bleeding
  - Bladder neck bleeding
  - Trigone bleeding
- The whole stream (total haematuria)
  - Bleeding above the level of the bladder
Types of haematuria according to origin

	Glomerular haematuria	Non-glomerular haematuria
Causes	Glomerulonephritis	Papillary necrosis, stone, cystitis, kidney cancer, urothelial cancer, etc.
Colour	Cola-coloured	Red or pink
Clots	No	Sometimes
RBC morphology	Dysmorphic RBCs	Normal RBCs
RBC casts	Sometimes	No
Proteinuria	> 500 mg/day	< 500 mg/day

Further tests
- Cystoscopy – to check for bladder cancer
- Urinalysis
- Blood test
  - Inflammatory markers
  - Renal function
- Abdominal CT with contrast

8. Urethral catheterization: Types, indications, and technique

Types
- Straight catheter
  - For acquiring urinary sample
  - Inserted into the urethral opening
  - Not for indwelling
- Foley catheter or standard balloon catheter
  - Most common indwelling urinary catheter
  - Has two lumens
    - One lumen opens to the end of the catheter and allows urine to flow out
    - One lumen opens to a deflated balloon at the end of the catheter
      - Saline is injected into the other end, which inflates the balloon inside the bladder and prevents it from being dragged out
  - Inserted into the urethral opening
  - Contraindications
    - Acute prostatitis
    - Urethral trauma
- 3-way catheter
  - Like a Foley catheter, but has one additional lumen
  - This additional lumen is connected to a large bag of saline on one end, and it empties into the bladder
  - This provides continuous irrigation of the bladder, which prevents formation of clots
  - Used after certain urological surgeries where there is bleeding
- Suprapubic catheter
  - Bladder should be full – to prevent going through the bladder, and to prevent the peritoneum from covering the bladder
  - Has two lumens, like Foley
  - The patient’s haemostasis parameters should be known and considered
  - Inserted 2 cm above pubic symphysis
  - Indications
    - Contraindications to Foley, like urethral trauma, acute prostatitis
    - Inability to place Foley
Indications of indwelling catheters
- Diagnostic
  - Acquire urinary sample
  - Monitor urinary output
    - Especially important in critically ill patients
  - To allow instillation of diagnostic agents
- Therapeutic
  - Urinary retention
  - To allow instillation of therapeutic agents
Technique
- Ask for latex or lidocaine allergy
- Patient lies on their back
- The area of the urethral opening should be disinfected 2 – 3x, working from the centre and outwards
- Cover the patient with sterile isolating sheet, with a hole for genitalia
- Insert lidocaine gel
  - This gel lubricates, disinfects, and anaesthetizes the urethra
  - Give it a few minutes to take effect
- Insert the catheter into the urethra, keep the kidney bowl at the other end of the catheter
  - When urine starts to drain the correct position is achieved
- Inflate the balloon with saline through the other lumen
  - This usually requires 5 – 10 mL of saline
- Pull the catheter back until it stops
- Attach a urine collection bag to the urine-draining lumen
Potential difficulties
- The first pubic flexure in men is straightened by elevating the penis during initial insertion
  - The perineal flexure is unavoidable
- The female urethral orifice may be difficult to find
Catheter size
- Measured in French (Fr)
- 1 Fr = 0,33 mm
- Standard sizes are 14 – 18 Fr
- The smallest size which is adequate for the indication should be used
  - Larger sizes have higher risk of erosion or stricture formation
- Larger sizes are used to drain blood clots

9. Cystourethroscopy: Requirements, technique, and indications

Cystourethroscopy or cystoscopy is an endoscopic examination of the urethra and bladder
Can diagnose inflammation, tumours, stones
Can also be used therapeutically
- The endoscope itself may be combined with therapeutic tools through working ports
Types
- Rigid cystoscope
  - Is not flexible and therefore more painful to use, especially for men
- Flexible cystoscope
  - Takes on the shape of the urethra -> more comfortable
Indications
- Haematuria
- Suspicion of tumour
- Urinary obstruction
- Recurrent UTIs
- Urinary incontinence
- Bladder biopsy
- Placement of DJ stent
Contraindications
- Acute urethritis, prostatitis, epididymitis
- Febrile UTI
Technique
- Disinfection of urethral area
- Application of lidocaine gel
- Prepare conductive or non-conductive irrigation fluid
  - See topic 40 regarding TUR syndrome
- Insert the cystourethroscope
- Inspect all parts of the urethra, bladder, and ureteral orifices

10. Urinary tract imaging: Purpose, and indications

Plain abdominal x-ray
- Also called kidney-ureter-bladder (KUB) film
- Not much used
- Indications
  - Stones
    - Only those with high calcium content
  - Calcifications
  - Evaluate position of urinary stents
Intravenous (IV) urography
- Not much used (replaced by CT)
- Also called IV pyelography or excretory urography
- Procedure
  - A normal KUB (a scout film) is taken
  - IV contrast is applied
  - X-rays taken 5, 10, and 15 minutes after IV
  - As the contrast is filtered by the kidneys and excreted, different parts of the urinary tracts are visible
- Indications
  - Stones
    - Can see all stones
  - Haematuria
Retrograde urography
- Procedure
  - A ureteral catheter is placed by cystoscopy
  - The catheter is advanced to the renal pelvis
  - A scout image is taken
  - Contrast is retrogradely instilled into the renal pelvis through the catheter
  - Fluoroscopic images are taken
- Indications
  - Same as IV urography, but used in case of contrast allergy
Anterograde urography
- Procedure
  - A catheter is inserted percutaneously into the renal pelvis
  - A scout image is taken
  - Contrast is anterogradely instilled into the renal pelvis
  - Fluoroscopic images are taken
- Indications
  - Same as retrograde urography, but used in cases where retrograde is impossible
Static cystography
- Procedure
  - Scout image is taken
  - A Foley catheter is placed
  - Contrast material is instilled into the bladder through the catheter
  - Multiple images are taken with the bladder full of contrast
  - The contrast is drained out of the bladder
  - A post-drainage image is taken
- Indications
  - Bladder trauma
  - Bladder fistulae
Voiding cystography
- Procedure
  - Scout image is taken
  - A Foley catheter is placed
  - Contrast material is instilled into the bladder through the catheter
  - The catheter is withdrawn
  - Fluoroscopy is taken while the patient voids the contrast
- Indications
  - Vesicoureteral reflux
  - Voiding problems
  - Evaluation of posterior urethra
Ultrasound
- Indications
  - Renal tumour
  - Renal cysts
  - Nephrolithiasis
  - To guide kidney biopsy or intervention
  - Hydronephrosis
  - Bladder stone
  - Urinary retention
    - Ultrasound can measure the amount of urine remaining in the bladder after urination
  - Testicular torsion
  - Cryptorchidism
  - Epididymitis
- Can also evaluate
  - Kidney
    - Size
    - Shape
    - Location
    - Masses
    - Cysts
  - Bladder
    - Size
    - Wall thickness
    - Colour doppler allows visualization of the ureteral jet
  - Prostate
    - Using transrectal probe
    - Size
    - Shape
    - Masses
  - Scrotum
    - Presence/absence
    - Cryptorchidism in the inguinal canal
    - Inguinal lymph nodes
CT urography
- = Contrast CT of the urinary system
- Procedure
  - A non-contrast CT is taken
  - IV contrast is injected
  - Several CT scans are taken afterwards
- Is generally used instead of regular x-rays
- Indications
  - Gold standard for stones and renal masses
  - Staging of renal and bladder cancers
  - Hydronephrosis
  - Trauma
  - Retroperitoneal masses
  - Retroperitoneal lymph nodes
  - Adrenal masses
MRI
- Used if other imaging methods are inconclusive

11. Interventional uro-radiology: Principles, technique, indications, and contraindications

Nonvascular interventional procedures
- Percutaneous nephrostomy (PCN)
- Percutaneous nephrolithotomy (PCNL)
- Ureteral stenting
- Percutaneous balloon dilatation of ureteral strictures
Vascular interventional procedures
- Renal artery angioplasty and stenting
- Transcatheter embolization
Percutaneous nephrostomy
- = percutaneous opening to the renal pelvis
- US guided
- Procedure
  - A needle is advanced through the flank into the collecting system
  - Urine is aspirated
  - A guidewire is inserted through the needle
  - The needle is removed
  - The lumen is enlarged by passing dilators over the guidewire
  - Once the lumen is large enough a pigtail catheter is placed
- Indications
  - Complete urinary tract obstruction
Percutaneous nephrolithotomy
- See topic 16
Ureteral stenting
- Ureter stent = double-J stent = DJ stent
  - It is a tube, where one end is placed in the renal pelvis and the other in the bladder
  - Urine can flow through this tube and bypass the obstruction
- Indications
  - Complete upper urinary tract obstruction
  - Obstruction which causes renal failure
  - Upper urinary tract infection with obstruction
- Procedure
  - Ureteral stenting can be performed retrogradely by using a cystoscope, or anterogradely through a nephrostomy
  - Anterograde is used when retrograde ureteral stenting is not possible
  - After a few days the stent is removed, and a normal Foley catheter is inserted
Transcatheter embolization
- Indications
  - Arteriovenous fistulas or malformations
  - Bleeding
  - RCC
  - Varicocele
Contraindications
- Uncorrected bleeding disorder

12. Radionuclide imaging in urology

Used to assess renovascular perfusion, renal function, and obstruction
Indications
- Renovascular hypertension
- Accurate determination of renal function
- Evaluation of renal transplants
- Vesicoureteral reflux
- Diagnosis of phaeochromocytoma
Static renal scintigraphy
- Uses 99mTc-DMSA
  - It accumulates in the kidney parenchyme but is not excreted
- Imaging is performed 3 hours after injection
- Visualizes the renal morphology
Dynamic renal scintigraphy
- Uses 99mTc-MAG3
  - It is rapidly excreted by the kidneys
- Imaging is performed serially from the time of the injection and for 30 min
- Gives the renal function

