CHAPTER 39- UROLOGY.txt

gerota's fascia

renal vein, renal artery, and renal pelvis

Right renal artery crosses posterior to the IVC

Ureters cross over iliac vessels

the left renal vein can be ligated from the IVC secondary to increased collaterals (left adrenal vein, left gonadal vein, and left ascending lumbar vein)

vas deferens

hypotension

severe colicky pain, restlessness

• 1) blood
• 2) stones

can demonstrate stones and associated hydronephrosis

• 1) calcium oxalate (phosphate) stones-
• 1- most common (75%); radiopaque
• 2- inceased in patients with terminal ileum resection due to increased oxalate absorption in colon

• 2) Mg ammonium phosphate (struvite stones)-
• 1- 15% radiopaque
• 2- can occur with infections (proteus mirabilis) that are urease producing
• 3- can cause staghorn calculi (fill the renal pelvis)

• 3) Uric acid stones
• 1- 7%; radiolucent
• 2- increased in patients with ileostomies, gout and myeloproliferative disorders

• 4) Cysteine stones
• 1) 2%; radiolucent and radiopaque
• 2) associated with congenital disorders in the reabsorption of cysteine

• 1) intractable pain or infection
• 2) progressive obstruction
• 3) progressive renal damage
• 4) solitary kidney
• 5) 90% of kidney stones opaque; >6mm not likely to pass

• 6) Tx:
• 1) ESWL (extracorporeal shock wave lithotripsy)
• 2) ureteroscopy with stone extraction or placement of stent past the stone obstruction
• 3) percutaneous nephrostomy tube
• 4) open nephrolithotomy
• 5) urethrotomy

• 1) #1 cancer killer in men 25-35
• 2) Symptom: painless hard mass
• 3) Testicular mass- the patient needs an orchiectomy through an inguinal incision (not a trasscrotal incision --> does not want to disrupt lymphatics). The testicle and attached mass constitute the biopsy specimen.

most testicular masses are malignant

• 1) ultrasound
• 2) chest x-ray to check for pulmonary metastases
• 3) chest and abdominal CT- to check for retroperitoneal and mediastinal burden

1) LDH

Also need a B-HCG and AFP level

90% of tumors are germ cells- seminoma or nonseminoma

• 1) Undescended testicles (crytorchidism) increases the risk of testicular Ca.
• 2) most likely to get seminoma

• 1) #1 testicular tumor
• 2) 10% of seminomatous tumors have beta-HCG elevation
• 3) should not have AFP elevation (if elevated, need to treat like nonseminomatous)
• 4) spreads to retroperitoneum
• 5) seminoma is extremely sensitive to XRT
• 6) Treatment:
• 1- all stages get oriectomy and retroperitoneal XRT- some patients have occult retroperitoneal metastases
• 2- if the paraaortic nodes in the abdomen are enlarged, need to extend XRT to the mediastinum
• 3) positive nodes, metastatic disease, or bulky retroperitoneal disease--> chemo (cisplatin, bleomycin, VP-16)
• 4) if the patient still has disease after XRT and chemo, needs to go with surgery

• 1) types-
• 1- embryonal
• 2- teratoma
• 3- choriocarcinoma
• 4- yolk sac

• 2) Alpha fetoprotein and beta-HCG- 90% have these markers
• 3) spreads hematogenously to lungs
• 4) also spreads to retroperitoneum
• 5) classically, tumors with increased teratoma components are more likely to metastasize to the retroperitoneum
• 6) Surgical Treatment:
• 1- Stage I- orchiectomy, prophylactic retroperitoneal node dissection
• 2- Stage II or greater- orchiectomy, XRT, and chemo (cisplatin, bleomycin, VP-16); surgical resection of residual metastases

posterior lobe

• 1) bone
• 2) osteoblastic; x-ray demonstrates hyperdense areas

• 1) many patients become impotent after resection
• 2) can also get urethral strictures

• 1) transrectal Bx
• 2) CXR
• 3) abd/pelvic CT
• 4) PSA
• 5) alkaline phosphatase
• 6) possible bone scan

• 1) XRT
• 2) radical prostatectomy with pelvic lymph node dissection (if lifespan >10 years)
• 3) do nothing depending on age/health

• 1) Hormonal Tx:
• 1- leuprolide (LH-RH blocker)
• 2- flutamide (testosterone blocker)
• 3- bilateral orchiectomy
• 4) ketoconazole
• 5) XRT for bone pain

• 2) Chemotherapy:
• 1- reserved for metastatic disease not responding to hormonal therapy

nothing

With prostatectomy, PSA should go to 0 after 3 weeks. If not, get bone scan to check for metastases

normal PSA <4 in a patient who has a prostate gland

• PSA can be increased with:
• 1) prostatitis
• 2) BPH
• 3) chronic catheterization

metastasis or extracapsular disease

• 1) #1 primary tumor of kidney (15% calcified)
• 2) risk factor: smoking
• 3) Abdominal pain, mass, and hematuria

1) 1/3 have metastatic disease at the time of diagnosis.