13. Kidney function investigations

Normal GFR depends on age, gender, body size
- GFR decreases with age
- Females have lower GFR
Approx 120 mL/min/1,73 m² of body surface
The degree of GFR loss correlates to prognosis, especially in chronic kidney disease
GFR estimation
- In clinical practice exact measurement of GFR isn’t needed, so GFR is estimated
- The clearance of creatinine is almost equal to the GFR (because creatinine is 99% filtered and very little secreted)
  - The creatinine clearance is around 10% higher than the GFR
- The clearance of creatinine can be estimated from the serum creatinine by using an equation
  - Normal serum creatinine is 80 – 120 µM
  - These equations estimate GFR less accurately in certain populations, like those with normal kidney function, elderly, children, pregnant, specific ethnic groups, those with very high or very low muscle mass, etc.
- However, GFR estimation is not accurate when the kidney function is unstable, i.e. rapidly increasing or increasing
Proteinuria
- Proteinuria = more than 150 mg/day
- Etiology
  - Diabetic nephropathy
  - Hypertensive nephropathy
  - Glomerulonephritis
  - Interstitial nephritis
Specific gravity and urine osmolality
- Isosthenuria or hyposthenuria -> decreased ability to concentrate or dilute urine
  - -> the osmolality of the urine will approach the osmolality of the plasma
- Specific gravity
  - Refers to the density of urine compared to water
  - Normally 1,003 – 1,030
Serum blood urea nitrogen (BUN) or simply urea
- The ratio between BUN and creatinine can give information on renal function
- BUN:creatinine ratio is normally between 10:1 and 20:1
- BUN:creatinine ratio > 20:1
  - Indicates prerenal causes of renal dysfunction
- BUN:creatinine ratio < 10:1
  - Indicates renal causes of renal dysfunction
  - Renal damage decreases the reabsorption of urea
Electrolytes
- Sodium
- Potassium
- Calcium
- Phosphate

14. Genitourinary tract biopsy: Indications and technique

Techniques of biopsy
- Bleeding parameters should be evaluated before
- Percutaneous biopsies are usually guided by US with local anaesthesia
- Urothelial lesions
  - Biopsied with cystoscopy or through percutaneous catheters
- Other lesions
  - Renal masses
  - Retroperitoneal masses
  - Retroperitoneal lymph nodes
  - Biopsied percutaneously or by open surgery
Kidney biopsy
- Not for urological diseases but for nephrological diseases (GN)
- Indications
  - Glomerulonephritis
  - Renal transplant evaluation
  - Renal mass where non-invasive imaging is inconclusive
    - Renal masses can be diagnosed with high specificity by non-invasive imaging in most cases
- Technique
  - Can be acquired percutaneously or by open surgery
- Complications
  - Bleeding
  - Tumour seeding is rare
Bladder biopsy
- Very frequently performed
- Indications
  - Suspicion of malignancy
- Pre-procedure
  - White light urethrocystoscopy
    - To identify and visualize lesion
    - Exophytic tumours visible
    - Can’t see cancer in situ
  - Urine cytology is also performed
    - If urethrocystoscopy is negative but cytology shows malignant cells:
    - Either a cancer in situ or upper urinary tract cancer
  - If no tumours are visible but cytology is positive
    - -> mapping biopsy
      - Biopsies are taken blindly from high predilection areas
    - -> photodynamic diagnosis (PDD)
      - Oral 5-ALA + fluorescent light source
      - Malignant areas become fluorescent
    - -> Narrow band imaging
      - Light with narrow band of wavelengths
      - Hypervascularized tissues become more visible
- Procedure
  - Transurethral resection of bladder (TUR-B)
    - Both therapeutic and diagnostic
  - Bressel technique for sample acquisition
    - 1 sample from tumour
    - 1 sample from muscular layer of bladder
      - To look for muscle invasion – important for further treatment
    - 4 samples of the sides of the tumor
      - To determine the border of the tumor
Prostate biopsy
- Prostate cc
  - Histological confirmation necessary for diagnosis
  - When should we perform biopsy?
    - Based on DRE, PSA
    - See prostate cc topic
- Procedure
  - Perioperative antibiotic prophylaxis
  - Local anaesthesia
  - Transrectal US guidance
  - Minimum 6 samples, usually 10
  - Taken transrectally, transperineally, or transurethrally
  - McNeal technique
  - Take samples as peripherally as possible (peripheral zone)
Testicular biopsy
- Biopsy to evaluate infertility
- Never biopsy in testicular cancer

15. Evaluation and management of urological emergencies: Renal colic, suprapubic pain, acute scrotum, gross haematuria, anuria, and urinary retention

A urological emergency is anything which
- Is life threatening
- May lead to organ loss or permanent impairment
- Is highly contagious
- Is causing severe pain
Most important ones
- Urologic trauma
- Scrotal emergencies
- Urosepsis
- Urinary retention
- Penile emergencies
  - Paraphimosis
Urologic trauma
- See topics 29, 30
Urosepsis
- Sepsis originating from the urinary tract
- Generally lower mortality than other types of sepsis, but still very high
- Etiology
  - Pyelonephritis
  - Acute prostatitis
  - Prostatic abscess
  - Fournier gangrene
  - Bladder rupture
  - Foreign body
- Treatment
  - Antibiotics
Paraphimosis
- = retracted foreskin which cannot be returned to original position
- Causes oedema of the glans, which worsens the problem
- Can cause ischaemia and necrosis
- Treatment
  - Manual reduction after anaesthesia
    - Local or regional anaesthesia
  - Surgery
  - Circumcision
Priapism
- = erection which lasts for more than 4 hours and which is not due to sexual excitation
  - Not relieved by ejaculation
- Low-flow priapism
  - Due to inadequate venous drainage
    - Sildenafil, sickle cell disease, other drugs, thrombosis, etc.
  - Treatment
    - Cavernosal aspiration and irrigation
    - Phenylephrine
    - Surgery
- High-flow priapism
  - Not as urgent as low-flow, not painful
  - Due to excessive arterial inflow
    - Injury -> fistula between artery and corpus cavernosum
  - Treatment
    - Ice pack
    - Embolization of the fistula
    - Surgery
Acute scrotum
- Testicular torsion
  - = sudden twisting of spermatic cord, usually internal rotation
    - 1/3 of cases are due to external rotation
  - Most frequent in childhood and adolescents
  - Etiology
    - Idiopathic
    - May be related to bell-clapper deformity
  - Clinical features
    - Abrupt onset testicular pain
    - Swollen testicle
    - Testicle lies transversally in the scrotum rather than longitudinally as usual
  - Diagnosis
    - Mainly clinical, after differentiated from acute epididymitis
      - Negative Prehn sign
      - Absent cremaster reflex
    - Duplex ultrasound
  - Results in irreversible necrosis within hours
    - Sertoli cells die before Leydig
  - Treatment
    - Should be within 6 hours
    - Manual detorquation (manual untwisting, also called detorsion)
      - Externally rotate the testes one or two full 360 degree turns
        
        Clockwise for right testicle
        
        Counter-clockwise for left testicle
      - Can be tried, but should not delay surgery
      - If there is pain relief, the testis lies lower in the scrotum, and Doppler shows blood flow, it was a success
        
        If not, detorqutation in the opposite direction may be tried
    - Surgery
      - In all cases!
        
        Surgery should be performed even if manual untwisting was performed, to prevent recurrence and to make sure the untwisting is complete
      - Surgical detorqutation
      - Orchidopexy of both testicles = fixation the testis to the scrotum, to prevent recurrence
      - Orchidectomy if necrotic testis
- Acute epididymitis
  - See topic 20
- Fournier gangrene
  - See topic 22
Renal colic
- See treatment of stone disease
Suprapubic pain
- Acute urinary retention
- UTI
- Cystitis
- Pelvic inflammatory disease
- Ectopic pregnancy
- Diverticulitis
Gross haematuria
- Topic 7
Anuria and oliguria
- Anuria = < 50 mL urine/24 hour
- Pre-renal causes
  - Hypovolaemia
  - Renal artery occlusion
  - Shock
- Intrarenal causes (Acute kidney injury)
  - Acute tubular nephropathy
  - Interstitial nephritis
  - Rapidly progressive glomerulonephritis
- Postrenal causes
  - Complete bilateral urinary tract obstruction
Urinary retention
- See topic 27

16. Role of minimal invasive procedures in urology

Advantages of minimally invasive procedures
- Lower infection
- Faster recovery
- Less time spent in hospital
- Smaller scar
- Less postoperative pain
Disadvantages of minimally invasive procedures
- Difficult to learn
- Longer operation time
- Limited view
Laparoscopic nephrectomy
- Radical nephrectomy – Small RCC
- Simple nephrectomy – benign kidney tumour
Laparoscopic nephropexy
- For nephroptosis
Laparoscopic nephroureterectomy
- For urothelial cancer
Laparoscopic pelvic lymphadenectomy
Percutaneous nephrolithotomy
- Procedure
  - Similar to PCN, but tools to break and aspirate the stone are inserted into the nephrostomy rather than a catheter
- Indications
  - Kidney stones which can’t be treated by other method
Adrenalectomy
- Used for benign tumours of adrenal

Non-cancerous diseases

17. Congenital anomalies of the nephric system (kidney, pyelon, ureter)

Caused by hereditary factors, environmental factors, in utero exposure to RAAS drugs, etc.
Kidney
- Congenital solitary kidney
  - Usually asymptomatic
    - However, they have a higher risk for kidney disease and should be monitored regularly
  - The remaining kidney is usually hypertrophic
  - Anatomical congenital solitary kidney
    - The other kidney is absent (renal agenesis)
  - Functional congenital solitary kidney
    - The other kidney is non-functional
    - Renal aplasia, renal dysplasia, or renal hypoplasia
- Horseshoe kidney
  - The left and right inferior poles are fused
  - Usually asymptomatic, but have increased risk of kidney disease
- Ectopic kidney
  - Kidney is in abnormal position
  - Usually asymptomatic
- Autosomal dominant polycystic kidney disease
  - Presents with chronic renal failure or hypertension in adulthood
  - Decreases life expectancy
- Autosomal recessive polycystic kidney disease
  - Presents with chronic renal and liver failure in childhood
  - Either die within the first month or within 15 years
    - Those that die within the first month have pulmonary hypoplasia
Pyelon and ureter
- Ureteropelvic junction obstruction (UPJO)
  - Male > female
  - Etiology: malformation of ureter
  - Causes hydronephrosis in utero
    - Most common cause of abdominal mass in children
    - In most cases hydronephrosis is diagnosed in utero by US
  - Diagnosis
    - Ultrasound
    - IV urography
  - Treatment
    - Observation in asymptomatic cases
    - Surgical correction if symptomatic
- Congenital vesicoureteral reflux
  - Etiology
    - Duplicated ureter
    - Ectopic ureter
    - Ureterocoele
    - Posterior urethral valves
  - Causes hydronephrosis in utero
    - In most cases hydronephrosis is diagnosed in utero by US
  - Causes recurrent UTIs and kidney failure in children
  - Diagnosis
    - Ultrasound
    - Voiding cystography
  - Treatment
    - VUR often improves spontaneously
    - Prophylactic antibiotics
    - Bladder training
    - Endoscopic injection
    - Surgical correction if the reflux is high-grade

18. Congenital anomalies of the gonads and vesicourethral unit (bladder, urethra)

Gonads
- Cryptorchidism
  - = failure of one or both testicles to descend into scrotum
  - 1% of boys
    - It’s the most common congenital anomaly of genitourinary tract
  - Risk factors
    - Prematurity
  - Diagnosis
    - Testis cannot be palpated in the scrotum
  - Treatment
    - Many spontaneously descent, but not after 6 months
    - Within 6 – 18 months
    - Orchidopexy
    - Laparoscopic surgery
- Congenital hydrocele
  - Causes painless, enlarged scrotum
  - Usually resolves spontaneously
- Ectopic testes
  - Testes is located outside the normal path of descent
  - In superficial inguinal pouch, perineum, femoral canal, suprapubic region
  - Treatment: orchidopexy
- Congenital varicocele
Bladder
- Bladder exstrophy
  - Male > female
  - Bladder is herniated through defect in abdominal wall
  - Associated with separation of pubic bones
  - Treatment: surgery
Urethra
- Posterior urethral valve
  - = tissue which obstructs the posterior urethra
  - Common cause of urinary tract obstruction in newborn males
    - Only affects males
  - Associated with pulmonary hypoplasia
  - Diagnosis by voiding cystogram
  - Treatment: Valve ablation with cystoscopy
- Hypospadias
  - External urethral opening on ventral penis
  - Only symptomatic cases require surgery
- Epispadias
  - External urethral opening on dorsal penis
  - Often associated with bladder exstrophy
  - Treatment: surgery

19. Lower urinary tract infections in women: Classification, pathogenesis, and management

Asymptomatic bacteriuria
- = isolation of significant quantities of bacteria in urine, but without signs or symptoms of infection
Lower urinary tract infections
- Refers to infection of bladder, urethra, prostate
  - Cystitis is more common than urethritis and prostatitis
  - Is almost always an ascending bacterial infection from the urethra
- Women are at higher risk for UTI than men
  - Due to short urethra and close proximity of anus and urethra
- Microbiology
  - Gram-negative rods
    - E. coli (causes 80% of UTIs)
    - Proteus
    - Klebsiella
  - Staphylococci
  - Enterococci
  - Ureaplasma urealyticum
- Cystitis
  - Most commonly bacterial
  - Dysuria, urgency, frequency, suprapubic pain
- Types
  - Uncomplicated (lower) UTI
  - Complicated (lower) UTI
  - Nosocomial (lower) UTI
- UTI which doesn’t improve should be examined for urological diseases, like stone, obstruction, tumour, etc.
Uncomplicated UTI
- Uncomplicated UTI refers to lower UTI in those with low risk for progression to upper UTI (pyelonephritis)
  - UTIs in immunocompetent, premenopausal, non-pregnant women
- Diagnosis
  - Clinical diagnosis
  - Typical symptoms
  - Dipstick showing pyuria, nitrite can help diagnosis
- Rarely causes complications
- Treatment
  - Varies depending on region. These are the Norwegian standards
  - Short courses
  - TMP/SMX
  - Nitrofurantoin
  - Pivmecillinam
- Prevention
  - Drink a lot, especially urine acidifying juices
  - Urinating after intercourse
Complicated UTI
- Complicated UTI refers to high risk for progression to pyelonephritis
- UTI in patients with any of the following are automatically characterised as complicated
  - Male gender
  - Pregnancy
  - Children
  - Postmenopausal women
  - Immunocompromise
  - Diabetes
  - Urological pathologies
  - Recent use of endoscopy or catheter
- Clinical features
  - Symptoms of cystitis
  - Symptoms of pyelonephritis may be present
- Diagnosis
  - Urine culture
  - Imaging if obstruction or other renal disease
- Treatment
  - Pregnant, children, elderly and other high-risk patients should be admitted and treated inpatient with IV antibiotics
  - Low-risk patients may be treated outpatient
  - Medical (varies depending on region. These are the Norwegian standards)
    - TMP/SMX
    - Pivmecillinam
    - Ciprofloxacin
    - Longer antibiotic treatment than uncomplicated UTI
Nosocomial UTI
- Often due to indwelling catheter, endoscopic procedures, etc.
- Often caused by more virulent bacteria, or drug-resistant bacteria
- Nosocomial UTI is per definition a complicated UTI

20. Prostatitis and lower urinary tract infections in men: Diagnosis and treatment

Lower urinary tract infections in men
- Less frequent than in women
- Can cause cystitis, prostatitis, epididymitis, urethritis
Acute bacterial prostatitis
- It’s a serious bacterial infection
- Etiology
  - UTIs
  - Genitourinary tract interventions
- Clinical features
  - High fever
  - Pain
    - Perineal or pelvic area
    - On defecation
  - Dysuria
  - Frequency
- Diagnosis
  - Urinalysis
  - Urine culture
  - DRE
    - Usually not needed
    - Very carefully, to prevent bacteriaemia
    - Painful, firm, swollen prostate
- Treatment
  - Inpatient treatment in most cases
  - Long duration antibiotic treatment (6 weeks)
    - Fluoroquinolones and sulphonamides penetrate the prostate
  - Suprapubic catheter in case of urinary retention
Chronic bacterial prostatitis
- Etiology
  - Often a complication of acute bacterial prostatitis, due to inadequate or too short treatment
- Clinical features
  - Same as acute, but intermittent and less severe
  - No systemic symptoms
- Diagnosis
  - Four-glass test
  - Enlarged, soft or boggy, moderately tender prostate
- Treatment
  - Long duration antibiotic treatment (6 – 12 weeks)
    - Fluoroquinolones and sulphonamides penetrate the prostate
  - NSAIDs
Chronic abacterial prostatitis (= chronic pelvic pain syndrome)
- Inflammatory type (WBCs in four-glass test)
- Non-inflammatory type (no WBCs)
- Clinical features
  - Pain or discomfort
    - Perineal, suprapubic, rectal, etc.
  - Pain upon ejaculation
  - Bloody ejaculate
- Diagnosis
  - CPPS is a diagnosis of exclusion
  - No bacteria on four-glass test
- Treatment
  - Antibiotics
    - No bacteria can be detected but it’s worth to try
  - Alpha blockers
  - Biofeedback
  - Physiotherapy
  - NSAIDs
  - Phytotherapy
Asymptomatic prostatitis
Urethritis
- STD-related urethritis
  - Chlamydia or Gonorrhoea
  - Treatment – ceftriaxone + azithromycin
- STD-unrelated urethritis
  - Ureaplasma, mycoplasma, trichomonas
  - After endoscopic procedures
  - Treatment – macrolides
- Clinical features
  - Can be asymptomatic
  - Local discomfort or pain
(Acute) Epididymitis
- Most frequent in adults
- Etiology
  - Ascending from UTI
  - STD
- Clinical features
  - Gradual onset pain
  - Unilateral pain and swelling
  - Symptoms of UTI or STD
- Diagnosis
  - Clinical diagnosis
  - Positive Prehn sign
    - = the pain is reduced when scrotum is elevated
  - Intact cremaster reflex
  - Elevated inflammatory markers
- Treatment
  - Antibiotics
  - Ice packs
  - NSAIDs

21. Kidney infection: Pathogenesis, diagnosis, and treatment

Upper urinary tract infection = pyelonephritis = infection of renal pelvis and parenchyme
Etiology
- Most commonly due to ascension of lower UTI
  - Especially from complicated UTI
  - Caused by same pathogens as lower UTI
- Haematogenous spread
  - Very rare
  - From infectious endocarditis, osteomyelitis, etc.
Clinical features
- Fever
- Chills
- Flank pain
- Nausea
- Symptoms of lower UTI
Uncomplicated pyelonephritis
- Pyelonephritis in immunocompetent, nonpregnant, non-postmenopausal female with normal genitourinary anatomy and renal function
- Has lower risk for complications
Complicated pyelonephritis
- Pyelonephritis in any of the following
  - Male
  - Elderly
  - Anatomical abnormalities of genitourinary tract
  - Hospital-acquired infection
  - Renal dysfunction
  - Immunosuppression
- Has higher risk for complications
Diagnosis
- Typical symptoms + current or previous symptoms of lower UTI
- Urinalysis
  - Leukocyte casts
- Urine culture, blood culture
  - To direct AB treatment
- Imaging
  - If suspicion for obstruction, stone, abscess, congenital abnormalities, etc.
  - Also in cases of treatment failure
  - Contrast CT abdomen and pelvis
  - Ultrasound
    - In pregnant, contrast allergy, etc.
Treatment
- AB choice based on culture (urine or blood)
  - Fluoroquinolone is generally good as empiric treatment while waiting for results
- Uncomplicated pyelonephritis
  - Generally outpatient
  - 10 day treatment
- Complicated pyelonephritis
  - Generally inpatient
  - 14 – 21 days treatment
- Pyelonephritis with obstruction is a urological emergency
  - -> Urgent relief of obstruction
Complications
- Chronic pyelonephritis
  - Due to recurrent or persistent acute pyelonephritis
    - There is often an underlying condition, like obstruction or vesicoureteral reflux
  - Scarring and atrophy of kidney
  - Nonspecific symptoms + abdominal or flank pain
  - Treatment of underlying cause
- Urosepsis
- Emphysematous pyelonephritis
- Xanthogranulomatous pyelonephritis