2) can perform wedge resection of isolated lung and colon metastases

lung

Erythrocytosis can occur secondary to increased erythropoietin (HTN)

• 1) radical nephrectomy with regional nodes
• 2) XRT
• 3) chemotherapy

• 1- radical nephrectomy takes kidney, adrenal, fat, gerota's fascia, and regional nodes
• 2- predilection for growth in the IVC; can still resect even if going up IVC--> can pull the tumor thrombus out of the IVC
• 3- partial nephrectomies should be considered only for patients who would require dialysis after nephrectomy
• 4- embolization can be used to palliate large tumors or as preop for large tumors to facilitate removal

metastasis from the breast

• 1) erythropoetin
• 2) PTHrp
• 3) ACTH
• 4) insulin

radical nephroureterectomy

benign

1) hamartomas; can occur with tuberous sclerosis

2) large tumors (>4cm) may be symptomatic and require excision or embolization

• 1) multifocal and recurrent RCC
• 2) renal cysts
• 3) CNS tumors
• 4) pheochromocytomas

transitional cell cancer

painless hematuria

• 1) males
• 2) prognosis based on stage and grade

• 1) smoking
• 2) aniline dyes
• 3) cyclophosphamide

• 1) cystoscopy
• 2) IVP

1) intravesical BCG (Bacillus Calmette-Guerin) or transurethral resection if muscle is not involved (T1)

• 2) If muscle wall is invaded (T2 or greater)-
• 1- cystectomy with ileal conduit
• 2- chemotherapy (MVAC: methotrexate, vinblastine, adriamycin (doxorubicin), and cisplatin)
• 3- XRT

3) Metastatic disease- chemotherapy

• Avoid stasis as this predisposes to:
• 1- infection
• 2- stones (calcium resorption)
• 3- ureteral reflux

Reservoirs or neobladders may also be options

schistosomiasis infection

• 1) peaks in 15 year olds
• 2) involved testis almost never viable
• 3) usually has intravaginal torsion of the spermatic cord if viable
• 4) torsion is usually toward the midline
• 5) Treatment: bilateral orchiopexy
• 1- if not, resection and orchiopexy of contralateral testis

• 1) if going to repair end-to-end
• 1- spatulate ends
• 2- use absorbable suture to avoid stone formation
• 3- stent the ureter to avoid stenosis
• 4- place drains to identify and potentially help treat leaks

2) avoid stripping the soft tissue on the ureter, as it will compromise blood supply

transitional zone

• 1- nocturia
• 2- frequency
• 3- dysuria
• 4- weak stream
• 5- urinary retention

1) Alpha blockers- terazosin, doxazosin (relax smooth muscle)

2) 5-alpha-reductase inhibitors- finasteride --> inhibits the conversion of testosterone to dihydrotestosterone (inhibits prostate hypertrophy)

• TURP (Transurethral resection of the prostate) :
• 1- for recurrent UTIs
• 2- gross hematuria
• 3- stones
• 4- renal insufficiency
• 5- failure of medical therapy

1) hyponatremia secondary to irrigation with water; can precipitate seizures from cerebral edema

2) Treatment: careful correction of Na with diuresis

most patients with TURP have retrograde ejaculation

• 1) most commonly secondary to spinal compression
• 2) patient urinates all the time
• 3) injury above T12
• 4) Treatment: surgery to improve bladder resistance

• 1) incomplete emptying
• 2) injury below T12; can occur with APR
• 3) Treatment: intermittent catherization

• 1) because of hypermobile urethra or loss of sphincter mechanism
• 2) Treatment:
• 1- kegel exercises
• 2- alpha-adrenergic agents
• 3- surgery for urethral suspension or pubovaginal sling

• 1) sense of urgency or frequency
• 2) because of involuntary detrusor contraction without neurologic disorder
• 3) Treatment:
• 1- anticholinergics
• 2- behavior modification
• 3- cystoplasty
• 4- urinary diversion (last resort)

• 1) urgency or frequency
• 2) decreased bladder capacity; associated with neurologic conditions--> spinal cord dysfunction, stroke, multiple sclerosis
• 3) Treatment:
• 1- treat underlying neurologic disorder
• 2- behavior modification
• 3- surgical options- cystoplasty or urinary diversion

• 1) incomplete emptying and enlarged bladder
• 2) obstruction (BPH) leads to the distention and leakage
• 3) Treatment: TURP

• 1) continuous leakage and nocturnal enuresis; sphincter mechanism is bypassed
• 2) Tx: surgical correction (bladder exstrophy, ureteral diversion)

treatment: pyeloplasty

treatment: reimplantation with long bladder portion

most common urintary tract abnormality

treatment: reimplantation

treatment: resect and reimplant

• 1) ventral
• 2) repair at 6 months with penile skin

• 1) dorsal
• 2) Treatment: surgery

1) usually joined at lower poles

• 2) complications:
• 1- UTI
• 2- urolithiasis
• 3- hydronephrosis

3) may need pyeloplasty

resection only if symptomatic

• 1) connection between umbilicus and bladder
• 2) occurs in patients with bladder outlet obstructive disease (wet umbilicus)
• 3) Treatment: resection of sinus/cyst and closure of the bladder; relieve obstruction

sterile epididymitis can occur from increased abdominal straining

worrisome for renal cell Ca (left gonadal vein inserts into left renal vein; obstruction by renal tumor causes varicocele); could also be caused by another retroperitoneal malignancy

if acute, suspect tumor elsewhere; transluscent

most common cause is diverticulitis and subsequent formation of colovesical fistula

• 1) pyelonephritis
• 2) glomerulonephritis

glomerulonephritis

• 1) fever
• 2) rash
• 3) arthralgias
• 4) eosinophils

50% pregnancy rate after repair of vasectomy

• Treatment:
• 1) aspiration of the corpus cavernosum with dilute epinephrine or phenylephrine
• 2) may need to create a communication through the glans with a scalpel
• 3) Risk factors:
• 1- sickle-cell anemia
• 2- hypercoagulable states
• 3- trauma
• 4- intracorporeal injections for impotence

penectomy with 2 cm margin

• 1) indigo carmine
• 2) methylene blue

treatment: dorsal slit

no, erythropoetin is decreased in patients with renal failure

A spermatocele is a fluid-filled cystic structure separate from and superior to the testis along the epididymis

Treatment: surgical removal