22. Specific infections of the genitourinary tract

Genitourinary tuberculosis
- = M. tuberculosis which has spread to urinary tract
- Genitourinary TB is the second most common extrapulmonary manifestation of TB
  - After lymph node
  - Spreads haematogenously to kidney -> bacteria descend
- Very rare complications of intravesical BCG
- Genitourinary TB presents 5 – 25 years after initial infection
- Clinical features
  - Dysuria
  - Flank pain
  - Haematuria
  - Pyuria
  - Low-grade fever
  - Gender-specific
    - Male – prostatitis
    - Female – amenorrhoea, discharge
- Diagnosis
  - Apparent sterile pyuria
    - Pyuria with negative bacterial culture
    - PCR or special culture will show TB
  - Imaging: calcifications, strictures, parenchymal destruction
- Treatment
  - Normal TB therapy
  - Surgery to remove adhesions, strictures
- Complications
  - Ureteropelvic junction obstruction
  - Bladder fibrosis
  - Ureteral stricture
  - Adhesions of fallopian tube
    - Can cause infertility
Genitourinary schistosomiasis
- Pathogenesis
  - Caused by Schistosoma haematobium parasite
  - Live in contaminated water
  - Parasite penetrates the skin and enters the circulation
  - Travels to the bladder
  - May take years for symptoms to appear
- Epidemiology
  - Endemic in Africa and Middle east
- Clinical features
  - Haematuria
  - Hydronephrosis
- Pathology
  - Cause granulomatous inflammation
- Diagnosis
  - Eosinophilia on labs
  - Calcified bladder on imaging
  - Observation of eggs in urine
- Complications
  - Infertility (women)
  - SCC of the bladder
- Treatment
  - Praziquantel
Genital filariasis
- Epidemiology
  - Endemic in tropical countries
- Pathogenesis
  - Caused by the parasite Wuchereria bancrofti
  - Transmitted by mosquito bite
  - Larvae migrate to lymphatic vessels and lymph nodes and mature there
- Clinical features
  - Lymphangitis and lymphadenitis
  - Elephantiasis (severe lymphoedema of the legs)
  - Hydrocele
- Diagnosis – blood smear taken at night
  - Parasite is released from the lymph vessels to the blood at night
- Treatment – Diethylcarbamazine (DEC)
Fournier gangrene
- Fulminant polymicrobial necrotizing fasciitis of penis, scrotum, perineum
  - Bacteria enter the region through abscess, fissure, fistula, colon perforation, etc.
  - More prevalent in immunocompromised
- = a urological emergency
- High mortality (20%)
- Clinical features
  - Pain
  - Foul-smelling
  - Cellulitis
  - Necrosis
  - Fever
  - Sepsis
- Treatment
  - Wide spectrum antibiotic therapy
    - Against both aerobes and anaerobes
  - Suprapubic catheter
  - Surgical excision and debridement
  - Hyperbaric oxygen therapy

23. Urinary stone: Epidemiology, composition, and etiology of specific stone types

Epidemiology
- Prevalence 2 – 4%
- Male > female
- 30 – 60 years
Risk factors
- Low fluid intake
- Family history
- See individual types
Pathogenesis
- Solution phase
  - No crystallization occurs
- Metastable phase
  - The solution is supersaturated, but inhibitors prevent crystallization
- Stone formation phase
  - The inhibitors can no longer prevent crystallization
  - -> stone is formed
- Growing phase
  - Precipitation and aggregation cause the stones to grow
Types
- Calcium oxalate stone
- Uric acid stone
- Struvite stone
- Cystine stone
Calcium oxalate and calcium phosphate stone
- 75% of stones
- Hard and brown
- Etiology
  - Hypercalcuria
  - Hyperoxaluria
    - Occurs in Crohn disease
  - Aciduria
- Radiopaque
  - Visible on x-ray
Uric acid stone
- 10% of stones
- Etiology
  - Gout
  - Hyperuricaemia
  - Aciduria
- Radiolucent
Struvite stone
- 5% of stones
- Grow quickly
- Can form staghorn calculi
- Etiology
  - UTI with urease-producing bacteria
  - Proteus, Klebsiella, Pseudomonas

24. Clinical manifestations and diagnosis of urolithiasis

Clinical features
- Stones in the renal pelvis
  - Asymptomatic or cause blunt kidney pain
- Stones in the ureter
  - Renal colic
  - Haematuria
  - Clinical features of concomitant UTI
Diagnosis of urolithiasis
- Imaging may show the stone itself and/or hydronephrosis
  - Nonenhanced abdominal and pelvic CT
    - Gold standard
  - Ultrasound
    - For children, pregnant
- Labs
  - Kidney function
  - Calcium
  - Uric acid

25. Management and medical treatment of patients with urinary stones

Conservative treatment
- High fluid intake
- Spasmolytics
- Painkillers
- Calcium channel blockers
- Alpha blockers
Stones < 5 mm which are uncomplicated
- Symptomatic treatment
- Wait 4 – 6 weeks and repeat imaging to see if the stone has passed
- If not -> non-medical treatment
Uric acid stones
- Dissolve when the urine is alkalinized
- By potassium citrate or sodium bicarbonate

26. Non-medical treatment of urolithiasis: Therapeutic modalities, indications, and contraindications

Indications
- Stones > 5 – 10 mm
- Complicated stones
  - Hydronephrosis
  - Pyelonephritis
  - Urosepsis
  - Acute kidney injury
  - Lasting haematuria
  - Haemodynamic instability
- Stones which haven’t passed after 4 – 6 weeks
Modalities
- Extracorporeal shockwave lithotripsy (ESWL)
  - First choice in most cases
  - Procedure
    - The stone is located by x-ray or US
    - Uses shockwaves to fragment the stones into fragments which can pass spontaneously
    - May have to be repeated
  - Indications
    - Kidney stone < 20 mm
    - Ureter stone < 10 mm
    - Uric acid stones
  - Contraindications
    - Non-urological
      - Untreated hypertension
      - Pregnancy
      - Uncorrected bleeding disorder
      - Aortic aneurysm
    - Urological
      - Kidney dysfunction
      - Untreated UTI
      - Obstruction distal to stone
  - Complications
    - Generally very safe
    - Perirenal or intrarenal haematoma
    - Haematuria
- Percutaneous nephrolithotomy (PCNL)
  - Percutaneous access into the renal pelvis -> stones fragmented by shockwaves or laser -> fragments are removed by forceps
  - Indications
    - Stones unsuitable for ESWL
    - ESWL treatment failure
  - Contraindications
    - Uncorrected bleeding disorder
    - Untreated UTI
  - Complications
    - Injuries of adjacent organs
    - Haematoma
    - AV fistula
- Ureterorenoscopy (URS)
  - Indications
    - Ureteric stones
    - Ureteral strictures
  - Complications rare
- Open surgery
  - For complex stones (staghorn calculi), or if other methods have failed

27. Urinary obstruction and stasis: Differential diagnosis and management

Etiology
- Most common cause according to age
  - Children – congenital abnormalities
    - Posterior urethral valves
    - Ureteropelvic junction obstruction
    - Strictures
  - Adults – nephrolithiasis
  - Elderly – BPH, prostate cancer, pelvic cancer
Diagnosis
- Ultrasound
  - Generally first choice
  - Can show hydronephrosis, stones, distended bladder, etc.
- Urinalysis
  - May give information on underlying cause
- Labs
  - Hyperkalaemia
  - BUN
  - Creatinine
- CT
  - If stone is suspected
- Voiding cystography
  - If vesicoureteral reflux is suspected
Upper urinary tract obstruction (supravesical)
- Etiology
  - Nephrolithiasis
  - Ureterolithiasis
  - Urothelial cancer
  - Stricture
  - Blood clots
- Clinical features
  - Acute obstruction
    - Acute kidney injury
    - Pain
      - Hydronephrosis itself is painless, but the underlying cause may be painful
      - Renal colic
      - Pyelonephritis
    - Oliguria/anuria
  - Chronic obstruction
    - Often asymptomatic until they develop complications
    - -> chronic renal failure
    - -> UTI
- Treatment to relieve acute obstruction
  - Ureteric (DJ) stent (see topic 11)
  - Percutaneous nephrostomy (see topic 11)
  - Ureterorenoscopy (topic 26)
Lower urinary tract obstruction (infravesical)
- Etiology
  - Stone
  - Tumour
  - Urethral stricture
  - BPH
  - Prostate cancer
  - Pelvic cancer
  - Posterior urethral valve
  - Neurogenic bladder
- Clinical features
  - Acute obstruction
    - Suprapubic pain
      - Acute infravesical obstruction -> bladder distension
    - Palpable bladder
    - Urinary retention
  - Chronic obstruction
    - Lower urinary tract symptoms (LUTS)
    - Chronic renal failure
- Treatment to relieve acute obstruction
  - Foley or suprapubic catheterization

28. Ptosis of the kidney: Symptoms, diagnosis, and treatments

Nephroptosis – a kidney which is not fixed and therefore “floats”
- The kidney will drop > 5 cm or > 2 vertebral columns when switching from supine to upright position
- More common in thin females
- In the upright position, the renal artery or pelvis may be compressed, causing renal ischaemia or upper urinary tract obstruction
Symptoms
- Often asymptomatic
- Feeling of heaviness in abdomen
- Pain after standing for long
  - Pain is relieved by lying down
- Dietl’s crisis
  - Due to decreased renal perfusion and urinary obstruction
  - Severe flank pain
  - Haematuria/proteinuria
  - Tachycardia
  - Oliguria
Diagnosis
- In upright position
  - Urine analysis
    - RBC, protein
  - BP
- Supine and standing intravenous pyelography
- Doppler ultrasound
  - Detect decreased perfusion in upright position compared to supine
- Radionuclide imaging
Treatment
- Indication for surgery
  - Orthostatic hypertension
  - Orthostatic perfusion disturbance
  - Orthostatic urinary occlusion
  - Chronic pain
- Techniques
  - Conservative
    - Weigh gain (for thin persons)
    - Abdominal exercise
    - Abdominal wall binders
  - Laparoscopic nephropexy
    - Most common
    - Suture lower pole of kidney to muscle
  - Percutaneous nephropexy
    - Alternative
    - Invented by professor at POTE uro clinic

29. Injuries of the kidney and ureter: Etiology, evaluation, classification, and management

Kidney trauma
- Epidemiology
  - Kidney injury occurs in 1 – 5% of all trauma
  - Kidney injury is the most common genitourinary injury
- Etiology
  - Blunt trauma to abdomen
  - Penetrating wounds of abdomen
  - Motor vehicle accidents
- Suspicious features
  - Haematuria
  - Pain
  - Bruising
  - Haematoma
  - Fracture of lower ribs
- Evaluation
  - Contrast CT
    - To grade kidney damage
- Grading of kidney trauma
  - Grade I
    - Subcapsular haematoma without laceration
  - Grade II
    - Perirenal haematoma
    - Laceration into kidney parenchyme < 1 cm deep
  - Grade III
    - Laceration into kidney parenchyme > 1 cm deep
  - Grade IV
    - Laceration involving the collecting system
    - Renal artery or vein injury
  - Grade V
    - Shattered kidney
    - Renal artery or vein avulsion
- Management
  - Kidney trauma is mainly managed nonoperatively
    - Patients are kept on bed rest until the urine is grossly normal (no haematuria)
  - Grade I – III kidney trauma -> monitoring
  - Grade IV – V kidney trauma
    - Haemodynamically stable -> monitoring
    - Haemodynamically unstable -> open surgery
Ureteral trauma
- Most ureteral injuries are iatrogenic, due to procedures
- External trauma is rare
  - Sometimes seen in penetrating trauma and motor vehicle accidents
  - Other abdominal injuries are often present
- Suspicious features
  - Haematuria
  - Flank pain
  - Fever
- Diagnosis
  - CT
- Treatment
  - DJ stent placement or nephrostomy
  - Afterwards, any surgical repair may be performed

30. Injuries of the bladder, urethra, penis, and scrotum

Bladder
- Etiology
  - Pelvic fracture
  - Iatrogenic
- Diagnosis
  - CT cystography
- Types
  - Intraperitoneal -> injury communicates with peritoneum
    - Damage of bladder dome, which is intraperitoneal
  - Extraperitoneal -> injury is confined to extraperitoneal space
    - The rest of the bladder is extraperitoneal
- Clinical features
  - Gross haematuria
  - Suprapubic pain
  - Inability to urinate
  - Intraperitoneal -> peritoneal irritation
- Treatment
  - Foley or suprapubic catheter
  - Extraperitoneal bladder injury -> non-operative
  - Penetrating injury -> surgery
  - Intraperitoneal bladder injury -> surgery
Urethral trauma
- Types
  - Affecting the posterior urethra
    - Due to pelvic fracture
  - Affecting the anterior urethra
    - Due to straddle injury
- Clinical features
  - Inability to void
  - Blood at urethral opening
- Diagnosis
  - Retrograde urethrogram
- Treatment
  - Posterior urethra injury -> suprapubic catheter
  - Anterior urethra injury -> surgery
Penile trauma
- Usually due to traumatic bending of erect penis during intercourse
  - The tunica albuginea ruptures
  - Often associated with anterior urethra injury
- Clinical features
  - Snapping sound as the tunica albuginea ruptures
  - Immediate loss of erection
  - Pain
  - Swelling, curving, and haematoma
    - Gives it an “eggplant” appearance
- Diagnosis: clinical
- Treatment
  - Surgical repair of tunica albuginea
  - Surgical evacuation of haematoma
Scrotal injury
- Laceration of skin -> surgical repair
- Complete scrotal avulsion -> transplant the testis into subcutaneous thigh pouches -> transplant it back into the scrotum later with a skin graft
Testicular injury
- Blunt trauma
- Clinical features
  - Severe pain
    - Locally and abdominally
  - Swelling
  - Nausea/vomiting
  - Haematocele
- Diagnosis
  - Ultrasound
  - Surgical exploration
- Treatment
  - Small haematocele -> conservative treatment
  - Large haematocele -> surgical drainage
  - Testicular rupture -> immediate surgery

31. Foreign bodies in the urinary tract

Most foreign bodies find their way into the urethra or bladder
Etiology
- Sexual curiosity
- Iatrogenic
Clinical features
- Obstruction
- Local pain
- UTI
Diagnosis
- Anamnesis
- KUB x-ray – if the object is radiopaque
- CT – if object is radiolucent
Treatment
- Endoscopic extraction through urethra
  - First choice
- Extraction through suprapubic cystotomy
  - Objects in posterior urethra can be relocated to the bladder by endoscopy and extracted from there
- Open surgery
  - For objects which are difficult to remove
- Postoperative
  - Foley catheter
    - To decrease risk for urethral stricture
  - Cystourethroscopy
    - To diagnose urothelial injuries

32. Non-malignant intrascrotal disorders: Differential diagnosis, and treatment

Hydrocele
- = accumulation of fluid between the layers of the tunica vaginalis
- Can occur in any age
  - Most common in infants
- Etiology
  - Idiopathic
    - Maybe due to impaired reabsorption of fluid by the tunica vaginalis
  - Lymphatic filariasis
  - Trauma
  - Tumour
  - Torsion
  - Congenital
- Communicating hydrocele
  - = the hydrocele communicates with the peritoneal cavity
  - Due to failed closure of the processus vaginalis
  - The fluid in the hydrocele originates from the peritoneal cavity
  - Affects infants
  - The hydrocele is reducible
    - = the fluid can be “pushed” back into the peritoneal cavity
  - Valsalva manoeuvre increases the size of the hydrocele
    - Because peritoneal fluid is forced into the scrotum
  - Usually resolves spontaneously within 1 year
- Noncommunicating hydrocele
  - = the hydrocele does not communicate with the peritoneal cavity
  - The hydrocele is not reducible
  - Valsalva manoeuvre does not influence the size
- Clinical features
  - Painless swelling of the affected hemiscrotum
- Diagnosis
  - Clinical diagnosis
  - Positive transillumination
  - US
    - Shows hypoechoic fluid
- Treatment
  - Surgery for most cases
    - Communicating hydrocele which doesn’t resolve within 1 year
    - Unacceptable discomfort
    - Compromised scrotal skin integrity
  - Surgical excision of the hydrocele sac
  - Sclerotherapy
    - A sclerosing agent is injected into the hydrocele after the fluid has been aspirated
    - The space will be closed, preventing future hydroceles
    - There is a high incidence of recurrence after sclerotherapy
Varicocele
- = obstruction of spermatic vein -> enlarged and tortuous pampiniform plexus in scrotum
- Very common (15% of men)
- Etiology
  - Idiopathic
  - Secondary to diseases which obstruct spermatic vein
    - Retroperitoneal mass
    - Thrombosis
- Clinical features
  - Typically affects left side
  - Dull pain
  - “Bag of worms” appearance
  - Symptoms improve when lying down
    - Only in primary cases
- Diagnosis
  - Clinical
  - Negative transillumination
  - Ultrasound
- Treatment
  - Conservative
    - For most patients
    - Regular follow-up
    - Scrotal support
  - Surgical repair
    - Indications
      - Testicular atrophy
      - Infertility
    - Ligation of affected venous branches or percutaneous embolization
- Complications
  - May increase the risk of infertility
  - Testicular atrophy
Spermatocele
- Located at the upper pole of the epididymis
- Asymptomatic, harmless
- Rarely requires treatment
Inguinal hernia
- = herniation of intra-abdominal contents into the scrotum
- (I don’t think inguinal hernia belongs to urology, but rather to general surgery. I think it’s important to differentiate hydrocele from it, though.)
- Indirect inguinal hernia
  - Herniation through the deep inguinal ring
  - Epidemiology
    - More common than direct
    - Mostly affects male infants and older men
  - Etiology
    - Incomplete obliteration of processus vaginalis during foetal development
  - May not be apparent until adulthood
- Direct inguinal hernia
  - Herniation through a weakened posterior wall of the inguinal canal
  - Epidemiology
    - Mostly affects older men
  - Etiology
    - Chronically increased intraabdominal pressure
    - COPD
    - Constipation
    - Straining during exercise
- Clinical features
  - Mass in the scrotum or groin
  - Inguinal pain
  - Worsening symptoms during physical activity
- Diagnosis
  - Clinical
  - Palpation with the finger through the inguinal canal
    - Ask the patient to cough
    - Bulging can be felt at the fingertip
  - Ultrasound
- Treatment
  - Surgery
    - Elective surgery if uncomplicated and mild symptoms
    - Urgent surgery otherwise
- Complications
  - Incarceration
  - Strangulation

33. Non-tumorous diseases of the penis and urethra

Paraphimosis and priapism
- See topic 15
Balanitis and balanoposthitis
- Balanitis = inflammation of glans
- Balanoposthitis = inflammation of glans and foreskin
- Etiology
  - Poor genital hygiene
  - Phimosis
  - STD
  - Yeast infection
  - Drug reaction
  - Local irritants
- Clinical features
  - Pruritus
  - Pain
  - Oedema
  - Erythematous, ulcerated lesions
- Diagnosis
  - Clinical
  - Bacterial culture
  - KOH test for fungal infection
- Treatment
  - Treatment/prevention of underlying cause
  - Topical antifungal, antibiotic, glucocorticoids, etc.
  - Daily washing under foreskin
  - Avoid irritants
Phimosis
- = foreskin which cannot be completely retracted over the glans penis
- Physiological in early years
  - Affects almost all newborns, but only 1% of seventh grade boys
- Etiology
  - Congenital
  - Complication of balanitis
  - Scarring after trauma
- Treatment
  - Topical glucocorticoids and stretching
  - Surgical incision of the constricting parts
  - Circumcision
Peyronie disease
- = idiopathic fibroproliferative disorder causing formation of fibrous plaque in the tunica albuginea
- Affects middle-aged and older men
- Clinical features
  - Painful erection
  - Abnormal curving of the erect penis
  - Indurations of the penis
  - Erectile dysfunction
- Treatment
  - Pentoxifylline
  - Intralesional injection of collagenase
  - Surgery
Urethral stricture
- = fibrotic narrowing of urethra
- Etiology
  - Trauma
  - Iatrogenic
    - Catheterization
    - Instrumentation
    - Inappropriate removal of Foley catheter
  - Congenital
  - Idiopathic
  - Post-infectious
- Clinical features
  - Causes partial or complete lower urinary tract obstruction
  - Slow urinary stream
  - Incomplete bladder emptying
  - Dribbling
- Diagnosis
  - Uroflowmetry
    - Shows a plateau
  - Retrograde and voiding urethrography
- Treatment
  - Urethral dilation
    - Symptomatic, not curative
  - Urethrotomy
    - Endoscopic incision of stricture
    - Stricture frequently recurs
  - Urethroplasty
    - Open surgical reconstruction of stricture
    - If urethrotomy fails

34. Urinary incontinence and urodynamic studies

Urinary incontinence
- = uncontrollable voiding
- Epidemiology
  - More frequent in elderly
  - Female > male
- Types
  - Stress incontinence
  - Urge incontinence
  - Overflow incontinence
  - Mixed incontinence
    - Mixed features or etiologies
- General diagnosis
  - Anamnesis
  - Evaluation of life impact by using questionnaires
    - King’s health questionnaire
    - Gaudenz score
  - Physical examination
    - Vaginal examination
    - DRE
    - Neurological examination
  - Pad test
    - A pad is weighed before and after a 24 hour period
    - To assess severity or monitor treatment response
- General treatment
  - Decrease consumption of diuretic drugs and drinks
  - Weight loss
  - Bladder training
  - Kegel exercises
  - Biofeedback
  - Vaginal pessary
Stress incontinence
- Urinary leakage occurs due to increased intra-abdominal pressure
  - Due to urethral hypermobility or intrinsic sphincter deficiency
  - Leakage occurs during laughing, coughing, exercising, etc.
- More common in females
- Etiology
  - Urethral hypermobility
    - Childbirth
    - Trauma
    - Postmenopausal
    - Obesity
  - Intrinsic sphincter deficiency
    - Prostate surgery (radical or TUR)
    - Pelvic surgery
- Diagnosis
  - Boney stress test – the urethra is visualized while the patient is asked to cough or Valsalva
- Treatment
  - Kegel exercises
  - Alpha blockers
  - Electrostimulation
  - Surgical elevation of urethra (midurethral sling)
Urge incontinence
- The urinary leakage is preceded by a strong, sudden sense of urgency
- More common in males
- Motor urge incontinence
  - Due to involuntary and uncontrolled detrusor contractions
  - Etiology
    - Detrusor overactivity/overactive bladder
      - Stroke
      - MS
      - Spinal cord injury
    - Chronic lower urinary tract obstruction
      - The detrusor hypertrophies in response to the chronic obstruction
      - BPH
  - Treatment
    - Anticholinergics (Oxybutynin)
    - Alpha blockers
    - Botulinum toxin injection into detrusor
    - Bladder augmentation
      - Last resort
- Sensory urge incontinence
  - Due to hypersensitive bladder, which results in reflex bladder emptying
  - Etiology
    - Cystitis
    - Bladder stone
    - Bladder tumour
  - Treatment
    - Treatment of underlying cause
Overflow incontinence
- For some reason the bladder can’t empty, causing it to fill with urine and eventually overflow
  - When the intravesical pressure becomes higher than the pressure in the urethra, urine will leak
- Etiology
  - Decreased detrusor contractility
  - Chronic lower urinary tract obstruction
- Treatment
  - Treatment of obstruction
Urodynamic studies
- Indicated in
  - Incontinence
  - LUTS
  - Recurrent UTIs
- Can differentiate different causes of incontinence, LUTS, etc.
- Types
  - Uroflowmetry
  - Pressure flow study
  - Valsalva leak point pressure
Uroflowmetry
- Only non-invasive urodynamic study
- Measures the volume of urine voided over time
- Should be done with ~150 mL in the bladder to prevent false positives
- Normal
  - Continuous, peaked, bell-shaped curve
  - Normal peak urine flow – > 30 mL/s
  - Duration < 30 seconds
- Abnormal
  - Flat/plateau curve (urine flow is constant but very low) -> urethral stricture
  - Saw-tooth curve -> detrusor sphincter dyssynergia
  - Flattened bell-shaped curve -> BPH
Pressure flow study
- Invasive urodynamic study
- Measures the detrusor pressure while voiding
- Gives information on bladder stability, contractility, and sensibility
Valsalva leak point pressure
- Measures the intraabdominal pressure at which urine loss occurs

35. Male sexual dysfunction, male infertility

Male sexual dysfunction
- Erectile dysfunction
- Ejaculation disorders
  - Premature ejaculation
    - Idiopathic
    - Treated with psychotherapy, local anaesthetics, or SSRIs
  - Delayed ejaculation
    - Caused by psychological stress
    - Treated with psychotherapy
- Peyronie disease
- Priapism
Physiological erection
- Flaccid penis
  - Sympathetic nervous system predominates
  - Cavernous smooth muscle is contracted
  - Artery is vasoconstricted
- Erect penis
  - Parasympathetic nervous system predominates
  - Cavernous smooth muscle relaxes
  - Artery is vasodilated
Erectile dysfunction (ED)
- = the persistent inability to achieve and/or maintain a sufficient erection
- Epidemiology
  - Affects 50% of men aged 40 – 70
  - Prevalence increases with age
- Causes psychosexual morbidity -> psychogenic ED -> evil cycle
  - Decreased self-esteem
  - Anxiety, depression
- Diagnosis
  - Clinical
  - Anamnesis
    - International Index of Erectile Function (IIEF)
  - Physical examination
    - Hypogonadism
    - Neurological disease
    - Vascular disease
  - Labs
    - Testosterone
    - CVD risk factors
  - Nocturnal penile tumescence
    - Erections physiologically occur during the night
    - This test monitors the penis for erections during the night
      - If erections -> most likely psychogenic ED
      - If no erections -> most likely organic ED
- Organic erectile dysfunction
  - Due to vasculogenic, neurologic, hormonal, or cavernosal abnormalities
  - Often co-exists with cardiovascular disease
    - ED can be an early manifestation of CVD
  - Etiology
    - Hypertension
    - Diabetes
    - Cardiovascular disease
    - Smoking
    - Alcohol
    - Neurologic disease
    - SSRIs
    - Radical prostatectomy
    - Pelvic injury
- Psychogenic erectile dysfunction
  - Due to central inhibition of the erectile mechanism
  - Etiology
    - Depression
    - Anxiety
    - Relationship issues
    - Stress
- Mixed type erectile dysfunction
  - Features of both organic and psychogenic ED
- Treatment
  - Psychotherapy
  - First line
    - PDE5 inhibitors
      - Sildenafil
      - Vardenafil
      - Tadalafil
      - Contraindicated in patients who take nitrates or other NO-donor drugs
    - Vacuum tumescence device
      - Vacuum tube creates negative pressure around the penis
  - Second line therapy
    - Intracavernous injection
    - Intraurethral insertion of pellet
    - Alprostadil
  - Third line
    - Penile prosthesis implantation
Male infertility
- Infertility = inability to conceive despite 1 year of unprotected sex
- Etiology
  - Idiopathic in 30% of cases
  - Diabetes mellitus
  - Hypertension
  - Obesity
  - Chronic STD
  - Alcohol
  - Anabolic steroids
  - Varicocele
  - Testicular trauma
- Diagnosis
  - Anamnesis
  - Hormone tests
  - Semen analysis
Semen analysis
- Used to evaluate male fertility and confirm sterility after vasectomy
- Procedure
  - No ejaculation for 3 – 5 days before
  - Semen is collected after masturbation into a sterile container
    - Container should be stored at body temperature
  - Analysis should be performed within 1 hour
  - Analysis should be repeated at least 2x with 12 weeks in-between
- Normal parameters
  - Volume = 1,5 – 5 mL
  - Colour = Whitish
  - Liquefaction = Complete within 30 minutes
  - pH = 7,2 – 8,0
  - Sperm per ejaculate = more than 40 million sperm
  - Sperm concentration = more than 15 million per mL
  - Vitality = more than 58% sperm should be alive
  - Morphology = more than 4% of sperm should be morphologically normal
    - Yes, this sounds very low. But it’s true
  - Progressive motility = more than 32%
    - Progressive motility means sperm which move in only one direction
  - Fructose content = more than 13 µM
  - Leukocytes = < 1 million WBCs per mL
- Pathological findings
  - Aspermia – no ejaculate
  - Hypospermia – ejaculate volume < 1,5 mL
  - Azoospermia – no spermatozoa in ejaculate
  - Cryptozoospermia – < 1 million spermatozoa/mL
  - Oligospermia – < 15 million spermatozoa/mL
  - Teratozoospermia – > 4% of spermatozoa are morphologically abnormal
  - Asthenozoospermia – < 32% of spermatozoa show progressive motility

Onco-urology

36. Renal parenchymal neoplasms: Types, clinical features, diagnosis, and treatment

Kidney tumours
- Usually incidental finding during US or CT
- Asymptomatic until late stage
- Rare to biopsy for tumours
  - A biopsy would not influence the treatment in most cases
  - It’s often better to just remove the tumour
  - Indications
    - If a renal metastasis or lymphoma is suspected
    - Before ablative therapy
    - In case of advanced metastatic disease
Renal cell carcinoma
- Epidemiology
  - Males > females
  - Elderly
  - 85% of renal cancers in adults
- Etiology
  - Smoking
  - Obesity
  - Hypertension
  - Family history
  - Hereditary RCC syndromes
    - von Hippel Lindau
    - Hereditary papillary RCC
- Pathology
  - These are adenocarcinomas which arise from tubular epithelium
  - 80 – 90% are clear cell carcinoma
  - 10 – 15% are papillary carcinoma
  - Chromophobe type is rare
- Clinical features
  - Mostly asymptomatic
  - 50% are incidental findings on imaging
  - Anaemia
  - Symptoms of local tumour growth
    - Haematuria
    - Palpable flank mass
    - Flank pain
    - Varicocele
  - Symptoms of metastases
  - Paraneoplastic syndromes
- Spreads to
  - IVC
  - Lung
  - Bone
  - Retroperitoneal lymph nodes
- Stages
  - T1 – tumour < 7 cm
  - T2 – tumour > 7 cm
  - T3 – Tumour extends into renal vein or perinephric tissues
  - T4 – Tumour extends beyond Gerota fascia
- Risk groups
  - The risk for progression to metastatic disease is based on the following factors:
  - TNM stage
  - Tumour size
  - Presence of histological necrosis
  - Tumour grade
  - Abnormal labs (LDH, Hb, Plt, etc.)
- Diagnosis
  - CT abdomen with contrast
- Work-up after diagnosis
  - CT/MRI chest
- Treatment
  - Surgery
    - Nephron-sparing surgery (= partial nephrectomy)
      - Preferred, when feasible
      - Only the tumour and some surrounding renal parenchyme is removed
    - Radical nephrectomy
      - Removes entire kidney + fat capsule + Gerota fascia
  - Radiotherapy
    - Stereotactic radiotherapy
    - For inoperable patients
  - Chemotherapy is not used
  - Targeted therapy
    - Anti-VEGF
    - mTOR inhibitors
    - Tyrosine kinase inhibitors
    - Immunotherapy
  - Localized disease
    - Surgery
  - Metastatic disease
    - Consider cytoreductive surgery
    - Consider removal of oligometastases
    - Consider prophylactic brain irradiation
    - Targeted therapy
Angiomyolipoma
- Benign
- Consists of blood vessels, smooth muscle, fat cells
- 4x more common in females
- Associated with tuberous sclerosis
- Mostly asymptomatic
- Diagnosis
  - Images show tumour with high fat content
  - US or CT
- Treatment
  - Laparoscopic partial nephrectomy
  - Indications for treatment
    - Symptomatic tumours
    - Large asymptomatic tumours
    - Diagnostic uncertainty (low fat content)
Oncocytoma
- Benign
- Clinically indistinguishable from RCC -> treated as RCC
- May transform into oncocytic RCC
Renal cyst
- Frequent incidental finding
  - On CT or US
- Most are harmless
- Intervention rarely indicated
  - Only if high risk for complications, or if it causes symptoms
Wilms tumour (nephroblastoma)
- In children

37. Urothelial carcinoma: Location, clinical features, diagnosis, and staging

Most commonly affects bladder, but can affect renal pelvis, ureter, urethra, etc.
- 90% affect bladder
Epidemiology
- Most common cancer of the urinary system
- 70 years
- Men > women
Etiology
- Smoking
- Aromatic hydrocarbons
- Irradiation
- Arsenic
- Chronic cystitis
Clinical features
- Painless gross haematuria
  - Most common
  - 30% of patients with gross haematuria have bladder cancer
- Irritative voiding symptoms
- Dysuria
- Increased frequency
- Urinary urgency
Stages
- Non-muscle invasive bladder cancer (NMIBC) = stage I
  - Also called superficial bladder cancer
  - Ta, T1 or Tis
- Muscle-invasive bladder cancer (MIBC) = stage II, III
  - Also called invasive bladder cancer
  - T2, T3, T4
- Metastatic bladder cancer = stage IV
  - M1
Diagnosis
- Urine cytology
  - Shows cancer cells
- Cystoscopy
  - Often combined with photodynamic diagnostics (PDD), which causes tumour cells to fluoresce
  - Simple biopsies can be taken
- Transurethral resection of bladder tumour (TUR-B)
  - Both diagnostic and therapeutic
  - In all (non-metastatic) bladder cancers it’s important to know whether the cancer has invaded the muscular layer or not, which only TUR-B can tell
Work-up after diagnosis
- CT urography
  - These cancers are often multifocal, so the entire urinary tract must be examined
- If the cancer isn’t muscle-invasive, no further work-up is necessary
- CT abdomen and pelvis

38. Urothelial carcinoma: Treatment modalities

Treatment
- Surgery
  - Transurethral resection of bladder tumour (TUR-B)
    - The tumour and some surrounding bladder tissue are removed with a transurethral resectoscope
    - This is both diagnostic and therapeutic
    - After the resection, chemotherapeutical drugs or BCG are instilled into the bladder to reduce any residual cancer cells
  - Radical cystectomy
    - Bladder, prostate, seminal vesicle/uterus removed
    - Urine deviation
      - Ileal conduit, neobladder, nephrostomy
  - Bladder preservation therapy
    - (Extensive) TUR-B followed by radiochemotherapy
    - An alternative to radical cystectomy which preserves the bladder
    - Check-up after 1 month
      - Tumour still present -> radical cystectomy
Radiotherapy
- Inoperable tumours
- As part of bladder preservation therapy
Systemic therapy
- Chemotherapy
- Immunotherapy
- BCG vaccine
  - Intravesical BCG helps the immune system kill urothelial cancer
Non-muscle-invasive bladder cancer
- TUR-B alone is often enough
- Intravesical BCG or chemo is instilled after TUR-B
Muscle-invasive bladder cancer
- Radical cystectomy with pelvic lymphadenectomy or bladder preservation therapy
Metastatic bladder cancer
- TUR-B is not performed
- Palliative
- Chemotherapy or immunotherapy

39. Benign prostatic hyperplasia (BPH): Clinical features and diagnosis

Epidemiology
- Prevalence increases with age
- Affects 70% of males > 60 years
Etiology
- Multifactorial
- Sensitization of the prostate to androgens and oestrogens
- Higher oestrogen/testosterone ratio in elderly
Pathophysiology
- BPH originates from the transitional zone of the prostate
- BPH -> chronic bladder outlet obstruction -> LUTS
Clinical features
- Lower urinary tract symptoms
- See topic 4
Complications
- Recurrent UTI
- Bladder stone
- Urinary retention
- Urinary incontinence
- There is no increased risk for prostate cancer
Diagnosis
- Diagnosis of BPH is clinical
  - Based on presence of LUTS in absence of other causes of LUTS
  - BPH does not require prostate biopsy
- International prostate symptom score (IPSS)
  - A questionnaire used to screen for, diagnose, and follow up symptoms of BPH
  - Points given from answers, the sum ranges from 0 – 35
  - The sum gives the severity of symptoms
- Urine analysis
  - If pyuria -> infection, which can cause similar symptoms
  - If haematuria -> can be tumor or ureter stone
- PSA
  - To look for co-existing prostate cancer
- Ultrasound
  - Can see stones, tumor, dilation of upper urinary tract
  - Can see prostate size
  - Can look for residual urine
  - Can see thickened bladder wall (detrusor hypertrophy)
- DRE
  - Symmetrically enlarged
  - Smooth (no nodules)
  - Firm
  - Nontender
  - Rubbery texture
- Uroflowmetry
  - Low peak flow, prolonged duration

40. Benign prostatic hyperplasia (BPH): Medical and surgical treatment

Behavioural modifications
- Restrict fluid intake before bedtime to prevent nycturia
- Reduce intake of diuretics like coffee, alcohol
- Urinating in sitting position
Medical therapy
- For voiding symptoms
  - Alpha-blockers
    - Tamsulosin, alfuzosin
    - Relax smooth muscle in bladder neck
    - Can cause hypotension, retrograde ejaculation
  - 5-alpha-reductase inhibitors
    - Finasteride, dutasteride
    - Decrease size of prostate
    - Takes 6 months for effect to set in
    - Can cause sexual dysfunction, gynecomastia
- For storage symptoms
  - Antimuscarinics
    - Oxybutynin, darifenacin
    - Decrease detrusor tone, increase bladder capacity
    - Can cause constipation, dry mouth, cognitive dysfunction (in elderly)
  - β-3 agonists
    - Mirabegron
    - Decrease detrusor tone, increase bladder capacity
    - More expensive
    - Does not have side effects of antimuscarinics
Surgical therapy
- Indications
  - Severe LUTS
  - BPH with complications
- Transurethral resection of the prostate (TUR-P)
  - Gold standard for BPH
  - Done under spinal/general anaesthesia
  - Only if the prostate is (not very large) < 80 g
  - A cautery resectoscope is led through the urethral opening and into the area of the prostate
    - The resectoscope has a camera like a cystoscope but is thicker, and has a metallic loop on the end
    - The metallic loop is a monopolar cautery, which is used to resect the prostate from the inside of the urethra
  - The prostate capsule is not removed
  - The remaining cavity will be epithelialized after a few months
  - TUR syndrome is a possible complication
- Simple prostatectomy
  - For large prostates (> 80g)
  - Only central and transitional zones are removed
    - Peripheral zone remains
  - Most commonly transvesically
    - Entry suprapubically
    - Operation is called transvesical adenectomy or Freyer prostatectomy
  - Can also be accessed through the perineum or the lower abdomen (retropubic)
- Newer methods
  - Laser ablation
  - Radioablation
  - Thermal ablation
- Radical prostatectomy is NOT used for BPH, only prostate cc!
TUR syndrome
- = A syndrome which can occur during TUR
- During cauterization bleeding and thermal burns occur, which is washed out with fluid
- Because of the monopolar resectoscope, the fluid used to wash must be non-conductive (distilled, ion-free water)
- During a TUR-P procedure even 50 L of washing fluid may be used
- Some of this hypotonic water is absorbed, causing hypotonicity and potentially RBC swelling and haemolysis
- To prevent TUR syndrome each TUR-P lasts max 1 hour
- Glycine solution, which is isotonic but non-conductive, can also be used, but is more expensive
- A bipolar cautery device eliminates the need for non-conductive washing solution, but is also expensive

41. Carcinoma of the prostate gland: Incidence, diagnosis, grading, and staging

Epidemiology
- The most frequent cancer in men in developed countries
- Third leading cause of cancer mortality in developed countries
Etiology
- Family history
- BRCA mutation
- Afro-American race
- Diet high in animal fat
Pathology
- 95% are adenocarcinoma
- 5% are neuroendocrine or sarcoma
- Prostate cancer develops from the peripheral zone
  - Because the peripheral zone is not removed during simple prostatectomy or TUR-P, prostate cancer can still develop after these procedures
Clinical features
- Asymptomatic in early stages
- LUTS due to obstruction
- Haematuria
- Symptoms of metastases
  - Bone pain, especially lower back
Diagnosis
- Diagnosis is confirmed by biopsy
  - See topic 14
  - Indicated when
    - DRE is suspicious for cancer
    - PSA is suspicious for cancer
    - The patient will benefit from the diagnosis
- DRE – irregular, nodular prostate
- Elevated PSA
  - See topic 3
  - PSA is also used to follow up
- Transrectal ultrasound
  - Used to calculate prostate volume
  - Used to guide biopsy
Work-up of diagnosed prostate cancer
- Histological examination of biopsy
  - Gleason grade
    - According to the abnormal glandular architecture
    - Grade 1 – best
    - Grade 5 – worst
  - Gleason score
    - Two numbers added together
      - The first number shows the Gleason grade of the most abundant tissue type
      - The second number shows the Gleason grade of the second most abundant tissue type
    - The best Gleason score is 2
      - However, scores below 6 are very rarely seen
    - The worst Gleason score is 10
    - Important for choice of therapy
- MRI
- PET/CT
- Bone scan
Stages
- T1 – incidental finding
  - Not palpable or visible on imaging
  - Present biochemically (as elevated PSA)
- T2 – localized cancer
  - Localized to prostate
- T3, T4 – locally advanced cancer
- N+ or M+ – metastatic cancer

42. Carcinoma of the prostate: Treatment modalities

Determination of risk
- The disease can be low, medium, or high risk depending on the following factors:
- PSA level
- Gleason score
- TNM stage
Progression of localized prostate cancer
- If cancer is not completely cured during the primary treatment, it will relapse
- Relapsed cancer is often treated with hormone therapy
- Hormone therapy initially helps, as the cancer at this stage is hormone-naïve or castrate-sensitive prostate cancer (CSPC)
- After some time, however, hormone therapy loses its efficacy. The cancer has become castration-resistant prostate cancer (CRPC)
- At this point the testosterone levels are still at castration levels (low), but the tumour has grown independent of testosterone
  - This doesn’t mean that hormone therapy is useless
  - CRPC is often metastatic
Modalities
- Active surveillance
  - Regular cancer re-staging
  - Treatment only starts if the tumour progresses
  - Used for low and middle-risk patients
- Radical prostatectomy
  - ± pelvic lymphadenectomy
  - Laparoscopic or open
  - Removal of prostate, seminal vesicle, vas deferens
  - Complications
    - Erectile dysfunction, incontinence, strictures, etc.
- Radiotherapy
  - External beam radiotherapy or brachytherapy, often combined
  - Neoadjuvant or adjuvant
- Chemotherapy
  - Docetaxel
- Androgen deprivation therapy
  - Surgical castration (orchidectomy)
  - Chemical castration
    - LHRH agonist
    - LHRH antagonist
    - Antiandrogens
- New antiandrogens
  - Abiraterone, enzalutamide
Treatment according to stage and risk
- Localized prostate cancer
  - Active surveillance
  - Radical prostatectomy
  - Radiotherapy
- Locally advanced or high-risk localized prostate cancer
  - Radical prostatectomy
  - Radiotherapy + androgen deprivation therapy
- Metastatic prostate cancer
  - Treatment with palliative intent
  - Hormone-naïve cancer
    - ADT + antiandrogens
  - Castration-resistant cancer
    - ADT + antiandrogens + chemo/immunotherapy
  - Bone-targeting therapy
    - Bisphosphonates
    - Denosumab
    - Radium-223
Follow-up
- Mainly by PSA monitoring
- After curative therapy PSA should drop to undetectable levels

43. Tumors of the testis: Risk factors, classification, diagnosis, and staging

Epidemiology
- Most common cancers in men 15 – 35
- More common in whites than blacks
- Surprisingly rare in women
- High cure rate (80 – 90%)
Etiology
- Cryptorchidism
- Klinefelter syndrome
- Contralateral testicular cancer
Pathology
- Germ cell tumours (95%)
  - Seminomas (50%)
    - Very radiosensitive
  - Non-seminomas (50%)
    - Often a combination of embryonal carcinoma, yolk sac, choriocarcinoma, etc.
    - Moderately radiosensitive
- Stroma cell tumours (5%)
- Spreads primarily by lymph
Clinical features
- Mostly asymptomatic
- Painless testicular lump
- Symptoms of metastasis
  - Cough, chest pain, bone pain
Stages
- Limited disease – cancer limited to testicles
- Locally advanced disease – retroperitoneal lymph node involvement
- Metastatic disease – M1
Diagnosis
- Histological examination is required for diagnosis
  - However, biopsy is never performed because it can cause seeding
  - If there is a strong suspicion orchidectomy should be performed -> histological confirmation
- Testicular ultrasound
  - Often enough to establish the presence of malignant tumour
- Tumor markers
  - LDH
  - hCG
  - AFP
Work-up after diagnosis
- Tumour markers
- CT chest, abdomen, pelvis

44. Complex treatment of testis tumors

Surgery
- Radical (inguinal) orchidectomy
  - Performed in all cases
  - The spermatic cord is clamped to prevent tumour seeding
  - Testicle is removed through inguinal canal
- Retroperitoneal lymph node dissection (RPLND)
  - In some cases
  - Para-aortic lymph nodes are most commonly affected
Radiotherapy
- External beam radiotherapy
- Generally only used in seminomas, not non-seminomas
- Radiotherapy is less and less used, chemo is more and more preferred instead
  - There’s a 7x risk in secondary cancer 10 years after testicular radiotherapy
Chemotherapy
- Platinum-based
- Cisplatin, etoposide, bleomycin
Localized disease (stage I)
- Orchidectomy +
- Active surveillance
  - In low-risk localized disease
- Adjuvant polychemotherapy
  - In intermediate and high-risk localized disease
Locally advanced disease (stage II)
- Orchidectomy + adjuvant radio (targeting retroperitoneal lymph nodes) or polychemotherapy or RPLND
Metastatic disease (stage III)
- Orchidectomy + polychemotherapy

45. Tumors of the penis, scrotum, and urethra.

Penile cancer
- = SCC
- Epidemiology
  - Relatively rare
  - More common in developing countries
  - Most common in elderly
- Etiology
  - HPV
  - Poor hygiene
  - Phimosis
  - Chronic balanitis
- Precancerous lesions
  - Bowen disease
  - Erythroplasia of Queyrat
- Clinical features
  - Most commonly in the glans
  - Painless lump or ulcerative lesion on penis
  - Swollen inguinal lymph node
- Diagnosis
  - Histological diagnosis
  - Excisional biopsy
    - Gold standard
- Differential
  - Condyloma acuminata
  - STD
- Treatment
  - Partial penectomy
    - If penile length is adequate after surgical excision with a 2 cm margin
  - Total penectomy
    - A urethrostomy is made on the perineum
  - T1 tumour
    - Hasn’t invaded any of the corpora
    - Surgical excision, laser ablation, radiotherapy
  - T2 – T4 or N+ tumour
    - Partial or total penectomy
    - Ipsilateral lymph node dissection (if N+)
    - Adjuvant chemotherapy
  - Metastatic disease
    - Palliative chemotherapy
Scrotal cancer
- Mostly SCC
- Related to topical carcinogens: soot, tar, etc. and poor hygiene
- Painless, slow growing mass or ulceration
- Diagnosis by biopsy
- Treatment by surgical excision
Urethral carcinoma
- More common in females
- 70% SCC, 20% urothelial carcinoma
- Causes obstruction or haematuria
- Diagnosis by biopsy
- Treatment of proximal urethral cancer
  - Radical cystourethrectomy + inguinal lymph node removal + urine deviation
- Treatment of distal urethral cancer
  - Women – surgical resection + radiation
  - Men – transurethral resection, amputation, or radiation

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Fourth year

6 thoughts on “Urology”

Anonymous says:

June 22, 2021 at 19:38

You wrote:
o Manual untwisting (internally rotate them)
 Can be tried, but should not delay surgery
 Surgery should be performed even if manual untwisting was performed
 Clockwise for right testicle
 Counter-clockwise for left testicle

Isn’t the right testicle untwisted counter-clock wise and vice versa for the left? Because you also wrote internally rotate them which is the opposite of what you stated in the last two points.
1. Nikolas says:
  
  June 24, 2021 at 17:08
  
  You are right, they should be externally rotated, not internally. fixed it now
Merrill XXXXX says:

March 24, 2021 at 17:30

Hey! I’m at work surfing around your blog from my new iphone 3gs! Just wanted to say I love reading through your blog and look forward to all your posts! Keep up the outstanding work!
1. Nikolas says:
  
  April 2, 2021 at 13:09
  
  How do you have an iphone 3gs in 2021?
dfgb says:

December 6, 2020 at 20:09

avagsrbsb
1. Anonymous says:
  
  May 22, 2021 at 18:32
  
  yes

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